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Care Coordination Models and Tools-Systematic Review and Key Informant Interviews. J Gen Intern Med 2022; 37:1367-1379. [PMID: 34704210 PMCID: PMC9086013 DOI: 10.1007/s11606-021-07158-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 09/17/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Care coordination (CC) interventions involve systematic strategies to address fragmentation and enhance continuity of care. However, it remains unclear whether CC can sufficiently address patient needs and improve outcomes. METHODS We searched MEDLINE, CINAHL, Embase, Cochrane Database of Systematic Reviews, AHRQ Evidence-based Practice Center, and VA Evidence Synthesis Program, from inception to September 2019. Two individuals reviewed eligibility and rated quality using modified AMSTAR 2. Eligible systematic reviews (SR) examined diverse CC interventions for community-dwelling adults with ambulatory care sensitive conditions and/or at higher risk for acute care. From eligible SR and relevant included primary studies, we abstracted the following: study and intervention characteristics; target population(s); effects on hospitalizations, emergency department (ED) visits, and/or patient experience; setting characteristics; and tools and approaches used. We also conducted semi-structured interviews with individuals who implemented CC interventions. RESULTS Of 2324 unique citations, 16 SR were eligible; 14 examined case management or transitional care interventions; and 2 evaluated intensive primary care models. Two SR highlighted selection for specific risk factors as important for effectiveness; one of these also indicated high intensity (e.g., more patient contacts) and/or multidisciplinary plans were key. Most SR found inconsistent effects on reducing hospitalizations or ED visits; few reported on patient experience. Effective interventions were implemented in multiple settings, including rural community hospitals, academic medical centers (in urban settings), and public hospitals serving largely poor, uninsured populations. Primary studies reported variable approaches to improve patient-provider communication, including health coaching and role-playing. SR, primary studies, and key informant interviews did not identify tools for measuring patient trust or care team integration. Sustainability of CC interventions varied and some were adapted over time. DISCUSSION CC interventions have inconsistent effects on reducing hospitalizations and ED visits. Future work should address how they should be adapted to different healthcare settings and which tools or approaches are most helpful for implementation. TRIAL REGISTRATION PROSPERO #CRD42020156359.
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Abstract
BACKGROUND The policy several countries is to provide people with a terminal illness the choice of dying at home; this is supported by surveys that indicate that the general public and people with a terminal illness would prefer to receive end-of-life care at home. This is the fifth update of the original review. OBJECTIVES To determine if providing home-based end-of-life care reduces the likelihood of dying in hospital and what effect this has on patients' symptoms, quality of life, health service costs and caregivers compared with inpatient hospital or hospice care. SEARCH METHODS We searched CENTRAL, Ovid MEDLINE(R), Embase, CINAHL, and clinical trials registries to 18 March 2020. We checked the reference lists of systematic reviews. For included studies, we checked the reference lists and performed a forward search using ISI Web of Science. We handsearched palliative care journals indexed by ISI Web of Science for online first references. SELECTION CRITERIA Randomised controlled trials evaluating the effectiveness of home-based end-of-life care with inpatient hospital or hospice care for people aged 18 years and older. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality. When appropriate, we combined published data for dichotomous outcomes using a fixed-effect Mantel-Haenszel meta-analysis to calculate risk ratios (RR) with 95% confidence intervals (CI). When combining outcome data was not possible, we reported the results from individual studies. MAIN RESULTS We included four randomised trials and found no new studies from the search in March 2020. Home-based end-of-life care increased the likelihood of dying at home compared with usual care (RR 1.31, 95% CI 1.12 to 1.52; 2 trials, 539 participants; I2 = 25%; high-certainty evidence). Admission to hospital varied among the trials (range of RR 0.62, 95% CI 0.48 to 0.79, to RR 2.61, 95% CI 1.50 to 4.55). The effect on patient outcomes and control of symptoms was uncertain. Home-based end-of-life care may slightly improve patient satisfaction at one-month follow-up, with little or no difference at six-month follow-up (2 trials; low-certainty evidence). The effect on caregivers (2 trials; very low-certainty evidence), staff (1 trial; very low-certainty evidence) and health service costs was uncertain (2 trials, very low-certainty evidence). AUTHORS' CONCLUSIONS The evidence included in this review supports the use of home-based end-of-life care programmes for increasing the number of people who will die at home. Research that assesses the impact of home-based end-of-life care on caregivers and admissions to hospital would be a useful addition to the evidence base, and might inform the delivery of these services.
