Provision of health services for elderly populations in rural and remote areas in Australia: A systematic scoping review

INTRODUCTION

Although various studies have examined availability, access barriers and patient experiences of rural health services for the ageing population, no synthesis of this literature exists in Australia.

OBJECTIVE

The objective of this study was to examine the current literature surrounding rural service provision and to evaluate the barriers to access for older individuals and to recognise gaps in the literature.

DESIGN

A systematic scoping review of peer-reviewed literature from three online databases (PUBMED, SCOPUS and Web of Science).

FINDINGS

Thirty-two papers were included in analysis. The most prominent types of health service discussed were residential aged care (n = 12) and community health care (n = 10). More studies explored the perspectives of health personnel than the service end users. Qualitative synthesis revealed three themes associated with health service and rural ageing: access to services, health workforce experiences and end user experiences.

DISCUSSION

Access to health services for the elderly population is a complex issue. Promoting positive experiences for both health providers and patients is critical to assisting in healthy ageing for people living in rural and remote areas. This requires intervention on a social and institutional level. Key research gaps in the literature include the effectiveness of an integrated approach to institutional interventions, utilisation of preventative measures such as screening programs for cancer and greater identification of the health needs and perceptions among culturally diverse elderly residents. These studies are critical to promote appropriate and patient-centred care for elderly populations in rural and remote areas.

CONCLUSION

The review highlights the need to address availability, retention and service innovations across health services to improve access to care and health outcomes of rural elderly residents.

Improving In-Hospital Care For Older Adults: A Mixed Methods Study Protocol to Evaluate a System-Wide Sub-Acute Care Intervention in Canada

Introduction:

Acute care hospitals often inadequately prepare older adults to transition back to the community. Interventions that seek to improve this transition process are usually evaluated using healthcare use outcomes (e.g., hospital re-visit rates) only, and do not gather provider and patient perspectives about strategies to better integrate care. This protocol describes how we will use complementary research approaches to evaluate an in-hospital sub-acute care (SAC) intervention, designed to better prepare and transition older adults home.

Methods:

In three sequential research phases, we will assess (1) SAC transition pathways and effectiveness using administrative data, (2) provider fidelity to SAC core practices using chart audits, and (3) SAC implementation outcomes (e.g., facilitators and barriers to success, strategies to better integrate care) using provider and patient interviews.

Results:

Findings from each phase will be combined to determine SAC effectiveness and efficiency; to assess intervention components and implementation processes that ‘work’ or require modification; and to identify provider and patient suggestions for improving care integration, both while patients are hospitalized and to some extent after they transition back home.

Discussion:

This protocol helps to establish a blueprint for comprehensively evaluating interventions conducted in complex care settings using complementary research approaches and data sources.

Comparison of end-of-life care for people living in home settings versus residential aged care facilities: A nationwide study among Australian general practitioners

We have little knowledge of differences in end-of-life care between home settings and residential aged care facilities (RACFs) where people spend most of their last year of life. This study aimed to compare end-of-life care between home settings and RACFs from the perspective of Australian general practitioners (GPs). A descriptive study was conducted with 62 GPs from Western Australia, Queensland and Victoria. Participants were asked to provide reports on end-of-life care of decedents in their practice using a validated clinic-based data collection process developed by our team between September 2018 and August 2019. Of the 213 reported expected deaths, 66.2% mainly lived at home in the last year of life. People living at home were more likely to die at a younger age (median 77 vs. 88, p < 0.001), to be male (51.1% vs. 33.3%, p = 0.01) and to die of cancer (53.9% vs. 4.2%, p < 0.001) compared to those in RACFs. There were no significant differences between the two patient groups for seven out of the eight assessed symptoms, except nausea. GPs' perceived roles in caring for patients and levels of their involvement in provision of common palliative care services were comparable between the two groups. The usual accommodation setting was most frequently considered the preferred place of death in both groups. However, more home residents ended up dying in hospital compared to RACF residents. There were significantly higher frequencies of end-of-life discussions (ORs ranged 5.46-9.82 for all topic comparisons) with GPs associated with people living at home versus RACFs. One opportunity for improved care is through promoting greater involvement of GPs in end-of-life discussions with RACF residents and staff. In general, more Australians could potentially remain at home until death if provided with greater access to essential specialist palliative care services and supportive services in home settings.

Critical care resource use associated with tourism in Central Australia

OBJECTIVE

Tourism to regional and remote Australia is increasing. Its impact on regional critical care services is incompletely understood. We describe tourist admissions and their impact on critical care resources relative to the local population.

DESIGN

Single-centre retrospective study using prospectively collected data from January 2009 to December 2018.

SETTING

Australian regional intensive care unit.

PARTICIPANTS

All critical care admissions for patients aged over 18 years for whom postcode data were available were included.

