Clinical challenges in the care of frail older persons

Integration and continuity of primary care: polyclinics and alternatives – a patient-centred analysis of how organisation constrains care co-ordination

Background

An ageing population, the increasing specialisation of clinical services and diverse health-care provider ownership make the co-ordination and continuity of complex care increasingly problematic. The way in which the provision of complex health care is co-ordinated produces – or fails to produce – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational and relational). Care co-ordination is accomplished by a combination of activities by patients themselves; provider organisations; care networks co-ordinating the separate provider organisations; and overall health-system governance. This research examines how far organisational integration might promote care co-ordination at the clinical level.

Objectives

To examine (1) what differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical co-ordination of care; (2) what difference provider ownership (corporate, partnership, public) makes; (3) how much scope either structure allows for managerial discretion and ‘performance’; (4) differences between networked and hierarchical governance regarding the continuity and integration of primary care; and (5) the implications of the above for managerial practice in primary care.

Methods

Multiple-methods design combining (1) the assembly of an analytic framework by non-systematic review; (2) a framework analysis of patients’ experiences of the continuities of care; (3) a systematic comparison of organisational case studies made in the same study sites; (4) a cross-country comparison of care co-ordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics; and (5) the analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute inpatient care.

Results

Starting from data about patients’ experiences of the co-ordination or under-co-ordination of care, we identified five care co-ordination mechanisms present in both the integrated organisations and the care networks; four main obstacles to care co-ordination within the integrated organisations, of which two were also present in the care networks; seven main obstacles to care co-ordination that were specific to the care networks; and nine care co-ordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than did care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and a larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care co-ordination because of their impact on general practitioner workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance.

Conclusions

On balance, an integrated organisation seems more likely to favour the development of care co-ordination and, therefore, continuities of care than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings. Future research is therefore required, above all to evaluate comparatively the different techniques for coordinating patient discharge across the triple interface between hospitals, general practices and community health services; and to discover what effects increasing the scale and scope of general practice activities will have on continuity of care.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Health information technologies in geriatrics and gerontology: a mixed systematic review

OBJECTIVE

To review, categorize, and synthesize findings from the literature about the application of health information technologies in geriatrics and gerontology (GGHIT).

MATERIALS AND METHODS

This mixed-method systematic review is based on a comprehensive search of Medline, Embase, PsychInfo and ABI/Inform Global. Study selection and coding were performed independently by two researchers and were followed by a narrative synthesis. To move beyond a simple description of the technologies, we employed and adapted the diffusion of innovation theory (DOI).

RESULTS

112 papers were included. Analysis revealed five main types of GGHIT: (1) telecare technologies (representing half of the studies); (2) electronic health records; (3) decision support systems; (4) web-based packages for patients and/or family caregivers; and (5) assistive information technologies. On aggregate, the most consistent finding proves to be the positive outcomes of GGHIT in terms of clinical processes. Although less frequently studied, positive impacts were found on patients' health, productivity, efficiency and costs, clinicians' satisfaction, patients' satisfaction and patients' empowerment.

DISCUSSION

Further efforts should focus on improving the characteristics of such technologies in terms of compatibility and simplicity. Implementation strategies also should be improved as trialability and observability are insufficient.

CONCLUSIONS

Our results will help organizations in making decisions regarding the choice, planning and diffusion of GGHIT implemented for the care of older adults.

Patient-centered approach to building problem solving skills among older primary care patients: problems identified and resolved

This article describes problems identified by older primary care patients enrolled in Problem Solving Therapy (PST), and explores factors associated with successful problem resolution. PST patients received 1 to 8, 45-min sessions with a social worker. Patients identified problems in their lives and directed the focus of subsequent sessions as consistent with the steps of PST. The 107 patients identified 568 problems, 59% of which were resolved. Most commonly identified problems included health related issues such as need for exercise or weight loss activities, medical care and medical equipment needs, home and garden maintenance, and gathering information on their medical condition. Problems identified by patients were 2.2 times more likely to be solved than those identified by a health care professional. Using PST in primary care may facilitate patients in addressing key health and wellness issues.

