Integrated Care Program Research Articles

Supplemental Material for A Randomized Controlled Implementation Trial of a Multicomponent Integrated Care Program to Empower Mental Health Service Users and Their Relatives Throughout the Recovery Process

Supplemental Material for A Randomized Controlled Implementation Trial of a Multicomponent Integrated Care Program to Empower Mental Health Service Users and Their Relatives Throughout the Recovery Process

Knowledge of Vaccination Against Influenza and Pneumococcus in Patients with Chronic Obstructive Pulmonary Disease in an Integrated Care Program.

To compare the level of knowledge in vaccination against influenza and pneumococcus of patients with chronic obstructive pulmonary disease (COPD) who are managed in an Integrated Care Program (ICP) with those who receive usual care (UC). A telephone survey of patients diagnosed with COPD registered in public care networks or private institutions was done. A descriptive and comparative analysis of the characteristics of the ICP and UC groups was carried out. The relationship between belonging to an ICP and the level of knowledge about vaccination was evaluated using Propensity Score Matching (PSM) and multivariate logistic and ordinal regression models. Of 674 study participants, 27.2% were from the ICP group. ICP patients were older, more frequently men, from a higher socioeconomic stratum and a higher educational level (p<0.05). 75.5% of the patients in the ICP group had a high level of vaccination knowledge compared to 42.7% in the UC group (p<0.001). In the multivariate analysis, adjusting for sociodemographic variables, years of COPD diagnosis, and comorbidities, belonging to the ICP was associated with a higher probability of answering questions about vaccination correctly and having a high level of knowledge (OR 3.397, IC 95% 2.058-5.608, p<0.001). Patients with COPD managed in an ICP have a higher level of knowledge in vaccination against influenza and pneumococcus, compared to patients in usual care.

Reducing unplanned hospital admissions from care homes: a systematic review

Background Care homes predominantly care for older people with complex health and care needs, who are at high risk of unplanned hospital admissions. While often necessary, such admissions can be distressing and provide an opportunity cost as well as a financial cost. Objectives Our objective was to update a 2014 evidence review of interventions to reduce unplanned admissions of care home residents. We carried out a systematic review of interventions used in the UK and other high-income countries by synthesising evidence of effects of these interventions on hospital admissions; feasibility and acceptability; costs and value for money; and factors affecting applicability of international evidence to UK settings. Data sources We searched the following databases in December 2021 for studies published since 2014: Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature; Health Management Information Consortium; Medline; PsycINFO; Science and Social Sciences Citation Indexes; Social Care Online; and Social Service Abstracts. ‘Grey’ literature (January 2022) and citations were searched and reference lists were checked. Methods We included studies of any design reporting interventions delivered in care homes (with or without nursing) or hospitals to reduce unplanned hospital admissions. A taxonomy of interventions was developed from an initial scoping search. Outcomes of interest included measures of effect on unplanned admissions among care home residents; barriers/facilitators to implementation in a UK setting and acceptability to care home residents, their families and staff. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers. We used published frameworks to extract data on intervention characteristics, implementation barriers/facilitators and applicability of international evidence. We performed a narrative synthesis grouped by intervention type and setting. Overall strength of evidence for admission reduction was assessed using a framework based on study design, study numbers and direction of effect. Results We included 124 publications/reports (30 from the UK). Integrated care and quality improvement programmes providing additional support to care homes (e.g. the English Care Homes Vanguard initiatives and hospital-based services in Australia) appeared to reduce unplanned admissions relative to usual care. Simpler training and staff development initiatives showed mixed results, as did interventions aimed at tackling specific problems (e.g. medication review). Advance care planning was key to the success of most quality improvement programmes but do-not-hospitalise orders were problematic. Qualitative research identified tensions affecting decision-making involving paramedics, care home staff and residents/family carers. The best way to reduce end-of-life admissions through access to palliative care was unclear in the face of inconsistent and generally low-quality evidence. Conclusions Effective implementation of interventions at various stages of residents’ care pathways may reduce unplanned admissions. Most interventions are complex and require adaptation to local contexts. Work at the interface between health and social care is key to successful implementation. Limitations Much of the evidence identified was of low quality because of factors such as uncontrolled study designs and small sample size. Meta-analysis was not possible. Future work We identified a need for improved economic evidence and the evaluation of integrated care models of the type delivered by hospital-based teams. Researchers should carefully consider what is realistic in terms of study design and data collection given the current context of extreme pressure on care homes. Study registration This study is registered as PROSPERO database CRD42021289418. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (award number NIHR133884) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 18. See the NIHR Journals Library website for further project information.

