Acute Health Care Services Research Articles

A longitudinal cohort study evaluating the impact of a geriatrician-led residential care outreach service on acute healthcare utilisation.

over the last decade, high demand for acute healthcare services by long-term residents of residential care facilities (RCFs) has stimulated interest in exploring alternative models of care. The Residential Care Intervention Program in the Elderly (RECIPE) service provides expert outreach services to RCFs residents, interventions include comprehensive care planning, management of inter-current illness and rapid access to acute care substitution services. to evaluate whether the RECIPE service decreased acute healthcare utilisation. a retrospective cohort study using interrupted time series analysis to analyse change in acute healthcare utilisation before and after enrolment. a 300-bed metropolitan teaching hospital in Australia and 73 RCFs within its catchment. there were 1,327 patients enrolled in the service with a median age of 84 years; 61% were female. data were collected prospectively on all enrolled patients from 2004 to 2011 and linked to the acute health service administrative data set. Primary outcomes change in admission rates, length of stay and bed days per quarter. in the 2 years prior to enrolment, the mean number of acute care admissions per patient per year was 3.03 (SD 2.9) versus post 2.4 (SD 3.3), the service reducing admissions by 0.13 admissions per patient per quarter (P = 0.046). Prior to enrolment, the mean length of stay was 8.6 (SD 11.0) versus post 3.5 (SD 5.0), a reduction of 1.5 days per patient per quarter (P = 0.003). this study suggests that an outreach service comprising a geriatrician-led multidisciplinary team can reduce acute hospital utilisation rates.

San Francisco children living in redeveloped public housing used acute services less than children in older public housing.

Understanding the links between housing and health is increasingly important. Poor housing quality is a predictor of poor health and developmental problems in low-income children. We examined associations between public housing type and recurrent pediatric emergency and urgent care hospital visits. Children ages 0-18 with public insurance who sought emergency care from any of three large medical systems in San Francisco were categorized by whether they lived in public housing redeveloped through the federal HOPE VI program, nonredeveloped public housing, or nonpublic housing in a census tract that also contained public housing. After we adjusted for potential confounding characteristics, we found that children living in nonredeveloped public housing were 39 percent more likely to have one or more repeat visits within one year for acute health care services unrelated to the initial visit, compared to children who lived in redeveloped HOPE VI housing. We observed no differences in repeat visits between children in redeveloped HOPE VI housing and those in nonpublic housing. These findings support the continued redevelopment of public housing as a means of both improving the health of vulnerable high-risk children from low-income neighborhoods and reducing health care costs.

Are specialist psychiatric services losing the PbR race?: commentary on… clustering in mental health payment by results

SummaryPayment by results (PbR) is a payment platform for healthcare services. Introduced to acute physical healthcare services in England in 2003–2004, the system has continued to expand and is currently being implemented in acute mental health services. Owing to the variations and complexities of the patients who access specialist psychiatric services, existing clusters do not always accurately capture their needs. The development of PbR tools specific to psychiatric subspecialties is ongoing, but might not be available in the short term. The funding of acute mental health services through PbR might have funding implications for specialist services such as psychiatry of intellectual disability.

Feasibility and impact of a post-discharge geriatric evaluation and management service for patients from residential care: the Residential Care Intervention Program in the Elderly (RECIPE).

BackgroundGeriatric evaluation and management has become standard care for community dwelling older adults following an acute admission to hospital. It is unclear whether this approach is beneficial for the frailest older adults living in permanent residential care. This study was undertaken to evaluate (1) the feasibility and consumer satisfaction with a geriatrician-led supported discharge service for older adults living in residential care facilities (RCF) and (2) its impact on the uptake of Advanced Care Planning (ACP) and acute health care service utilisation.MethodsIn 2002–4 a randomised controlled trial was conducted in Melbourne, Australia comparing the geriatrician–led outreach service to usual care for RCF residents. Patients were recruited during their acute hospital stay and followed up at the RCF for six months. The intervention group received a post-discharge home visit within 96 hours, at which a comprehensive geriatric assessment was performed and a care plan developed. Participants and their families were also offered further meetings to discuss ACPs and document Advanced Directives (AD). Additional reviews were made available for assessment and management of intercurrent illness within the RCF. Consumer satisfaction was surveyed using a postal questionnaire.ResultsThe study included 116 participants (57 intervention and 59 controls) with comparable baseline characteristics. The service was well received by consumers demonstrated by higher satisfaction with care in the intervention group compared to controls (95% versus 58%, p = 0.006).AD were completed by 67% of participants/proxy decision makers in the intervention group compared to 13% of RCF residents prior to service commencement. At six months there was a significant reduction in outpatient visits (intervention 21 (37%) versus controls 45 (76%), (p < 0.001), but no difference in readmissions rates (39% intervention versus 34% control, p = 0.6). There was a trend towards reduced hospital bed-day utilisation (intervention 271 versus controls 372 days).ConclusionIt is feasible to provide a supported discharge service that includes geriatrician assessment and care planning within a RCF. By expanding the service there is the potential for acute health care cost savings by decreasing the demand for outpatient consultation and further reducing acute care bed-days.

