The (cost-)effectiveness of preventive, integrated care for community-dwelling frail older people: A systematic review

Does Allostatic Load in 50-89-Year-Olds Predict the Development of Frailty? Evidence From a National Longitudinal Study Over 12 Years

Frailty is characterised by a loss of function across several domains but is not an inevitable aspect of ageing and can be reversed with intervention. Determining those who are more likely to become frail before physical deficits become manifest will allow earlier intervention. One promising indicator of the potential for frailty is allostatic load, a physiological status associated with prolonged stress that is, characterised by multisystem dysfunction. Previous research has sought to understand the links between allostatic load and frailty, but has not yet explored whether allostatic load may be a predictive factor at younger ages and-if so-at what age it may be predictive. The present study sets out establish whether allostatic load can be used as a predictive indicator of frailty. Using the English Longitudinal Survey on Ageing (ELSA) data with an anticipated sample of 1500 people between 50 and 89 years old, time series analysis will determine if, and at what age, allostatic load may be predictive of pre-frailty and frailty. The findings of these analyses may be supportive of early identification of frailty by establishing an age at which a diagnostic test for allostatic load may prove a critical indicator for future frailty.

'"Health" Is Just One Piece in the Puzzle of Wellbeing': Shifting From Preventing Health Deterioration to Improving Wellbeing in a Participatory Action Research Project With Care-Experienced Older People

INTRODUCTION

Prevention of health deterioration is a key policy objective in Sweden informed by active and healthy ageing initiatives. However, the perspectives of older people with mobility and health limitations on current prevention initiatives are seldom gained meaning these initiatives may fail to align to with the priorities of people whose health has ostensibly already deteriorated. We aimed to explore older care-experienced people's perspectives on the topic of health deterioration prevention and highlight aspects that they think are important to prioritise.

METHOD

Eight older people with experience in giving or receiving formal or informal care were involved as lay co-researchers in a participatory action research project that involved recruiting 11 further older informants to participate in peer interviews or complete a logbook. In a series of 13, 2-h workshops held over 1 year, we undertook data generation, training, reflection and analytic activities inspired by framework analysis.

FINDINGS

The lay co-researchers found the topic of health deterioration to be negatively and narrowly focussed opting instead to pursue a focus on articulating aspects, or puzzle pieces, that influence the improvement of wellbeing. Six influential puzzle pieces (stigma, digitalisation, services, losses, meaning and interactions) were regarded as important to prioritise which together illustrated that wellbeing is continually shaped in an interplay with dominant, but manipulable, social norms.

CONCLUSION

This study highlights how the language of active and healthy ageing, which pervades policy and practice, is imbued with ageist and ableist subtexts that can influence older people's wellbeing and lead to exclusionary experiences in society. We highlight wider societal trends, particularly digitalisation and effectivisation, whose negative impact on older people's wellbeing could be mitigated through inclusive co-design and resistance to normative influences.

PUBLIC CONTRIBUTION

This project was initiated in dialogue with stakeholder representatives from pensioner organisations in a larger scale participatory action research project. The care-experienced lay co-researchers collaborated in all phases of this project-gaining funding, formulating research questions, planning the study design, generating data in peer interviews, analysing and interpreting data, disseminating findings, prioritising future research and co-authoring articles.

A Novel Integrated Geriatric Services Hub for Frailty Identification and Comprehensive Management of Community-Dwelling Older Adults in Singapore: Impact on Health Service Utilization

BACKGROUND

Healthcare systems need to address the high healthcare use of frail older adults. The Geriatric Services Hub (GSH) is a novel program in Singapore that delivers frailty screening, comprehensive geriatric assessment and coordinated care for community-dwelling older persons with bio-psycho-social needs. We aimed to evaluate the effects of the GSH on healthcare use.

METHODS

We compared healthcare utilization of 634 GSH participants with 634 unique propensity score-matched non-GSH community-dwelling older adults at 12 months before and after GSH enrolment. Baseline matching covariates included demographics, socioeconomic status, disease burden, calendar quarter of enrolment, and past healthcare utilization. We did exact matching on frailty categories (Clinical Frailty Score (CFS) score 4, 5, and 6-7). Difference-in-differences technique was used to derive effect estimates.

RESULTS

After propensity score matching, baseline covariates were adequately balanced. Healthcare utilization declined in both groups after GSH enrolment. Relative to the comparators and after accounting for pre-enrolment differences, participation in the GSH was associated with greater primary care (mean difference: 0.06, 95% CI-0.64 to 0.77) and specialist outpatient clinic visits (mean difference: 0.42, 95% CI -0.29 to 1.13), and fewer emergency department visits (mean difference: -0.18, 95% CI -0.69 to 0.34). However, these effects did not reach statistical significance. While number of hospitalizations did not differ between the groups, cumulative length of stay differed by 1.15 bed-days and was not statistically significant. No statistically significant differences were observed within CFS groups.

CONCLUSION

GSH was not associated with significant reductions in healthcare use in the first year of enrolment. Higher utilization of primary care and specialist outpatient clinic services could reflect the increased identification of care needs with the potential to reduce unnecessary healthcare use such as emergency department visits. Prospective studies with a longer follow-up would ascertain if the GSH translates to reduced healthcare utilization as hypothesized.

The valuation of older adult homecare services under a joint medical-social budgetary perspective

Background

Homecare, a cornerstone of public health, is essential for health systems to achieve the Sustainable Development Goal (SDG) of universal health coverage while maintaining its own sustainability. Notwithstanding homecare's system-level significance, there is a lack of economic evaluations of homecare services in terms of their system-wide cost-savings. Specifically, decisions informed by a joint medical-social budgetary perspective can maximize the allocative efficiency of assigning a diverse service mix to address the complex needs of the older adult population. However, little is known regarding which homecare service mix is most system-wide cost-effective when paired with which clinical profiles.

Methods

Valuation of homecare's complex interventions was performed under a generalized cost-effectiveness analysis (GCEA) framework with proportional hazard-adjusted metrics representing the common numeraire between medical and social care.

Results

Instrumental homecare, on its own or combined with either one or both of the other homecare services, yielded the greatest cost savings compared to other services or the lack thereof. When expressed under a joint medical-social budgetary perspective, instrumental homecare can reduce medical costs of HK$34.53 (US$4.40) and HK$85.03 (US$10.84) for every HK$1 (US$0.13) invested in instrumental and instrumental-restorative homecare, respectively.

Conclusion

Instrumental homecare can increase hospitalization-free days among community-dwelling older adult and yield significant net system-wide cost savings. Thus, the current study demonstrated the feasibility of data-informed decision-making in system-wide resource allocation under a joint medical-social budget perspective.

Integrated care for older people improved intrinsic capacity in elderly patients: a case control study

OBJECTIVES

Observe the effect of integrated care for older people on intrinsic capacity in elderly patients.

METHODS

Sixty elderly patients from department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology between June 2021 and December 2021 were selected and divided into control group and intervention group with 30 patients in each group using random sampling method. Two groups implement routine care, and the intervention group implement integrated care by a "hospital-community-family" multidisciplinary team. After 12 weeks of intervention, the differences in frailty, cognition, depression scores, comprehension social support scores, and World Quality of Life Scale scores were compared between the two groups.

RESULTS

Before intervention, there was no significant difference in the grip strength, step speed, frailty scores, cognition, depression scores, social support and quality of survival between the control group and the intervention group. After intervention, grip strength and depression scores improved both in the control group and the intervention group, but there was no difference between the two groups. Cognitive scores, comprehension social support and quality of survival scores improved only in the intervention group, while only the cognitive ability showed significant differences between the intervention group and the control group after 12 weeks of intervention (P<0.05).

CONCLUSIONS

Integrated care for older people intervention can help to improve the intrinsic capacity of the patients, especially cognitive abilities.

Impact of frailty in older people on health care demand: simulation modelling of population dynamics to inform service planning

Background

As populations age, frailty and the associated demand for health care increase. Evidence needed to inform planning and commissioning of services for older people living with frailty is scarce. Accurate information on incidence and prevalence of different levels of frailty and the consequences for health outcomes, service use and costs at population level is needed.

Objectives

To explore the incidence, prevalence, progression and impact of frailty within an ageing general practice population and model the dynamics of frailty-related healthcare demand, outcomes and costs, to inform the development of guidelines and tools to facilitate commissioning and service development.

Study design and methods

A retrospective observational study with statistical modelling to inform simulation (system dynamics) modelling using routine data from primary and secondary health care in England and Wales. Modelling was informed by stakeholder engagement events conducted in Hampshire, England. Data sources included the Royal College of General Practitioners Research and Surveillance Centre databank, and the Secure Anonymised Information Linkage Databank. Population prevalence, incidence and progression of frailty within an ageing cohort were estimated using the electronic Frailty Index tool, and associated service use and costs were calculated. Association of frailty with outcomes, service use and costs was explored with multistate and generalised linear models. Results informed development of a prototype system dynamics simulation model, exploring population impact of frailty and future scenarios over a 10-year time frame. Simulation model population projections were externally validated against retrospective data from Secure Anonymised Information Linkage.

