Care Of Frail Elderly Patients Research Articles

Effect of comprehensive geriatric assessment for frail elderly patients operated for colorectal cancer—the colorectal cancer frailty study: study protocol for a randomized, controlled, multicentre trial

BackgroundColorectal cancer (CRC) is the third most common cancer worldwide, with a median age of 72–75 years at diagnosis. Curative treatment usually involves surgery; if left untreated, symptoms may require emergency surgery. Therefore, most patients will be accepted for surgery, despite of high age or comorbidity. It is known that elderly patients suffer higher risks after surgery than younger patients, in terms of complications and mortality. Assessing frailty and offering frail elderly patients individualized treatment according to the comprehensive geriatric assessment (CGA) and care concept has been shown to improve the outcome for frail elderly patients in other clinical contexts.MethodsThis randomized controlled multicentre trial aims to investigate if CGA and care prior to curatively intended surgery for CRC in frail elderly patients will improve postoperative outcome. All patients ≥ 70 years with surgically curable CRC will be screened for frailty using the Clinical Frailty Scale (CFS-9). Frail patients will be offered inclusion. Randomization is stratified for colon or rectal cancer. Patients in the intervention group are, in addition to standard protocol, treated according to CGA and care. This consists of individualized assessments and interventions, established by a multiprofessional team. Patients in the control group are treated according to best known practice as stipulated by Swedish colorectal cancer treatment guidelines, within an enhanced recovery after surgery (ERAS) setting. The primary outcome is 90-day mortality. Secondary outcomes are the length of hospital stay and total number of hospital days within 3 months, discharge destination, 30-day readmission, ADL, safe medication assessment, CFS-9 score, complications, Health-Related Quality of Life (HRQoL) at 2-month follow-up in comparison to baseline measurements, health economical calculations including cost-effectiveness analysis based on costs of hospital care and primary care, mortality and HRQoL at baseline, 2- and 12-month follow-up and all-cause 1-year mortality.DiscussionThe trial is the first of its size and extent to investigate intervention with CGA and care prior to surgery for CRC in frail elderly patients. If this addition proves to be favourable, it could have implications on future care of frail elderly patients with CRC.Trial registrationClinicalTrials.gov NCT04358328. Registered on 4 February 2020

Essential information for transition of care for frail elderly patients in Japan: A qualitative study.

BackgroundInformation exchange between hospitals and primary care physicians is suboptimal. Most physicians are dissatisfied with the current referral process, and poor communication leads to negative care transition outcomes.MethodTo identify the key information needed for a successful transition of care, we conducted a qualitative study using consecutive, semistructured in‐person interviews and focus group sessions. We recruited five participants engaged in clinical work for individual interviews and 16 participants for focus groups. We analyzed all data using qualitative thematic analysis. All results were returned to the participants and modified based on their feedback.ResultsThe five individual interviews provided a general picture of the current referral process and an interview guide for the following focus group sessions. The focus group discussions were used to identify the essential information needed at admission and discharge from the hospital. Essential information on hospital admission was as follows: (1) basic medical and care information, (2) care resources available at home, (3) the purpose of admission and the goals of care during hospitalization, and (4) status of advance care planning (ACP) and patient's will in an emergency. Essential information on hospital discharge was as follows: (1) clinical course, (2) explanation of medical condition during hospitalization, (3) status of ACP and patient's will in an emergency, and (4) medical procedures to be continued at home.ConclusionsWe identified the essential information needed for a successful transition of care in Japan. The clinical effectiveness of a template that contains the information identified in our study warrants further investigation.

The Impact of Medication Reviews Conducted in Primary Care on Hospital Admissions and Mortality: An Observational Follow-Up of a Randomized Controlled Trial.