G24(P) Exploring the relationship between infectious disease and acute health seeking behaviour in the paediatric population

Aims In the United Kingdom, over four and a half million paediatric emergency care attendances were recorded in 2010/11: across developed healthcare economies there has been a dramatic rise in the number of children attending secondary healthcare for non-urgent reasons. The majority of paediatric medical illness consists of self-limiting childhood infections, which can be managed in the community. Despite this, record numbers of children and young people are admitted to hospital, with most admissions lasting less than 24 h. This work explores how infectious disease in the paediatric population impacts on developed economy acute healthcare, and how the utilisation of these services as first contact for children and their caregivers affects the spread of infectious diseases. Methods Literature searches in (i) NCBI PubMed using MeSH terms “Paediatrics”, “Paediatric Hospitals”, “Infection” and “Emergency Medicine” and (ii) Outbreak Database (an online database of nosocomial outbreaks). The results were hand sorted to include relevant papers and a thematic analysis performed along the themes of health-seeking behaviour and use of acute healthcare services for non-urgent care in paediatric infectious disease. Results Regarding the impact of paediatric infectious disease in acute healthcare provision, three main themes emerged: (i) “Can’t cope”: Lack of understanding of infectious disease and the impact of socioeconomic stressors; (ii) “Won’t cope”: Phobia of risk, uncertainty regarding infectious disease and the cult of convenience and (iii) “No Hope”: Barriers to primary and preventative healthcare and failure of trust in healthcare professionals. Acute healthcare attendance can propagate infectious disease via contact with acute healthcare workers, cohorting in the waiting room and as a result of unnecessary admission to hospital. Conclusions Families should be better supported by health visitor input and school education and by integration of primary and secondary care. Education in infectious disease for Paediatricians and General Practitioners will promote consistent messages regarding normal childhood illnesses. Debate is needed concerning mandatory vaccination of acute healthcare workers. New healthcare facilities need to be designed to allow for cohorting and separation of infectious cases, and more publicity given to hand and cough hygiene for children and their carers whilst in the acute healthcare setting.

Care transitions for frail, older people from acute hospital wards within an integrated healthcare system in England: a qualitative case study.

Frail older people experience frequent care transitions and an integrated healthcare system could reduce barriers to transitions between different settings. The study aimed to investigate care transitions of frail older people from acute hospital wards to community healthcare or community hospital wards, within a system that had vertically integrated acute hospital and community healthcare services. The research design was a multimethod, qualitative case study of one healthcare system in England; four acute hospital wards and two community hospital wards were studied in depth. The data were collected through: interviews with key staff (n = 17); focus groups (n = 9) with ward staff (n = 36); interviews with frail older people (n = 4). The data were analysed using the framework approach. THREE THEMES ARE PRESENTED: Care transitions within a vertically integrated healthcare system, Interprofessional communication and relationships; Patient and family involvement in care transitions. A vertically integrated healthcare system supported care transitions from acute hospital wards through removal of organisational boundaries. However, boundaries between staff in different settings remained a barrier to transitions, as did capacity issues in community healthcare and social care. Staff in acute and community settings need opportunities to gain better understanding of each other's roles and build relationships and trust.