S635 A Virtual Integrated Care Program Improves Patient Outcomes, Engagement, and Satisfaction at Reduced Costs: A Prospective Trial

S635 A Virtual Integrated Care Program Improves Patient Outcomes, Engagement, and Satisfaction at Reduced Costs: A Prospective Trial

134 Evaluation of the Community Rehabilitation Inpatient Specialist Program (CRISP)—an advanced nurse practitioner (RANP)-led program for frail older adults

Abstract Background Frail older adults disproportionately access acute healthcare services. Novel integrated care programs are needed to redesign care delivery focusing on community-based health promotion, as opposed to crisis response. CRISP is a bespoke, RANP-led program that provides direct access for community-dwelling older adults to short-term (2-weeks) in-patient intensive multidisciplinary rehabilitation based on a Comprehensive Geriatric Assessment. Referrals are received from Geriatric ED services, geriatric/neurology/rehabilitation medicine outpatient clinics, ICPOP and local GPs. Admission to a Model 2 Age- Related rehabilitation centre occurs within 4–8 weeks of referral. Methods This Prospective cohort study examines the short to medium-term effects of the CRISP program. Functional, mobility and Quality-of-Life (QoL) measures were collected on admission and discharge. Fall rates, QoL and carer stress are measured four months after completion of the program. Data were analysed using Microsoft Excel. Functional outcome and QoL measurements were compared using paired t-test. Results 73 patients (78%) completed the program and attended for follow up (2021–2022), average age: 80.9 yrs, SD-6.6 yrs, frailty index 5.6 (mild to moderate frailty). There have been statistically significant gains made in performance in activities of daily living (Barthel Index; 76.7A vs 83.9 DC) (p &amp;lt; 0.001), balance (Berg Balance Scale:29.6A vs 36.3 DC) (p &amp;lt; 0.001 and QOL (EQ5D:45.2 A vs 69.8 DC) (p &amp;lt; 0.001). CRISP delivers long-term positive benefits including reduction in falls rates: 2.9(4 months pre-admission) vs 0.5 (4 months following completion of the program) (p &amp;lt; 0.001) and improvement in self-reported QoL, EQ5D:45.2 A vs 62.6 at 4 months following completion of the program. Carers who reported stress 62% (n-45), 91% reported a reduction in stress levels 4 months following the program. Conclusion CRISP provides early intervention at the lowest level of care complexity resulting in reduced fall rates and consequent crisis presentations to acute care. CRISP improves mobility and function promoting independence and improving QoL for community dwelling older adults.

287 Profile of patients receiving physiotherapy within an Integrated Care Programme for Older Persons (ICPOP) service covering a large geographical area