OUTCOME MEASURES

Primary outcome was hospital mortality. Secondary outcomes examined resource use (intensive care unit and hospital length of stay, mechanical ventilation, interhospital transfer) and admission diagnosis.

RESULTS

Tourists comprise 6.1% of critical care admissions, occupying 5.7% of intensive care unit bed days. They were less likely to be Indigenous (6.3% vs 72.7%), but older (61.5 vs 49.2 years) and male (65.4% vs 52.6%). They were more frequently admitted following acute myocardial infarction (14.2% vs 8.9%) or trauma (20.0% vs 5.0%). There was no difference in hospital mortality (2.9% vs 4.0%) or intensive care unit mortality (2.4% vs 1.8%); however, tourists were more than twice as likely to require interhospital transfer (31.7% vs 14.0%). These findings persisted after adjustment for illness severity.

CONCLUSION

Tourists are an appreciable caseload of this regional intensive care unit and are more likely to require interhospital transfer. There was no difference in mortality. Further research is required across regional and rural Australia to better understand the epidemiology and impact of tourism on critical care resources, and the economic implications of becoming unwell in a regional area.

Can facility-based transitional care improve patient flow? Lessons from four Canadian regions

Units providing transitional, subacute, or restorative care represent a common intervention to facilitate patient flow and improve outcomes for lower acuity (often older) inpatients; however, little is known about Canadian health systems' experiences with such "transition units." This comparative case study of diverse units in four health regions (48 interviews) identified important success factors and pitfalls. A fundamental requirement for success is to clearly define the unit's intended population and design the model around its needs. Planners must also ensure that the unit be resourced and staffed to deliver truly restorative care. Finally, streamlined processes must be developed to help patients access and move through the unit. Units that were perceived as more effective appeared to have satisfactorily addressed these population, capacity, and process issues, whereas those perceived as less effective continued to struggle with them. Findings suggest principles to support optimal design and implementation of transition units.

Risk Factors of Readmissions in Geriatric Rehabilitation Patients: RESORT

OBJECTIVE

To evaluate the risk factors associated with 30- and 90-day hospital readmissions in geriatric rehabilitation inpatients.

DESIGN

Observational, prospective longitudinal inception cohort.

SETTING

Tertiary hospital in Victoria, Australia.

PARTICIPANTS

Geriatric rehabilitation inpatients of the REStORing Health of Acutely Unwell AdulTs (RESORT) cohort evalutated by a comprehensive geriatric assessment including potential readmission risk factors (ie, demographic, social support, lifestyle, functional performance, quality of life, morbidity, length of stay in an acute ward). Of 693 inpatients, 11 died during geriatric rehabilitation. The mean age of the remaining 682 inpatients was 82.2±7.8 years, and 56.7% were women.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Thirty- and 90-day readmissions after discharge from geriatric inpatient rehabilitation.

RESULTS

The 30- and 90-day unplanned all-cause readmission rates were 11.6% and 25.2%, respectively. Risk factors for 30- and 90-day readmissions were as follows: did not receive tertiary education, lower quality of life, higher Charlson Comorbidity Index and Cumulative Illness Rating Scale (CIRS) scores, and a higher number of medications used in the univariable models. Formal care was associated with increased risk for 90-day readmissions. In multivariable models, CIRS score was a significant risk factor for 30-day readmissions, whereas high fear of falling and CIRS score were significant risk factors for 90-day readmissions.

CONCLUSIONS

High fear of falling and CIRS score were independent risk factors for readmission in geriatric rehabilitation inpatients. These variables should be included in hospital readmission risk prediction model developments for geriatric rehabilitation inpatients.

Age-friendly care for older adults within rural Australian health systems: An integrative review

OBJECTIVES

To identify the core elements of interventions and models that facilitate age-friendly care for older adults within rural Australian health systems, and assess the extent to which these align with core elements of the Institute for Health Improvement's (IHI) Age-Friendly Health Systems 4Ms Model.

METHODS

Peer-reviewed journal articles examining core elements of Australian rural geriatric care models were collected and analysed using an integrative review methodology.

RESULTS

Identified models and interventions addressed all four core elements of the IHI model-what matters, medications, mobility and mentation. There was more evidence relating to mobility and mentation, with lesser evidence relating to medications and what matters. A series of core elements not aligned with the model were also identified.

CONCLUSION

The IHI 4Ms Model appears to be applicable in the rural Australian context. More high-quality, systematic evidence is needed to investigate the core elements of age-friendly care across diverse rural contexts.

Vital sign abnormalities as predictors of clinical deterioration in subacute care patients: A prospective case-time-control study

BACKGROUND

Emergency interhospital transfers from inpatient subacute care to acute care occur in 8% to 17.4% of admitted patients and are associated with high rates of acute care readmission and in-hospital mortality. Serious adverse events in subacute care (rapid response team or cardiac arrest team calls) and increased nursing surveillance are the strongest known predictors of emergency interhospital transfer from subacute to acute care hospitals. However, the epidemiology of clinical deterioration across sectors of care, and specifically in subacute care is not well understood.