Study population

The Royal College of General Practitioners Research and Surveillance Centre sample comprised an open cohort of the primary care population aged 50 + between 2006 and 2017 (approx. 2.1 million people). Data were linked to Hospital Episode Statistics data and Office for National Statistics death data. A comparable validation data set from Secure Anonymised Information Linkage was generated.

Baseline measures

Electronic Frailty Index score calculated annually and stratified into Fit, Mild, Moderate and Severe frailty categories. Other variables included age, sex, Index of Multiple Deprivation score, ethnicity and Urban/rural.

Outcomes

Frailty transitions, mortality, hospitalisations, emergency department attendances, general practitioner visits and costs.

Findings

Frailty is already present in people aged 50-64. Frailty incidence was 47 cases per 1000 person-years. Frailty prevalence increased from 26.5% (2006) to 38.9% (2017). Older age, higher deprivation, female sex, Asian ethnicity and urban location independently predict frailty onset and progression; 4.8% of 'fit' people aged 50-64 years experienced a transition to a higher frailty state in a year, compared to 21.4% aged 75-84. Individual healthcare use rises with frailty severity, but Mild and Moderate frailty groups have higher overall costs due to larger population numbers. Simulation projections indicate frailty will increase by 7.1%, from 41.5% to 48.7% between 2017 and 2027, and associated costs will rise by £5.8 billion (in England) over an 11-year period.

Conclusions

Simulation modelling indicates that frailty prevalence and associated service use and costs will continue to rise in the future. Scenario analysis indicates reduction of incidence and slowing of progression, particularly before the age of 65, has potential to substantially reduce future service use and costs, but reducing unplanned admissions in frail older people has a more modest impact. Study outputs will be collated into a commissioning toolkit, comprising guidance on drivers of frailty-related demand and simulation model outputs.

Study registration

This study is registered as NCT04139278 www.clinicaltrials.gov.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/116/43) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 44. See the NIHR Funding and Awards website for further award information.

Women's Health Hubs: a rapid mixed-methods evaluation

Background

Women's sexual and reproductive health needs are complex and vary across the life course. They are met by a range of providers, professionals and venues. Provision is not well integrated, with inequalities in access. In some areas of the United Kingdom Women's Health Hubs have been established to improve provision, experience and outcomes for women, and to address inequalities and reduce costs. These models were established prior to the national implementation of Women's Health Hubs announced in the English 2022 Women's Health Strategy.

Objective

To explore the 'current state of the art', mapping the United Kingdom landscape, and studying experiences of delivering and using Women's Health Hubs across England, defining key features and early markers of success to inform policy and practice.

Design

A mixed-methods evaluation, comprising three work packages: Mapping the Women's Health Hub landscape and context and developing a definition of Women's Health Hubs, informed by an online national survey of Women's Health Hub leaders, and interviews with regional stakeholders. In-depth evaluation in four hub sites, including interviews with staff and women, focus groups in local communities and documentary analysis. Interviews with national stakeholders and consolidation of findings from work packages 1 and 2. Fieldwork was undertaken from May 2022 to March 2023. The evaluation was initiated prior to the national scale-up of Women's Health Hubs announced in the 2022 Women's Health Strategy.

Results

Most areas of the United Kingdom did not have a Women's Health Hub. Seventeen active services were identified, established between 2001 and 2022. Women's Health Hubs were diverse, predominantly GP-led, with different perspectives of the role and definition of a hub. Women using hubs reported positive experiences, finding services caring and convenient. Implementation facilitators included committed, collaborative leaders working across boundaries, sufficient workforce capacity and a supportive policy context. Challenges included access to funding, commissioning, workforce issues, facilities and equipment, stakeholder engagement and wider system integration, priorities and pressures. Leaders were committed to addressing inequalities, but evidence of impact was still emerging.

Limitations

It was challenging to locate models; therefore, some may have been missed. Data availability limited assessment of impact, including inequalities. Some population groups were not represented in the data, and the evaluation was more provider-oriented. It was not possible to develop a typology of Women's Health Hubs as planned due to heterogeneity in models.

Conclusions

Existing Women's Health Hub models were providing integrated approaches to meet local needs. Many were at an early stage of development. Evidence of system-level impact and costs was still emerging. Women's Health Hubs may widen inequalities if models are more accessible to advantaged groups. The important role of committed leaders in existing 'bottom-up' models may limit scalability and sustainability. Findings suggest that national scale-up will take time and requires funding and that it is necessary to design models according to local needs and resources. In 2023, the Department of Health and Social Care announced funding to establish a Women's Health Hub in every Integrated Care System in England.

Future work

Future evaluation should consider system-level impact and costs, explore unintended consequences and test assumptions.

Funding

This award was funded by the National Institute of Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135589) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 30. See the NIHR Funding and Awards website for further award information.

Inside the Black Box: Examining the Interconnectivity of Components of Integrated Person-Centred Care for Vulnerable Groups Through a Realist Lens

Integrated person-centred care (IPCC) for vulnerable groups is complex and multifaceted and cannot be reduced to simple cause-and-effect relationships. The effectiveness varies across settings due to differing contexts and mechanisms. By applying realist research, this dissertation examines the relationships between the context in which IPCC for vulnerable groups in the Netherlands is applied, the mechanisms by which IPCC (does not) work(s), and the outcomes resulting from this interaction. The findings provide deeper insights into interrelatedness of items that influence effectiveness of IPCC, emphasizing the significance of understanding their interplay and recognizing that they form a larger interconnected system rather than acting independently.

Healthcare Professionals' Perceptions about the Implementation of Shared Decision-Making in Primary Care: A Qualitative Study from a Virtual Community of Practice

Background

The incorporation of shared decision making (SDM) is a central part of empowerment processes, as it facilitates greater activation on the part of patients, increasing the likelihood of them gaining control over their healthcare and developing skills to solve their health problems. Despite these benefits, there are still difficulties in the implementation of SDM among healthcare professionals due to internal and external factors related to the context and health systems.

Aim

To explore primary care professionals (PCPs)' perceptions of the SDM model, based on their preconceptions and experience in clinical practice.

Methods

A framework analysis was conducted on qualitative data derived from a virtual community practice forum, within a cluster-randomized clinical trial developed in the e-MPODERA project.

Results

The most important points in the opinions of the PCPs were: exploring the patients' values, preferences and expectations, providing them with and checking their understanding of up-to-date and evidence-based health information. The analysis revealed three themes: determinants of the implementation process of SDM, lack of consistency and dilemmas and benefits of PCP active listening, motivation and positive expectations of SDM.

Discussion

In our initial analysis, we examined the connections between the categories of the TDC model and its application in the primary care context. The categories related to the model reflect the theoretical understanding of professionals, while those related to perceptions of its application and use show certain discrepancies. These discrepancies could indicate a lack of understanding of the model and its real-world implications or insufficient commitment on the part of professionals or the organization to ensure its effective implementation.

Conclusions

Specific targeted training that addresses knowledge, attitudes and practice may resolve the aforementioned findings.

Preventive interventions to improve older people's health outcomes: systematic review and meta-analysis

BACKGROUND

Systematic reviews of preventive, non-disease-specific primary care trials for older people often report effects according to what is thought to be the intervention's active ingredient.

AIM

To examine the effectiveness of preventive primary care interventions for older people and to identify common components that contribute to intervention success.

DESIGN AND SETTING

A systematic review and meta-analysis of 18 randomised controlled trials (RCTs) published in 22 publications from 2009 to 2019.

METHOD

A search was conducted in PubMed, MEDLINE, Embase, Web of Science, CENTRAL, CINAHL, and the Cochrane Library. Inclusion criteria were: sample mainly aged ≥65 years; delivered in primary care; and non-disease-specific interventions. Exclusion criteria were: non-RCTs; primarily pharmacological or psychological interventions; and where outcomes of interest were not reported. Risk of bias was assessed using the original Cochrane tool. Outcomes examined were healthcare use including admissions to hospital and aged residential care (ARC), and patient-reported outcomes including activities of daily living (ADLs) and self-rated health (SRH).

RESULTS

Many studies had a mix of patient-, provider-, and practice-focused intervention components (13 of 18 studies). Studies included in the review had low-to-moderate risk of bias. Interventions had no overall benefit to healthcare use (including admissions to hospital and ARC) but higher basic ADL scores were observed (standardised mean difference [SMD] 0.21, 95% confidence interval [CI] = 0.01 to 0.40) and higher odds of reporting positive SRH (odds ratio [OR] 1.17, 95% CI = 1.01 to 1.37). When intervention effects were examined by components, better patient-reported outcomes were observed in studies that changed the care setting (SMD for basic ADLs 0.21, 95% CI = 0.01 to 0.40; OR for positive SRH 1.17, 95% CI = 1.01 to 1.37), included educational components for health professionals (SMD for basic ADLs 0.21, 95% CI = 0.01 to 0.40; OR for positive SRH 1.27, 95% CI = 1.05 to 1.55), and provided patient education (SMD for basic ADLs 0.28, 95% CI = 0.09 to 0.48). Additionally, admissions to hospital in intervention participants were fewer by 23% in studies that changed the care setting (incidence rate ratio [IRR] 0.77, 95% CI = 0.63 to 0.95) and by 26% in studies that provided patient education (IRR 0.74, 95% CI = 0.56 to 0.97).

