Home Care Organizations Research Articles

Development and preliminary validation of an Observation List for detecting mental disorders and social Problems in the elderly in primary and home care (OLP).

ObjectiveEven though the prevalence of mental disorders and social problems is high among elderly patients, it is difficult to detect these in a primary (home) care setting. Goal was the development and preliminary validation of a short observation list to detect six problem areas: anxiety, depression, cognition, suspicion, loneliness, and somatisation.MethodsA draft list of indicators identified from a short review of the literature and the opinions of 22 experts was evaluated by general practitioners (GPs) and home care organisations for feasibility. It was then used by GPs and home care personnel to observe patients, who also completed validated tests for psychological disorders (General Health Questionnaire 12 item version (GHQ‐12)), depression (Geriatric Depression Scale 15‐item version (GDS‐15)), anxiety and suspicion (Symptom Checklist‐90 (SCL‐90)), loneliness (University of California, Los Angeles (UCLA)), somatisation (Illness Attitude Scale (IAS)), and cognition (Mini‐Mental State Examination (MMSE)).ResultsGPs and home care personnel observed 180 patients (mean age 78.4 years; 66% female) and evaluated the draft list during a regular visit. Cronbach's α was 0.87 for the draft list and ≥0.80 for the draft problem areas (loneliness and suspicion excepted). Principal component analysis identified six components (cognition, depression + loneliness, somatisation, anxiety + suspicion, depression (other signs), and an ambiguous component). Convergent validity was shown for the indicators list as a whole (using the GHQ‐12), and the subscales of depression, anxiety, loneliness, cognition, and somatisation. Using pre‐set agreed criteria, the list was reduced to 14 final indicators divided over five problem areas.ConclusionThe Observation List for mental disorders and social Problems (OLP) proved to be preliminarily valid, reliable, and feasible for use in primary and home care settings. Copyright © John Wliey & Sons, Ltd.

Development evaluation of a multidisciplinary controlled substances committee within a patient-centered medical home

ObjectiveTo present the development of a multidisciplinary controlled substances committee and describe its effectiveness in relation to prescribers’ acceptance of committee recommendations, the number of premature deaths associated with controlled substances, and prescribers’ need for education on controlled substances. SettingA patient-centered medical home and accountable care organization in Maine that serves more than 60,000 patients across a large rural area, 70% of whom are classified as lower income. Practice descriptionA multidisciplinary group of prescribers and PharmD residents created a committee to influence organizational culture regarding controlled substances. The Controlled Substances Initiative Committee (CSIC) updated institutional policies, developed provider education, and made personalized patient recommendations to prescribers. Main outcome measuresThe primary outcome was average change in daily morphine equivalent dose (MED) in patients for whom CSIC recommended a dose reduction to the patient’s prescriber. Secondary outcomes included the proportion of patients who died of a known overdose or suspected drug-related death during 2012–2013 or 2013–2014. In addition, prescriber beliefs about controlled substances were measured via a needs assessment. ResultsThe average daily MED for patients whom CSIC recommended dose reduction was lower after 3months compared with at baseline (175.5 ± 344.3mg vs. 292.7 ± 466.5mg; P <0.05). The proportion of patients who died of a known overdose did not differ between 2012–2013 and 2013–2014 (11.8% vs. 11.1%; P = 1.00). However, a greater number of patients had a suspected drug-related death during 2013–2014 compared with during 2012–2013 (0% vs. 27.3%; P = 0.05). ConclusionA multidisciplinary controlled substances committee may improve patient safety and outcomes by offering prescriber support and helping alter prescribing culture.

Factors associated with the self-perceived ability of nursing staff to remain working until retirement: a questionnaire survey.