OBJECTIVES

To explore the trajectory of clinical deterioration in patients who did and did not have an emergency interhospital transfer from subacute to acute care; and develop an internally validated predictive model to identify the role of vital sign abnormalities in predicting these emergency interhospital transfers.

DESIGN

This prospective, exploratory cohort study is a subanalysis of data derived from a larger case-time-control study.

SETTING

Twenty-two wards of eight subacute care hospitals in five major health services in Victoria, Australia. All subacute care hospitals were geographically separate from their health services' acute care hospitals.

PARTICIPANTS

All patients with an emergency transfer from inpatient rehabilitation or geriatric evaluation and management unit to an acute care hospital within the same health service were included. Patients receiving palliative care were excluded.

METHODS

Study data were collected between 22 August 2015 and 30 October 2016 by medical record audit. The Cochran-Mantel-Haenszel test and bivariate logistic regression analysis were used to compare cases with controls and to account for health service clustering effect.

RESULTS

Data were collected on 603 transfers (557 patients) and 1160 controls. Adjusted for health service, ≥2 vital sign abnormalities in subacute care (adjusted odds ratio=8.81, 95% confidence intervals:6.36-12.19, p<0.001) and serious adverse events during the first acute care admission (adjusted odds ratio=1.28, 95% confidence intervals:1.08-1.99, p=0.015) were the clinical factors associated with increased risk of emergency interhospital transfer. An internally validated predictive model showed that vital sign abnormalities can fairly predict emergency interhospital transfers from subacute to acute care hospitals.

CONCLUSION

Serious adverse events in acute care should be a key consideration in decisions about the location of subacute care delivery. During subacute care, 15.7% of cases had vital signs fulfilling organisational rapid response team activation criteria, yet missed rapid response team activations were common suggesting that further consideration of the criteria and strategies to optimise recognition and response to clinical deterioration in subacute care are needed.

Nursing research priorities based on CINAHL database: A scoping review

Aim

To analyse nursing research based on the CINAHL database to identify research priorities for nursing.

Design

A scoping literature review was conducted. The CINAHL Plus (EBSCO) Full Text was searched between 2012-2018.

Methods

Out of 1522 original publications, 91 fulfilled the inclusion criteria. The Joanna Briggs Institute critical appraisal tools were applied. Data were analysed by a thematic analysis method.

Results

A strong emphasis should be put on development and evaluation of nursing theories and, in addition, randomized controlled trial studies, meta-synthesis, experimental and intervention studies are needed in nursing research. Development of competencies and skills in the nursing profession ought to be studied more extensively and research should be focused on variety fields of nursing practice.

Consumer preference to utilise a mobile health app: A stated preference experiment

BACKGROUND

One prominent barrier faced by healthcare consumers when accessing health services is a common requirement to complete repetitive, inefficient paper-based documentation at multiple registration sites. Digital innovation has a potential role to reduce the burden in this area, through the collection and sharing of data between healthcare providers. While there is growing evidence for digital innovations to potentially improve the effectiveness and efficiency of health systems, there is less information on the willingness of healthcare consumers to embrace and utilise technology to provide data.

AIM

The study aims to improve understanding of consumers' preference for utilising a digital health administration mobile app.

METHODS

The online study used a stated preference experiment design to explore aspects of consumers' preference for a mobile health administration app and its impact on the likelihood of using the app. The survey was answered by a representative sample (by age and gender) of Australian adults, and sociodemographic factors were also recorded for analysis. Each participant answered eight choice sets in which a hypothetical app (defined by a set of dimensions and levels) was presented and the respondent was asked if they would be willing to provide data using that app. Analysis was conducted using bivariate logistic regression.

RESULTS

For the average respondent, the two most important dimensions were the time it took to register on the app and the electronic governance arrangements around their personal information. Willingness to use any app was found to differ based on respondent characteristics: people with higher education, and women, were relatively more willing to utilise the mobile health app.

CONCLUSION

This study investigated consumers' willingness to utilise a digital health administration mobile app. The identification of key characteristics of more acceptable apps provide valuable insight and recommendations for developers of similar digital health administration technologies. This would increase the likelihood of achieving successful acceptance and utilisation by consumers. The results from this study provide evidence-based recommendations for future research and policy development, planning and implementation of digital health administration mobile applications in Australia.

Characteristics and outcomes of emergency interhospital transfers from subacute to acute care for clinical deterioration

OBJECTIVE

To describe characteristics and outcomes of emergency interhospital transfers from subacute to acute hospital care and develop an internally validated predictive model to identify features associated with high risk of emergency interhospital transfer.