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Affiliation(s)
- Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Sharon E Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of Toronto, Toronto, Canada
| | - Bee Wee
- Nuffield Department of Medicine and Sir Michael Sobell House, Churchill Hospital, Oxford, UK
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Dang S, Olsan T, Karuza J, Cai X, Gao S, Intrator O, Li J, Gillespie SM. Telehealth in Home‐Based Primary Care: Factors and Challenges Associated With Integration Into Veteran Care. J Am Geriatr Soc 2019; 67:1928-1933. [DOI: 10.1111/jgs.16045] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/28/2019] [Accepted: 05/29/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Stuti Dang
- Miami Veterans Affairs Geriatric Research Education and Clinical Center Miami Florida
- Miami Veterans Affairs Healthcare System Miami Florida
- Division of Geriatrics and Palliative Care University of Miami Miller School of Medicine Miami Florida
| | - Tobie Olsan
- Canandaigua Veteran Affairs Medical Center Canandaigua New York
- School of Nursing, University of Rochester Rochester New York
| | - Jurgis Karuza
- Canandaigua Veteran Affairs Medical Center Canandaigua New York
- Division of Geriatrics and Aging Department of Medicine, University of Rochester School of Medicine and Dentistry Rochester New York
- Department of Psychology Buffalo State College Buffalo New York
| | - Xueya Cai
- Canandaigua Veteran Affairs Medical Center Canandaigua New York
- Department of Biostatistics and Computational Biology University of Rochester School of Medicine and Dentistry Rochester New York
| | - Shan Gao
- Canandaigua Veteran Affairs Medical Center Canandaigua New York
- Department of Biostatistics and Computational Biology University of Rochester School of Medicine and Dentistry Rochester New York
| | - Orna Intrator
- Canandaigua Veteran Affairs Medical Center Canandaigua New York
- Department of Public Health Sciences University of Rochester Rochester New York
| | - Jiejin Li
- Canandaigua Veteran Affairs Medical Center Canandaigua New York
- Department of Public Health Sciences University of Rochester Rochester New York
| | - Suzanne M. Gillespie
- Canandaigua Veteran Affairs Medical Center Canandaigua New York
- Division of Geriatrics and Aging Department of Medicine, University of Rochester School of Medicine and Dentistry Rochester New York
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4
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Daaleman TP, Ernecoff NC, Kistler CE, Reid A, Reed D, Hanson LC. The Impact of a Community-Based Serious Illness Care Program on Healthcare Utilization and Patient Care Experience. J Am Geriatr Soc 2019; 67:825-830. [DOI: 10.1111/jgs.15814] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 12/12/2018] [Accepted: 12/21/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Timothy P. Daaleman
- Department of Family Medicine; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
- Cecil G. Sheps Center for Health Services Research; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - Natalie C. Ernecoff
- Cecil G. Sheps Center for Health Services Research; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
- Gillings School of Global Public Health; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - Christine E. Kistler
- Department of Family Medicine; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
- Cecil G. Sheps Center for Health Services Research; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - Alfred Reid
- Department of Family Medicine; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - David Reed
- Cecil G. Sheps Center for Health Services Research; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
| | - Laura C. Hanson
- Cecil G. Sheps Center for Health Services Research; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
- Division of Geriatrics and Palliative Care Program, Department of Medicine; University of North Carolina at Chapel Hill; Chapel Hill North Carolina
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5
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Kramer BJ, Creekmur B, Mitchell MN, Saliba D. Expanding Home-Based Primary Care to American Indian Reservations and Other Rural Communities: An Observational Study. J Am Geriatr Soc 2018. [DOI: 10.1111/jgs.15193] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- B. Josea Kramer
- Geriatric Research Education and Clinical Center; Veterans Affairs Greater Los Angeles Healthcare System; Los Angeles California
- Division of Geriatric Medicine; David Geffen School of Medicine, University of California Los Angeles; Los Angeles California
| | | | - Michael N. Mitchell
- Geriatric Research Education and Clinical Center; Veterans Affairs Greater Los Angeles Healthcare System; Los Angeles California
| | - Debra Saliba
- Geriatric Research Education and Clinical Center; Veterans Affairs Greater Los Angeles Healthcare System; Los Angeles California
- Division of Geriatric Medicine; David Geffen School of Medicine, University of California Los Angeles; Los Angeles California
- University of California, Los Angeles/Jewish Home Borun Center for Gerontological Research; Los Angeles California
- RAND Corporation; Santa Monica California
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6
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Edwards ST, Peterson K, Chan B, Anderson J, Helfand M. Effectiveness of Intensive Primary Care Interventions: A Systematic Review. J Gen Intern Med 2017; 32:1377-1386. [PMID: 28924747 PMCID: PMC5698228 DOI: 10.1007/s11606-017-4174-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 06/28/2017] [Accepted: 08/18/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Multicomponent, interdisciplinary intensive primary care programs target complex patients with the goal of preventing hospitalizations, but programs vary, and their effectiveness is not clear. In this study, we systematically reviewed the impact of intensive primary care programs on all-cause mortality, hospitalization, and emergency department use. METHODS We searched PubMed, CINAHL, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Reviews of Effects from inception to March 2017. Additional studies were identified from reference lists, hand searching, and consultation with content experts. We included systematic reviews, randomized controlled trials (RCTs), and observational studies of multicomponent, interdisciplinary intensive primary care programs targeting complex patients at high risk of hospitalization or death, with a comparison to usual primary care. Two investigators identified studies and abstracted data using a predefined protocol. Study quality was assessed using the Cochrane risk of bias tool. RESULTS A total of 18 studies (379,745 participants) were included. Three major intensive primary care program types were identified: primary care replacement (home-based; three RCTs, one observational study, N = 367,681), primary care replacement (clinic-based; three RCTs, two observational studies, N = 9561), and primary care augmentation, in which an interdisciplinary team was added to existing primary care (five RCTs, three observational studies, N = 2503). Most studies showed no impact of intensive primary care on mortality or emergency department use, and the effectiveness in reducing hospitalizations varied. There were no adverse effects reported. DISCUSSION Intensive primary care interventions demonstrated varying effectiveness in reducing hospitalizations, and there was limited evidence that these interventions were associated with changes in mortality. While interventions could be grouped into categories, there was still substantial overlap between intervention approaches. Further work is needed to identify program features that may be associated with improved outcomes.