BackgroundDrug-related problems among the elderly population are common and increasing. Multi-professional medication reviews (MR) have arisen as a method to optimize drug therapy for frail elderly patients. Research has not yet been able to show conclusive evidence of the effect of MRs on mortality or hospital admissions.AimThe aim of this study was to assess the impact of MRs’ on hospital admissions and mortality after six and 12 months in a frail population of 369 patients in primary care in a cohort from a randomized controlled study.MethodsPatients were blindly randomized to an intervention group (receiving MRs) and a control group (receiving usual care). Descriptive data on mortality and hospital admissions at six and 12 months were collected. Survival analysis was performed for time to death and time to the first hospital admission within 12 months.ResultsAn observational follow-up was performed in a cohort of 369 patients, previously randomized to an intervention group (182) and a control group (187). Most of the patients (75%) were females and lived in nursing homes. At six months, 50 patients of the baseline population (27%) in the control group had been admitted to hospital at least once, compared to 40 patients (21%) in the intervention group. At 12 months, the percentage had increased to 70 (37%) in the control group compared to 53 (29%) in the intervention group. Compared to usual care, we found that MRs reduced the risk of hospital admissions within 12 months by 42% (HR = 0.58, 95% CI 0.37–0.92, p=0.021), but found no difference in mortality (HR = 1.12, 95% CI 0.78–1.61, p=0.551) between the groups.ConclusionWe suggest that MRs should be recommended in the care of frail elderly patients with expected benefits on delayed hospital admissions. The study is registered at ClinicalTrials.gov, registration number NCT04040855, Unique Protocol ID 2018/8.

Evaluation of the health pathway through the patient-experience in the French program PAERPA

Abstract The patient-experience is an emerging concept in research and medico-social action, and its consideration in the development of care pathways is encouraged (e.g. ’Ma Santé 2020’ national plan in France). In addition, the patient-experience of the elderly subject has specific dimensions and his collection presents difficulties insufficiently explored. PAERPA (elderly people at risk of loss of autonomy), French national experiment for the care of frail elderly patients, offers an opportunity to return to these issues. The objective of this study, mandated by the ARS of Hauts-de-France, was to collect the experience of the elderly PAERPA. Faced with the difficulties of current methodologies, several methodological approaches have been combined: semi-structured individual interviews face-to-face or by telephone, dedicated questionnaire. In addition, a specific grid was developed to explore the home-based patient experience, including seven dimensions of the patient-experience identified in the literature. This study was conducted in the second half of 2018 (3 years and a half of the start of the project). The experience of 43 seniors and / or caregivers was collected. Patients PAERPA are generally satisfied with their care but they have difficulties in making the link between their care and the actors and devices specific to PAEPRA experimentation. Human connection and listening seem essential for the elderly patients included. Other dimensions, such as stakeholder coordination, remain controversial and more difficult to grasp. Methodologically, the particular situation of seniors, such as sensory or memory disorders, requires a major adaptation of the survey tools. In PAERPA, the patient-experience of the frail elderly subject passes mainly through the feeling of a human connection. Current methodologies do not seem fully adapted to collectively capture the experience of frail elderly patients. Key messages Evaluating the patient-experience to improve the health pathway is possible and necessary through a qualitative collection, regularly, in itinere. The peculiarities of older people often require the participation of carers, who need to be involved in the assessment of the patient-experience and raised awareness.

Short-term Resource Utilization and Cost-Effectiveness of Comprehensive Geriatric Assessment in Acute Hospital Care for Severely Frail Elderly Patients

ObjectiveThe objective of this study was to estimate the 3-month within-trial cost-effectiveness of comprehensive geriatric assessment (CGA) in acute medical care for frail elderly patients compared to usual medical care, by estimating health-related quality of life and costs from a societal perspective. DesignClinical, prospective, controlled, 1-center intervention trial with 2 parallel groups. InterventionStructured, systematic interdisciplinary CGA-based care in an acute elderly care unit. If the patient fulfilled the inclusion criteria, and there was a bed available at the CGA unit, the patient was included in the intervention group. If no bed was available at the CGA unit, the patient was included in the control group and admitted to a conventional acute medical care unit. Setting and ParticipantsA large county hospital in western Sweden. The trial included 408 frail elderly patients, 75 years or older, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n = 206) or control group (n = 202). Mean age of the patients was 85.7 years, and 56% were female. MeasuresThe primary outcome was the adjusted incremental cost-effectiveness ratio associated with the intervention compared to the control at the 3-month follow-up. ResultsWe undertook cost-effectiveness analysis, adjusted by regression analyses, including hospital, primary, and municipal care costs and effects. The difference in the mean adjusted quality-adjusted life years gained between groups at 3 months was 0.0252 [95% confidence interval (CI): 0.0082-0.0422]. The incremental cost, that is, the difference between the groups, was −3226 US dollars (95% CI: −6167 to −285). ConclusionThe results indicate that the care in a CGA unit for acutely ill frail elderly patients is likely to be cost-effective compared to conventional care after 3 months.

