Increase In Multimorbidity Research Articles

The complex pa¬tient with diabetes and cardio-renal comorbidities: a mana¬gement model proposal

Type 2 diabetes mellitus (DM) is a metabolic disorder and its prevalence has been increasing in the world population and represents one of the chronic diseases with the highest socioeconomic impact on the health systems. It is expected that in the next decade life expectancy and population aging will increase with the consequences of the increasing incidence of diabetes and its associated comorbidities. (DM) is the main cause of chronic kidney disease and it is associated with a significant increasing in cardiovascular risk. The coexistence of cardiac and kidney diseases on a metabolic basis, named “cardiorenal metabolic syndrome”, in elderly patients affected by multimorbidity increase their clinical and care complexity. In order to assess clinical complexity it is necessary to change paradigm from a reactive approach to a proactive one and the integration of territorial, hospital and social services according to the Chronic Care Model (CCM) is important. The proactive management of the complex patient suffering from chronic diseases and multimorbidity has been implemented at the National ARNAS Civico Hospital in Palermo with the MUSE (Multidimensional aSsessment of Elderly) project. The interaction between hospital and territorial services to respond to patients’ needs should be a priority. The hospital must therefore be conceived as a highly specialized center for chronic disease management that works with primary care according to a multidimensional and multidisciplinar model of care reducing rehospitalization and negative outcomes in patients affected by chronic diseases. KEY WORDS diabetes mellitus type2; comorbidity; management model; complexity; cardiorenal syndrome.

Multimorbidity in Community-Dwelling Older Adults in Beijing: Prevalence and Trends, 2004-2017.

The burden of multimorbidity is increasing worldwide; however, little is known about trends in multimorbidity prevalence among Chinese older adults. We aimed to estimate the prevalence and trends of multimorbidity in community-dwelling older adults in Beijing. Longitudinal. Residents of Beijing aged ≥60 years. Data were derived from the Beijing Longitudinal Study of Aging, using cluster, stratification, and random sampling. A total of 1842, 2914, and 1837 participants were included in the 2004, 2011, and 2017 sample, respectively. Multimorbidity was defined as the presence of two or more chronic conditions. Trends in multimorbidity were examined by age, sex, and geographical area. The prevalence of multimorbidity was 32.5%, 52.9%, and 53.2% in 2004, 2011, and 2017, respectively, following an upward trend over time (P =0.003). A similar multimorbidity increase trend was present in age-, sex-, and region-stratified analysis for the 2004-2017 period (all P<0.05). The most common chronic diseases in 2004 were hypertension (34.3%), cataract (18.2%), coronary heart disease (CHD) (15.6%), stroke (14.3%), and chronic obstructive pulmonary disease (7.9%); in 2011, these were hypertension (49.6%), arthritis (30.9%), CHD (22.3%), stroke (21.9%), and diabetes (15.1%); in 2017, these were hypertension (54.4%), arthritis (26.3%), stroke (22.6%), cataract (20.5%), and CHD (20.1%). The proportion of older adults diagnosed with ≥3 chronic diseases significantly increased from 13.4% in 2004 to 73.1% in 2011 and 69.5% in 2017. Multimorbidity is common and the overall and age-, sex-, and region-specific multimorbidity prevalence has been increasing over the past 13 years. Public health policies should account for the more complex care needs and growing costs associated with increasing prevalence of chronic disease and multimorbidity in Chinese older adults.

Contrasting Trends in Prevalence of Chronic Diseases and Multimorbidity, Canada 1978–2014