BackgroundIt is important to learn how employers in European countries can prevent nursing staff from changing occupation or taking early retirement in order to counteract expected nursing shortages. However, to date research on nursing staff’s ability to remain working until retirement age has been limited. The purpose of this study was to gain insight into the associations between different job and organisational characteristics, job satisfaction, occupational commitment and the self-perceived ability to continue working in the current line of work until the official retirement age.MethodsThe questionnaire-based, cross-sectional study included 730 nursing staff members employed in Dutch hospitals, nursing homes, organisations for psychiatric care, homes for the elderly, care organisations for disabled people and home care organisations (mean age: 48; 89 % female). Linear and logistic regression analyses and mediation analyses were applied to test hypothesised associations.ResultsReducing work pressure and increasing appreciation by senior management in particular have positive consequences for nursing staff’s self-perceived ability to continue working until the official retirement age. The job and organisational characteristics of autonomy, work pressure, supportive leadership, educational opportunities, communication within the organisation and appreciation of nursing staff by senior management together have substantial impact on nursing staff’s job satisfaction. Job satisfaction in turn is related to the self-perceived ability to continue working until the retirement age. However, job satisfaction mainly summarises the joint effect of job and organisational characteristics and has no supplementary effect on the self-perceived ability to continue working.ConclusionEmployers should primarily focus on work pressure and the appreciation of nursing staff by senior management in order to retain nursing staff even as they get older.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-1006-x) contains supplementary material, which is available to authorized users.

Autonomous home-care nursing staff are more engaged in their work and less likely to consider leaving the healthcare sector: A questionnaire survey

BackgroundThe need for home care is rising in many Western European countries, due to the ageing population and governmental policies to substitute institutional care with home care. At the same time, a general shortage of qualified home-care staff exists or is expected in many countries. It is important to retain existing nursing staff in the healthcare sector to ensure a stable home-care workforce for the future. However, to date there has been little research about the job factors in home care that affect whether staff are considering leaving the healthcare sector. ObjectiveThe main purpose of the study was to examine how home-care nursing staff's self-perceived autonomy relates to whether they have considered leaving the healthcare sector and to assess the possible mediating effect of work engagement. Design, setting and participantsThe questionnaire-based, cross-sectional study involved 262 registered nurses and certified nursing assistants employed in Dutch home-care organisations (mean age of 51; 97% female). The respondents were members of the Dutch Nursing Staff Panel, a nationwide group of nursing staff members in various healthcare settings (67% response rate). MethodsThe questionnaire included validated scales concerning self-perceived autonomy and work engagement and a measure for considering pursuing an occupation outside the healthcare sector. Logistic regression and mediation analyses were conducted to test associations between self-perceived autonomy, work engagement and considering leaving the healthcare sector. ResultsNursing staff members in home care who perceive more autonomy are more engaged in their work and less likely to have considered leaving the healthcare sector. The positive association between self-perceived autonomy and considering leaving, found among nursing staff members regardless of their level of education, is mediated by work engagement. ConclusionIn developing strategies for retaining nursing staff in home care, employers and policy makers should target their efforts at enhancing nursing staff's autonomy, thereby improving their work engagement.

Linkages between informal and formal care-givers in home-care networks of frail older adults

ABSTRACTIn ageing societies, policy makers aim for more contact between informal and formal care-givers as it may enhance the quality of care. So far, the linkage between formal and informal care-givers is generally studied from a one-sided or a single dyadic perspective, without taking into account that care networks of community-dwelling older adults often exist of multiple informal and formal care-givers. The current study examines discussion of care between all potential informal–formal care-giver dyads in a care network, and relates this to characteristics of the older care recipient, the care network and the care-givers. Seventy-four Dutch older care recipients provided information on all care-givers who helped with five different types of tasks; 410 care-givers reported on the contact between all care-givers identified. Multi-level logistic regression was conducted in 2,150 informal–formal care-giver dyads and revealed that in 26 per cent of all these dyads discussion on care occurred. This was more likely when both care-givers performed multiple types of tasks, the informal care-giver was residing with the care recipient, and contact within the formal and the informal sub-network was higher. To enhance discussion of care between informal and formal care-givers in care networks where no discussion occurs at all, home-care organisations may need to allocate formal care-givers who form a bridge with an extra-residential care-giver of care recipients living alone.

Meaning creation and employee engagement in home health caregivers.