Emergency department utilisation among formerly homeless adults with mental disorders after one year of Housing First interventions: a randomised controlled trial

Homeless individuals represent a disadvantaged and marginalised group who experience increased rates of physical illness as well as mental and substance use disorders. Compared to stably housed individuals, homeless adults with mental disorders use hospital emergency departments and other acute health care services at a higher frequency. Housing First integrates housing and support services in a client-centred model and has been shown to reduce acute health care among homeless populations. The present analysis is based on participants enrolled in the Vancouver At Home Study (n = 297) randomised to one of three intervention arms (Housing First in a ‘congregate setting’, in ‘scattered site’ [SS] apartments in the private rental market, or to ‘treatment as usual’ [TAU] where individuals continue to use existing services available to homeless adults with mental illness), and incorporates linked data from a regional database representing six urban emergency departments. Compared to TAU, significantly lower numbers of emergency visits were observed during the post-randomisation period in the SS group (adjusted rate ratio 0.55 [0.35,0.86]). Our results suggest that Housing First, particularly the SS model, produces significantly lower hospital emergency department visits among homeless adults with a mental disorder. These findings demonstrate the potential effectiveness of Housing First to reduce acute health care use among homeless individuals and have implications for future health and housing policy initiatives.

Discharge planning in mental health care: an integrative review of the literature

To identify the evidence base related to discharge planning in the context of acute and community mental healthcare service provision to ascertain the need for future research. Discharge planning is an important activity when preparing consumers to transition from hospital to home. The efficiency of discharge planning for consumers living with a mental health issue can influence both the number of future readmissions to acute-care facilities and their quality of life at home. An integrative review of the peer-reviewed literature. This review uses specific search terms and a 21-year time frame to search two key nursing databases CINAHL (Cinahl Information Systems, Glendale, CA, USA) and PSYCHINFO (American Psychological Association, Washington, DC, USA) for research reports investigating the substantive area of enquiry. Hand searches of reference lists and author searches were also conducted. Nineteen peer-reviewed journal articles met the inclusion criteria for this review. Research findings about discharge planning for people living with a mental health issue identify the importance of communication between health professionals, consumers and their families to maximise the effectiveness of this process. The complexity of consumer's healthcare needs influences the discharge planning process and impacts on aftercare compliance and readmission rates. There is a limited amount of research findings relating to differences between health professionals and families' perceptions of the level of information required for effective discharge planning, and the appropriate level of involvement of individuals living with a mental health issue in their own discharge planning. Results from this integrative review will inform future research related to this topic. Discharge planning for consumers living with a mental health issue involves many stakeholders who have different expectations regarding the type of information required and the necessary level of involvement of people living with a mental health issue in this process. Comprehensive discharge planning can result in reduced readmissions to both acute and community mental health services. Understanding the impact of effective communication on the outcomes of discharge planning is an important step in promoting success.

The Language of Compassion in Acute Mental Health Care

In this article we examine the language of compassion in acute mental health care in the United Kingdom. Compassion is commonly defined as being sensitive to the suffering of others and showing a commitment to relieve it, yet we know little about how this is demonstrated in health professional language and how it is situated in the context of acute mental health care services. We report on a corpus-assisted discourse analysis of 20 acute mental health practitioner interview narratives about compassion and find a striking depletion in the use of "compassionate mentality" words, despite the topic focus. The language used by these practitioners placed more emphasis on time pressures, care processes, and organizational tensions in a way that might compromise best practice and point to the emergence of a "production-line mentality."

GPs to hold hospitals to account for transparency on patient safety

GPs will be able to hold hospitals and other NHS organisations to account for their approach to patient safety incidents through a new duty of openness in contracts for commissioned services. The government plans to introduce new regulations that will require the NHS Commissioning Board to include a contractual commitment to transparency in all commissioning contracts with NHS providers of acute care, ambulance, community, and mental healthcare services. All NHS standard contracts signed off after April 2013 must include a clause …