Chronic diseases and multimorbidity prevalence are of concern in Canada owing to rapid aging population and increase in life expectancy. This study explored (1) trends in chronic disease prevalence and multimorbidity in Canadians from 1978 to 2014 and (2) how chronic diseases and multimorbidity can be ascribed to population aging compared with other contributing factors. This was a cross-sectional study of Canadian national health survey data. Data from this study were from three national Canadian health surveys for the years 1978 to 2014. Trends in prevalence rates over time, with and without standardization for age–sex population changes, were examined. A standard list of twelve (12) chronic diseases were tracked. The cross-sectional surveys used similar diagnostic criteria over the years. A decrease from 31.0 to 26.7% in chronic disease prevalence was found over the period. Standardization to the population in 2014 showed a 4.3 percentage point decrease in chronic disease trend. The decrease was significant for both women and men (4.9 vs 3.7). An increase in multimorbidity from 19.4 to 32.1% was recorded, a 12.7 percentage point increase. Standardization to the population in 2014 reduced the increase to 12.4 percentage points. About 2.4% of respondents reported multimorbidity due to aging. More women than men (4.4% vs 1.6%) reported multimorbidity due to aging. Chronic disease prevalence decreased while multimorbidity increased between 1978 and 2014. Population aging only explained part of the increase in multimorbidity; other driving forces besides the changing age–sex population structure may be largely responsible for the increase.

Impact of an 8-Year Intensive Lifestyle Intervention on an Index of Multimorbidity.

Type 2 diabetes mellitus and obesity are sometimes described as conditions that accelerate aging. Multidomain lifestyle interventions have shown promise to slow the accumulation of age-related diseases, a hallmark of aging. However, they have not been assessed among at-risk individuals with these two conditions. We examined the relative impact of 8 years of a multidomain lifestyle intervention on an index of multimorbidity. Randomized controlled clinical trial comparing an intensive lifestyle intervention (ILI) that targeted weight loss through caloric restriction and increased physical activity with a control condition of diabetes support and education (DSE). Sixteen U.S. academic centers. A total of 5,145 volunteers, aged 45 to 76, with established type 2 diabetes mellitus and overweight or obesity who met eligibility criteria for a randomized controlled clinical trial. A multimorbidity index that included nine age-related chronic diseases and death was tracked over 8 years of intervention delivery. Among individuals assigned to DSE, the multimorbidity index scores increased by an average of .98 (95% confidence interval [CI] = .94-1.02) over 8 years, compared with .89 (95% CI = .85-.93) among those in the multidomain ILI, which was a 9% difference (P = .003). Relative intervention effects were similar among individuals grouped by baseline body mass index, age, and sex, and they were greater for those with lower levels of multimorbidity index scores at baseline. Increases in multimorbidity over time among adults with overweight or obesity and type 2 diabetes mellitus may be slowed by multidomain ILI. J Am Geriatr Soc 68:2249-2256, 2020.

Factors associated with sedentary lifestyle among older people with the ability to walk, living in nursing homes

Due to sedentary lifestyle, not only the risk of many chronic diseases and multimorbidity increase, but older people also lose their functional independency earlier. The first step to design effective interventions aiming to decrease sedentary lifestyle is to explore the factors associated with sedentary lifestyle. Our aims were to describe the type and duration of sitting activities and to examine the factors associated with sedentary lifestyle, namely 1) sociodemographic factors (i.e., age, gender, education level, marital status); 2) medical factors (chronic diseases, use of walking aids); 3) lifestyle factors (i.e., duration of institutionalization, smoking status) among older people living in nursing homes providing long-term care. Data collected with questionnaire from 248 participants were analysed using logistic regression. There were 159 participants (64.1%) in total who were characterized by sedentary lifestyle. In our sample, the sedentary lifestyle was associated with the smoking status, the number of age-related chronic diseases, the duration of institutionalization, and the use of walking aids. The older people who have more chronic diseases, who are smokers and were institutionalized earlier are more likely to be characterised by sedentary lifestyle. Therefore, decision-making graduate health-care professionals should preferably focus their efforts on these older people in order to change the sedentary lifestyle by providing information about risk of this lifestyle, and offering programs relevant to older people's interests and functional status. Orv Hetil. 2020; 161(26): 1175-1180.

Health gap for multimorbidity: comparison of models combining uniconditional health gap.