Effects of a physical training and nutritional intervention program in frail elderly people regarding habitual physical activity level and activities of daily living--a randomized controlled pilot study

The aim of this randomized controlled pilot study is to describe the effects of a physical training and nutritional intervention program on the physical activity level and activities of daily living (ADL) in frail elderly people. Ninety-six community-dwelling frail elderly people (58 women) above the age of 75 were included in the study. The 12-week physical and/or nutritional intervention program was followed by six months of home-based exercises for the training groups, followed up with training diaries. At baseline the subjects were screened for physical activity level, walking habits, and ADL. These measurements were repeated immediately after the intervention at 3 months, and at 2nd follow-up at 9 months. ADL data were also collected 24 months after baseline at 3rd follow-up. The intention-to-treat analyses showed an increase of the habitual physical activity level and walking duration at 1st follow-up for the two training groups compared to the other groups. These increases remained at 2nd follow-up. The nutrition intervention did not show any significant results. No significant effects on ADL were shown however, there were moderate correlations between increases in physical activity level and ADL as well as between the amounts of home-based exercises and ADL for the two training groups.

Selection bias and utilization of the dual eligibles in Medicare and Medicaid HMOs

OBJECTIVE

To examine the existence of selection bias in the first 3 years of the Minnesota Senior Health Options (MSHO) demonstration and to estimate the MSHO effects on medical services utilization after adjusting for selection bias.

DATA SOURCES

Monthly dual eligibility data and MSHO encounter data of March 1997-December 2000 and Medicaid encounter data of January 1995-December 2000 from the Minnesota Department of Human Services; Medicare fee-for-service claims data of January 1995-December 2000 from the Centers for Medicare and Medicaid Services.

STUDY DESIGN

Quasi-experimental design comparing utilization between MSHO and control groups; multiple econometric and statistical models were estimated with time-invariant and time-varying covariates.

PRINCIPAL FINDINGS

Favorable MSHO selection was found in the nursing home (NH) and community populations, but selection bias did not substantially affect the findings. Enrollment in MSHO for more than 1 year reduced inpatient hospital admissions and days, emergency room and physician visits for NH residents, and lowered physician visits for community residents.

CONCLUSIONS

There was favorable selection in the first 3 years of the MSHO program. Enrollment in MSHO reduced several types of utilization for the NH group and physician visits for community enrollees.

Screening for poor performance of lower extremity in primary care: the Camucia Project

BACKGROUND AND AIMS

Individuals with poor lower extremity performance are prime candidates for disability prevention. The Camucia Project is a collaborative study between geriatricians and primary care physicians (PCPs) testing the hypothesis that PCPs can use a simple performance-based test to identify older persons with poor lower extremity function, without excessive interference with their clinical routine. We also hypothesized that the number needed to screen (NNTS) a positive case would be lower in physicians' clinics than in the general population.

METHODS

23 PCPs administered the short physical performance battery (SPPB) to 360 consecutive, non-disabled and non-demented, 70- to 79-year-old outpatients. PCPs were asked to: 1) evaluate the feasibility and usefulness of administering the SPPB; 2) ascertain selected diseases according to predefined criteria; 3) identify causes of poor lower extremity function in patients with a SPPB score < or =9. NNTS from this study were compared with those estimated in non-disabled and non-demented, 70- to 79-year-old persons randomly selected from the InCHIANTI study population.

RESULTS

The majority of PCPs (20/23) reported that using the SPPB to evaluate older patients was feasible and useful. The NNTS in the outpatient clinics was lower than in the InCHIANTI participants (1.6 vs 4.3). Poor lower extremity performance was attributed to musculo-skeletal diseases in 75%, to more than one cause in 55% (128/234), and to no specific cause in 16.2% (37/234) of the participants with SPPB < or =9.

CONCLUSIONS

Screening of older persons with poor lower extremity perfomance by PCPs is feasible and efficient.