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Affiliation(s)
- Samuel T Edwards
- Section of General Internal Medicine, VA Portland Health Care System, Portland, OR, USA. .,Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA. .,Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, OR, USA. .,Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Kim Peterson
- Evidence-based Synthesis Program (ESP) Coordinating Center, VA Portland Health Care System, Portland, OR, USA
| | - Brian Chan
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, OR, USA
| | - Johanna Anderson
- Evidence-based Synthesis Program (ESP) Coordinating Center, VA Portland Health Care System, Portland, OR, USA
| | - Mark Helfand
- Section of General Internal Medicine, VA Portland Health Care System, Portland, OR, USA.,Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.,Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, OR, USA.,Evidence-based Synthesis Program (ESP) Coordinating Center, VA Portland Health Care System, Portland, OR, USA
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Karuza J, Gillespie SM, Olsan T, Cai X, Dang S, Intrator O, Li J, Gao S, Kinosian B, Edes T. National Structural Survey of Veterans Affairs Home-Based Primary Care Programs. J Am Geriatr Soc 2017; 65:2697-2701. [DOI: 10.1111/jgs.15126] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Jurgis Karuza
- Canandaigua Veterans Affairs Medical Center; Canandaigua New York
- Division of Geriatrics; School of Medicine and Dentistry; University of Rochester; Rochester New York
- Department of Psychology; State University of New York at Buffalo State; Buffalo New York
| | - Suzanne M. Gillespie
- Canandaigua Veterans Affairs Medical Center; Canandaigua New York
- Division of Geriatrics; School of Medicine and Dentistry; University of Rochester; Rochester New York
| | - Tobie Olsan
- Canandaigua Veterans Affairs Medical Center; Canandaigua New York
- School of Nursing; University of Rochester; Rochester New York
| | - Xeuya Cai
- Department of Biostatistics; University of Rochester; Rochester New York
| | - Stuti Dang
- Miami Veterans Affairs Healthcare System; Miami Florida
| | - Orna Intrator
- Canandaigua Veterans Affairs Medical Center; Canandaigua New York
- Public Health Sciences; University of Rochester; Rochester New York
| | - Jiejin Li
- Department of Biostatistics; University of Rochester; Rochester New York
| | - Shan Gao
- Department of Biostatistics; University of Rochester; Rochester New York
| | - Bruce Kinosian
- Division of Geriatrics; School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
- Geriatrics and Extended Care Data Analysis Center; Philadelphia Veterans Affairs Medical Center; Philadelphia Pennsylvania
| | - Thomas Edes
- Geriatrics and Extended Care; Office of Clinical Operations and Management; U.S. Department of Veterans Affairs; Washington District of Columbia
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Kramer BJ, Cote SD, Lee DI, Creekmur B, Saliba D. Barriers and facilitators to implementation of VA home-based primary care on American Indian reservations: a qualitative multi-case study. Implement Sci 2017; 12:109. [PMID: 28865474 PMCID: PMC5581481 DOI: 10.1186/s13012-017-0632-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/26/2017] [Indexed: 11/28/2022] Open
Abstract
Background Veterans Health Affairs (VA) home-based primary care (HBPC) is an evidence-based interdisciplinary approach to non-institutional long-term care that was developed in urban settings to provide longitudinal care for vulnerable older patients. Under the authority of a Memorandum of Understanding between VA and Indian Health Service (IHS) to improve access to healthcare, 14 VA medical centers (VAMC) independently initiated plans to expand HBPC programs to rural American Indian reservations and 12 VAMC successfully implemented programs. The purpose of this study is to describe barriers and facilitators to implementation in rural Native communities with the aim of informing planners and policy-makers for future program expansions. Methods A qualitative comparative case study approach was used, treating each of the 14 VAMC as a case. Using the Consolidated Framework for Implementation Research (CFIR) to inform an open-ended interview guide, telephone interviews (n = 37) were conducted with HBPC staff and clinicians and local/regional managers, who participated or oversaw implementation. The interviews were transcribed, coded, and then analyzed using CFIR domains and constructs to describe and compare experiences and to identify facilitators, barriers, and adaptations that emerged in common across VAMC and HBPC programs. Results There was considerable variation in local contexts across VAMC. Nevertheless, implementation was typically facilitated by key individuals who were able to build trust and faith in VA healthcare among American Indian communities. Policy promoted clinical collaboration but collaborations generally occurred on an ad hoc basis between VA and IHS clinicians to optimize patient resources. All programs required some adaptations to address barriers in rural areas, such as distances, caseloads, or delays in hiring additional clinicians. VA funding opportunities facilitated expansion and sustainment of these programs. Conclusions Since program expansion is a responsibility of the HBPC program director, there is little sharing of lessons learned across VA facilities. Opportunities for shared learning would benefit federal healthcare organizations to expand other medical services to additional American Indian communities and other rural and underserved communities, as well as to coordinate with other healthcare organizations. The CFIR structure was an effective analytic tool to compare programs addressing multiple inner and outer settings.