Are frail elderly patients treated in a CGA unit more satisfied with their hospital care than those treated in conventional acute medical care?

ObjectivesOur aim was to study whether the acute care of frail elderly patients directly admitted to a comprehensive geriatric assessment (CGA) unit is superior to the care in a conventional acute medical care unit in terms of patient satisfaction.DesignTREEE (Is the TReatment of frail Elderly patients Effective in an Elderly care unit?) is a clinical, prospective, controlled, one-center intervention trial comparing acute treatment in CGA units and in conventional wards.SettingThis study was conducted in the NÄL-Uddevalla county hospital in western Sweden.ParticipantsIn this follow-up to the TREEE study, 229 frail patients, aged ≥75 years, in need of acute in-hospital treatment, were eligible. Of these patients, 139 patients were included in the analysis, 72 allocated to the CGA unit group and 67 to the conventional care group. Mean age was 85 years and 65% were female.InterventionDirect admittance to an acute elderly care unit with structured, systematic interdisciplinary CGA-based care, compared to conventional acute medical care via the emergency room.MeasurementsThe primary outcome was the satisfaction reported by the patients shortly after discharge from hospital. A four-item confidential questionnaire was used. Responses were given on a 4-graded scale.ResultsThe response rate was 61%. In unadjusted analyses, significantly more patients in the intervention group responded positively to the following three questions about the hospitalization: “Did you get the nursing from the ward staff that you needed?” (p=0.003), “Are you satisfied with the information you received on your diseases and medication?” (p=0.016), and “Are you satisfied with the planning before discharge from the hospital?” (p=0.032). After adjusted analyses by multiple regression, a significant difference in favor of the intervention remained for the first question (p=0.027).ConclusionAcute care in a CGA unit with direct admission was associated with higher levels of patient satisfaction compared with conventional acute care via the emergency room.

Clinical leadership in service redesign using Clinical Commissioning Groups: a mixed-methods study

BackgroundA core component of the Health and Social Care Act 2012 (Great Britain.Health and Social Care Act 2012. London: HMSO; 2012) was the idea of devolving to general practitioners (GPs) a health service leadership role for service redesign. For this purpose, new Clinical Commissioning Groups (CCGs) were formed in the English NHS.ObjectivesThis research examined the extent to which, and the methods by which, clinicians stepped forward to take up a leadership role in service redesign using CCGs as a platform.DesignThe project proceeded in five phases: (1) a scoping study across 15 CCGs, (2) the design and administration of a national survey of all members of CCG governing bodies in 2014, (3) six main in-depth case studies, (4) a second national survey of governing body members in 2016, which allowed longitudinal comparisons, and (5) international comparisons.ParticipantsIn addition to GPs serving in clinical lead roles for CCGs, the research included insights from accountable officers and other managers and perspectives from secondary care and other provider organisations (local authority councillors and staff, patients and the public, and other relevant bodies).ResultsInstances of the exercise of clinical leadership utilising the mechanism of the CCGs were strikingly varied. Some CCG teams had made little of the opportunity. However, we found other examples of clinicians stepping forward to bring about meaningful improvements in services. The most notable cases involved the design of integrated care for frail elderly patients and others with long-term conditions. The leadership of these service redesigns required cross-boundary working with primary care, secondary care, community care and social work. The processes enabling such breakthroughs required interlocking processes of leadership across three arenas: (1) strategy-level work at CCG board level, (2) mid-range operational planning and negotiation at programme board level and (3) the arena of practical implementation leadership at the point of delivery. The arena of the CCG board provided the legitimacy for strategic change; the programme boards worked through the competing logics of markets, hierarchy and networks; and the practice arena allowed the exercise of clinical leadership in practical problem-solving, detailed learning and routinisation of new ways of working at a common-sense everyday level.LimitationsAlthough the research was conducted over a 3-year period, it could be argued that a much longer period is required for CCGs to mature and realise their potential.ConclusionsDespite the variation in practice, we found significant examples of clinical leaders forging new modes of service design and delivery. A great deal of the service redesign effort was directed at compensating for the fragmented nature of the NHS – part of which had been created by the 2012 reforms. This is the first study to reveal details of such work in a systematic way.Future workFurther focus is needed on the emergent sustainability and transformation plans and the locality/hubs/primary care homes that integrate care across population groups.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Maccabi proactive Telecare Center for chronic conditions \u2013 the care of frail elderly patients