Abstract Background The Physiotherapist is a key member of the ICPOP team and the need for intervention is identified through Comprehensive Geriatric Assessment (CGA) and interdisciplinary collaboration which includes effective communication with Primary Care to avoid duplication. Our aim was to: (1) Examine the profile of those who received Physiotherapy within ICPOP and (2) Identify those known to Primary Care (PC) Physiotherapy. Methods We conducted an audit of 85 patients who received ICPOP Physiotherapy from January 2023—April 2023. Key demographics were obtained along with Clinical Frailty Scale (CFS) score, reason for referral to ICPOP and rationale for Physiotherapy intervention. Results Of this cohort 59% were Female (n = 50) with Median age of 83 years. One third were referred to ICPOP for evaluation of Falls, one third for Frailty, 21% for evaluation of cognition and the remainder were a combination of two or more of the above. Of those requiring Physiotherapy, 28% had a recent decline in mobility, 28% had overall deconditioning, 26% had falls, and the remainder had balance and pain issues. Median CFS score was 5. Timed Up and Go (TUG): median 19.85 s, median grip strength: 14 kg. Initial mobility assessment showed 65% requiring gait assistance. 76% of initial assessments took place in a domiciliary setting. 58% of people were previously known to PC Physiotherapy. Conclusion CGA can identify a need for Physiotherapy intervention for older adults not outlined as a concern at initial referral. We identified, an unmet need for patients with reversible frailty and the importance of a close working relationship with PC Physiotherapists to ensure timely and appropriate service provision to this cohort. This audit identified two main challenges-the large geographical area currently covered and the lack of dedicated ICPOP hubs for assessment and optimal intervention.

321 The barriers and enablers to an effective integrated care programme for older persons: a qualitative study

Abstract Background In line with Slaintecare goals, the Integrated Care Programme for Older Persons (ICPOP) South Lee Hub, Cork, was developed to provide onsite access to geriatrician and specialist nurse-led clinics, allied healthcare professionals, and an outreach service. ICPOP aims to avoid unnecessary hospital admissions and maximise collaboration between primary and secondary healthcare teams locally. An effective interface between primary and secondary care is, therefore, fundamental to the functioning of ICPOP. However, no research to date has examined this interface from the perspective of the clinical staff in the hubs and primary care providers in the community. This study aims to explore the barriers and enablers to the effective functioning of an ICPOP service from the perspective of both Primary Care Team (PCT) members and the ICPOP hub team. Methods Semi-structured interviews were conducted with healthcare professionals working in the ICPOP service in Cork and in primary care. All interviews were analysed thematically by two independent researchers. Results 29 semi-structured interviews were conducted; 14 with members of the ICPOP team and 15 with GP’s and members of the PCT in the ICPOP catchment area. The challenges of communicating patient information both into and out of the ICPOP hub was highlighted by both primary and secondary care teams. The GPs and other members of the PCT felt ‘on the outside’ with all the contextual knowledge of the individual patient but without a clear understanding of the functioning of the ICPOP hub. Conversely, the clinical team in the ICPOP hub found it challenging to retrieve the contextual knowledge of the patient and were challenged by administrative frustrations. Conclusion In the context of a newly emerging ICPOP service, it is essential that collaboration between primary care and the clinical hub is maximised, to provide optimal patient care.

163 Examining the appropriateness of tilt-testing within a community integrated care hub for older persons services

Abstract Background Tilt-testing has been widely used in acute hospitals for more than 20 years in Ireland. Its use in community settings has been promoted in recent years with the development of the National Integrated Care Programme for Older Persons (NICPOP). In our integrated care hub our focus lies in the assessment of falls and frailty. We propose to examine if the current rational for performing tilt-testing has showed a diagnostic yield. Methods We retrospectively reviewed all tilt reports in the ambulatory care hub from November 2021 to May 2023. We examined the rationale for ordering the test, the number of patients who received a diagnosis of Orthostatic Hypotension (OH) and treatment that was commenced. Results 59 tilt reports were examined between the 18 month period. The average age of the patients were 83 (range 68–93). The male to female ratio was 1:1.3. All patients had an indicator for testing. The 5 indicators that emerged were falls, syncope, orthostatic intolerance, lying and standing blood pressure drop and dizziness. 11/59 (19%) patients had one indicator, 18/59 (31%) patients had two indicators, 15/59 (25%) patients had three indicators and 15/59 (25%) patients had four indicators for performing a tilt. OH was diagnosed in 36/59 (61%) patients of whom 9/36 (25%) had symptomatic OH during both HUT and AS, 8/36 (22%) had symptoms during HUT alone, 6/36 (17%) had symptoms during AS and 9/36 (25%) were asymptomatic throughout testing. 4/36 (11%) had no documentation regarding their symptoms during tilting. De-prescribing was performed in 16/36 (44%) patients and Midodrine was commenced in 18/36 (50%) patients with fludrocortisone being started on 2/36 (6%) patients. Conclusion We demonstrated a high yield from the tilt-test investigations and in combination with Ambulatory BP monitoring had a significant number of medications de-prescribed. The greater preponderance of more than one indicator for tilt-testing was greater than what we perceived.