CONCLUSION

Preventive primary care interventions are beneficial to older people's functional ability and SRH but not other outcomes. To improve primary care for older people, future programmes should consider delivering care in alternative settings, for example, home visits and phone contacts, and providing education to patients and health professionals as these may contribute to positive outcomes.

Effectiveness of care models for chronic disease management: A scoping review of systematic reviews

OBJECTIVE

To conduct a scoping review of models of care for chronic disease management to identify potentially effective components for management of chronic traumatic brain injury (TBI).

METHODS

Information sources: Systematic searches of three databases (Ovid MEDLINE, Embase, and Cochrane Database of Systematic Reviews) from January 2010 to May 2021.

ELIGIBILITY CRITERIA

Systematic reviews and meta-analyses reporting on the effectiveness of the Chronic Care Model (CCM), collaborative/integrated care, and other chronic disease management models.

DATA

Target diseases, model components used (n = 11), and six outcomes (disease-specific, generic health-related quality of life and functioning, adherence, health knowledge, patient satisfaction, and cost/health care use).

SYNTHESIS

Narrative synthesis, including proportion of reviews documenting outcome benefits.

RESULTS

More than half (55%) of the 186 eligible reviews focused on collaborative/integrated care models, with 25% focusing on CCM and 20% focusing on other chronic disease management models. The most common health conditions were diabetes (n = 22), depression (n = 16), heart disease (n = 12), aging (n = 11), and kidney disease (n = 8). Other single medical conditions were the focus of 22 reviews, multiple medical conditions of 59 reviews, and other or mixed mental health/behavioral conditions of 20 reviews. Some type of quality rating for individual studies was conducted in 126 (68%) of the reviews. Of reviews that assessed particular outcomes, 80% reported disease-specific benefits, and 57% to 72% reported benefits for the other five types of outcomes. Outcomes did not differ by the model category, number or type of components, or target disease.

CONCLUSIONS

Although there is a paucity of evidence for TBI per se, care model components proven effective for other chronic diseases may be adaptable for chronic TBI care.

Effectiveness of information and communication technology-based integrated care for older adults: a systematic review and meta-analysis

Background

Information and communication technology (ICT) is a key factor in advancing the implementation of integrated care for older adults in the context of an aging society and the normalization of epidemics. This systematic review aims to comprehensively evaluate the effectiveness of ICT-based integrated care for older adults to provide input for the construction of intelligent integrated care models suitable for the context of an aging population in China.

Methods

A systematic review and meta-analysis were conducted using PubMed, Web of Science Core Collection, Scopus, MEDLINE, EBSCO, EMBASE, CINAHL with full text, ProQuest, and Cochrane Library databases, along with the Google Scholar search engine, for papers published between January 1, 2000, and July 25, 2022, to include randomized controlled trials and quasi-experimental studies of ICT-based integrated care for older adults. Two reviewers independently performed literature screening, quality assessment (JBI standardized critical appraisal tool), and data extraction. The results were pooled using a random effects model, and narrative synthesis was used for studies with insufficient outcome data.

Results

We included 32 studies (21 interventions) with a total of 30,200 participants (14,289 in the control group and 15,911 in the intervention group). However, the quality of the literature could be improved. The meta-analysis results showed that ICT-based integrated care significantly improved the overall perceived health status of older adults (n=3 studies, MD 1.29 (CI 0.11 to 2.46), no heterogeneity) and reduced the number of emergency department visits (n=11 studies, OR 0.46 (CI 0.25 to 0.86), high heterogeneity) but had no significant effect on improving quality of life, mobility, depression, hospital admissions and readmissions, or mortality in older adults, with a high degree of study heterogeneity. Narrative analysis showed that the overall quality of care, primary care service use, and functional status of older adults in the intervention group improved, but the cost-effectiveness was unclear.

Conclusions

ICT-based integrated care is effective in improving health outcomes for older adults, but the quality and homogeneity of the evidence base need to be improved. Researchers should develop intelligent integrated care programs in the context of local health and care welfare provision systems for older adults, along with the preferences and priorities of the older adults.

DementiaNet facilitates a sustainable transition toward integrated primary dementia care: A long-term evaluation

INTRODUCTION

Care integration is a promising strategy to achieve sustainable health-care systems. With DementiaNet, a 2-year program, we facilitated collaboration between primary health-care professionals. We studied changes in primary dementia care integration during and after DementiaNet participation.

METHODS

A longitudinal follow-up study was performed. Networks started between 2015 and 2020; follow-up ended in 2021. Quantitative and quantitative data were collected annually to assess quality of care, network collaboration, and number of crisis admissions. Growth modeling was used to identify changes over time.

RESULTS

Thirty-five primary care networks participated. Network collaboration and quality of care of newly formed networks increased significantly in the first 2 years (respectively, 0.35/year, P < .001; 0.29/year, P < .001) and thereafter stabilized.

CONCLUSION

Primary care networks improved their collaboration and quality of care during DementiaNet participation, which persisted after the program ended. This indicates that DementiaNet facilitated a sustainable transition toward integrated primary dementia care.

The development of an integrated neighborhood approach for health promotion and prevention: a qualitative exploration of stakeholders' views

BACKGROUND

Although the promise of integrated neighborhood approaches, including the essential roles of communities and collaboration between the medical and social domains, has been widely acknowledged, the realization of such approaches in practice often remains difficult. To gain insight into the development of integrated neighborhood approaches, this case study describes the experiences of stakeholders involved in such an approach for health promotion and prevention in Rotterdam.

METHODS

Interviews with 18 stakeholders (including health and social care professionals, health insurance employees, and policymakers) were conducted, and stakeholders' statements were analyzed thematically.

RESULTS

The results reveal a lack of alignment among the professional, organizational, and system levels. Elements needed for collaboration between health and social care professionals are not supported at the organizational and system levels. The lack of integration at the policy and organizational levels encourages competition and self-interest instead of stimulating collaboration.

CONCLUSIONS

Intersectoral collaboration and coordination must take place not only between professionals, but also at the organizational and policy levels. As long as integration at the organizational and system levels is lacking, professionals' ability to collaborate and provide coordinated support to neighborhood residents will be compromised.

Effectiveness of holistic assessment-based interventions for adults with multiple long-term conditions and frailty: an umbrella review of systematic reviews

Holistic assessment-based interventions (HABIs) are effective in older people admitted to hospital, but it is unclear whether similar interventions are effective in adults with multiple long-term conditions or frailty in the community. We conducted an umbrella review to comprehensively evaluate the literature on HABIs for adults (aged ≥18 years) with multiple long-term conditions, and frailty. We searched eight databases for systematic reviews reporting on experimental or quasi-experimental studies. Of 9803 titles screened, we identified 29 eligible reviews (14 with meta-analysis) reporting on 14 types of HABIs. The evidence for the effectiveness of HABIs was largely inconsistent across different types of interventions, settings, and outcomes. We found evidence of no benefit from hospital HABIs on health-related quality of life (HRQoL) and emergency department re-attendance, and evidence of no benefit from community HABIs on overall health-care utilisation rates, emergency department attendance, nursing home admissions, and mortality. The best evidence of effectiveness was for hospital comprehensive geriatric assessment (CGA) on nursing home admissions, keeping patients alive and in their own homes. There was some evidence of benefit from community CGA on hospital admissions, and from CGA spanning community and hospital settings on HRQoL. Patient-centred medical homes had beneficial effects on HRQoL, mental health, self-management, and hospital admissions.

An Integrated Patient-Centred Medical Home (PCMH) Care Model Reduces Prospective Healthcare Utilisation for Community-Dwelling Older Adults with Complex Needs: A Matched Observational Study in Singapore

The global ageing population is associated with increased health service use. The PCMH care model integrates primary care and home-based care management to deliver comprehensive and personalised healthcare to community-dwelling older adults with bio-psycho-social needs. We examined if an integrated PCMH reduced healthcare utilisation burden of older persons in Singapore. We compared the healthcare utilisation between the intervention group and coarsened exact matched controls for a follow-up of 15 months. Baseline matching covariates included socio-demographics, health status, and past healthcare use. We accounted for COVID-19 social distancing effects on health-seeking behaviour. The intervention group consisted of 165 older adults with complex needs. We analysed national administrative healthcare utilisation data from 2017 to 2020. We applied multivariable zero-inflated regression modelling and presented findings stratified by high (CCI ≥ 5) and low disease burden (CCI < 5). Compared to controls, there were significant reductions in emergency department (β = -0.85; 95%CI = -1.55 to -0.14) and primary care visits (β = -1.70; 95%CI = -2.17 to -1.22) and a decrease in specialist outpatient visits (β = -0.29; 95%CI = -0.64 to 0.07) in the 3-month period immediately after one-year enrolment. The number of acute hospitalisations remained stable. Compared to controls, the intervention group with high and low comorbidity burden had significant decreases in primary care use, while only those with lower comorbidity burden had significant reductions in utilisation of other service types. An integrated PCMH appears beneficial in reducing healthcare utilisation for older persons with complex needs after 1 year in the programme. Future research can explore longer-term utilisation and scalability of the care model.