The purpose of this study is to contribute to an understanding on how home health caregivers experience engagement in their work, and specifically, how aspects of home healthcare work create meaning associated with employee engagement. Although much research on engagement has been conducted, little has addressed how individual differences such as worker orientation influence engagement, or how engagement is experienced within a caregiving context. The study is based on a qualitative study in two home homecare organisations in Denmark using a think-aloud data technique, interviews and observations. The analysis suggests caregivers experience meaning in three relatively distinct ways, depending on their work orientation. Specifically, the nature of engagement varies across caregivers oriented towards being 'nurturers', 'professionals', or 'workers', and the sources of engagement differ for each of these types of caregivers. The article contributes by (i) advancing our theoretical understanding of employee engagement by emphasising meaning creation and (ii) identifying factors that influence meaning creation and engagement of home health caregivers, which should consequently affect the quality of services provided home healthcare patients.

Development and testing of a scale for assessing the quality of home nursing.

To develop a home nursing quality scale and to evaluate its psychometric properties. This was a 3-year study. In the first year, 19 focus group interviews with caregivers of people using home nursing services were carried out in northern, central and southern Taiwan. Content analysis was carried out and a pool of questionnaire items compiled. In the second year (2007), study was carried out on a stratified random sample selected from home nursing organizations covered by the national health insurance scheme in southern Taiwan. The study population was the co-resident primary caregivers of home care nursing service users. Item analysis and exploratory factor analysis were carried out on data from 365 self-administered questionnaires collected from 13 selected home care organizations. In the third year (2008), a random sample of participants was selected from 206 hospital-based home care nursing organizations throughout Taiwan, resulting in completion of 294 questionnaires from 27 organizations. Confirmatory factor analysis was then carried out on the scale, and the validity and reliability of the scale assessed. The present study developed a reliable and valid home nursing quality scale from the perspective of users of home nursing services. The scale comprised three factors: dependability, communication skills and service usefulness. This scale is of practical value for the promotion of long-term community care aging in local policies. The scale is ready to be used to assess the quality of services provided by home care nursing organizations.

Performance-based contracting in home-care work in The Netherlands: professionalism under pressure?

Our aim was to improve the understanding of the relationships between performance-based contracting, management supportiveness and professionalism in home care. Using path analysis, this article explores the relationships between home-care workers' perceptions of management support, implementation of performance-based contracting (i.e. use of strict time registration rules and cost-efficiency measures) and autonomy and intrinsic job satisfaction. We hypothesised that: use of strict time registration rules and cost-efficiency measures relates to lower levels of autonomy and intrinsic job satisfaction (H1); there is an indirect relationship between use of strict time registration rules and use of cost-efficiency measures and intrinsic job satisfaction via autonomy (H2); higher levels of management support relate to the use of looser time registration rules and less use of cost-efficiency measures (H3); and higher levels of management support relate to higher levels of autonomy and intrinsic job satisfaction (H4). We used data from a cross-sectional survey conducted in 2010 of a sample of Dutch home-care workers (N=156, response rate=34%). Overall, our study suggests that the consequences of performance-based contracting for professionalism are ambiguous. More specifically, using strict time registration rules is related to lower levels of autonomy, whereas using cost-efficiency measures does not seem to affect autonomy (H1). Performance-based contracting has no consequences for the level of fulfilment home-care workers find in their job, as neither of the two contracting dimensions measured was directly or indirectly related to intrinsic job satisfaction (H1, H2). The role of managers must be taken into account when studying performance-based contracting, because perceived higher management support is related to managers' less frequent use of both strict time registration rules and of cost-efficiency measures (H3). The insight we gained into the importance of supportive managers for both autonomy and job satisfaction (H4) can help home-care organisations improve the attractiveness of home-care work.

Mixed care networks of community-dwelling older adults with physical health impairments in the Netherlands.

As part of long-term care reforms, home-care organisations in the Netherlands are required to strengthen the linkage between formal and informal caregivers of home-dwelling older adults. Information on the variety in mixed care networks may help home-care organisations to develop network type-dependent strategies to connect with informal caregivers. This study first explores how structural (size, composition) and functional features (contact and task overlap between formal and informal caregivers) contribute to different types of mixed care networks. Second, it examines to what degree these network types are associated with the care recipients' characteristics. Through home-care organisations in Amsterdam, the Netherlands, we selected 74 frail home-dwelling clients who were receiving care in 2011-2012 from both informal and formal caregivers. The care networks of these older adults were identified by listing all persons providing help with five different types of tasks. This resulted in care networks comprising an average of 9.7 caregivers, of whom 67% were formal caregivers. On average, there was contact between caregivers within 34% of the formal-informal dyads, and both caregivers carried out at least one similar type of task in 29% of these dyads. A principal component analysis of size, composition, contact and task overlap showed two distinct network dimensions from which four network types were constructed: a small mixed care network, a small formal network, a large mixed network and a large formal network. Bivariate analyses showed that the care recipients' activities of daily living level, memory problems, social network, perceived control of care and level of mastery differed significantly between these four types. The results imply that different network types require different actions from formal home-care organisations, such as mobilising the social network in small formal networks, decreasing task differentiation in large formal networks and assigning co-ordination tasks to specific dyads in large mixed care networks.