The aim of this study is to identify the best-fitting model in predicting the health gap of multimorbid status based on the health gap of uniconditional status. This study analyzed data of adults aged 50years or older derived from the cross-sectional, nationally representative 6th Korean National Health and Nutrition Examination Survey (KNHANES). We translated the EQ-5D utility score assessed from the KNHANES using the Korean EQ-5D-3L into the health gap by subtracting the EQ-5D utility score from one. The predicted health gap of multimorbid status was calculated based on the health gap of uniconditional status using the additive, multiplicative, and maximum limit models. We assessed the performance of the multimorbidity adjustment models based on the root mean square error and mean absolute error. We also examined the impact of multimorbidity adjustment on the estimated disease burden in the best-fitting model. Of the three approaches, the multiplicative adjustment model had the smallest root mean square error between the predicted and observed health gap of multimorbid status. The total number of prevalence-based years lived with the disability after adjusting for multimorbid status using the multiplicative model decreased compared to that without adjustment for multimorbid status. Using the appropriate methodology to adjust for multimorbidity in estimations of population health is becoming more important as the prevalence of multimorbidity increases, particularly in older populations. Further empirical research is required to develop additional general adjustment approaches that consider the independent co-occurrence of multiple diseases, and to understand how multimorbidity influences health gap.

Organ System Crosstalk in Cardiometabolic Disease in the Age of Multimorbidity.

The close association among cardiovascular, metabolic, and kidney diseases suggests a common pathological basis and significant interaction among these diseases. Metabolic syndrome and cardiorenal syndrome are two examples that exemplify the interlinked development of disease or dysfunction in two or more organs. Recent studies have been sorting out the mechanisms responsible for the crosstalk among the organs comprising the cardiovascular, metabolic, and renal systems, including heart–kidney and adipose–liver signaling, among many others. However, it is also becoming clear that this crosstalk is not limited to just pairs of organs, and in addition to organ–organ crosstalk, there are also organ–system and organ–body interactions. For instance, heart failure broadly impacts various organs and systems, including the kidney, liver, lung, and nervous system. Conversely, systemic dysregulation of metabolism, immunity, and nervous system activity greatly affects heart failure development and prognosis. This is particularly noteworthy, as more and more patients present with two or more coexisting chronic diseases or conditions (multimorbidity) due in part to the aging of society. Advances in treatment also contribute to the increase in multimorbidity, as exemplified by cardiovascular disease in cancer survivors. To understand the mechanisms underlying the increasing burden of multimorbidity, it is vital to elucidate the multilevel crosstalk and communication within the body at the levels of organ systems, tissues, and cells. In this article, we focus on chronic inflammation as a key common pathological basis of cardiovascular and metabolic diseases, and discuss emerging mechanisms that drive chronic inflammation in the context of multimorbidity.

A multi-centre, parallel-group, randomised controlled trial to assess the efficacy and safety of eurythmy therapy and tai chi in comparison with standard care in chronically ill elderly patients with increased risk of falling (ENTAiER): a trial protocol

BackgroundIn elderly poeple, multimorbidity and polypharmacy increase while sensory, motor and cognitive functions decrease. Falls occur in 30% of people aged 65 years and older at least once per year, with injuries at 10–20%. Reducing falls and enhancing physical, emotional and cognitive capacities are essential for healthy aging despite chronic disease. Eurythmy therapy (EYT) and Tai Chi train balance, mobility and concentrative and sensory capacities.MethodsIn eight trial sites (academic or community hospitals), 550 outpatients aged 65 years and older with chronic disease and increased risk of falling (history of imbalance, Berg Balance Scale (BBS) score ≤ 49) will be randomly assigned (1:1:1) to receive either EYT or Tai Chi (each provided in one-hour group sessions, twice, later once per week plus practice at home, for over 24 weeks) added to standard care or standard care alone. Standard care includes a detailed written recommendation on fall prevention and the visit of a primary care doctor. Seniors living a reclusive life or economically disadvantaged elderly will be particularly addressed. A motivation and communication concept supports the trial participants’ compliance with trial procedures and practicing. Public and patient representatives are involved in the planning and conduction of the trial. Falls will be documented daily in a diary by the participants. These falls as well as injuries and complications will be ascertained during monthly phone visits. The falls efficacy scale, BBS, cognition (MoCA), Mood (GDS-15), quality of life (SF12), instrumental activities of daily living (IADL), use of medical and non-medical services (FIMA) and adherence will be assessed at months 3, 6, and 12 and inner correspondence with practices (ICPH) at month 6. The trial is funded by the Federal Ministry of Education and Research (BMBF 01GL1805).DiscussionThis study will determine whether EYT and Tai Chi reduce falls, injurious falls, fear of falling and healthcare utilisation and improve mobility, cognition, mood, quality of life and functional independence. A reduction of fall risk and fear of falling and an improvement of mobility, autonomy, quality of life, mood, and cognition are highly relevant for older people to cope with aging and diseases and to reduce healthcare costs.Trail registrationwww.drks.de. DRKS00016609. Registered 30th July 2019.