Effectiveness of interventions to address different types of vulnerabilities in community-dwelling older adults: An umbrella review

Background

Frailty, social isolation, loneliness, and poverty may render older adults vulnerable to social or health stressors. It is imperative to identify effective interventions to address them especially in the context of COVID-19 pandemic.

Objective

To identify effective community-based interventions to address frailty, social isolation, loneliness, and poverty among community-dwelling older adults.

Design

Umbrella review.

Data Source

We systematically searched PubMed, Ovid MEDLINE, Embase, Cochrane CENTRAL, EBM-Reviews, CINAHL via EBSCO, and APA PsycInfo via Ovid from January 2009 to December 2022.

Eligibility Criteria

We included systematic reviews or quantitative reviews of non-pharmacologic interventions targeting community-dwelling older adults.

Data Selection Extraction and Management

Two review authors independently screened the titles and abstracts, performed data extraction and appraised the methodological quality of the reviews. We used a narrative synthesis approach to summarize and interpret the findings. We assessed the methodological quality of the studies using AMSTAR 2.0 tool.

Results

We identified 27 reviews incorporating 372 unique primary studies that met our inclusion criteria. Ten of the reviews included studies conducted in low-middle-income countries. Twelve reviews (46%, 12/26) included interventions that addressed frailty. Seventeen reviews (65%, 17/26) included interventions that addressed either social isolation or loneliness. Eighteen reviews included studies with single component interventions, while 23 reviews included studies with multi-component interventions. Interventions including protein supplementation combined with physical activity may improve outcomes including frailty status, grip strength, and body weight. Physical activity alone or in combination with diet may prevent frailty. Additionally, physical activity may improve social functioning and interventions using digital technologies may decrease social isolation and loneliness. We did not find any review of interventions addressing poverty among older adults. We also noted that few reviews addressed multiple vulnerabilities within the same study, specifically addressed vulnerability among ethnic and sexual minority groups, or examined interventions that engaged communities and adapted programs to local needs.

Conclusion

Evidence from reviews support diets, physical activity, and digital technologies to improve frailty, social isolation or loneliness. However, interventions examined were primarily conducted under optimal conditions. There is a need for further interventions in community settings and conducted under real world settings in older adults living with multiple vulnerabilities.

Case management for integrated care of older people with frailty in community settings

BACKGROUND

Ageing populations globally have contributed to increasing numbers of people living with frailty, which has significant implications for use of health and care services and costs. The British Geriatrics Society defines frailty as "a distinctive health state related to the ageing process in which multiple body systems gradually lose their inbuilt reserves". This leads to an increased susceptibility to adverse outcomes, such as reduced physical function, poorer quality of life, hospital admissions, and mortality. Case management interventions delivered in community settings are led by a health or social care professional, supported by a multidisciplinary team, and focus on the planning, provision, and co-ordination of care to meet the needs of the individual. Case management is one model of integrated care that has gained traction with policymakers to improve outcomes for populations at high risk of decline in health and well-being. These populations include older people living with frailty, who commonly have complex healthcare and social care needs but can experience poorly co-ordinated care due to fragmented care systems.

OBJECTIVES

To assess the effects of case management for integrated care of older people living with frailty compared with usual care.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Health Systems Evidence, and PDQ Evidence and databases from inception to 23 September 2022. We also searched clinical registries and relevant grey literature databases, checked references of included trials and relevant systematic reviews, conducted citation searching of included trials, and contacted topic experts.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared case management with standard care in community-dwelling people aged 65 years and older living with frailty.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures recommended by Cochrane and the Effective Practice and Organisation of Care Group. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 20 trials (11,860 participants), all of which took place in high-income countries. Case management interventions in the included trials varied in terms of organisation, delivery, setting, and care providers involved. Most trials included a variety of healthcare and social care professionals, including nurse practitioners, allied healthcare professionals, social workers, geriatricians, physicians, psychologists, and clinical pharmacists. In nine trials, the case management intervention was delivered by nurses only. Follow-up ranged from three to 36 months. We judged most trials at unclear risk of selection and performance bias; this consideration, together with indirectness, justified downgrading the certainty of the evidence to low or moderate. Case management compared to standard care may result in little or no difference in the following outcomes. • Mortality at 12 months' follow-up (7.0% in the intervention group versus 7.5% in the control group; risk ratio (RR) 0.98, 95% confidence interval (CI) 0.84 to 1.15; I2 = 11%; 14 trials, 9924 participants; low-certainty evidence) • Change in place of residence to a nursing home at 12 months' follow-up (9.9% in the intervention group versus 13.4% in the control group; RR 0.73, 95% CI 0.53 to 1.01; I2 = 0%; 4 trials, 1108 participants; low-certainty evidence) • Quality of life at three to 24 months' follow-up (results not pooled; mean differences (MDs) ranged from -6.32 points (95% CI -11.04 to -1.59) to 6.1 points (95% CI -3.92 to 16.12) when reported; 11 trials, 9284 participants; low-certainty evidence) • Serious adverse effects at 12 to 24 months' follow-up (results not pooled; 2 trials, 592 participants; low-certainty evidence) • Change in physical function at three to 24 months' follow-up (results not pooled; MDs ranged from -0.12 points (95% CI -0.93 to 0.68) to 3.4 points (95% CI -2.35 to 9.15) when reported; 16 trials, 10,652 participants; low-certainty evidence) Case management compared to standard care probably results in little or no difference in the following outcomes. • Healthcare utilisation in terms of hospital admission at 12 months' follow-up (32.7% in the intervention group versus 36.0% in the control group; RR 0.91, 95% CI 0.79 to 1.05; I2 = 43%; 6 trials, 2424 participants; moderate-certainty evidence) • Change in costs at six to 36 months' follow-up (results not pooled; 14 trials, 8486 participants; moderate-certainty evidence), which usually included healthcare service costs, intervention costs, and other costs such as informal care.

AUTHORS' CONCLUSIONS

We found uncertain evidence regarding whether case management for integrated care of older people with frailty in community settings, compared to standard care, improved patient and service outcomes or reduced costs. There is a need for further research to develop a clear taxonomy of intervention components, to determine the active ingredients that work in case management interventions, and identify how such interventions benefit some people and not others.

Challenges to Systems of Long-Term Care: Mapping of the Central Concepts from an Umbrella Review

The ageing of the population poses urgent challenges to the health and social protection sectors, including the need for greater adequacy and integration of health care services provided to older people. It is considered necessary and urgent to understand the state-of-the-art of community-based models of care for older people in institutional care and at home. This study aims to map the concepts that politicians and providers need to address through an umbrella review as a review method. Articles describing the structuring aspects of care models appropriate to the needs in long-term care and systematic reviews or meta-analyses targeting people aged 65 years or more were considered. A total of 350 studies met the inclusion criteria and were included in the review. The results identified the need to contribute to effective and more efficient integration and articulation of all the stakeholders, based essentially on professional care at the patient's homes, focused on their needs using the available technologies, empowering patients and families. Eight categories emerged that addressed factors and variables involved in care models for the long-term care needs of institutionalised and home-based older people as a guarantee of accessibility to healthcare and to enhance the well-being and quality of life of patients and family caregivers.

Protocol for a mixed methods feasibility and implementation study of a community-based integrated care model for home-dwelling older adults: The INSPIRE project

BACKGROUND

Evaluations of integrated care models for home-dwelling frail older adults have shown inconclusive results on health and service outcomes. However, limited research has focused on the implementation of integrated care models. Applying implementation science methods may facilitate uptake of integrated care models, thus generating positive outcomes e.g., reduced hospital admissions. This paper describes the protocol to assess the feasibility of an integrated care model (featuring a four-step comprehensive geriatric assessment: screening, a multi-dimensional assessment, a coordinated individualized care plan and follow-up) designed for a new community-based center for home-dwelling older adults in Switzerland. The study includes the following objectives: 1) to assess implementation by a) monitoring respondents to the outreach strategies and describing the Center's visitors; b) assessing implementation outcomes related to the care model (i.e., adoption, acceptability, feasibility, fidelity) and implementation processes related to collaboration; and 2) assessing implementation costs.

METHODS

For objective 1a, we will use a descriptive design to assess respondents to the outreach strategies and describe the Center's visitors. We will use a parallel convergent mixed methods design for objective 1b. Implementation outcomes data will be collected from meetings with the Center's staff, interviews with older adults and their informal caregivers, and reviewing older adults' health records at the Center. Implementation processes related to collaboration will be assessed through a questionnaire to external collaborators (e.g., GPs) towards the end of the study. For objective 2, implementation costs will be calculated using time-driven activity-based costing methods. Data collection is anticipated to occur over approximately six months.

DISCUSSION

This study of a contextually adapted integrated care model will inform adaptations to the outreach strategies, care model and implementation strategies in one community center, prior to evaluating the care model effectiveness and potentially scaling out the intervention.

TRIAL REGISTRATION

Feasibility study registration ID with clinicaltrials.gov: NCT05302310; registration ID with BMC: ISRCTN12324618.

Cost-effectiveness of a community-based integrated care model compared with usual care for older adults with complex needs: a stepped-wedge cluster-randomised trial

Objective

To assess the cost of implementation, delivery and cost-effectiveness (CE) of a flagship community-based integrated care model (OPEN ARCH) against the usual primary care.