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Affiliation(s)
- B Josea Kramer
- VA Greater Los Angeles Healthcare System, Geriatric Research Education and Clinical Center, 16111, St (11E), North Hills, Plummer, CA, 91343, USA. .,David Geffen School of Medicine at UCLA, Division of Geriatric Medicine, 10945 Le Conte Avenue, Suite 2339, Los Angeles, CA, 90095, USA.
| | - Sarah D Cote
- Rio Hondo College, Institutional Research & Planning, 3600 Workman Mill Road, Whittier, CA, 90601, USA
| | - Diane I Lee
- VA Greater Los Angeles Healthcare System, Geriatric Research Education and Clinical Center, 16111, St (11E), North Hills, Plummer, CA, 91343, USA
| | - Beth Creekmur
- Kaiser Permanente Research, Department of Research and Evaluation, 100 South Los Robles, Pasadena, CA, 91101, USA
| | - Debra Saliba
- VA Greater Los Angeles Healthcare System, Geriatric Research Education and Clinical Center, 16111, St (11E), North Hills, Plummer, CA, 91343, USA.,David Geffen School of Medicine at UCLA, Division of Geriatric Medicine, 10945 Le Conte Avenue, Suite 2339, Los Angeles, CA, 90095, USA.,UCLA/Jewish Home Borun Center for Gerontological Research, 10945 LeConte Ave, Suite 2339, Los Angeles, CA, 90095, USA.,RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA
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Lemieux-Charles L, McGuire WL. What Do We Know about Health Care Team Effectiveness? A Review of the Literature. Med Care Res Rev 2016; 63:263-300. [PMID: 16651394 DOI: 10.1177/1077558706287003] [Citation(s) in RCA: 482] [Impact Index Per Article: 60.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This review of health care team effectiveness literature from 1985 to 2004 distinguishes among intervention studies that compare team with usual (nonteam) care; intervention studies that examine the impact of team redesign on team effectiveness; and field studies that explore relationships between team context, structure, processes, and outcomes. The authors use an Integrated Team Effectiveness Model (ITEM) to summarize research findings and to identify gaps in the literature. Their analysis suggests that the type and diversity of clinical expertise involved in team decision making largely accounts for improvements in patient care and organizational effectiveness. Collaboration, conflict resolution, participation, and cohesion are most likely to influence staff satisfaction and perceived team effectiveness. The studies examined here underscore the importance of considering the contexts in which teams are embedded. The ITEM provides a useful framework for conceptualizing relationships between multiple dimensions of team context, structure, processes, and outcomes.
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Abstract
BACKGROUND The policy in a number of countries is to provide people with a terminal illness the choice of dying at home. This policy is supported by surveys indicating that the general public and people with a terminal illness would prefer to receive end-of-life care at home. This is the fourth update of the original review. OBJECTIVES To determine if providing home-based end-of-life care reduces the likelihood of dying in hospital and what effect this has on patients' symptoms, quality of life, health service costs, and caregivers, compared with inpatient hospital or hospice care. SEARCH METHODS We searched the following databases until April 2015: Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), Ovid MEDLINE(R) (from 1950), EMBASE (from 1980), CINAHL (from 1982), and EconLit (from 1969). We checked the reference lists of potentially relevant articles identified and handsearched palliative care publications, clinical trials registries, and a database of systematic reviews for related trials (PDQ-Evidence 2015). SELECTION CRITERIA Randomised controlled trials, interrupted time series, or controlled before and after studies evaluating the effectiveness of home-based end-of-life care with inpatient hospital or hospice care for people aged 18 years and older. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality. We combined the published data for dichotomous outcomes using fixed-effect Mantel-Haenszel meta-analysis. When combining outcome data was not possible, we reported the results from individual studies. MAIN RESULTS We included four trials in this review and did not identify new studies from the search in April 2015. Home-based end-of-life care increased the likelihood of dying at home compared with usual care (risk ratio (RR) 1.33, 95% confidence interval (CI) 1.14 to 1.55, P = 0.0002; Chi(2) = 1.72, df = 2, P = 0.42, I(2) = 0%; 3 trials; N = 652; high quality evidence). Admission to hospital while receiving home-based end-of-life care varied between trials, and this was reflected by a high level of statistical heterogeneity in this analysis (range RR 0.62 to RR 2.61; 4 trials; N = 823; moderate quality evidence). Home-based end-of-life care may slightly improve patient satisfaction at one-month follow-up and reduce it at six-month follow-up (2 trials; low quality evidence). The effect on caregivers is uncertain (2 trials; low quality evidence). The intervention may slightly reduce healthcare costs (2 trials, low quality evidence). No trial reported costs to patients and caregivers. AUTHORS' CONCLUSIONS The evidence included in this review supports the use of home-based end-of-life care programmes for increasing the number of people who will die at home, although the numbers of people admitted to hospital while receiving end-of-life care should be monitored. Future research should systematically assess the impact of home-based end-of-life care on caregivers.