BackgroundIn 2012, Maccabi Healthcare Services founded Maccabi Telecare Center (MTC), a multi-disciplinary healthcare service providing telemedical care to complex chronic patients. The current paper describes the establishment and operation of the MTC center, from the identification of the need for the service, through the design of its solution elements, to outcomes in several areas of care.We analyze the effects of the program on elderly frail patients, a growing population with complex and costly needs.MethodsObservational quasi-experimental analyses using propensity score matching was used to assess the effect of MTC’s operation on utilization outcomes including direct costs.ResultsResults for frail elderly patients with complex chronic conditions show significant reductions in hospitalization days and hospitalization costs. MTC interventions also entailed lower overall average monthly costs in frail patients.ConclusionWe conclude that a proactive telehealth service for complex chronic patients using education, empowerment to self-management, and coordination of care is a cost-effective means of improving quality care and health outcomes in frail elderly patients.

Co-designing a Systematic Approach to improving care for Frail Older Patients

The concept of frailty, is associated with key clinical syndromes including loss of mobility, falls, confusion, incontinence, and polypharmacy. Frail elderly patients are particularly vulnerable to adverse effects of hospitalisation, including deconditioning, immobility, and loss of independence.[i] [ii] [iii] Within St Vincent’s University (SVUH) hospital data analysis from the Special Delivery Unit for the period from January to August 2014 conducted on a sample of 382,334 attendances shows that more than one-third of attendances at ED during this period were in the 65+ age cohort, with 12.37% aged 75+.[iv] This from a population of over 65s that account for 11.67% of the total population, indicating a disproportionate level of use of ED by the older population.[v] This raises concern about whether services will be able to cope with rapidly increasing demand. Recently attention has focused on identifying the best pathways for treating frail elderly patients identified as a priority of the national program for older persons and the emergency department task force to develop pathways and processes aimed at improving care in this age group.[vi] [vii]. As a response the HRB funded SAFE project is project focused upon co-designing a systematic Approach to improving care for Frail Elderly patients within SVUH. This poster will present the findings of work stream one of the project that commenced in November 2016. In particular, findings from the rapid realist review[viii] of the evidence and results of a scoping of existing care pathways for frail older persons in SVUH will be presented. A range of ethnographic qualitative data collection methods will inform the development of a map of current care pathways, including the challenges and bottlenecks that cause delays and dissatisfaction and/or pose a risk to the quality and timeliness of patient care. The analysis presented will increase our understanding of the advantages and problems with the current model of care. Additionally, this will allow us to better plan for appropriate implementation of a solution.

Improving integrated care for frail elderly patients throught ict – the veneto region experience