Pay Experiment Worked Best in Dual-Eligibles

T he Medicare Physician Group Practice Demonstration, which was the inspiration for current accountable care organization pilots, achieved only “modest” overall savings, according to an analysis published in JAMA. On average, the Physician Group Practice Demonstration (PGPD) saved the Medicare program $114 annually per beneficiary. However, the biggest savings came from low-income beneficiaries who were dually eligible for both the Medicare and Medicaid programs. Physician groups enrolled in the pilot project were able to save the Medicare program $532 on average (or 5%) for dual-eligible beneficiaries. The average savings for beneficiaries who were eligible for only Medicare was $59 per year, which was not statistically significant ( JAMA 2012;308:1015-23). The findings could foreshadow the performance of ACOs, since the PGPD pilot also allowed physicians to share in savings if they could lower costs while improving quality and care coordination. ACO pilots were included in the Affordable Care Act in part because of promising results from the PGPD. In the program, 10 physician practices could earn up to 80% of any savings to the Medicare program, provided they generated at least 2% in savings. In addition, they had to show improvement on 32 quality measures that included chronic care management. Researchers at Dartmouth College analyzed 2001-2009 Medicare administrative data. The growth rate of spending for dual-eligible beneficiaries in the PGPD sites was 9.7%, compared with 15.3% for control practices during the study. The difference came mostly from fewer acute care hospitalizations, procedures, and home health care services for the dual-eligibles, the researchers wrote. Since the savings were similar across diagnosis groups, the researchers suggested that they were probably due to better overall care management, rather than disease-specific interventions. The results highlight the “potential benefits of the ACO model for patients with serious or complex illness, a group for whom improved quality and coordination is especially important,” the researchers wrote. The PGPD practices also had lower 30-day hospital readmission rates for medical reasons and lower readmissions for both medical and surgical admissions among dual-eligible beneficiaries. The researchers found significant variation in how PGPD sites performed, which also could hold clues for future ACO success. For instance, some sites were able to achieve large spending reductions, while others saw their costs increase compared to local control practices. Results of the latest analysis show an encouraging trend in lowering costs for beneficiaries who are dually eligible for Medicare and Medicaid programs, said Dr. Donald M. Berwick, former Centers for Medicare & Medicaid administrator and former president and CEO of the Institute for Healthcare Improvement. That group is critical because they account for more than $300 billion in annual costs and 40% of state Medicaid expenditures, Dr. Berwick noted in an editorial ( JAMA 2012;308:1038-9). While the ACO model holds a lot of promise, it is not the only option reforming the way care is delivered, he wrote. Whether federal officials are encouraged or discouraged by the PGPD experience, a lot more innovations than ACOs alone will be needed to emerge successfully from this fraught time, said Dr. Berwick. The research was funded by a grant from the National Institute on Aging, the Dartmouth Atlas Project, and the Commonwealth Fund. The funders had no role in the design and conduct of the study nor approval of the manuscript. The study authors reported having no financial conflict of interest. CfA

Reforming Health Production in Ireland

AbstractThe importance of socioeconomic conditions for health status has long since been recognised internationally, and there is general agreement that maximising health production requires action on all social, economic and environmental factors potentially influencing health status. In Ireland too, the multifaceted nature of health production has been acknowledged, but this has not led to real policy change in respect of prioritisation and consequent resource allocation. The emphasis in Ireland remains narrowly focused on access to acute health care services as the core strategy for equalising health opportunities across the population. While equal access for equal need is an essential component in ensuring better, and more equal, health outcomes, particularly in relation to accessing new technologies, it is insufficient in its own right to deal with many of the economic and social determinants associated with health production. This paper argues for a comprehensive health reform programme to encompass the many determinants of population health; such an approach would provide the opportunity for all citizens to maximise their health potential.

Intermediate geriatric care in Geneva: A 10-year experience

The ageing of the population generates an increased demand for acute healthcare services in persons aged over 65, who can represent up to half of the patients treated in intensive care units (ICU). However, the number of available ICU beds is limited. Intermediate care units (IntCU), requires less human and technical resources, and has been proposed as an alternative to intensive care in the geriatric population. This article reports a 10-year, single centre experience from Geneva of continuous care and its impact on mortality in a geriatric population. Between 1998–1999 and 2000–2001, after the creation of the IntCU, we observed a significant reduction in in-hospital mortality. Thanks to increased medical and nursing care, IntCUs provide greater security for patients and their family, thereby improving their satisfaction with care.

An overview of musculoskeletal conditions

Musculoskeletal conditions affect a significant number of people regardless of age or race. Osteoporosis, osteoarthritis and rheumatoid arthritis are common conditions, which have a considerable impact on acute and primary healthcare services. The management of musculoskeletal conditions emphasises the need for patient empowerment and education. The involvement of the multidisciplinary team is essential to maximise timely and effective management principles.