Design

A 9-month stepped-wedge cluster-randomised trial.

Setting and participants

Community-dwelling older adults with chronic conditions and complex care needs were recruited from primary care (14 general practices) in Far North Queensland, Australia.

Methods

Costs and outcomes were measured at 3-month windows from the healthcare system and patient’s out-of-pocket perspectives for the analysis. Outcomes included functional status (Functional Independence Measure (FIM)) and health-related quality of life (EQ-5D-3L and AQoL-8D). Bayesian CE analysis with 10 000 Monte Carlo simulations was performed using the BCEA package in R (V.3.6.1).

Results

The OPEN ARCH model of care had an average cost of $A1354 per participant. The average age of participants was 81, and 55% of the cohort were men. Within-trial multilevel regression models adjusted for time, general practitioner cluster and baseline confounders showed no significant differences in costs, resource use or effect measures regardless of the analytical perspective. Probabilistic sensitivity analysis with 10 000 simulations showed that OPEN ARCH could be recommended over usual care for improving functional independence at a willing to pay above $A600 (US$440) per improvement of one point on the FIM Scale and for avoiding or reducing inpatient stay for any willingness-to-pay threshold up to $A50 000 (US$36 500).

Conclusions and implications

OPEN ARCH was associated with a favourable Bayesian CE profile in improving functional status and dependency levels, avoiding or reducing inpatient stay compared with usual primary care in the Australian context.

Trial registration number

ACTRN12617000198325.

Moving Beyond Quality-Adjusted Life-Years in Elderly Care: How Can Multicriteria Decision Analysis Complement Cost-Effectiveness Analysis in Local-Level Decision Making

OBJECTIVES

This study aimed to investigate how multicriteria decision analysis (MCDA) could complement cost-effectiveness analysis (CEA) to support investment decisions in elderly care at local level.

METHODS

We used an integrated elderly care program in The Netherlands as a case study to demonstrate the application of both methods. In a 12-month quasi-experimental study (n = 384), data on the following outcome measures were collected: quality-adjusted life-years (CEA) and physical functioning, psychological well-being, social relationships and participation, enjoyment of life, resilience, person centeredness, continuity of care, and costs (MCDA). We performed regression analysis on inversed probability weighted data and controlled for potential confounders to obtain a double robust estimate of the outcomes. Probabilistic sensitivity analyses determined uncertainty for both methods.

RESULTS

The integrated elderly care program was not likely (ie, 36%) to be cost-effective according to the CEA (incremental cost-effectiveness ratios: €88 249 from a societal perspective) using the conventional Dutch willingness-to-pay threshold (ie, €50 000). The MCDA demonstrated that informal caregivers and professionals slightly preferred the intervention over usual care, driven by enjoyment of life and person centeredness. Patients did not prefer either the intervention or usual care, whereas payers and policy makers slightly preferred usual care, mainly due to higher costs of the intervention.

CONCLUSIONS

MCDA could provide local-level decision makers with a broader measurement of effectiveness by including outcomes beyond health and longevity and the preferences of multiple stakeholders. This additional information could foster the acceptability and implementability of cost-effective innovations in elderly care.

'Value-based methodology for person-centred, integrated care supported by Information and Communication Technologies' (ValueCare) for older people in Europe: study protocol for a pre-post controlled trial

Background

Older people receive care from multiple providers which often results in a lack of coordination. The Information and Communication Technology (ICT) enabled value-based methodology for integrated care (ValueCare) project aims to develop and implement efficient outcome-based, integrated health and social care for older people with multimorbidity, and/or frailty, and/or mild to moderate cognitive impairment in seven sites (Athens, Greece; Coimbra, Portugal; Cork/Kerry, Ireland; Rijeka, Croatia; Rotterdam, the Netherlands; Treviso, Italy; and Valencia, Spain). We will evaluate the implementation and the outcomes of the ValueCare approach. This paper presents the study protocol of the ValueCare project; a protocol for a pre-post controlled study in seven large-scale sites in Europe over the period between 2021 and 2023.

Methods

A pre-post controlled study design including three time points (baseline, post-intervention after 12 months, and follow-up after 18 months) and two groups (intervention and control group) will be utilised. In each site, (net) 240 older people (120 in the intervention group and 120 in the control group), 50–70 informal caregivers (e.g. relatives, friends), and 30–40 health and social care practitioners will be invited to participate and provide informed consent. Self-reported outcomes will be measured in multiple domains; for older people: health, wellbeing, quality of life, lifestyle behaviour, and health and social care use; for informal caregivers and health and social care practitioners: wellbeing, perceived burden and (job) satisfaction. In addition, implementation outcomes will be measured in terms of acceptability, appropriateness, feasibility, fidelity, and costs. To evaluate differences in outcomes between the intervention and control group (multilevel) logistic and linear regression analyses will be used. Qualitative analysis will be performed on the focus group data.

Discussion

This study will provide new insights into the feasibility and effectiveness of a value-based methodology for integrated care supported by ICT for older people, their informal caregivers, and health and social care practitioners in seven different European settings.

Trial registration

ISRCTN registry number is 25089186. Date of trial registration is 16/11/2021.

Implementation of a pan-European ecosystem and an interoperable platform for Smart and Healthy Ageing in Europe: An Innovation Action research protocol

As life expectancy continues to increase in most EU Member States, smart technologies can help enable older people to continue living at home, despite the challenges accompanying the ageing process. The Innovation Action (IA) SHAPES 'Smart and Healthy Ageing through People Engaging in Supportive Systems' funded by the EU under the Horizon 2020 Research and Innovation Programme (grant agreement number 857159) attends to these topics to support active and healthy ageing and the wellbeing of older adults. This protocol article outlines the SHAPES project's objectives and aims, methods, structure, and expected outcomes. SHAPES seeks to build, pilot, and deploy a large-scale, EU-standardised interoperable, and scalable open platform. The platform will facilitate the integration of a broad range of technological, organisational, clinical, educational, and social solutions. SHAPES emphasises that the home is much more than a house-space; it entails a sense of belonging, a place and a purpose in the community. SHAPES creates an ecosystem - a network of relevant users and stakeholders - who will work together to scale-up smart solutions. Furthermore, SHAPES will create a marketplace seeking to connect demand and supply across the home, health and care services. Finally, SHAPES will produce a set of recommendations to support key stakeholders seeking to integrate smart technologies in their care systems to mediate care delivery. Throughout, SHAPES adopts a multidisciplinary research approach to establish an empirical basis to guide the development of the platform. This includes long-term ethnographic research and a large-scale pan-European campaign to pilot the platform and its digital solutions within the context of seven distinct pilot themes. The project will thereby address the challenges of ageing societies in Europe and facilitate the integration of community-based health and social care. SHAPES will thus be a key driver for the transformation of healthcare and social care services across Europe.

Values Underpinning Integrated, People-Centred Health Services: Similarities and Differences among Actor Groups Across Europe

Introduction:

In addition to the functional aspects of healthcare integration, an understanding of its normative aspects is needed. This study explores the importance of values underpinning integrated, people-centred health services, and examines similarities and differences among the values prioritised by actors across Europe.

Methods:

Explorative cross-sectional design with quantitative analysis. A questionnaire of 18 values was conducted across Europe. A total of 1,013 respondents indicated the importance of each of the values on a nine-point scale and selected three most important values. Respondents were clustered in four actor groups, and countries in four European sub-regions.

Results:

The importance scores of values ranged from 7.62 to 8.55 on a nine-point scale. Statistically significant differences among actor groups were found for ten values. Statistically significant differences across European sub-regions were found for six values. Our analysis revealed two clusters of values: ‘people related’ and ‘governance and organisation’.

Discussion and conclusion:

The study found that all 18 values in the set are considered important by the respondents. Additionally, it revealed distinctions in emphasis among the values prioritised by actor groups and across sub-regions. The study uncovered two clusters of values that contribute to a conceptually based definition of integrated, people-centred health services.

Frailty in older people: Rehabilitation Treatment Research Examining Separate Settings (FORTRESS): protocol for a hybrid type II stepped wedge, cluster, randomised trial

Background

Frailty in older people is associated with increased risk of falls, longer length of stay in hospital, increased risk of institutionalisation and death. Frailty can be measured using validated tools. Multi-component frailty interventions are recommended in clinical practice guidelines but are not routinely implemented in clinical practice.

Methods

The Frailty in Older people: Rehabilitation, Treatment, Research Examining Separate Settings (FORTRESS) trial is a multisite, hybrid type II, stepped wedge, cluster, randomised trial with blinded assessment and intention-to-treat analysis being conducted in Australia. The study aims to determine the effectiveness and cost-effectiveness of an embedded individualised multicomponent frailty intervention (commencing in hospital and continuing in the community) on readmissions, frailty and quality of life when compared with usual care. Frail older people admitted to study wards with no significant cognitive impairment, who are expected to return home after discharge, will be eligible to participate. Participants will receive extra sessions of physiotherapy, pharmacy, and dietetics during their admission. A Community Implementation Facilitator will coordinate implementation of the frailty management strategies and primary network liaison. The primary outcome is number of days of non-elective hospital readmissions during 12 month follow-up period. Secondary outcomes include frailty status measured using the FRAIL scale; quality of life measured using the EQ-5D-5L; and time-to-event for readmission and readmission rates. The total cost of delivering the intervention will be assessed, and cost-effectiveness analyses will be conducted. Economic evaluation will include analyses for health outcomes measured in terms of the main clinical outcomes. Implementation outcomes will be collected as part of a process evaluation. Recruitment commenced in 2020 and we are aiming to recruit 732 participants over the three-year duration of the study.