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Affiliation(s)
- Sasha Shepperd
- University of OxfordNuffield Department of Population HealthRosemary Rue Building, Old Road CampusHeadingtonOxfordOxfordshireUKOX3 7LF
| | - Daniela C. Gonçalves‐Bradley
- University of OxfordNuffield Department of Population HealthRosemary Rue Building, Old Road CampusHeadingtonOxfordOxfordshireUKOX3 7LF
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of TorontoKnowledge Translation Program30 Bond StreetTorontoONCanadaM5B 1W8
| | - Bee Wee
- Churchill HospitalNuffield Department of Medicine and Sir Michael Sobell HouseOld RoadHeadingtonOxfordUKOX3 7LJ
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Hoenig H, Lee J, Stineman M. Conceptual Overview of Frameworks for Measuring Quality in Rehabilitation. Top Stroke Rehabil 2015; 17:239-51. [DOI: 10.1310/tsr1704-239] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
BACKGROUND The policy in a number of countries is to provide people with a terminal illness the choice of dying at home. This policy is supported by surveys indicating that the general public and patients with a terminal illness would prefer to receive end of life care at home. OBJECTIVES To determine if providing home-based end of life care reduces the likelihood of dying in hospital and what effect this has on patients' symptoms, quality of life, health service costs and care givers compared with inpatient hospital or hospice care. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library) to October 2009, Ovid MEDLINE(R) 1950 to March 2011, EMBASE 1980 to October 2009, CINAHL 1982 to October 2009 and EconLit to October 2009. We checked the reference lists of articles identified for potentially relevant articles. SELECTION CRITERIA Randomised controlled trials, interrupted time series or controlled before and after studies evaluating the effectiveness of home-based end of life care with inpatient hospital or hospice care for people aged 18 years and older. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed study quality. We combined the published data for dichotomous outcomes using fixed-effect Mantel-Haenszel meta-analysis. When combining outcome data was not possible we presented the data in narrative summary tables. MAIN RESULTS We included four trials in this review. Those receiving home-based end of life care were statistically significantly more likely to die at home compared with those receiving usual care (RR 1.33, 95% CI 1.14 to 1.55, P = 0.0002; Chi (2) = 1.72, df = 2, P = 0.42, I(2) = 0% (three trials; N=652)). We detected no statistically significant differences for functional status (measured by the Barthel Index), psychological well-being or cognitive status, between patients receiving home-based end of life care compared with those receiving standard care (which included inpatient care). Admission to hospital while receiving home-based end of life care varied between trials and this was reflected by high levels of statistically significant heterogeneity in this analysis. There was some evidence of increased patient satisfaction with home-based end of life care, and little evidence of the impact this form of care has on care givers. AUTHORS' CONCLUSIONS The evidence included in this review supports the use of end of life home-care programmes for increasing the number of patients who will die at home, although the numbers of patients being admitted to hospital while receiving end of life care should be monitored. Future research should also systematically assess the impact of end of life home care on care givers.
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Affiliation(s)
- Sasha Shepperd
- Department of Public Health, University of Oxford, Oxford, UK
| | - Bee Wee
- Nuffield Department of Medicine and Sir Michael Sobell House, Churchill Hospital, Oxford, UK
| | - Sharon E Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital and University of Toronto, Toronto, Canada
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Daniels R, Metzelthin S, van Rossum E, de Witte L, van den Heuvel W. Interventions to prevent disability in frail community-dwelling older persons: an overview. Eur J Ageing 2010; 7:37-55. [PMID: 28798616 DOI: 10.1007/s10433-010-0141-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Accepted: 01/20/2010] [Indexed: 12/24/2022] Open
Abstract
This narrative review was conducted to provide an overview of the variety of interventions aimed at disability prevention in community-dwelling frail older persons and to summarize promising elements. The search strategy and selection process found 48 papers that met the inclusion criteria. The 49 interventions described in these 48 papers were categorized into 'comprehensive geriatric assessment', 'physical exercise', 'nutrition', 'technology', and 'other interventions'. There is a large diversity within and between the groups of interventions in terms of content, disciplines involved, duration, intensity, and setting. For 18 of the 49 interventions, significant positive effects for disability were reported for the experimental group. Promising features of interventions seem to be: multidisciplinary and multifactorial, individualized assessment and intervention, case management, long-term follow-up, physical exercise component (for moderate physically frail older persons), and the use of technology. Future intervention studies could combine these elements and consider the addition of new elements.