352 Integrated care programme for older persons—community specialist teams: evaluating the patient experiences

Abstract Background Following a successful Slaintecare pilot project (2019–2021) two teams were established in Community Healthcare Networks (CHN) 4&amp;5 and CHN 6&amp;7. The aim of our service is to provide a Comprehensive Geriatric Assessment (CGA) to older people. Service user experience/feedback are critically important to ensure that we are meeting their needs. We also looked to compare the results against previous patient experience survey undertaken in 2021. Methods The survey was designed by the multidisciplinary team, consisting of 15 closed/3 open questions. A Likert scale was utilised for closed questions and thematic analysis for open questions. 208 service users who attended our teams and have received a CGA from January 2023 to April 2023 were invited to participate in a postal survey. All participants received a covering letter, questionnaire and a stamped address envelope to return their completed surveys. Results There was a 35% response rate (73/208). 89% were aged ≥75. 49% of participants completed the survey themselves, 51% required assistance. 66% have had 2 or more interactions with the teams. Vast majority or those who responded highlighted the importance of having their care at home or at centres close to home. 97% agreed/strongly agreed that they were satisfied with the service. 99% felt they were treated with dignity/respect and had confidence in the service. 96% felt that when they had an important question they got an answer that they could understand. 94% reported their carers had the opportunity to discuss concerns. Conclusion Service users had an overwhelmingly positive experience when they engaged with both our teams. CGA assessment and team interventions in the home and local healthcare settings was seen as been beneficial The importance of having time to engage with members of the team, not feeling rushed was also a recurring theme.

110 Identification of Urinary Incontinence through Comprehensive Geriatric Assessment among an integrated care programme of older persons population

Abstract Background Urinary incontinence (UI) is an under-reported and treatable condition, associated with reduced quality of life. The Integrated Care programme of Older Persons (ICPOP) supports people with complex care needs in their home. There is no available research on the rate of UI among the ICPOP population. This study aimed to assess UI in this group. Methods A convenience sample of 100 patient records selected randomly from an ICPOP serving approximately 30,000 people from 2017 to present were retrospectively reviewed; including patients charts, Comprehensive Geriatric Assessments (CGAs) and outpatient letters. As part of the CGA each person was assessed for UI on domiciliary visit. Irish geriatric medicine trainees were surveyed to assess their self-reported confidence assessing and treating UI. Results Of the 100 patients CGAs reviewed, 62% were female. 11% had UI reported on their referral to ICPOP. 56% reported UI during their CGA. Only 18% of those with UI had UI generated on to their problem list. Of those patients with UI, polypharmacy (≥5 medications) was noted in 89%. 77% of those with UI were on a medication associated with worsening UI, while only 18% of those with UI were on a treating medication for UI. 25% had their UI assessed at clinic, including 7% who were referred onwards to urology for management of their UI. 80% of geriatric medicine trainees said that they did not feel confident managing UI and 100% said they would like to receive further teaching on UI. Conclusion CGA is an excellent method for identifying UI. This data suggests that UI is more prevalent among the ICPOP as compared with an inpatient population and the general population in the same age group. Further specialist teaching is needed to improve trainee confidence in this area.