Discussion

This study will reveal whether intervening with frail older people to address factors contributing to frailty can reduce hospital readmissions and improve frailty status and quality of life. If the FORTRESS intervention provides a clinically significant and cost-effective result, it will demonstrate an improved approach to treating frail patients, both in hospital and when they return home.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12620000760976p. ANZCTR registered 24 July 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03178-1.

Home care for patients with dirty homes: a qualitative study of the problems experienced by nurses and possible solutions

BACKGROUND

Home-care nurses are often the first care professionals to enter a dirty home. The perceived problems and support needs of home-care nurses in these situations are largely unknown.

OBJECTIVE

To examine the problems home-care nurses encounter in caring for patients living in dirty homes, and possible solutions for these problems.

DESIGN

Qualitative descriptive research.

SETTING

Communities across the Netherlands.

PARTICIPANTS

Twenty-three participants to investigate the problems or needs experienced, and 20 participants to investigate solutions. Participants included patients, home-care nurses and other professionals working in the community.

METHODS

Semi-structured interviews were conducted with 23 participants and analysed according to the principles of deductive thematic analysis. Subsequently, in interviews with 4 (representatives of) patients and four focus-group sessions with 16 professionals, the problems found were validated and solutions to the problems discussed.

RESULTS

Ten subthemes emerged that were clustered into three main themes: 'dilemmas arise in choosing the right nursing care'; 'cooperation and an integrated approach are often necessary, but lacking'; 'home-care nurses have insufficient competencies'. Seven possible solutions were found: (1) strengthening collaboration between organizations in the community; (2) involving others sooner; (3) case management; (4) person-centred care; (5) taking more time; (6) providing home-care nurses with tools and support services; and (7) strengthening the competencies of nurses.

CONCLUSIONS

Care for patients with a dirty home is complex. An integrated person-centred care approach is often necessary and home-care nurses need extra support to provide such care. Interventions should not only focus on patients, but address the nurses, the organization, and the collaboration between organizations in the community.

Effectiveness of a multi-component community-based care approach for older people at risk of care dependency - results of a prospective quasi-experimental study

Background

Due to demographic changes, the elderly population in western countries is constantly growing. As the risk of functional decline and multimorbidity increases with age, health care systems need to face the challenge of high demand for health care services and related costs. Therefore, innovative health care approaches and geriatric screenings are needed to provide individualised care. This study aims to expand the state of research by investigating the effectiveness of a multi-component care approach for the elderly in a German community setting.

Methods

A prospective, quasi-experimental study was initiated by statutory health insurance (SHI) companies. The innovative care approach includes a geriatric assessment, a case and network management as well as digital supporting tools and was implemented at the Center for Geriatrics and Gerontology (Albertinen Haus, Hamburg-Eimsbuettel). Participants of the intervention were compared to matched controls recruited in comparable urban areas. The primary outcome measure was the progression in long-term care grade during the period of observation (21 months), which was analysed on the basis of SHI claims data. Secondary endpoints were morbidity, mortality and self-reported health-related quality of life (HRQoL) measured by SF-36.

Results

Overall, 2,670 patients (intervention group (IG) n=873; control group (CG) n=1,797) were analysed. Logistic regression analysis showed no statistically significant difference in progression of long-term care grade between IG and CG (Odds Ratio (OR)=1.054; 95% confidence interval (CI) 0.856-1.296; p-value=0.616). Differentiated analyses indicated an initial effect, which might be attributable to the geriatric assessment. However, an adapted regression model resulted in a reversed but even non-significant effect (OR=0.945; 95% CI 0.757-1.177; p-value=0.619). While secondary analyses of long-term care grade, mortality and HRQoL did not show intervention effects, a statistically significant relative change of 0.865 (95% CI 0.780, 0.960; p-value=0.006) in morbidity indicated a potential benefit for the IG.

Conclusions

The analyses did not reveal a significant effect of the community-based intervention on the primary outcome and thus we are not able to recommend a transfer into SHI standard care. Tendencies in secondary analyses need to be proved in further research.

Trial registration

German Clinical Trials Register, retrospective registration on February 01, 2022 (DRKS00027866).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02923-w.

Value-based person-centred integrated care for frail elderly living at home: a quasi-experimental evaluation using multicriteria decision analysis

OBJECTIVE

To evaluate the value of the person-centred, integrated care programme Care Chain Frail Elderly (CCFE) compared with usual care, using multicriteria decision analysis (MCDA).

DESIGN

In a 12-month quasi-experimental study, triple-aim outcomes were measured at 0, 6 and 12 months by trained interviewers during home-visits.

SETTING

Primary care, community-based elderly care.

PARTICIPANTS

384 community-dwelling frail elderly were enrolled. The 12-month completion rate was 70% in both groups. Propensity score matching was used to balance age, gender, marital status, living situation, education, smoking status and 3 month costs prior to baseline between the two groups.

INTERVENTION

The CCFE is an integrated care programme with unique features like the presence of the elderly and informal caregiver at the multidisciplinary team meetings, and a bundled payment.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The MCDA results in weighted overall value scores that combines the performance on physical functioning, psychological well-being, social relationships and participation, enjoyment of life, resilience, person-centredness, continuity of care and costs, with importance weights of patients, informal caregivers, professionals, payers and policy-makers.

RESULTS

At 6 months, the overall value scores of CCFE were higher in all stakeholder groups, driven by enjoyment of life (standardised performance scores 0.729 vs 0.685) and person-centredness (0.749 vs 0.663). At 12 months, the overall value scores in both groups were similar from a patient's perspective, slightly higher for CCFE from an informal caregiver's and professional's perspective, and lower for CCFE from a payer's and policy-maker's perspective. The latter was driven by a worse performance on physical functioning (0.682 vs 0.731) and higher costs (€22 816 vs €20 680).

CONCLUSIONS

The MCDA indicated that the CCFE is the preferred way of delivering care to frail elderly at 6 months. However, at 12 months, MCDA results showed little difference from the perspective of patients, informal caregivers and professionals, while payers and policy-makers seemed to prefer usual care.

A multifactorial interdisciplinary intervention to prevent functional and mobility decline for more participation in (pre-)frail community-dwelling older adults (PromeTheus): study protocol for a multicenter randomized controlled trial

BACKGROUND

Age-related decline in physical capacity can lead to frailty, associated with an increased vulnerability to adverse health outcomes and greater healthcare utilization. In an aging population, effective strategies to prevent physical decline and frailty, and preserve independence are needed. Prevention programs for vulnerable community-dwelling older adults are, however, often not yet established and implemented in routine practice. Research on the feasibility, implementation, and (cost-)effectiveness of multifactorial, interdisciplinary intervention programs that take advantage of available services of healthcare providers is also limited. The main aim of this study is to evaluate the effectiveness of such an intervention program (PromeTheus) to prevent functional and mobility decline for more participation in community-dwelling (pre-)frail older adults.

METHODS

The study is designed as a three-center, randomized controlled trial with a 12-month intervention period. Four hundred community-dwelling (pre-)frail (Clinical Frailty Scale score 4-6) older adults (≥70 years) will be randomized in a 1:1 ratio to the intervention group (IG) or the control group (CG). The IG will receive the PromeTheus program consisting of obligatory home-based physical exercises (Weight-bearing Exercise for Better Balance) accompanied by physiotherapists and facultative counseling services (person-environment-fit, coping with everyday life, nutrition, group-based activities) delivered via existing healthcare structures (e.g., social workers, nutritionists). The CG will receive usual care and a one-time counseling session on recommendations for physical activity and nutrition. Primary outcomes assessed at months 6 and 12 are the function component of the Late-Life Function and Disability Instrument and the University of Alabama at Birmingham Life-Space Assessment. Secondary outcomes are disability, physical capacity and activity, frailty, nutritional status, falls, fear of falling, health status, and psychosocial components. Process and economic evaluations are also conducted. Primary statistical analyses will be based on the intention-to-treat principle.

DISCUSSION

Compared to usual care, the PromeTheus program is expected to result in higher function and mobility, greater independence and lower need for care, and more participation. As the PromeTheus program draws on existing German healthcare structures, its large-scale translation and delivery will be feasible, if evidence of (cost-)effectiveness and successful implementation can be demonstrated.

TRIAL REGISTRATION

German Clinical Trials Register, . Registered on March 11, 2021.

Out-of-pocket expenses related to aging in place for frail older people: a scoping review

OBJECTIVE

The objective of this scoping review was to map and describe the available evidence reporting out-of-pocket expenses related to aging in place for older people with frailty and their caregivers.

INTRODUCTION

As the global population ages, there has been increasing attention on supporting older people to live at home in the community as they experience health and functional changes. Older people with frailty often require a variety of supports and services to live in the community, yet the out-of-pockets costs associated with these resources are often not accounted for in health and social care literature.