Reciprocal Touch

Reciprocal Touch

Task shifting in the provision of home and social care in Ontario, Canada: implications for quality of care.

Growing healthcare costs have caused home-care providers to look for more efficient use of healthcare resources. Task shifting is suggested as a strategy to reduce the costs of delivering home-care services. Task shifting refers to the delegation or transfer of tasks from regulated healthcare professionals to home-care workers (HCWs). The purpose of this paper is to explore the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers. This qualitative study was completed in collaboration with a large home and community care organisation in Ontario, Canada, in 2010-2011. Using a purposive sampling strategy, semi-structured telephone interviews were conducted with 46 home healthcare workers including HCWs, home-care worker supervisors, nurses and therapists. Study participants reported that the most common skills transferred or delegated to HCWs were transfers, simple wound care, exercises, catheterisation, colostomies, compression stockings, G-tube feeding and continence care. A thematic analysis of the data revealed mixed opinions on the impacts of task shifting on the quality of care. HCWs and their supervisors, more often than nurses and therapists, felt that task shifting improved the quality of care through the provision of more consistent care; the development of trust-based relationships with clients; and because task shifting reduced the number of care providers entering the client's home. Nurses followed by therapists, as well as some supervisors and HCWs, expressed concerns that task shifting might compromise the quality of care because HCWs lacked the knowledge, training and education necessary for more complex tasks, and that scheduling problems might leave clients with inconsistent care once tasks are delegated or transferred. Policy implications for regulating bodies, employers, unions and educators are discussed.

A FUZZY-BASED PARTICLE SWARM OPTIMISATION APPROACH FOR TASK ASSIGNMENT IN HOME HEALTHCARE

Home healthcare (HHC) organisations provide coordinated healthcare services to patients at their homes. Motivated by the ever-increasing need for home-based care, the assignment of tasks to available healthcare staff is a common and complex problem in homecare organisations. Designing high quality task schedules is critical for improving worker morale, job satisfaction, service efficiency, service quality, and competitiveness over the long term. The desire is to provide high quality task assignment schedules that satisfy the patient, the care worker, and the management. This translates to maximising schedule fairness in terms of workload assignments, avoiding task time window violation, and meeting management goals as much as possible. However, in practice, these desires are often subjective as they involve imprecise human perceptions. This paper develops a fuzzy multi-criteria particle swarm optimisation (FPSO) approach for task assignment in a home healthcare setting in a fuzzy environment. The proposed approach uses a fuzzy evaluation method from a multi-criteria point of view. Results from illustrative computational experiments show that the approach is promising.

Spreading and sustaining best practices for home care of older adults: a grounded theory study.

BackgroundImproving health care quality requires effective and timely spread of innovations that support evidence-based practices. However, there is limited rigorous research on the process of spread, factors influencing spread, and models of spread. It is particularly important to study spread within the home care sector given the aging of the population, expansion of home care services internationally, the high proportion of older adult users of home care services, and the vulnerability of this group who are frail and live with multiple chronic conditions. The purpose of this study was to understand how best practices related to older adults are spread within home care organizations.MethodsFour home care organizations in Ontario, Canada that had implemented best practices related to older adults (falls prevention, pain management, management of venous leg ulcers) participated. Using a qualitative grounded theory design, interviews were conducted with frontline providers, managers, and directors at baseline (n =44) and 1 year later (n =40). Open, axial, and selective coding and constant comparison analysis were used.ResultsA model of the process of spread of best practices within home care organizations was developed. The phases of spread included (1) committing to change, (2) implementing on a small scale, (3) adapting locally, (4) spreading internally to multiple users and sites, and (5) disseminating externally. Factors that facilitated progression through these phases were (1) leading with passion and commitment, (2) sustaining strategies, and (3) seeing the benefits. Project leads, champions, managers, and steering committees played vital roles in leading the spread process. Strategies such as educating/coaching and evaluating and feedback were key to sustaining the change. Spread occurred within the home care context of high staff and manager turnover and time and resource constraints.ConclusionsSpread of best practices is optimized through the application of the phases of spread, allocation of resources to support spread, and implementing strategies for ongoing sustainability that address potential barriers. Further research will help to understand how best practices are spread externally to other organizations.