Ageing population and the related increasing incidence of chronic and frail patients are the main challenges that the EU countries are facing nowadays, these challenges affect directly the sustainability of the social and health care systems and impact on life quality of the people. In this context, the European project CareWell, started in February 2014 and with a 37 month duration, aims to improve and develop a better coordination among the social and healthcare professionals using the ICT. The idea is to achieve a more multidisciplinary approach of the professionals and a more close integration in frail-elderly patients treatments in the six European regions. This project pursues its aim through two pathways: the integrated care coordination and the patient empowerment. The Veneto pilot site (Local Health Authority n.2- Feltre) has developed and implemented a new model of integrated care delivery based on three services: ICT platform called “patient’s dashboard”; inter-consultation among professionals via Health Electronic Record (HER) and vital signs monitoring services at patient’s home. This new model has been tested by an intervention group (81 patients that fulfill the inclusion criteria: older than 65 years old, at least two chronic conditions one among COPD, CHF and diabetes, and in social or health frail condition) - followed with the new services- for at least 9 months and compared with a control group (that received the usual-care services) with the same characteristics. The delivery of integrated care is supported by the Patient’s dashboard, an ICT platform that shares all the relevant information coming from health and social care, home-care services, and hospital records. Regarding the patient empowerment, training materials have been uploaded on the website and the home care nurses provided a training service to patient’s home in order to increase illness-management of the patients. The new model implementation is expected to improve the quality of the chronic patient’s life. The first results are going in this direction, in fact, in the intervention group, the user’s satisfaction increased, in particular they felt more looked after and acknowledged a better coordination among professionals. From the professional’s prospective the new services allow a better coordination, thanks to the possibility to access the patient’s information collected by other professionals, and a reduction in time been wasted. The positive impact in our organization spurs the willingness to maintain and develop the CareWell services for the next years and the willingness to transfer it to other sites. Thanks to an ICT data/information sharing approach that allows to different health and social care providers to have a look at the information collected and reported by other services avoiding misunderstandings and time wasting, this experience is easily transferable and also sustainable on an economic level because it is focused to change the methodologies the different entities used to deliver services to frail patients. This experience has highlighted the relevance of a changing management approach that involves the professionals at the beginnings of the new model implementation in order to reduce the professionals’ resistance.

Flawed communications: Health professionals’ experience of collaboration in the care of frail elderly patients

Frail elderly patients who have multiple illnesses do not fare well in modern health care systems, mainly due to a lack of care planning and flawed communication between health professionals in different care organisations. This is especially noticeable when patients are discharged from hospital. The aim of this study was to explore health care professionals' experience of obstacles and opportunities for collaboration. Health professionals were invited to participate in three focus groups, each consisting of a hospital physician, a primary care physician, a hospital nurse, a primary care nurse, a municipal home care nurse or an assistant officer, a physical or occupational therapist and a patient or a family member representative. These individual people were then asked to discuss the obstacles and opportunities for communication between themselves and with the patients and their relatives when presented with the case report of a fictitious patient. Content analysis was used to identify categories. Several obstacles were identified for effective communication and care planning: insufficient communication with patients and relatives; delayed collaboration between care-givers; the lack of an adequate responsible person for care planning; and resources not being distributed according to the actual needs of patients. The absence of an overarching responsibility for the patient, beyond organisational borders, was a recurring theme. These obstacles could also be seen as opportunities. Obstacles for collaboration were found on three levels: societal, organisational and individual. As health care professionals are well aware of the problems and also see solutions, management for health care should support employees' own initiatives for changes that are of benefit in the care of frail elderly patients with multiple illnesses.

Is the acute care of frail elderly patients in a comprehensive geriatric assessment unit superior to conventional acute medical care?

ObjectiveThe aim of this study was to investigate whether the acute care of frail elderly patients in a comprehensive geriatric assessment (CGA) unit is superior to the care in a conventional acute medical care unit.DesignThis is a clinical, prospective, randomized, controlled, one-center intervention study.SettingThis study was conducted in a large county hospital in western Sweden.ParticipantsThe study included 408 frail elderly patients, aged ≥75 years, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n=206) or control group (n=202). Mean age of the patients was 85.7 years, and 56% were female.InterventionThis organizational form of care is characterized by a structured, systematic interdisciplinary CGA-based care at an acute elderly care unit.MeasurementsThe primary outcome was the change in health-related quality of life (HRQoL) 3 months after discharge from hospital, measured by the Health Utilities Index-3 (HUI-3). Secondary outcomes were all-cause mortality, rehospitalizations, and hospital care costs.ResultsAfter adjustment by regression analysis, patients in the intervention group were less likely to present with decline in HRQoL after 3 months for the following dimensions: vision (odds ratio [OR] =0.33, 95% confidence interval [CI] =0.14–0.79), ambulation (OR =0.19, 95% CI =0.1–0.37), dexterity (OR =0.38, 95% CI =0.19–0.75), emotion (OR =0.43, 95% CI =0.22–0.84), cognition (OR = 0.076, 95% CI =0.033–0.18) and pain (OR =0.28, 95% CI =0.15–0.50). Treatment in a CGA unit was independently associated with lower 3-month mortality adjusted by Cox regression analysis (hazard ratio [HR] =0.55, 95% CI =0.32–0.96), and the two groups did not differ significantly in terms of hospital care costs (P>0.05).ConclusionPatients in an acute CGA unit were less likely to present with decline in HRQoL after 3 months, and the care in a CGA unit was also independently associated with lower mortality, at no higher cost.