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Affiliation(s)
- Ramon Daniels
- Faculty of Health and Care, Zuyd University of Applied Sciences, Postbox 550, 6400 AN Heerlen, The Netherlands.,Centre of Research on Autonomy and Participation, Zuyd University of Applied Sciences, Heerlen, the Netherlands.,Centre of Research on Technology in Health Care, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | - Silke Metzelthin
- School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Erik van Rossum
- Centre of Research on Autonomy and Participation, Zuyd University of Applied Sciences, Heerlen, the Netherlands.,Centre of Research on Technology in Health Care, Zuyd University of Applied Sciences, Heerlen, The Netherlands.,School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Luc de Witte
- Centre of Research on Technology in Health Care, Zuyd University of Applied Sciences, Heerlen, The Netherlands.,School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Wim van den Heuvel
- School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
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Abstract
The veterans health care system administered by the U.S. Department of Veterans Affairs (VA) was established after World War I to provide health care for veterans who suffered from conditions related to their military service. It has grown to be the nation's largest integrated health care system. As the system grew, a number of factors contributed to its becoming increasingly dysfunctional. By the mid-1990s, VA health care was widely criticized for providing fragmented and disjointed care of unpredictable and irregular quality, which was expensive, difficult to access, and insensitive to individual needs. Between 1995 and 1999, the VA health care system was reengineered, focusing especially on management accountability, care coordination, quality improvement, resource allocation, and information management. Numerous systemic changes were implemented, producing dramatically improved quality, service, and operational efficiency. VA health care is now considered among the best in America, and the VA transformation is viewed as a model for health care reform.
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Chang C, Jackson SS, Bullman TA, Cobbs EL. Impact of a Home-Based Primary Care Program in an Urban Veterans Affairs Medical Center. J Am Med Dir Assoc 2009; 10:133-7. [DOI: 10.1016/j.jamda.2008.08.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2008] [Revised: 07/17/2008] [Accepted: 08/08/2008] [Indexed: 10/21/2022]
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16
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17
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Martire LM, Lustig AP, Schulz R, Miller GE, Helgeson VS. Is it beneficial to involve a family member? A meta-analysis of psychosocial interventions for chronic illness. Health Psychol 2005; 23:599-611. [PMID: 15546228 DOI: 10.1037/0278-6133.23.6.599] [Citation(s) in RCA: 293] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Links between chronic illness and family relationships have led to psychosocial interventions targeted at the patient's closest family member or both patient and family member. The authors conducted a meta-analytic review of randomized studies comparing these interventions with usual medical care (k=70), focusing on patient outcomes (depression, anxiety, relationship satisfaction, disability, and mortality) and family member outcomes (depression, anxiety, relationship satisfaction, and caregiving burden). Among patients, interventions had positive effects on depression when the spouse was included and, in some cases, on mortality. Among family members, positive effects were found for caregiving burden, depression, and anxiety; these effects were strongest for nondementing illnesses and for interventions that targeted only the family member and that addressed relationship issues. Although statistically significant aggregate effects were found, they were generally small in magnitude. These findings provide guidance in developing future interventions in this area.
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Affiliation(s)
- Lynn M Martire
- University of Pittsburgh, Department of Psychiatry and University Center for Social and Urban Research, Pittsburgh, PA 15260, USA.
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19
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Feldman PH, Peng TR, Murtaugh CM, Kelleher C, Donelson SM, McCann ME, Putnam ME. A randomized intervention to improve heart failure outcomes in community-based home health care. Home Health Care Serv Q 2004; 23:1-23. [PMID: 15160686 DOI: 10.1300/j027v23n01_01] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This study examines the effects of a home health intervention designed to standardize nursing care, strengthen nurses' support for patient self-management and yield better CHF patient outcomes. Participants were 371 Medicare CHF patients served by 205 nurses randomized to intervention and control groups in a large urban home healthcare agency (HHA). The intervention consisted of an evidence-based nursing protocol, patient self-care guide, and training to improve nurses'teaching and support skills. Outcome measures included home care,physician and emergency department (ED) use, hospital admission, condition-specific quality of life (QoL), satisfaction with home care services and survival at 90 days. The intervention was associated with a marginally significant reduction in the volume of skilled nursing visits (p = .074), and a reduction variation in the typical number of visits provided (p < .05), without a significant increase in physician or ED use or patient mortality. Hypothesized improvement in other outcomes did not occur.
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Affiliation(s)
- Penny H Feldman
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, NY 10021, USA.
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20
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Abstract
BACKGROUND A growing number of homebound frail older adults have multiple chronic diseases with frequent flare ups of acute episodes. A physician house call program affiliated with a nonprofit community health system was deployed as a strategy to improve quality of care for homebound patients. PROGRAM DESCRIPTION A medical team (either a physician and a medical assistant or a nurse practitioner), with a vehicle filled with portable medical equipment and supplies, fulfills the house call and primary care physician functions, establishes diagnoses, designs a treatment plan, arranges for any other needed services, and fosters continuity of medical care. EVALUATION Interviews and focus groups with selected patients, family caregivers, program staff, and other service providers indicated that the program operated consistently with its intent. For example, the patient and caregiver interviews converged on four major themes: (1) the program improves patients' medication and health management and optimizes health, (2) caregivers felt more informed about the patients' medical conditions and medications and relieved of the burden of transporting patients to physicians, (3) the program reduces use of hospital and emergency services, and (4) the programs enables patients to die at home. DISCUSSION The success of any future programs and further replications will depend on creating trusting relationships with local service providers and getting decision makers of affiliated community health systems or hospitals to embrace the necessary vision.
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Affiliation(s)
- Naoko Muramatsu
- School of Public Health, University of Illinois at Chicago, Chicago, USA.