American society for parenteral and enteral nutrition (a.s.p.e.N.) standards of practice for nutrition support pharmacists.

American society for parenteral and enteral nutrition (a.s.p.e.N.) standards of practice for nutrition support pharmacists.

Does an outreaching stepped care program reduce depressive symptoms in community-dwelling older adults? A randomized implementation trial.

To examine the effects of an outreaching stepped care intervention program (Lust for Life) compared with usual care on depressive symptoms in older adults living in the community. Randomized clinical implementation trial. 18 general practices and a home care organization in the Netherlands. 263 community-dwelling 65+-year-olds with depressive symptoms according to the Patient Health Questionnaire-9 (PHQ-9). After three months of watchful waiting, participants could sequentially choose between the following evidence-based interventions: 1) guided self-help or an exercise program, 2) problem solving treatment or life review, and 3) a referral to their general practitioner. The outcome measure was depression severity (PHQ-9), measured every three months over 2 years. After the provision of the stepped care program, a significant short-term positive effect on depressive symptoms was found in the first three months after implementation, in which average PHQ-9 scores dropped from 9.34 (SE: 0.61, 95% CI: 8.14-10.5) to 7.83 (SE: 0.51, 95% CI: 6.84-8.81). The Lust for Life program has a promising potential to relieve depressive symptoms of older adults in primary care in the short term. Providing one single clinical intervention in accordance with participants' choices instead of stepped care could be sufficient.

Emerging Lessons From Regional and State Innovation in Value‐Based Payment Reform: Balancing Collaboration and Disruptive Innovation

In recent decades, practitioners and policymakers have turned to value-based payment initiatives to help contain spending on health care and to improve the quality of care. The Robert Wood Johnson Foundation funded 7 grantees across the country to design and implement value-based, multistakeholder payment reform projects in 6 states and 3 regions of the United States. As the external evaluator of these projects, we reviewed documents, conducted Internet searches, interviewed key stakeholders, cross-validated factual and narrative interpretation, and performed qualitative analyses to derive cross-site themes and implications for policy and practice. The nature of payment reform and its momentum closely reflects the environmental context of each project. Federal legislation such as the Patient Protection and Affordable Care Act and federal and state support for the development of the patient-centered medical home and accountable care organizations encourage value-based payment innovation, as do local market conditions for payers and providers that combine a history of collaboration with independent innovation and experimentation by individual organizations. Multistakeholder coalitions offer a useful facilitating structure for galvanizing payment reform. But to achieve the objectives of reduced cost and improved quality, multistakeholder payment innovation must overcome such barriers as incompatible information systems, the technical difficulties and transaction costs of altering existing billing and payment systems, competing stakeholder priorities, insufficient scale to bear population health risk, providers' limited experience with risk-bearing payment models, and the failure to align care delivery models with the form of payment. From the evidence adduced in this article, multistakeholder, value-based payment reform requires a trusted, widely respected "honest broker" that can convene and maintain the ongoing commitment of health plans, providers, and purchasers. Change management is complex and challenging, and coalition governance requires flexibility and stable leadership, as market conditions and stakeholder engagement and priorities shift over time. Another significant facilitator of value-based payment reform is outside investment that enables increased investment in human resources, information infrastructure, and care management by provider organizations and their collaborators. Supportive community and social service networks that enhance population health management also are important enablers of value-based payment reform. External pressure from public and private payers is fueling a "burning bridge" between the past of fee-for-service payment models and the future of payments based on value. Robust competition in local health plan and provider markets, coupled with an appropriate mix of multistakeholder governance, pressure from organized purchasers, and regulatory oversight, has the potential to spur value-based payment innovation that combines elements of "reformed" fee-for-service with bundled payments and global payments.