INCLUSION CRITERIA

Sources that reported on the financial expenses incurred by older people (60 years or older) with frailty living in the community, or on the expenses incurred by their family and friend caregivers, were eligible for inclusion in the review.

METHODS

We searched for published and unpublished (ie, policy papers, theses, and dissertations) studies written in English or French between 2001 and 2019. The following databases were searched: CINAHL, MEDLINE, Scopus, Embase, PsycINFO, Sociological Abstracts, and Public Affairs Index. We also searched for gray literature in a selection of websites and digital repositories. JBI scoping review methodology was used, and we consulted with a patient and family advisory group to support the relevance of the review.

RESULTS

A total of 42 sources were included in the review, including two policy papers and 40 research papers. The majority of the papers were from the United States (n = 18), with others from Canada (n = 6), the United Kingdom (n = 3), Japan (n = 2), and one each from Australia, Brazil, China, Denmark, Israel, Italy, The Netherlands, Poland, Portugal, Singapore, South Korea, Taiwan, and Turkey. The included research studies used various research designs, including cross-sectional (n = 18), qualitative (n = 15), randomized controlled trials (n = 2), longitudinal (n = 2), cost effectiveness (n = 1), quasi-experimental (n = 1), and mixed methods (n = 1). The included sources used the term "frailty" inconsistently and used various methods to demonstrate frailty. Categories of out-of-pocket expenses found in the literature included home care, medication, cleaning and laundry, food, transportation, medical equipment, respite, assistive devices, home modifications, and insurance. Five sources reported on out-of-pocket expenses associated with people who were frail and had dementia, and seven reported on the out-of-pocket expenses for caregivers of people with frailty. While seven articles reported on specific programs, there was very little consistency in how out-of-pocket expenses were used as outcome measures. Several studies used measures of combined out-of-pocket expenses, but there was no standard approach to reporting aggregate out-of-pocket expenses.

CONCLUSIONS

Contextual factors are important to the experiences of out-of-pocket spending for older people with frailty. There is a need to develop a standardized approach to measuring out-of-pocket expenses in order to support further synthesis of the literature. We suggest a measure of out-of-pocket spending as a percentage of family income. The review supports education for health care providers to assess the out-of-pocket spending of community-dwelling older people with frailty and their caregivers. Health care providers should also be aware of the local policies and resources that are available to help older people with frailty address their out-of-pocket spending.

Provider and Manager Perspectives on the Use of an Integrated Clinical Pathway for Community-Dwelling Older Adults: A Qualitative Case Study

Background:

Integrated care pathways (ICPs) could improve the organisation and delivery of care for community dwelling older adults. An ICP was developed and implemented in Québec to support home care processes. This study explores the perspectives of home care staff on the use of an ICP to support the organisation and delivery of health and social care to community-dwelling older adults with complex needs.

Theory and Methods:

A case study based on eleven semi-structured interviews and analysis of documents was carried out in an urban home care unit. The Normalization Process Theory was used for mixed thematic analysis.

Results:

While its capacity to store data and enhance interprofessional information exchange was appreciated by home care staff, the broad scope, and automated features of the ICP tool were often problematic. Concerns about increased provider workloads, disruption to provider-client relationships during clinical encounters, and difficulties engaging clients in decision-making were main obstacles in the use of the ICP.

Conclusion:

Given the importance of ICPs in advancing clinical integration, it is critical to continuously adjust their design to align with providers’ realities in order to optimize their potential in real life contexts.

Health economic perspective on a community-based intervention for older people at risk of care dependency – results of a prospective quasi-experimental study

This prospective, quasi-experimental study aims to compare healthcare resource utilization (HCRU) and costs of a multi-component care approach for older people in a community setting (intervention group (IG)) with usual care in a matched control group (CG) during a 21-month observation period. The reablement-oriented intervention included a geriatric assessment, a case and network management and digital supporting tools. Regression models were applied to determine intervention effects regarding hospitalization, total hospital length of stay (LOS), number of physician consultations, and healthcare costs using claims data. 872 subjects were included in the IG and 1,768 in the CG. The analyses showed that the intervention did not affect hospitalization ( OR = 1.153; 95% CI: 0.971–1.369, p = .105). However, participating in the IG lead to a small but significant increase of physician contacts by a factor of 1.078 (Exp( ß) = 1.078; 95% CI: 1.011–1.149; p = .022). A non-significant mean difference in costs of €1,183 (95% CI: €−261.6 to €2,627.6, p = .108) per participant was identified. Further research is needed to generate robust evidence on the optimal design of care approaches for older people and the health economic implications of such interventions to improve care and resource allocation decision-making.

Trial registration: The study was registered at the German Clinical Trials Register (DRKS00027866).

Consensus on Integrated Care for Older People Among Dutch Experts: A Delphi Study

Introduction

In a previous rapid realist review (RRR), an initial programme theory (PT) was established giving insight into the interrelatedness of context items, mechanisms, programme-activities, and outcomes that influence integrated care programmes (ICPs) for community-dwelling frail older people. As ICPs need to be tailored to their local setting, the objective of this study is to assess consensus on the relevance of the items identified in the RRR for the Dutch setting, and refine the PT, where appropriate.

Methods

A two-round e-Delphi study was carried out among Dutch experts to determine the relevance of 71 items.

Results

Consensus on relevance was reached on 57 out of 71 items (80%). Items added to refine the PT included: increasing number of older people, decreasing access to hospital beds, well-designed ICP implementation processes, case management, having a clear portfolio of patients, the role of the government, aligning existing health and social care systems, management and monitoring of care activities, strong relationship between older person and healthcare providers (HCP), and providing continuous feedback to HCPs.

Conclusion and discussion

The initial PT was refined for the Dutch setting. Items on which no consensus was found, need to be further investigated on the reason behind it.

Impact of organizational context on patient outcomes in a proactive primary care program:a longitudinal observational study

BACKGROUND

The effectiveness of health care interventions is co-determined by contextual factors. Unknown is the extent of this impact on patient outcomes. Therefore, the aim of this study is to explore which characteristics of general practices are associated with patient outcomes in a proactive primary care program, the U-PROFIT 2.0.

METHODS

A longitudinal observational study was conducted from January 2016 till October 2017. Two questionnaires were send out, one to collect characteristics of general practices such as practice neighbourhood socio-economic status, general practice versus healthcare centre (involving multiple primary care professionals), and professional- frail older patient ratio per practice of general practitioners and practice nurses. Regarding delivering the program, the practice or district nurse who delivered the program, number of years since the start of the implementation, and choice of age threshold for frailty screening were collected. Patient outcomes collected by the second questionnaire and send to frail patients were daily functioning, hospital admissions, emergency department visits, and general practice out-of-hours consultations. Linear and generalized linear mixed models were used.

RESULTS

A total of 827 frail older people were included at baseline. Delivery of the program by a district nurse compared to a practice nurse was significantly associated with a decrease in daily functioning on patient-level (β = 2.19; P = < 0.001). Duration since implementation of 3 years compared to 9 years was significantly associated with less out-of-hours consultations to a general practice (OR 0.11; P = 0.001). Applying frailty screening from the age of 75 compared to those targeted from the age of 60 showed a significant increase in emergency visits (OR 5.26; P = 0.03).

CONCLUSION

Three associations regarding the organizational context 1) the nurse who delivered the program, 2) the number of years the program was implemented and 3) the age threshold for defining a frail patient are significant and clinically relevant for frail patients that receive a proactive primary care program. In general, contextual factors need more attention when implementing complex primary care programs which can result in better balanced choices to enhance effective proactive care for older people living in the community.

Health and Social Care Reform in Scotland - What Next?

INTRODUCTION

This paper analyses the important enablers, barriers and impacts of country-wide implementation of integrated health and social care in Scotland. It offers insights for other systems seeking to advance similar policy and practice.

DESCRIPTION

Landmark legislation was based on a shared vision and narrative about improving outcomes for people and communities. Implementation has involved coordination of multiple policies and interventions for different life stages, care groups, care settings and local context within a dynamic and complex system.

DISCUSSION

Relational and citizen led approaches are critical for success, but it takes time to build trusting relationships, influence organisational and professional cultures and cede power. Assessing national impacts is challenging and progress at a national level can seem slower than local experience suggests, due in part to the relative immaturity of national datasets for community interventions. Five years on there are many examples of innovation and positive outcomes despite increasing demographic, workforce, and financial challenges. However, inequalities continue to increase.

CONCLUSION

Realising the true value from integration will require a stronger focus on place-based prevention and early intervention to achieve a fairer Scotland where everybody thrives. Solidarity, equity, and human rights must guide the next phase of Scotland's story.

Evaluating an integrated care pathway for frail elderly patients in Norway using multi-criteria decision analysis

Background

To provide value-based care for patients with multi-morbidity, innovative integrated care programmes and comprehensive evaluations of such programmes are required. In Norway, a new programme called “Holistic Continuity of Patient Care” (HCPC) addresses the issue of multi-morbidity by providing integrated care within learning networks for frail elderly patients who receive municipal home care services or a short-term stay in a nursing home. This study conducts a multi-criteria decision analysis (MCDA) to evaluate whether the HCPC programme performs better on a large set of outcomes corresponding to the ‘triple aim’ compared to usual care.