Past-Year Acute Behavioral Health Care Utilization Among Individuals With Mental Health Disorders: Results From the 2008 National Survey on Drug Use and Health

Objective: Prevalence and correlates of past-year acute behavioral health care use were examined. Methods: Data are from the 2008 National Survey on Drug Use and Health (N = 10,069 adults with behavioral health disorders). Associations between past-year acute behavioral health care use and factors related to health care use were examined through bivariate and logistic regression analyses per Andersen's behavioral model of health services utilization. Results: Five percent of those with a behavioral health disorder used acute behavioral health care services. Several variables were significantly associated with acute care use in the final logistic regression model (R 2 = .179, p < .0001). Individuals with co-occurring mental illness and substance use disorders (OR = 2.58), severe mental illness (OR = 2.89), and co-occurring severe mental illness and substance use disorders (OR = 4.15) were more likely to utilize acute behavioral health care services compared to those with non-severe mental illness only. Individuals with only one type of behavioral health disorder were most likely to receive services targeting only that area of need. However, the majority of those with co-occurring disorders (i.e., > 80%) received acute care for only one of their behavioral health disorders. Those with any past-year criminal justice involvement (OR = 3.19) were also significantly more likely to receive acute behavioral care in the past year. Conclusions: Individuals with co-occurring disorders have the highest rates of acute behavioral health care service utilization. Treatment for both conditions is rarely obtained in acute care facilities, supporting the need for better integration of care in these settings.

The economic burden of chronic obstructive pulmonary disease in the elderly

Chronic obstructive pulmonary disease (COPD) is a high prevalence condition with a significant clinical and economic burden. In elderly people, COPD is often associated with other chronic comorbidities (i.e. cardiovascular diseases), determining clinical complications and requiring frequent acute healthcare interventions. The aim of this article is to review the economic studies evaluating costs and healthcare resource utilization in elderly (≥ 65 years) COPD patients. Sixteen of the initial 359 articles retrieved through our research strategy were found to include relevant cost information on elderly COPD patients or to evaluate the effect of older age on healthcare expenditure. Most studies were carried out in the United States and used administrative database claims to determine resource consumption and direct costs (attributable and not). Very few studies focused exclusively on elderly patients. Results showed a certain variability of cost estimations, mainly due to the different methodologies and adopted cost approach. However, we found a trend of direct cost growth in the elderly population, which can be explained by a more frequent use of acute healthcare services, especially for managing COPD exacerbations. These results cannot be considered definitive and new studies, targeting elderly people, are required in order to confirm these preliminary findings.

Comparing Service Use of Early Head Start Families of Children With and Without Disabilities

The current study compared patterns of service utilization reported by Early Head Start (EHS) families of children with and without disabilities by secondary analysis of data from the longitudinal investigation of the effectiveness of EHS. Findings reveal comparable positive trends for both groups of families for receipt of services corresponding to EHS performance standards promoting child and family development, family support, and health care. Service challenges remain in the low use of dental services overall and the higher use of acute health care services for children with disabilities. Future research should examine causes and outcomes of service use.

Maternal relationship style, paediatric health care use and infant health

The aim of the current exploratory study was to examine the relationships between maternal relationship style, paediatric health care use and infant health variables in a sample of middle-class and ethnically diverse mother-infant dyads. An initial cross-sectional cohort study obtained demographic and self-report data on mothers' relationship styles. As an extension of the original study, infants' patient files were reviewed for the year following initial recruitment to obtain data regarding the use of paediatric health care services and infant health. The final sample included 64 mothers and their infants. Correlational analyses revealed that mothers' higher endorsement of a dismissive relationship style were associated with fewer acute care visits and fewer reported infant illnesses. Compared with other relationship styles, mothers who highly endorsed a dismissive relationship style tended to use fewer acute paediatric health care services and reported fewer infant health problems. However, further longitudinal research is needed to clarify these relationships.

Crisis resolution in older people's mental healthcare

AbstractThe Crisis Resolution and Home Treatment (CRHT) team's role in acute mental healthcare services for working age adults is well established throughout England, but this is less so for older adults despite government policy and initiatives promoting equality of care. The authors highlight the need to extend this care model to older people's mental healthcare and suggest some possible ways of achieving this. Copyright © 2010 Wiley Interface Ltd

An overview of musculoskeletal conditions

Musculoskeletal conditions affect a significant number of people regardless of age or race. Osteoporosis, osteoarthritis and rheumatoid arthritis are common conditions, which have a considerable impact on acute and primary healthcare services. The management of musculoskeletal conditions emphasises the need for patient empowerment and education. The involvement of the multidisciplinary team is essential to maximise timely and effective management principles.