Implementing an outreaching, preference-led stepped care intervention programme to reduce late life depressive symptoms: results of a mixed-methods study.

BackgroundDepressive symptoms are highly prevalent in old age, but they remain mostly untreated. Several clinical trials have shown promising results in preventing or reducing depressive symptoms. However, it is not clear how robust these effects are in the real world of day-to-day care. Therefore, we have implemented the ‘Lust for Life’ programme, which significantly reduced depressive symptoms in community-dwelling older adults in the first three months after implementation. This mixed-methods study was conducted alongside the trial to develop a contextualised understanding of factors affecting the implementation.MethodsA total of 263 persons of 65 years and older with depressive symptoms were recruited from 18 general practices and home care organizations in the Netherlands. We used qualitative data (in-depth interviews and focus group discussions with participants with depressive symptoms and healthcare professionals) as well as quantitative data (longitudinal data on the severity of depressive symptoms) to explore hindering and facilitating factors to the implementation of the ‘Lust for Life’ programme.ResultsThe uptake of the routine screening was poor and imposed significant burdens on participants and healthcare professionals, and drop-out rates were high. Participants’ perceived mental problems and need for care played a key role in their decision to participate in the programme and to step up to consequent interventions. Older people preferred interventions that focused on interpersonal contact. The programme was only effective when delivered by mental healthcare nurses, compared to home care nurses with limited experience in providing mental healthcare.ConclusionsThe intervention programme was effective in reducing depressive symptoms, and valuable lessons can be learned from this implementation trial. Given the low uptake and high investment, we advise against routine screening for depressive symptoms in general healthcare. Further, agreement between the participant and healthcare professional on perceived need for care and intervention is vital. Rather than providing a stepped care intervention programme, we showed that offering only one single preference-led intervention is effective. Lastly, since the provision of the interventions seems to ask for specific skills and experiences, it might require mental healthcare nurses to offer the programme.Trial registrationDutch trial register NTR2241Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-014-0107-y) contains supplementary material, which is available to authorized users.

‘I'm happy that I can still walk’ – Participation of the elderly in home care as a specific group with specific needs and wishes

Taking the needs, wishes and experiential knowledge of clients into account is considered to result in a better fit between the supply and demand of modern health care, contributing to the improvement of individual care, organizations, institutions and policy. However, the current generation of the elderly have had little experience of consumer-oriented public services. They are said to be less likely to discuss their needs and wishes with individual caregivers and health-care organisations. As a result, they might not receive care matching their needs and wishes. To examine how the elderly themselves refer to their age and their needs and wishes for individual and collective participation in home-based care to get a better understanding of their participation in their own health care. Content analysis of 20 semi-structured in-depth interviews with elderly recipients of care in the Netherlands. The need and ability of the elderly to discuss their experiences are strongly affected by physical and mental limitations, social cultural characteristics and their experiences of life. As a result, the elderly encounter many limitations in discussing their experiences with their individual caregivers and their home-care organisation. However, this does not mean that the elderly do not have needs and wishes that they want taken into account. The challenge is to create a more responsive environment and to find new, creative ways of facilitating the expression of the needs and wishes of the elderly, according to the specific values and norms of their generation.