Outcome parameters in orthogeriatric co‑management- amini-review.

Recognizing hip and other fragility fractures as an adverse event of chronic geriatric conditions led to the concept of orthogeriatric co-management (OGC). OGC today represents various forms of structural cooperation between orthopedic trauma surgeons and multiprofessional geriatric teams taking care of frail elderly patients. The models are country specific. Despite several published models there are still no clear recommendations on how this service should be best organized. The 12outcome parameters published by the Experts' Roundtable in 2013 were recommended to be used for the further assessment of different OCG models. This literature review was prepared accordingly and showed the need for further studies to determine the best OGC model and to define a uniform set of outcome parameters for use in future clinical studies.

Chemotherapy in Elderly Patients with Colorectal Cancer

Colorectal cancer (CRC) affects largely elderly populations. However, older patients with CRC are generally excluded from randomized clinical trials, and the healthy subjects who are recruited are not representative of the general elderly patient population. Nevertheless, recent data from clinical trials specifically targeting elderly patients and related subgroup analyses indicate that well-selected elderly patients can have a similar response to that of younger patients. Chronological age should not determine the candidacy for adjuvant or palliative chemotherapy in elderly patients with CRC. The appropriate management of healthy elderly patients would mean that they could receive aggressive chemotherapy in a similar regimen to that of younger patients, whereas the care of frail elderly patients and those with a short life expectancy should focus on palliation. The use of a comprehensive geriatric assessment could allow the use of safe and beneficial chemotherapy regimens in elderly patients with CRC. (Korean J Med 2014;87:530-536)

Opening the Black Box of Clinical Collaboration in Integrated Care Models for Frail, Elderly Patients

The purpose of the study was to understand better the clinical collaboration process among primary care physicians (PCPs), case managers (CMs), and geriatricians in integrated models of care. We conducted a qualitative study with semistructured interviews. A purposive sample of 35 PCPs, 7 CMs, and 4 geriatricians was selected in 2 integrated models of care for frail elderly patients in Canada and France: System of Integrated Care for Older Patients of Montreal and Coordination of Care for Older Patients of Paris. Data were analyzed using a grounded theory approach. The dynamics of the collaboration process develop in three phases: (1) initiating relationships, (2) developing real two-way collaboration, and (3) developing interdisciplinary teamwork. The findings suggest that CMs and geriatricians collaborated well from the start and throughout the care management process. Real collaboration between the CMs and the PCPs occurred only later and was mostly fostered by the interventions of the geriatricians. PCPs and geriatricians collaborated only occasionally. The findings provide information about PCPs' commitment to the integrated models of care, the legitimization of the CM's role among PCPs, and the appropriate positioning of geriatricians in such models.

Organizing integrated care for frail elderly patients in Switzerland, Italy, United States and Canada

Zusammenfassung Braucht es Integration im Gesundheitswesen? Und wenn ja, welches sind die Umweltbedingungen und die Faktoren, die zum Dienstleistungserfolg einer integrierten Pflegeinitiative gehoren? Das folgende Kapitel versucht diese Frage mit Hilfe von zwei Forschungsmethoden zu beantworten. Erstens, mit einer umfassenden Literaturdurchsicht zum Thema der diffusesten Integrationsstrategien in Europa und Nordamerika. Zweitens, mit Hilfe von 4 Fallstudien, welche auf Grund ihrer maximal Umweltunterschiede ausgewahlt wurden (Kanada, USA, Italien und Schweiz). Die Analyse basiert auf einem konzeptionellen Rahmen und involviert Elemente auf Makro-, Meso- und Mikrolevel: Zusammenhang, betriebliche Mittel, Transition Management Kultur und Organisationsmodelle. Resume Une integration dans le domaine sanitaire est-elle necessaire? Si oui, quelles sont les conditions contextuelles et les combinaisons des facteurs associes au succes des livraison de service dans les initiatives de soin integree? Ce chapitre veut tenter de repondre a ces questions sur la base d'une revue de la literature complete sur les strategies d'integration les plus diffusees en Europe et en Amerique du Nord et, sur la base de 4 etudes de cas, selectionnes selon un critere de differences contextuelles maximales (Canada, USA, Italie et Suisse). L'analyse se base sur une structure conceptuelle, qui inclue des elements au niveau macro, meso et micro: context, methodes operatives, culture manageriale de la transition, et modele d’organisation.