113 Training Gardaí in dementia awareness

Abstract Background There is increasing awareness of the need to inform public-facing services, and in particular police services, on dementia awareness so as to meet the differing needs of those living with dementia. While there have been programmes in Ireland such as the Dementia Elevator course, no specific course to date has been implemented for the Garda Síochána. Our experience in a pioneering Integrated Care Programme for Older People (ICPOP) team indicated a need to develop a course. We report on the feedback of community and probationary Gardaí to a dementia awareness course. Methods Questionnaire survey on 26 participants in course based on existing dementia support framework, and feedback from Gardaí at ICPOP steering group. Results The results indicated a positive (100%) (strongly agree/agree) response to: (a) application of knowledge learned, (b) content organised and easy to follow, (c) good quality of training, (d) trainers were knowledgeable, (e) adequate time given for questions and discussion and (f) participation and interaction encouraged. Overall rating of the course was 100% excellent. Useful feedback was given on improving the course—more up to date videos, and more cross organisational communication. Conclusion Police forces have a particularly important role in encountering people living with dementia, and a limited number of international reports exist on their implementation. The finding of this course development and survey point to a useful role for expanding dementia awareness training across the Gardaí at a national level, and consideration of delivery to all first-responders.

224 Profiling the first service users of a Community Specialist Team for older persons: a retrospective chart audit

Abstract Background Community Specialist Teams (CST) are a promising approach to reduce reliance on acute care and improve healthcare delivery for older people. This study aimed to profile the initial cohort of service users to a CST as part of the National Integrated Care Programme for Older Persons (NICPOP), focusing on those who sought assessment through a newly established ambulatory hub or home visits. Methods Using a comprehensive retrospective chart audit, data from 70 service users assessed and discharged during the team’s first year were analysed using Microsoft Excel. Results The median age of clients was 80, with a range of 66 to 92, and 51% were female. The Clinical Frailty Scale (CFS) scores ranged from 1 to 7, with a median of 5. Notably, 80% of service users were classified as frail, as indicated by a CFS score of 5 or higher (36% CFS 5, 33% CFS 6, and 11% CFS 7). Additionally, 23% of the service users lived alone. The most common reasons for referral included functional decline (77%), post-stroke rehabilitation (9%), non-injurious falls (7%), and injurious falls (7%). Geographically, the two Community Healthcare Networks (CHNs) showed a distribution of 56% and 44% respectively. The average length of stay (LOS) of 10 weeks service exceeded the target duration of six weeks. Conclusion Overall, our findings confirm that the CST effectively targets the appropriate cohort in accordance with the NICPOP framework. However, the study highlights an extended LOS, surpassing the intended duration. It is crucial to identify potential contributing factors to this increase, such as challenges in accessing equipment, increased frailty, and the impact of remote addresses. To optimise service delivery, further research should prioritise investigating these factors, enabling the development of targeted interventions. The insights gained from this study lay the groundwork for future initiatives aimed at enhancing the quality of care for older people.

142 Identifying common housing conditions affecting older people relevant to integrated Care for Older Persons in Ireland

Abstract Background The health and well-being of older people is significantly affected by housing, representing an essential aspect of preventative healthcare in the community. Good quality housing is an important factor in a person’s ability to maintain mental and physical health, as well as sustain optimal quality of life. This is particularly true for older people who may spend more time at home than other demographic groups. This study explores the linkages between housing conditions and the health and wellbeing of older people with the aim to inform housing designers, providers, and policy makers about the key aspects of healthy homes and common housing hazards, affecting older people. Methods The qualitative research programme involved an in-depth stakeholder engagement strategy, with activities including focus groups, diaries, and interviews to place the perspectives of older people at the centre of the work. The research also included a series of case study visits to the homes of patients of an Integrated Care Programme for Older People, where the research team conducted a series of qualitative semi-structured interviews with the patient, as well as a technical and quantitative survey of the home. Results Key themes identified throughout the research programme include overarching themes such as healthy ageing and housing and ageing in place; themes related to the hospital and integrated care, and the local authority; housing conditions and hazards; and built environment issues across the key spatial scales. Conclusion There is a need for better, more accessible data on the housing issues, conditions, and hazards for older people throughout Ireland. Additionally, it is essential to consider the needs of patients with additional care requirements, such as those living with dementia, as the built environment greatly impacts them.