Foreword

Chronic health conditions pose a significant burden on the health of Americans, and the number of people with chronic conditions is rapidly rising. In 2000, 125 million Americans had ≥1 chronic conditions. That number rose to an estimated 145 million in 2009, and will further rise to a projected 171 million persons in 2030.1 In addition, today some 26% of adults and 68% of Medicare beneficiaries have ≥2 chronic conditions, and two thirds of total healthcare spending is devoted to their care.1–3 To address this growing challenge, the US Department of Health and Human Services (HHS) created the Multiple Chronic Conditions (MCC) Interagency Workgroup, a department-wide effort to address the needs of people with MCC and the health systems that serve them. The Strategic Framework on Multiple Chronic Conditions,4 released by HHS in 2010 as a result of this effort, is designed to address the challenge of MCC across the spectrum of all population groups through 4 overarching goals: Fostering healthcare and public health system changes to improve the health of individuals with multiple chronic conditions. Maximizing the use of proven self-care management and other services by individuals with multiple chronic conditions. Providing better tools and information to healthcare, public health, and social services workers who deliver care to individuals with multiple chronic conditions. Facilitating research to fill knowledge gaps about, and interventions and systems to benefit, individuals with multiple chronic conditions. The papers in this supplement, resulting from 45 MCC research grant awards made by the Agency for Healthcare Research and Quality (AHRQ) that make up the AHRQ MCC Research Network, offer important findings and commentary addressing these goals. First, although newer, more coordinated models of care now exist, such as the patient-centered medical home and accountable care organizations (goal 1), patients with MCC may be less likely than patients without MCC to benefit from these innovations, and more likely to experience fragmented care. Second, although much is required of many MCC patients in managing their care (goal 2), complex treatment regimens can often prove burdensome for patients to follow. The researchers in the MCC Research Network studied how health systems and healthcare professionals can better partner with patients living with MCC to create patient-centered management plans. The articles in the supplement also propose and describe useful tools for the care of patients with MCC (goal 3), including a new scale to measure patients’ ability to follow treatment regimens they are asked to follow and new treatment guidelines for the joint management of several comorbid conditions. Finally, many of the articles contribute to mapping the landscape for future MCC research (goal 4), through a new conceptual model, description of methodological challenges in MCC research and possible remedies, and intriguing descriptive data that poses new questions for future researchers. HHS remains committed to leading the way on improving the care of patients with MCC. Important opportunities in this area include rapid analyses of secondary data to further develop clinical guidelines for patients with MCC, inclusion of patients with MCC in clinical trials, and development of effective behavioral interventions and useful quality measures for front-line providers caring for patients with MCC. The National Institutes of Health recently issued 4 important new funding opportunity announcements in these areas.5–8 However, HHS cannot meet the needs of MCC patients alone. We welcome the participation of public and private sector stakeholders who wish to take a coleadership role in expanding knowledge about the care of this population and rapidly translating research findings into practice. We hope you enjoy these pages and look forward to working with public and private partners to better guide, empower, and support patients with MCC and the healthcare professionals who serve them. We applaud the 45 AHRQ grantees comprising the AHRQ MCC Research Network for their ground breaking accomplishments to date. ACKNOWLEDGMENTS The authors would like to thank Therese Miller, DrPH, the Project Officer at AHRQ, and the guest editors Mary Tinetti, MD and Jayasree Basu, PhD for their intellectual contributions and for making this supplement possible. They would also like to thank the Medical Care staff, including the Deputy Editors, Amy Rosen, PhD, and Robert Weech-Maldonado, MBA, PhD, the Publisher, Druanne Martin, the Managing Editor, Karen Doyle, and the Abt Associates team, Lisa LeRoy, MBA, PhD, Melanie Wasserman, PhD, Meghan Woo, PhD, and Emma Oppenheim, for their technical contributions and logistical support.

Restraint use in home care: a qualitative study from a nursing perspective

BackgroundDespite the growing demand for home care and preliminary evidence suggesting that the use of restraint is common practice in home care, research about restraint use in this setting is scarce.MethodsTo gain insight into the use of restraints in home care from the perspective of nurses, we conducted a qualitative explorative study. We conducted semi-structured face-to-face interviews of 14 nurses from Wit-Gele Kruis, a home-care organization in Flanders, Belgium. Interview transcripts were analyzed using the Qualitative Analysis Guide of Leuven.ResultsOur findings revealed a lack of clarity among nurses about the concept of restraint in home care. Nurses reported that cognitively impaired older persons, who sometimes lived alone, were restrained or locked up without continuous follow-up. The interviews indicated that the patient’s family played a dominant role in the decision to use restraints. Reasons for using restraints included “providing relief to the family” and “keeping the patient at home as long as possible to avoid admission to a nursing home.” The nurses stated that general practitioners had no clear role in deciding whether to use restraints.ConclusionsThese findings suggest that the issue of restraint use in home care is even more complex than in long-term residential care settings and acute hospital settings. They raise questions about the ethical and legal responsibilities of home-care providers, nurses, and general practitioners. There is an urgent need for further research to carefully document the use of restraints in home care and to better understand it so that appropriate guidance can be provided to healthcare workers.