IDENTIFYING THE TRAJECTORIES OF MULTIMORBIDITY AND THEIR CORRELATES AMONG KOREAN OLDER ADULTS

Multimorbidity, the co-existence of two or more chronic diseases, has become prevalent among the older population. This study focused on identifying different patterns of multimorbidity trajectories across older adulthood and examining their predictors. We used six waves of the Korean Longitudinal Study of Aging (KLoSA), a nationally representative longitudinal data collected every two years from 2006 to 2016. The sample was older adults aged 65 years and older in 2006 (N=1,668). Multimorbidity was measured as the self-reported number of medically-diagnosed chronic diseases, and Growth Mixture Modeling was used to examine multimorbidity trajectories. Identified patterns of multimorbidity trajectories were then used as outcome variables in multinomial logistic regression models. Independent variables were socio-demographic, psychological, health-related behavioral and interpersonal factors at baseline. At Wave1, 76% of the sample had no or one chronic disease and 24% had two or more. At Wave6, 49% had none or one and 51% had two or more. Results identified four patterns of multimorbidity trajectory: “maintaining-low” (59.1%; reference), “maintaining-high” (7.3%), “moderately increasing”(26.4%), and “rapidly increasing” (7.2%). In terms of the correlates of these patterns, female older adults and respondents with higher depressive symptoms were more likely to be in the “maintaining-high” group. In addition, respondents who had less frequent meetings with friends, neighbors or relatives were more likely to be in the “rapidly increasing” group. The findings suggest that there are distinct patterns of multimorbidity trajectories across older adulthood, and interventions focusing on depressive symptoms or social engagement may be useful in preventing the increase in multimorbidity.

4.N. Workshop: Health workforce coordination and agency across sectors, organisations and professions

Abstract Background An increase in chronic illness and multimorbidity together with ‘ageing societies’ and demand for long-term care have created growing need for integrated care and improved coordination of services. However, health systems largely failed to respond to changing needs. Education and training of health professionals are still organised ‘in silos’; connections between health and social care and other groups providing relevant services are usually absent; and fragmentation of care according to specialisation remains the dominant organising principle of healthcare services. In this situation there is an urgent need for change to build skills and competencies, use health human resources more effectively and rearrange care according to population needs and preventative approaches. Objectives This workshop brings together research from different national and European research projects positioned at the interface of healthcare services and workforce development. The major aim is to foster the building of bridges across professions, organisations and sectors. The workshop seeks to explore the benefits and novel insights gained from comprehensive efforts to strengthen coordination and integrated models of care and how this may foster agency of the health professions as well as the implementation of new models of care that strengthen health promotion. The findings illustrate that capacity for innovating health systems can be improved through coordination and the crucial role of health professions in these transformations. Health professionals may act as facilitators of integrated work and care arrangements. Strengthening professional agency and coordination across sectors, organisations and professional groups embodies new opportunities for innovating health service provision and health workforce development. These transformations, in turn, may foster people-centred healthcare services. Key messages Building bridges between sectors, organisations and professions is a key to people-centred care. Coordination improves health workforce agency and service capacity to respond to population needs.