333 Integrated care and impact on length of Time-At-Home, a retrospective cohort study

Abstract Background The Integrated Care Programme for Older People (ICPOP) shifts care from unscheduled hospital attendance to planned ambulatory community care. The impact of these services should be measured to inform service delivery in the provision of sustainable healthcare for older adults. We aimed to measure the average Time-At-Home for patients attending an ICPOP service. Time-At-Home was defined as the time from review to next unscheduled attendance. Methods A retrospective cohort study was carried out on consecutive attendances at the ICPOP service, between January–March 2023 inclusive. Electronic health records of the Comprehensive Geriatric Assessment were reviewed and any subsequent unscheduled hospital attendance at our institution were recorded to measure the length of Time-At-Home for each patient (days). Predictors of longer Time-At-Home were calculated by regression analysis. Results 191 patients were analysed, 56% female (n = 107), mean age 81.9 years (SD 6.5), 82.7% GP referrals (n = 158). Reasons for referral included memory assessment (n = 90), falls (n = 43), frailty (n = 28), decreased mobility (n = 12), Parkinson’s disease (n = 6), home supports (n = 4) and miscellaneous (n = 8). Mean Clinical Frailty Score (CFS) was 4.72 (SD 1.6), median number of medications was 9 (IQR 5). Median duration of follow-up was 109 days (IQR 61 days). 25.7% (n = 49) of patients were admitted during period of follow-up. Reasons for attendance included delirium/memory-related issues (n = 4), falls/pre-syncope/syncope (n = 13), infection (n = 12), mobility (n = 4) and miscellaneous (n = 17). Those admitted were more likely have been referred from an acute hospital service (p = 0.03), had higher Clinical Frailty Scores (CFS) (p = 0.02) and higher degrees of polypharmacy (p = 0.01). Median length of Time-At-Home was 61 days (IQR 91). There was no difference in length of Time-At-Home by age, CFS or number of medications. Conclusion Reasons for and predictors of acute hospital attendance following ICPOP review are important to measure. This will inform the delivery of services going forward and areas to address to further reduce acute hospital attendance rates.

164 Association between medications and increased fall risk among older adults: implications for medication management and fall prevention interventions

Abstract Background Falls among older adults are a significant public health concern, and certain medications have been identified as potential risk factors. The National integrated care programme for older people is prioritising services to be developed for older people in the areas of frailty, dementia and falls. Methods Information on recurrent falls, polypharmacy, and the number of falls experienced by each patient was collected retrospectively via chart review. Logistic regression analysis was performed to assess the association between STOPPfall medication use and the risk of falling, with odds ratios and p-values reported. Results Data was available on 48 patients (median age 79, range 65–92) of a total of 73 patients seen. The gender distribution was 62.5% female. Among the patients included, 31 experienced recurrent falls, and polypharmacy was observed in 35 patients. The distribution of falls in the previous year was as follows: 8 patients had three or more falls, 5 patients had two falls, 18 patients had one fall, and 14 patients did not experience any falls. Logistic regression analysis revealed that the use of antihypertensive medications was associated with an increased risk of falling, with an odds ratio of 3.85 (CI =1.08–13.75, p = 0.037). There was no statistically significant association between falls and other STOPPfall medication. Conclusion In this study, antihypertensive medications were found to be significantly associated with an increased risk of falling among older adults. These findings emphasise the importance of considering medication-related factors when assessing fall risk in this population. Further research is warranted to determine whether appropriate medication management strategies can mitigate fall risk. Effective fall prevention interventions should incorporate comprehensive medication reviews, particularly for patients on antihypertensive therapy, to optimise patient safety and reduce the burden of falls in older adults.