Linking a Comprehensive Payment Model to Comprehensive Care of Frail Elderly Patients

FRAIL OLDER PATIENTS WITH MULTIPLE CHRONIC CONditions and complex health care needs receive services that are fragmented, incomplete, inefficient, and ineffective. Many of these patients are vulnerable to poor health outcomes because of age, multiple comorbidities, and poverty. Older adults with chronic health conditions spend a higher percentage of their income on health care. As a result, many frail elderly adults receive Medicare for physician and hospital care, and Medicaid, which covers some out-of-pocket costs and personal and social care services. Six million elderly adults are enrolled in both Medicare and Medicaid, also known as dual eligibles; they comprise 21% of Medicare beneficiaries. At the federal level, the Centers for Medicare & Medicaid Services (CMS) administers the Medicare and Medicaid programs. Unlike Medicare, for which all financing is federal, Medicaid funding is shared between the federal government and the states, and therefore, many Medicaid administrative decisions are made by states. Most Medicaid beneficiaries receive services through managed care; in many states this delivery model is mandatory. In contrast, a minority of Medicare beneficiaries receive services through managed care, which for Medicare is voluntary. Managed care has emerged as a potential organizational structure to coordinate the payment and program administration for dual-eligible individuals, to support the integration of medical and social services for this population. For dual-eligible individuals in managed care, health plans receive separate capitated payment from the federal government for Medicare services and the state government for Medicaid services. To date, the enrollment numbers remain relatively low with fewer than 140 000 individuals (2% of dual-eligible individuals) enrolled in these programs nationwide. The Program for All-inclusive Care for the Elderly (PACE) is one such program for community-dwelling elders who are nursing home–eligible. PACE provides a single set of requirements regarding Medicare and Medicaid services, allowing PACE organizations to enter into capitation agreements with Medicare and Medicaid for their respective services, fully integrating funding, management, and clinical decisions. In February 2010, 18 000 dual-eligible individuals were enrolled in PACE programs in 30 states. Some states have developed demonstration programs other than PACE to test models of integrated payment and service delivery for this population, stimulated by the Medicare Modernization Act of 2003, which enabled the creation of Medicare Advantage Special Need Plans. Eight states (Arizona, Massachusetts, Minnesota, New Mexico, New York, Texas, Washington, and Wisconsin) have integrated the full range of Medicare and Medicaid benefits (primary care, acute care, behavioral health, and long-term care) for approximately 120 000 dual-eligible beneficiaries through Medicare Advantage Special Need Plans. Integrated Medicare and Medicaid managed care programs have many potential advantages, including a focus on prevention, care coordination, and access to home and community-based services. Evaluation of integration projects has been limited to observational studies, the best of which have used appropriate control groups and statistical techniques. Results suggest that dual-eligible beneficiaries in these programs, as compared with those receiving services outside of managed care, have better access to home and community-based long-term care services and lower use of highcost services such as emergency department visits, hospitalizations, and nursing home stays. The voluntary nature of program participation and case selection by plans limits the ability to distinguish whether these programs are truly successful or whether the results are merely a reflection of underlying differences in the health and needs of the populations who receive care through managed care vs feefor-service. The cost-effectiveness of these programs is unproven and is dependent on the ability of plans to substitute lower-cost services for high-cost ones. Decision makers need more rigorous evaluation of these projects to establish their effectiveness, safety, and costs, and to determine the degree to which results can be generalized to important subgroups of the elderly population. There are challenges at the patient, clinician, and administrative levels of the state and federal agencies that hinder