Abstract P006: Association of Multimorbidity With Cardiovascular Endpoints in Elderly Patients With Atrial Fibrillation

Introduction: The prevalence of atrial fibrillation (AF) and multimorbidity increase with age; however, the burden imposed by concurrent conditions on outcomes is unknown. Therefore, we aimed to determine the effect of the number and type of comorbid conditions on outcomes in elderly individuals with incident AF. Methods: Patients with non-valvular AF 75 years and older were identified in the MarketScan Medicare Supplemental database from 2007-2015. Fourteen chronic conditions, defined by two occurrences of a diagnostic code from inpatient and outpatient claims prior to or at the time of AF diagnosis, were obtained and classified into two categories: cardiovascular (CV) or non-CV (listed in Table footnote). We used Cox regression to estimate the associations of the number and type of conditions with stroke, severe bleeding, and heart failure hospitalizations (HF). Results: Among 275,617 patients with AF (mean age 83 years, 51% women), 90% had at least one or more additional chronic conditions. The mean (SD) number of conditions per participant was 1.8 (0.9) for CV conditions and 2.1 (1.2) for non-CV conditions. Over a mean follow-up of 23 months, 7,814 strokes, 13,622 severe bleeds, and 19,252 HF events occurred. After adjustment for age, sex, the number of conditions in the other comorbidity group, an increase of one CV condition was associated with greater risk of stroke, severe bleeding, and HF (Table). In contrast, an increase in one non-CV condition was associated with a lower risk of stroke, and a small increase in bleeding and HF risk (Table). After further adjustments for frailty and medications, the strength of the associations within each group decreased across outcomes. Conclusion: CV conditions in AF patients 75 years and older are more strongly associated with stroke, HF, and bleeding than non-CV conditions. This underscores the effect of CV conditions on CV outcomes in a population in which multimorbidity is most common and health care management and delivery is complex.

Trends in multimorbidity and polypharmacy in the Flemish-Belgian population between 2000 and 2015.

ObjectivesThe aim of this paper was to describe the time trends in the prevalence of multimorbidity and polypharmacy in Flanders (Belgium) between 2000 and 2015, while controlling for age and sex.MethodsData were available from Intego, a Flemish-Belgian general practice-based morbidity registration network. The practice population between 2000 and 2015 was used as the denominator, representing a mean of 159,946 people per year. Age and gender-standardised prevalence rates were used for the trends of multimorbidity and polypharmacy in the total population and for subgroups. Joinpoint regression analyses were used to analyse the time trends and breaks in trends, for the entire population as well as for specific age and sex groups.ResultsOverall, in 2015, 22.7% of the population had multimorbidity, while the overall prevalence of polypharmacy was 20%. Throughout the study period the standardised prevalence rate of multimorbidity rose for both sexes and in all age groups. The largest relative increase in multimorbidity was observed in the younger age groups (up to the age of 50 years). The prevalence of polypharmacy showed a significant increase between 2000 and 2015 for all age groups except the youngest (0–25 years).ConclusionFor all adult age groups multimorbidity and polypharmacy are frequent, dynamic over time and increasing. This asks for both epidemiological and interventional studies to improve the management of the resulting complex care.

Development of integrated care tool - BRIEF for screening the unmet psychosociomedical needs of older Indians.

With demographic shifts, there is an unprecedented increase in noncommunicable diseases, multimorbidity, and geriatric syndromes among older adults, especially in economically weaker sectors. However, there is no socioculturally appropriate tool to screen older adults for age-related health needs, multimorbidity, and geriatric syndromes at their doorstep. Objective: Our objective was to create a self-assessment tool, "integrated care tool" (ICT), and to assess its psychometric properties by applying it on older adults from multiple settings such as hospital, community, and old-age home (assisted living services). new questionnaire was developed using standardized procedure including item development, pilot testing, and psychometric validation. After obtaining the institutional ethics committee clearance, data were collected from consenting respondents attending the Outpatient Department of Geriatric Medicine, All India Institute of Medical Sciences, New Delhi, community settings through health camps, and long-term care center, between May 2016 and February 2017. Data were computerized and analyzed by principal component analysis as extraction method and orthogonal varimax as rotation method. The final 30-item questionnaire was arranged into various domains as per rotated component matrix analysis. Overall internal consistency of the final questionnaire, as calculated by Cronbach's alpha, was 0.79, and the measure of sampling adequacy was 0.79. ICT-BRIEF is a simple, self-assessment/caregiver-assisted tool to screen the health needs of older adults. This tool can be validated for developing risk score and scaled up to generate a large database to create elderly centered care plans.