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Kodner DL, Kyriacou CK. Bringing managed care home to people with chronic, disabling conditions: prospects and challenges for policy, practice, and research. J Aging Health 2003; 15:189-22. [PMID: 12613468 DOI: 10.1177/0898264302239024] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article examines the challenges and opportunities inherent in the idea that home care organizations may be able to reinvent themselves into managed care systems for the frail elderly and chronically ill. Data come from three sources: (a) existing literature, (b) a survey with experts, and (c) insights from an organization with direct experience in designing and implementing first- and second-generation managed care programs. The authors conclude that although even the best-positioned home care organizations will face significant challenges in transitioning to managed care systems (e.g., establishing medical linkages, building managed care capacity, securing funding, dealing with regulatory hurdles), changes in the environment may enable these challenges to be overcome. Home care organizations are beginning to use innovative techniques to manage care, and those with a strong commitment to the chronically ill may be interested and capable of pursuing the option of becoming home-based managed chronic care programs.
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Affiliation(s)
- Dennis L Kodner
- DLK Care Strategies, Atlantic Highlands, NJ and New York University, USA
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22
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Abstract
This article focuses on the "efficiency" or cost-effectiveness of home care. Because home care encompasses a range of services targeted to many populations, it is necessary to take cognizance of case mix and clarify its goals to assess effectiveness. Goals for home care can be thought of as meeting and/or compensating for client dependency needs or making a difference in the client's clinical trajectory. The latter implies comparing actual to expected outcomes, where outcomes can cover a wide range of domains addressing quality of care and quality of life. Inferring the effect of treatment (i.e., home care) on various outcomes will likely rely heavily on epidemiological techniques that, in turn, rely on sophisticated statistical techniques. Problems measuring the costs of care include how to handle the costs of informal care and deciding whose costs should be of primary concern. Better data about the costs, and experimentation with different forms of caregiving, need to be pursued.
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Affiliation(s)
- R L Kane
- University of Minnesota School of Public Health, USA
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Chapko MK, Hedrick S. Cost as a study outcome: sensitivity of study conclusions to the method of estimating cost. Med Care 1999; 37:AS37-44. [PMID: 10217383 DOI: 10.1097/00005650-199904002-00006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The analyses presented here are intended to provide empirical guidance to two questions faced by researchers performing clinical trials which include a cost component: Which health care services should we track? Should we use facility specific costs or national average costs for individual services in estimating total costs? METHODS We reanalyzed cost data from the Department of Veterans Affairs (VA) multisite clinical trial which compared Adult Day Health Care (ADHC) to Customary Care for patients at high risk for nursing home care. The data presented here compares the original analysis (a combination of local and national costs) to an analysis based on purely facility-specific costs and to an analysis based upon purely VA national costs. Costs for hospital, clinic, nursing home, ADHC, hospital based home care, rehabilitation, pharmacy, and laboratory were included. RESULTS Hospital, nursing home, clinic, and ADHC in combination account for 98% of the variation in total cost per patient. Including only hospital, clinic, nursing home, ADHC, and hospital-based home care in total cost per patient closely replicated the findings for total cost when all services were included. The originally reported analysis and the 2 new analyses, using respectively facility specific costs and national average costs, did differ substantially in the magnitude of the difference between the total cost per patient of ADHC and Customary Care. They did differ with regard to statistical significance as the P values were either slightly above or below 0.05. CONCLUSIONS Ideally all health care costs should be included in the analysis. When this is not feasible, one should determine utilization and cost for the intervention itself, costly services (usually hospital, nursing home, and clinic care), and lower cost services that are likely to be affected by the intervention. Sensitivity analysis should be performed to determine if different methods of costing (eg, facility specific versus national costs) materially affect the conclusions of the study.
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Affiliation(s)
- M K Chapko
- VA Puget Sound Health Care System, Seattle Division, Department of Health Services, University of Washington, 98108, USA.
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24
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Abstract
BACKGROUND Estimates of health care cost are needed to conduct cost-effectiveness research at the facilities operated by the US Department of Veterans Affairs. METHODS The medical literature was searched for VA studies to characterize different cost methods and identify their advantages and disadvantages. RESULTS Different methods are appropriate for different studies. Analysts who wish to capture the effect of an intervention on resources used in a health care encounter may wish to create a detailed pseudo-bill by combining VA utilization data with unit costs from the non-VA sector. If a cost function can be estimated from non-VA data, VA costs may be determined more economically from a reduced list of utilization items. If the analysis involves a new intervention or a program that is unique to VA, direct measurement of staff time and supplies may be needed. It is often sufficient to estimate the average cost of similar encounters, for example, the average of all hospital stays with the same diagnosis and same length of stay. Such estimates may be made by combining VA cost and utilization data bases and by applying judicious assumptions. CONCLUSIONS Assumptions used to estimate costs need to be documented and tested. VA cost-effectiveness research could be facilitated by the creation of a universal cost data base; however, it will not supplant the detailed estimates that are needed to determine the effect of clinical interventions on cost.
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Affiliation(s)
- P G Barnett
- Health Services Research and Development Field Program, US Department of Veterans Affairs, Menlo Park, CA, USA.