A randomised trial of a geriatric evaluation and management consultation services in frail hospitalised patients

the usefulness of geriatric evaluation and management (GEM) approaches in the care of frail elderly patients remains uncertain. We examined whether an inpatient geriatric consultation service might be beneficial in a country with a social welfare system. we conducted a randomised trial with 345 patients from five centres. Ninety additional patients from four separate centres without GEM teams served as an external comparison. All patients were hospitalised, at least 65 years and frail. Patients were randomly assigned to either comprehensive geriatric assessment and management in the form of consultations and follow-up or usual care. Primary outcomes were rehospitalisation and nursing home placement 1 year after randomisation. Secondary outcomes were survival, functional, emotional and cognitive status, social situation and quality of life. at 12 months, the groups did not differ in the rate of rehospitalisation (intervention 67%, control 60%, P=0.30), nursing home placement (intervention 19%, control 14%, P=0.27), survival (intervention 81%, control 85%, P=0.56) or any of the other secondary measures. The external comparison groups were also similar in nursing home placement (16%, P=0.40), survival (80%, P=0.88) and all the secondary variables, but rehospitalisation was less (48%, P=0.04). No subgroup benefited from the intervention. care provided by consultation teams did not improve the rates of rehospitalisation or nursing home placement. This is not due to carry-over effects of geriatric knowledge into the control group.

Minimum data set for home care: a valid instrument to assess frail older people living in the community.

Optimal care for frail elderly patients depends on comprehensive assessment. This is especially true in the complex setting of interdisciplinary home care programs. To facilitate comprehensive assessment, as well as to generate a useful, policy-relevant patient database, standardized, multidimensional, and validated instruments are very helpful. The aim of the present study was to demonstrate that the Minimum Data Set assessment instrument for Home Care (MDS-HC) can be used to detect functional and cognitive impairment as defined by analogous research instruments. This was a cross-sectional correlation study. We studied 95 patients admitted to home care services of the Health Care Agency of Bergamo (Italy). The MDS-HC form was completed for all patients by well-trained nurses, independently of and with nurses blinded to the results from the research rating scales. The Barthel Activities of Daily Living (ADL) Index, the Instrumental Activities of Daily Living of Lawton (IADL), and the Mini Mental State Examination (MMSE) were considered the gold standard. Agreement between the MDS-HC scales and the research rating scales was assessed with Pearson's correlation coefficient. This coefficient was 0.74 for MDS-ADL versus Barthel Index, 0.81 for MDS-IADL versus Lawton Index, and 0.81 for Cognitive Performance Scale versus MMSE, indicating an excellent agreement. The MDS-HC scales, when performed by trained nurses using recommended protocols, provide a valid measure of function and cognitive status in frail home care patients. These findings point out the overall validity of the functional and clinical data contained in the MDS-HC assessment. Use of the MDS-HC gives the unique opportunity of setting up a database, a prerequisite for all epidemiological evidence-based medicine studies.

Fully integrated care for frail elderly: two American models

Integrated care for the frail elderly and other populations with complex, chronic, disabling conditions has taken centre stage among policymakers, planners and providers in the United States and other countries. There is a growing belief that integrated care strategies offer the potential to improve service co-ordination, quality outcomes, and efficiency. Therefore, it is critical to have a conceptual understanding of the meaning of integrated care and its various organisational models, as well as practical examples of how such models work. This article examines so-called "fully integrated" models of care in detail, concentrating on two major, well-established American programs, the social health maintenance organisation and the program of all-inclusive care for the elderly. A major challenge to understanding the performance and outcomes of fully integrated care and other organisational models is the lack of a meaningful, analytical paradigm. This article builds upon the work of Walter Leutz, to develop a framework by which new and existing programs can be analysed. This framework is then applied to the two American models that are the focus of this article. Existing data about integrated care in general, and the two model programs in particular, were collected and analysed from reports published by governmental and non-governmental organisations, and journal articles retrieved from Medline, HealthStar and other sources. This analysis strongly suggests that fully integrated models of care, such as the social health maintenance organisation and program of all-inclusive care for the elderly, are not only feasible, but offer significant potential to improve the delivery of health and social care for frail elderly patients. In addition, the authors identify the factors that are the most critical to the success of fully integrated care, and offer lessons for their development and implementation. Finally, issues are raised concerning the transferability of this complex model to other countries, as well as the vital importance of evidence-based evaluation research in furthering the evolution of integrated care.