Eigen regie en waardigheid in de zorg: een kwestie van persoonsgerichte praktijkvoering

Eigen regie en waardigheid in de zorg: een kwestie van persoonsgerichte praktijkvoering

How older adults with multimorbidity manage their own care within a formal care coordination program?

As the number of older adults with multimorbidity increases, care coordination programs are being designed to streamline the complex care older adults receive from multiple providers by improving health and reducing unnecessary costs. Well-coordinated care requires actions by both patients and providers. Yet little attention is paid to the what older adults do to manage their own care alongside a formal Care Coordination Program (CCP). This paper presents a qualitative descriptive study that explored what actions older adults took on their own to manage their care. Findings from this study identified that there were two actions older adults took to manage their care; they lived within their limits and they lived with grit. This study suggests that by recognizing what older adults do to self-manage their care within the context of a CCP, nurses can build on older adults’ actions and provide person-centered strategies for care coordination.

Trends in obesity and multimorbidity in Canada

Very few studies have examined trends in multimorbidity over time and even fewer have examined trends over time across different body mass index (BMI) groups. Given a general decline in death rates but increased cardiovascular risk factors among individuals with obesity, the trend in the association between obesity and multimorbidity is hypothesized to be increasing over time. The data for our study came from the 1996–97 National Population Health Survey and the 2005 and 2012–13 Canadian Community Health Surveys (N = 277,366 across all 3 surveys). We examined trends in the association between BMI groups and multimorbidity using a logistic regression model. We also investigated trends in the prevalence of specific chronic conditions, pairs of chronic conditions and different levels of multimorbidity across BMI groups. We found significantly greater levels of multimorbidity in 2005 (OR = 1.42; p < 0.001) and 2012–13 (OR = 1.58; p < 0.001) relative to 1996–97. Changes in multimorbidity levels were much greater among individuals with class II/III (OR = 1.48; p = 0.005) and class I obesity (OR = 1.38; p = 0.001) in 2012–13 relative to 1996–97. Much of the increase in multimorbidity among individuals living with obesity was due to increases in 3+ chronic conditions and conditions in combination with hypertension, and the greatest increase was found among seniors living with obesity. Our results highlight the need for interventions aimed at preventing obesity and the prevention of chronic conditions among individuals with obesity, especially among seniors.

Screening for Frailty and Sarcopenia Among Older Persons in Medical Outpatient Clinics and its Associations With Healthcare Burden