DESIGN

Prospective case-time-control study.

SETTING

Acute and subacute healthcare facilities from five health services in Victoria, Australia.

PARTICIPANTS

Cases were patients with an emergency interhospital transfer from subacute to acute hospital care. For every case, two inpatients from the same subacute care ward on the same day of emergency transfer were randomly selected as controls. Admission episode was the unit of measurement and data were collected prospectively.

MAIN OUTCOME MEASURES

Patient and admission characteristics, transfer characteristics and outcomes (cases), serious adverse events and mortality.

RESULTS

Data were collected for 603 transfers in 557 patients and 1160 control patients. Cases were significantly more likely to be male, born in a non-English speaking country, have lower functional independence, more frequent vital sign assessments and experience a serious adverse event during first acute care or subacute care admissions. When adjusted for health service, cases had significantly higher inpatient mortality, were more likely to have unplanned intensive care unit admissions and rapid response team calls during their entire hospital admission.

CONCLUSIONS

Patients who require an emergency interhospital transfer from subacute to acute hospital care have hospital admission rates and in-hospital mortality. Clinical instability during the first acute care admission (serious adverse events or increased surveillance) may prompt reassessment of patient suitability for movement to a separate subacute care hospital.

Issues of accessibility to health services by older Australians: a review

BACKGROUND

This review provides an in-depth investigation into the difficulties facing older Australians when accessing health care services.

METHODS

A literature search was conducted in December 2016 using Academic Premier to identify relevant publications. Key search terms were accessibility, health service, older people and Australia. Papers published between 1999 and 2016 were included. Statements of accessibility were extracted and then grouped using the five dimensions of accessibility by Penchansky and Thomas (1981): availability, accessibility, accommodation, affordability and acceptability.

RESULTS

Forty-one papers were included. Availability issues identified were inadequate health care services, particularly for culturally and linguistically diverse (CALD) populations and those residing in rural areas. Accessibility issues included difficulties accessing transport to health care services, which in turn restricted choice of appointment time. Issues of accommodation identified were long waiting times for appointments with both general practitioners and medical specialists. Affordability was a common problem, compounded by multi-morbidity requiring high health care use. Issues of acceptability centred on the role of the family, feelings of shame when receiving care from a non-family member, traditional practices and gender sensitivity.

CONCLUSIONS

The contribution of factors to health service accessibility varies according to an older person's geographical local and their accessibility to transport, as well as their level of multi-morbidity and cultural background. Improving access to health services could be improved by matching services to the population that they serve.

Role of rehabilitation in the elderly after an acute event: insights from a real-life prospective study in the subacute care setting

BACKGROUND

Any acute event, either primary or secondary to a chronic disease, is generally followed by some degree of physical impairment. Subacute care (SAC) represents one of the inpatient intermediate care settings aimed at completing recovery and restoring functional capacity. Debate exists on the role of the rehabilitation treatment in the SAC setting.

AIM

The aim of this study was to compare the outcomes of patients managed in two different SAC Units where A) patients undergo an individualized rehabilitation program on top of optimal medical therapy (OMT) B) patients receive OMT only.

DESIGN

Real-life prospective study.

SETTING

SAC units.

POPULATION

Seventy-five chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) patients transferred after an acute hospitalization.

METHODS

Upon SAC admission, the following scales were obtained: cumulative illness rating scale comorbidity and severity (CIRSC and CIRSS), mini mental state examination (MMSE), Performance-Oriented Mobility Assessment (POMA), Barthel Index (BI), the 10-meter walking test (10MWT). Pre-admission BI was also collected based on history. Upon SAC discharge, BI, POMA, and 10MWT were repeated.

RESULTS

Patients (44 in Group A, 31 in Group B) were similar with regard to age, gender, MMSE, clinical complexity, pre-admission BI, admission 10MWT, POMA, and bedrest conditions. Admission BI was lower in Group A. In both groups BI was lower when compared to the respective pre-admission score. Upon discharge, Group A patients were characterized by a higher BI and POMA compared to Group B. Indeed, BI and POMA improved at discharge only in Group A patients. Only this latter group reached the pre-morbid BI. Upon discharge the number of bedrest patients decreased only in Group A. The percentage of patients discharged home was also much higher in Group A, while a greater number of Group B patients were transferred to a rehabilitation ward or were enrolled in an integrated home care assistance program.

CONCLUSIONS

In a real-life prospective experience, a better outcome is demonstrated in elderly CHF and COPD patients undergoing a rehabilitative approach during their in-hospital SAC stay.

CLINICAL REHABILITATION IMPACT

An individualized rehabilitation program should integrate medical treatment of CHF and BPCO patients in the SAC setting. This approach demonstrates a better cost-effectiveness management of these patients.