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Abstract
BACKGROUND Medicare's home health care program, consisting primarily of home visits by nurses and health aides, was conceived as a means to facilitate hospital discharge. Because home health care is now one of the fastest-growing categories of Medicare expenditures, we analyzed Medicare claims data to determine current patterns of use. METHODS We used 1993 data from Medicare's National Claims History File to examine the temporal relation between home visits and hospital discharge, as well as the number of months Medicare enrollees received home health care. To determine whether home visits replaced hospital services, we calculated population-based utilization rates, adjusted for age and sex, for enrollees living in the 310 U.S. metropolitan statistical areas and determined whether the areas with higher rates of home health care also had lower admission rates or shorter lengths of stay. Finally, we compared the geographic variation in use of home health care with that of other Medicare services. RESULTS Roughly 3 million Medicare enrollees received over 160 million home health care visits in 1993. Seventy-eight percent of the visits either occurred more than a month after hospital discharge (35 percent) or were not associated with any inpatient care during the previous six months (43%). Home health care often represented a long-term intervention: 61 percent of the visits were to enrollees who received home health care for six months or more. We could find no evidence that home health care was substituted for hospital care; the metropolitan statistical areas with higher rates of home health care did not have fewer hospital admissions or shorter lengths of stay. There was more geographic variation in the use of home health care than in the use of other major categories of Medicare services (e.g., hospital admissions and physicians' services). Five states (all in the South) had more than 9000 visits per 1000 enrollees, and 14 states had fewer than 3000 visits per 1000 enrollees. CONCLUSIONS Home health care visits are used primarily to provide long-term care. There is no evidence that services provided at home replace hospital services, and the dramatic geographic variation in home visits suggests a lack of consensus about their appropriate use.
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Affiliation(s)
- H G Welch
- Veterans Affairs Medical Center, White River Junction, VT. 05009, USA
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27
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Williams BC, Fries BE, Mehr DR. Patterns and determinants of health services use and mortality after VA nursing home care. J Aging Health 1996; 8:280-301. [PMID: 10160562 DOI: 10.1177/089826439600800207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Risk factors for institutionalization and death for up to four years for a nationwide cohort (n = 6,488) of males discharged alive from Department of Veterans Affairs (DVA) nursing homes were identified through linked records of the DVA. Two-year cumulative probabilities of nursing home readmission, hospitalization, and death among nursing home dischargees were 0.30, 0.61, and 0.24, respectively. Using multivariate survival analyses, chronic functional impairments and past nursing home use were important predictors of nursing home readmission, whereas hospitalizations for exacerbations of chronic medical conditions were predictors of hospitalization and death. Past hospitalizations predicted all three outcomes. Differences in risk factors for nursing home readmission as compared with hospitalization or death among DVA nursing home dischargees suggest that high-risk patients can be identified at nursing home discharge and that different types of interventions will be necessary to decrease nursing home readmission as compared with hospitalization or death. Future development of linked record systems across multiple settings, both within and outside the DVA, will help to further characterize persons at high risk of institutionalization or death and to design and evaluate targeted interventions to decrease this risk.
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Affiliation(s)
- B C Williams
- University of Michigan, Ann Arbor VA Medical Center, USA
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Ashton CM, Menke TJ, Deykin D, Camberg LC, Charns MP. A state-of-the-art conference on databases pertaining to veterans' health. A resource for research and decision making. Med Care 1996; 34:MS1-8. [PMID: 8598681 DOI: 10.1097/00005650-199603001-00001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- C M Ashton
- Houston Center for Quality of Care and Utilization Studies, TX, USA
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Weissert WG, Hedrick SC. Lessons learned from research on effects of community-based long-term care. J Am Geriatr Soc 1994; 42:348-53. [PMID: 8120322 DOI: 10.1111/j.1532-5415.1994.tb01763.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- W G Weissert
- School of Public Health, University of Michigan, Ann Arbor 48109-2029
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30
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Length of Acute-Care Hospitalization in Alzheimer's Disease. Am J Geriatr Psychiatry 1993; 1:339-342. [PMID: 28530912 DOI: 10.1097/00019442-199300140-00008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/1992] [Revised: 05/09/1993] [Accepted: 06/15/1993] [Indexed: 11/26/2022]
Abstract
The authors conducted a retrospective study of acute-care hospitalization over a 2-year period for patients diagnosed with Alzheimer's disease (AD). These patients were compared to an age- and gender-matched group of non-AD patients. AD patients had fewer admissions and fewer comorbid medical diagnoses, but had a significantly longer total length of hospital stay. Possible explanations for the increased length of stay and suggestions for further research are discussed.
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Wan TT, Ferraro KF. Assessing the impacts of community-based health care policies and programs for older adults. J Appl Gerontol 1991; 10:35-52. [PMID: 10113552 DOI: 10.1177/073346489101000104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This article presents a framework for evaluating long-term care policies and programs to determine how well community-based programs benefit the older adult population. Equity, accessibility, quality, and efficiency are identified as core criteria for implementing and evaluating long-term care policy. Special problems with conducting process and/or outcome evaluation of community-based programs are noted, and findings of evaluation research on community-based health care programs are reviewed. Most previous research indicates that community-based health programs for older adults are not a substitute for institutional care and do not reduce either informal caregiving or ambulatory medical services. The article concludes with policy implications.
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Affiliation(s)
- T T Wan
- Medical College of Virginia, Virginia Commonwealth University
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