345 Integration of care for older adults: an evaluation analysis of the clinical pathways from the emergency department

Abstract Background There is an urgency globally to create novel healthcare models for the older adult population considering the ever-growing demographic. Ireland’s Integrated Care Programme for Older People (2016) emphasises the importance of delivering healthcare to older adults in their community with focus on the direct access to services from the Emergency Department (ED). This ‘frailty at the front door’ team sought to evaluate the clinical pathways facilitating direct integration of care into the community following completion of the Comprehensive Older Adult Assessment (COAA) in the ED of a model 3 hospital. Methods The team conducted an evaluation analysis of the critical pathways referring patients to the community directly from the ED. The team recorded the quantity of referrals to each community service on discharge over a period of six months from October 2022–March 2023. This included Health Services Executive (HSE) services and voluntary sector services. The results included admission avoidance pathways. The team completed a case study review for individuals readmitting to the ED within 7 days and 30 days. Results 796 Older Adults were assessed by the team in the ED. 368 Older Adults were discharged directly to the community. From January–March 2023 there were 79 admissions avoided. For those discharged, there were 440 onward referrals made to community-based services. These included 91 referrals to Primary Care Physiotherapy, 83 to Public Health Nurse, 60 to Primary Care OT, 45 to the Community Intervention Team, and 11 referrals to the Dementia Advisor. The 7 day readmission rate ranged from 0–4% per month. The 30 day readmission rate ranged from 5–13%. Conclusion There was a high level of integration of care between the ED ‘frailty at the front door’ team and voluntary or HSE community services. The low readmission rate demonstrates the effectiveness of the discharge pathways in enhancing the safety of discharges.

Differences in patients accessing inpatient versus outpatient palliative care at time of referral at a cancer centre

Outpatient palliative care clinics are a new and developing area of service delivery that can respond to increasing demand and facilitate earlier contact in the illness trajectory. Work is needed to standardise the criteria for referral to outpatient palliative care services and clarify which patients are likely to benefit the most from this mode of support. This study aimed to describe the demographic, clinical and symptom profile, and survival of patients referred to a newly established hospital-based integrated palliative care program. Comparisons were made between patients initially seen as outpatients versus those seen as inpatients. A retrospective population was identified from routinely collected hospital admitted inpatient and ambulatory databases comprising adult cancer patients receiving a new referral to the service during a 6-month period. Patients were grouped into two cohorts according to the setting of their first palliative care assessment and followed to death or study censor date. During the study period, 473 new referrals were made comprising 229 (48%) patients initially seen as outpatients and 244 (52%) initially seen as inpatients. The outpatient cohort had higher performance status, experienced higher symptom burden, lived longer, had fewer inpatient admissions, and received earlier referral to palliative care resulting in greater palliative care involvement up to their death (all p < .05). Early palliative care can be effectively delivered by an outpatient palliative care service for cancer patients who are experiencing symptom burden but are otherwise functional. These cases lived longer and had fewer subsequent inpatient visits, demonstrating the preliminary effectiveness of this integrated service.

Leveraging the electronic medical record to measure fidelity to the primary care behavioral health model: Implications for clinical and research pursuits.

