Abstract
The number of older people living with complex health conditions is increasing, with the majority of these managed in primary and community settings. Many models of care have been developed to support them, however, there is mixed evidence on their value and they include multiple overlapping components. We aimed to synthesise the evidence to learn what works for managing complex conditions in older people in primary and community care. We carried out a state-of-the-art review of systematic reviews. We searched three databases (January 2009 to July 2019) for models of primary and community care for long-term conditions, frailty, multimorbidity and complex neurological conditions common to older people such as dementia. We narratively synthesised review findings to summarise the evidence for each model type and identify components which influenced effectiveness. Out of 2,129 unique titles and abstracts, 178 full texts were reviewed and 54 systematic reviews were included. We found that the models of care were more likely to improve depressive symptoms and mental health outcomes than physical health or service use outcomes. Interventions including self-management, patient education, assessment with follow-up care procedures, and structured care processes or pathways had greater evidence of effectiveness. The level of healthcare service integration appeared to be more important than inclusion of specific professional types within a team. However, more experienced and qualified nurses were associated with better outcomes. These conclusions are limited by the overlap between reviews, reliance on vote counting within some included reviews and the quality of study reports. In conclusion, primary and community care interventions for complex conditions in older people should include: (a) clear intervention targets; (b) explicit theoretical underpinnings; and (c) elements of self-management and patient education, structured collaboration between healthcare professionals and professional support. Further work needs to determine the optimal intensity, length, team composition and role of technology in interventions.
Highlights
State-of-the-art reviews focus on narrative synthesis of the most up to date evidence to outline the current state of knowledge and priorities for future research, and do not include formal quality assessment (Grant & Booth, 2009)
As we did not intend to assess quality, we only included systematic reviews in order to draw upon their own selection of the highest quality evidence available, and focussed upon systematic reviews completed in the last 10 years on this topic as earlier reviews were likely to be out of date or superseded
In one review, having a theoretical basis was associated with improved mental functioning in nursing interventions for long-term conditions (LTCs) compared to controls, only 21% included studies reported being based on a theory (Amo-Setien et al, 2019)
Summary
We undertook a state-of-the-art review of systematic reviews to identify effective components of primary and community management of complex conditions in older people. In one review, having a theoretical basis was associated with improved mental functioning in nursing interventions for LTCs compared to controls (details not reported; effect size = 0.331, 95% CI 0.186–0.476, n = 13), only 21% included studies reported being based on a theory (Amo-Setien et al, 2019). Broader targets (e.g. controlling risks and complications in certain diseases, focussing on autonomy) had mixed outcomes (Boult et al, 2009; Morilla-Herrera et al, 2016) Targeting those with high baseline morbidity was associated with reduced hospital admissions compared to usual care in LTCs (Smith et al, 2017) and improved patient-reported outcomes (Baker et al, 2018). A longitudinal, preventative and communitybased approach typically containing six components, including community, health system, self-management support, decision support, delivery system design and clinical information systems (WHO, 2016)
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