ObjectivesWith an aging population and increase in multimorbidity, the importance of screening for frailty and sarcopenia has become a public health priority. Several tools to do so exist. This study aimed to examine whether the SARC-F and Edmonton frail screening tools are useful in clinical practice to identify at-risk patients for negative health outcomes who would benefit from intervention. DesignThis is a cross-sectional study of patients attending medical specialist outpatient clinics at the National University Hospital, Singapore from May 2015 to February 2016. MeasurementsFrailty and sarcopenia were identified using the Edmonton Frail Scale and SARC-F questionnaires, respectively. Other clinically relevant data including basic demographics, presence of caregiver, number of follow-ups, medications and hospital readmissions in the past 1 year, Charlson comorbidity index, and modified Barthel index were collected from chart review. ResultsA total of 115 patients 65 years old and older were screened. Of the sample, 44.3% (n = 51) of patients were sarcopenic, whereas 27.0% (n = 31) were classified as frail; 23.5% (n = 27) were both frail and sarcopenic; and 87.1% of frail patients were sarcopenic, whereas 47.1% of sarcopenic patients were frail. Sarcopenia and frailty were associated with a higher Charlson comorbidity index, higher likelihood of requiring a caregiver, more medical specialty follow-ups, polypharmacy, more than 2 hospital admissions within a year, a higher number of falls and falls with serious consequences. This affected their perceived health status with 50.0% of robust patients rating their health excellent compared with 19.6% of sarcopenic patients (P < .001), 9.7% of frail patients (P < .001) and sarcopenic and frail patients scoring the lowest with 3.7% (P < .001). ConclusionsThe prevalence of frailty and sarcopenia among older adults attending medical outpatient clinic is high. Both syndromes are predictors of recurrent hospital admissions, polypharmacy, multiple medical clinic appointments, higher rate of falls, and falls with serious consequences. Early identification of older adults at risk of adverse health outcomes would aid in instituting timely intervention to reduce healthcare burden and improve quality of life.

Exploring interprofessional, interagency multimorbidity care: case study based observational research.

BackgroundThe increase in multimorbidity or co-occurring chronic illnesses is a leading healthcare concern. Patients with multimorbidity require ongoing care from many different professionals and agencies, and often report a lack of integrated care.ObjectiveTo explore the daily help-seeking behaviours of patients with multimorbidity, including which health professionals they seek help from, how professionals work together, and perceptions and characteristics of effective interprofessional, interagency multimorbidity care.DesignUsing a case study observational research design, multiple data sources were assembled for four patients with multimorbidity, identified by two general practitioners in New Zealand. In this paper, two case studies are presented, including the recorded instances of contact and communication between patients and professionals, and between professionals. Professional interactions were categorized as consultation, coordination, or collaboration.ResultsThe two case studies illustrated two female patients with likely similar educational levels, but with different profiles of multimorbidity, social circumstances, and personal capabilities, involving various professionals and agencies. Engagement between professionals showed varying levels of interaction and a lack of clarity about leadership or care coordination. The majority of interactions were one-to-one consultations and rarely involved coordination and collaboration. Patients were rarely included in communications between professionals.ConclusionCases constructed from multiple data sources illustrate the complexity of day-to-day, interprofessional, interagency multimorbidity care. While consultation is the most frequent mode of professional interaction, targeted coordinated and collaborative interactions (including the patient) are highly effective activities. Greater attention should be given to developing and facilitating these interactions and determining who should lead them.

Addressing health care to geriatric patients in nursing homes in Barcelona and its metropolitan area