The primary care behavioral health (PCBH) model of integration has been widely implemented across a number of noteworthy health care systems. However, lack of consistent measurement and reporting of the degree to which the PCBH model has been implemented as developers intended has resulted in two disadvantages in the field. First, clinical quality improvement efforts are hampered by lack of clear guidance on what elements are central to PCBH implementation. Second, the dearth of empirical studies reporting model fidelity impedes cross-study comparisons and limits the rigor of PCBH-focused research. Efforts to expand measurement of PCBH model fidelity would benefit from identification of accessible, unbiased metrics that could complement existing self-report measures. In this article, we describe how we partnered with our clinical informatics team to incorporate PCBH fidelity metrics into the electronic medical record (EMR), allowing for monthly extraction and review of these data. Next, we describe how we have used monthly fidelity monitoring to inform clinical quality improvement efforts in the context of a developing integrated care program and provide an example of how PCBH fidelity data might be reported in a research article. Leveraging EMR data to support PCBH fidelity measurement has the potential to strengthen clinical quality improvement efforts and enable more consistent measurement and reporting of PCBH fidelity data in research. Future efforts should aim to parse out the relative contribution of different variables to the success of PCBH integration and evaluate the effectiveness of implementation strategies at supporting high fidelity. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Long-Term Impacts of an Integrated Care Programme on Hospital Utilisation among Older Adults in the South of England: A Synthetic Control Study.

Reducing hospital use is often viewed as a possible positive consequence of introducing integrated care (IC). We investigated the impact of an IC programme in North East Hampshire and Farnham (NEHF), in southern England, on hospital utilisation among older adults over a 55 months period. We used a Generalised Synthetic Control design to investigate the effect of implementing IC in NEHF between 2015 and 2020. For a range of hospital use outcomes, we estimated the trajectory that each would have followed in the absence of IC and compared it with the actual trajectory to estimate the potential impact of IC. Three years into the programme, emergency admission rates started reducing in NEHF relative to its synthetic control, particularly those resulting in overnight hospital stays. By year 5 of the study overall emergency admission rates were 9.8% lower (95% confidence interval: -17.2% to -0.6%). We found no sustained difference in rates of emergency department (ED) visits, and average length of hospital stay was significantly higher from year 2. An IC programme in NEHF led to lower than estimated emergency admission rates; however, the interpretation of the impact of IC on admissions is complicated as lower rates did not appear until three years into the programme and the reliability of the synthetic control weakens over a long time horizon. There was no sustained change in ED visit rates.

Maternal satisfaction with reduced postnatal length of stay in Brussels: evidence from the KOZI&Home program

BackgroundReducing the length of stay (LOS) after childbirth is a trend, including cost savings, a more family-centered approach and lower risk for nosocomial infection. Evaluating the impact of reduced LOS is important to improve the outcomes of care, which include maternal satisfaction. The aim of this study was to compare the maternal satisfaction, before and after the reduced LOS.MethodsThis study was conducted in the University Hospital Brussels, before and after implementing the KOZI&Home program (intervention). This KOZI&Home program consisted of a reduced length of stay of at least one day for both vaginal delivery and caesarean section. It also included three extra antenatal visits with the midwife, preparing for discharge and postnatal home care by an independent midwife. Women completed a questionnaire, including the Maternity Satisfaction Questionnaire (MSQ) and Home Satisfaction Questionnaire (HSQ), respectively at discharge and two weeks postpartum. Satisfaction was split into five dimensions: ‘Midwives time investment’, ‘Provision of information’, ‘Physical environment’, ‘Privacy’ and ‘Readiness for discharge’. A combination of forward and backward model selection (both directions) was used for statistical analysis.ResultsIn total, 585 women were included in this study. 332 women in the non-intervention group and 253 women in the intervention group. Satisfaction with ‘provision of information’ at home had a higher mean score of 4.47/5 in the intervention group versus 4.08/5 in the non-intervention group (p < 0.001). Women in the KOZI&Home group were more satisfied regarding ‘privacy at home’ (mean 4.74/5 versus 4.48/5) (p < 0.001) and ‘readiness for discharge’ (p = 0.02).ConclusionThe intervention was associated with a higher score in some of dimensions of satisfaction. Our study concludes that this integrated care program is acceptable for postpartum women and associated with some favourable outcomes.