The increase in life expectancy of the population suggests a scenario for the next few decades with an aging population and exponential increase in multimorbidity. These factors determine a high risk of health and social complexity. In recent years, there has been a general movement toward implementing alternative care models. We must respond to new arising needs from this population that has become more fragile, suffering a higher level of physical and / or psychological dependence, and is highly consumer of health and social resources. The geriatric population living in a nursing home keep their allocation to primary care team (public health) in the geographical area where it belongs. Nursing homes are required to provide enough staff to adequately care for residents (mostly private management). Mainly action from the primary care team becomes reactive to the demands of urgent attention and the resulting administrative processes, without any proactive action scheduled. And regarding the health teams of the nursing homes, these are a heterogeneous group with a high number of professionals who do not belong to the public health system and therefore do not make use of the tools it has to ensure the continuity of care for residents. In 2009 the CatSalut (Catalonia Department of Public Health) detects the need to strengthen care for this population. It creates a public competition to develop this program of care for institutionalized patients and Mutuam provider ends up being responsible for its implementation, and they creates the residential care teams (EAR). The main objective is to contribute to integrated care, resolute, efficient, adequate intensity and person centered of reference population. Always according to the frailty and morbidity of this population, adapting their care and treatment plans to existing needs. The EAR works in coordination and cooperation with both the direct care staff in nursing homes as primary care and hospitals in the area. In an initial pilot phase two basic indicators are monitored: the adequacy of prescription pharmaceuticals and the number of referral hospital emergency services. It creates a control and an intervention group and assessed the situation pre and post intervention. The chosen area is the area north of the city of Barcelona (n=1025). The first results are rated as very good and it was decided to extend it to the entire city of Barcelona, making a progressive deployment phases. Deployment further extends the area of Valles Occidental and Oriental Est (2013) and in the area of Baix Llobregat Litoral i Centre (2014). All EAR that are in these areas are managed by Mutuam. Actually the EAR are managing a population of 21.045, who are distributed in 322 nursing homes. The service model is based on comprehensive geriatric assessment and planning approach specific to each case. Following the lines that mark the last Health Plan (2011-2015), the corrent one (2016-2020) and the PPAC (program of prevention and chronic care). In this sense, once valued residents, we identify them with the criteria PCC/MACA (high complexity /terminal illness) and we developed a plan of individualized intervention (PIIC). The team is active all year round from 8 to 20 hours to provide scheduled service, acute care and urgent attention. It has a call-center reception where adequate resources are activated on demand. The main results are: decrease 13.1% in overall spending pharmacy in the intervention group (according to case-control study evaluation of the pilot in 2009) and variation in emergency referrals in the Hospital Tauli Sabadell from nursing homes in the opening hours of EAR is a reduction of 27.14% (p What we’ve learnt from this experience is that the EAR program offers institutionalised people the most appropriate resources in the right place, avoiding inadequate transitions in health and social system. At the same time, these results are a reflection of personalized attention focused on the person and the decisions agreed with him and / or his family, to secure the quality and continuity of care and clinical safety, when it is made appropriate use of social and health resources. In the near future we must improve our results by identifying areas of improvement, ensuring quality and safety care, and sustainability. The model discussed, with minor adaptations to local conditions, we believe that is transferable to other areas with high / medium concentration of nursing homes.

Behavioural health consultants in integrated primary care teams: a model for future care.

BackgroundSignificant challenges exist within primary care services in the United Kingdom (UK). These include meeting current demand, financial pressures, an aging population and an increase in multi-morbidity. Psychological services also struggle to meet waiting time targets and to ensure increased access to psychological therapies. Innovative ways of delivering effective primary care and psychological services are needed to improve health outcomes.SummaryIn this article we argue that integrated care models that incorporate behavioural health care are part of the solution, which has seldom been argued in relation to UK primary care. Integrated care involves structural and systemic changes to the delivery of services, including the co-location of multi-disciplinary primary care teams. Evidence from models of integrated primary care in the United States of America (USA) and other higher-income countries suggest that embedding continuity of care and collaborative practice within integrated care teams can be effective in improving health outcomes. The Behavioural Health Consultant (BHC) role is integral to this, working psychologically to support the team to improve collaborative working, and supporting patients to make changes to improve their health across management of long-term conditions, prevention and mental wellbeing. Patients’ needs for higher-intensity interventions to enable changes in behaviour and self-management are, therefore, more fully met within primary care. The role also increases accessibility of psychological services, delivers earlier interventions and reduces stigma, since psychological staff are seen as part of the core primary care service. Although the UK has trialled a range of approaches to integrated care, these fall short of the highest level of integration. A single short pilot of integrated care in the UK showed positive results. Larger pilots with robust evaluation, as well as research trials are required. There are clearly challenges in adopting such an approach, especially for staff who must adapt to working more collaboratively with each other and patients. Strong leadership is needed to assist in this, particularly to support organisations to adopt the shift in values and attitudes towards collaborative working.ConclusionsIntegrated primary care services that embed behavioural health as part of a multi-disciplinary team may be part of the solution to significant modern day health challenges. However, developing this model is unlikely to be straight-forward given current primary care structures and ways of working. The discussion, developed in this article, adds to our understanding of what the BHC role might consist off and how integrated care may be supported by such behavioural health expertise. Further work is needed to develop this model in the UK, and to evaluate its impact on health outcomes and health care utilisation, and test robustly through research trials.