Methods

Prospective longitudinal survey data were collected at baseline and follow-up after 6-months. The assessment of HCPC was implemented by a novel MCDA framework. The relative weights of importance of the outcomes used in the MCDA were obtained from a discrete choice experiment among five different groups of stakeholders. The performance score was estimated using a quasi-experimental design and linear mixed methods. Performance scores were standardized and multiplied by their weights of importance to obtain the overall MCDA value by stakeholder group.

Results

At baseline in the HCPC and usual care groups, respectively, 120 and 89 patients responded, of whom 87 and 41 responded at follow-up. The average age at baseline was 80.0 years for HCPC and 83.6 for usual care. Matching reduced the standardized differences between the groups for patient background characteristics and outcome variables. The MCDA results indicated that HCPC was preferred to usual care irrespective of stakeholders. The better performance of HCPC was mostly driven by improvements in enjoyment of life, psychological well-being, and social relationships and participation. Results were consistent with sensitivity analyses using Monte Carlo simulation.

Conclusion

Frail elderly with multi-morbidity represent complex health problems at large costs for society in terms of health- and social care. This study is a novel contribution to assessing and understanding HCPC programme performance respecting the multi-dimensionality of desired outcomes. Integrated care programmes like HCPC may improve well-being of patients, be cost-saving, and contribute to the pursuit of evidence based gradual reforms in the care of frail elderly.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06805-6.

Barriers and facilitators to interprofessional collaborative practice for community-dwelling older adults: An integrative review

AIMS AND OBJECTIVES

The aim of this integrative review was to synthesise empirical reports of interprofessional collaborative practice (IPCP) for community-dwelling older adults and uncover barriers and facilitators related to its success as a model of care for this population.

BACKGROUND

IPCP is a model of care that has demonstrated positive outcomes for community-dwelling older adults. However, a summary of barriers and facilitators to IPCP models has not been presented.

METHODS

An integrative review using the method posited by Whittemore and Knafl was completed to identify barriers and facilitators to IPCP for community-dwelling older adults. The literature search was reported following PRISMA guidelines.

RESULTS

Four themes emerged as barriers to IPCP: (1) A (Potential) Logistical Nightmare, (2) All About the Money, (3) If We Can't Test It, Can We Recommend It? and (4) Challenging for the Team, Challenging for the Client. Three themes emerged as facilitators to IPCP: (1) Reducing Resource Waste, (2) The "C" in IPCP and (3) What Matters Most.

CONCLUSIONS

IPCP models for community-dwelling older adults must adapt to the setting of care and client needs. Interprofessional education opportunities for team members facilitate effective IPCP. Healthcare policies and funding structures need to address IPCP for community-dwelling older adults for this model to be successful and sustainable.

RELEVANCE TO CLINICAL PRACTICE

Nurses participate on and lead IPCP teams caring for community-dwelling older adults and, therefore, need to be aware of barriers and facilitators to this model of care.

The effect of community nursing based on the Roy adaptation model on postpartum depression and sleep quality of parturients

OBJECTIVE

The study aimed to explore the effect of community nursing based on the Roy adaptation model on postpartum depression and sleep quality of parturients.

METHODS

According to different nursing methods, 96 parturients with postpartum depression were selected and divided into 47 cases in the regular group (undergoing regular nursing) and 49 cases in the combined group (undergoing community nursing based on the Roy adaptation model). The improvement in depression and sleep quality was compared between the two groups.

RESULTS

Comparison of the Hamilton Depression Scale (HAMD), Self-Rating Depression Scale (SDS) and Edinburgh Postpartum Depression Scale (EPDS) scores between the two groups showed that the above mentioned scores at intervention for 3 months < those of intervention for 2 months < those of intervention for 1 month < those of before intervention; showing significant differences (P<0.05). The scores of HAMA, SDS and EPDS in the combined group after intervention for 1, 2 and 3 months were significantly lower than those in the regular group (P<0.05). After intervention, the total score and the scores of all dimensions of Pittsburgh Sleep Quality Index (PSQI) were decreased in the two groups (P<0.05), and the combined group had scores that were significantly lower than the regular group (P<0.05).

CONCLUSION

The use of community nursing intervention based on the Roy adaptation model for postpartum depressed parturients can effectively alleviate depression and improve sleep quality.

Measuring Older Peoples' Experiences of Person-Centred Coordinated Care: Experience and Methodological Reflections from Applying a Patient Reported Experience Measure in SUSTAIN

Introduction

While several evaluation studies on (cost-)effectiveness of integrated care have been conducted in recent years, more insight is deemed necessary into integrated care from the perspective of service users. In the context of a European project on integrated care for older people living at home (SUSTAIN), this paper shares the experience and methodological reflections from applying a Patient Reported Experience Measure (PREM) on person-centred coordinated care -the P3CEQ- among this population.

Methods

A combination of quantitative and qualitative data and analysis methods was used to assess the usability and the quality of applying a PREM among older people presenting complex care needs, using the P3CEQ delivery in SUSTAIN as a case study. 228 service users completed the P3CEQ and nine SUSTAIN researchers participated in a consultation about their experience administering the questionnaire. P3CEQ scores were analysed quantitatively using principal component analysis and multilevel linear regression. P3CEQ open responses and researcher notes collected when administering the questionnaire were thematically analysed.

Results

Service user inclusion was high and most P3CEQ items had low non-response rates. Quantitative analysis and researcher experience indicate the relevance of face-to-face administration for obtaining such an amount of data in this population group. The presence of a carer increased inclusion of more vulnerable respondents, such as the cognitively impaired, but posed a challenge in data interpretation. Although several P3CEQ items were generally understood as intended by questionnaire developers, the analysis of open responses highlights how questions can lead to diverging and sometimes narrow interpretations by respondents. Cognitive impairment and a higher educational attainment were associated with lower levels of perceived person-centredness of care.

Conclusion

This study shows essential preconditions to meaningfully collect and analyse PREM data on older peoples' experiences with integrated care: face-to-face administration away from care providers, collection of reasons for non-response and open comments providing nuances to answers, and multilevel modelling taking into account diversity in the target population. Several areas of improvement for future PREM use in this population have been identified: use of administration and coding guides, inclusion of clear and easy to understand definitions and examples illustrating what questions do and do not mean, measures of the expectations of person-centred coordinated care, and procedures ensuring sound ethical research. These methodological learnings can enhance future evaluation of integrated care from a service user perspective.

Evaluating Complex Health and Social Care Program Using Multi-Criteria Decision Analysis: A Case Study of "Better Together in Amsterdam North"

OBJECTIVES

Multi-criteria decision analysis (MCDA) has been recommended to support policy making in healthcare. However, practical applications of MCDA are sparse. One potential use for MCDA is for the evaluation of programs for complex and vulnerable patients. These complex patients benefit from integrated care programs that span healthcare and social care and aim to improve more than just health outcomes. MCDA can evaluate programs that aim to improve broader outcomes because it allows the evaluation of multiple outcomes alongside each other. In this study, we evaluate an innovative integrated care program in the Netherlands using MCDA.

METHODS

We used an innovative MCDA framework with broad outcomes of health, well-being, and cost to evaluate the Better Together in Amsterdam North (BSiN) program using preferences of patients, partners, providers, payers, and policy makers in the Netherlands. BSiN provides case management support for a period of 6 months. Seven outcomes that previous research has deemed important to complex patients were measured, including physical functioning and social relationships and participation.

RESULTS

We find that the program improved the overall MCDA score marginally, and, thus, after 6 and after 12 months, BSiN was preferred to usual care by all stakeholders. BSiN was preferred to usual care, mostly owing to improvements in psychological well-being and social relationships and participation.

CONCLUSIONS

The integrated healthcare and social care program BSiN in the Netherlands was preferred to usual care according to an MCDA evaluation. MCDA seems a useful method to evaluate complex programs with benefits beyond health.

The INSPIRE Population Survey: development, dissemination and respondent characteristics

BACKGROUND

Most older adults prefer to continue living at home despite increasing care needs and demand for services. To aid in maintaining independence, integrated care models for community-dwelling older people are promoted as the most cost-effective approach. The implementation of such care models is challenging and often the end-users are not involved or their needs are not considered. We conducted a population survey in order to understand the needs and preferences of home-dwelling older adults living in Canton Basel-Landschaft, Switzerland. The aims of this paper are to chronicle the development of the INSPIRE Population Survey, outline its variables and measurements, describe the marketing strategy utilized for survey dissemination and report on the response rate and respondent characteristics.

METHODS

The INSPIRE Population Survey, conducted between March and August 2019, is a cross-sectional survey of older adults aged 75 and older living at home in Canton Basel-Landschaft. The questionnaire was developed by expert input and stakeholder involvement. Its readability and acceptability were pilot-tested with older people. To ensure the likelihood of a high and representative response rate, a meticulous step-by-step marketing strategy was developed prior to the dissemination of the questionnaire.

RESULTS

The overall response rate was 30.7% (n = 8,846), with variations between 20.6 and 34.5% across the different care regions in the canton. A generally higher response rate was found in the care regions with a higher density and which bordered the urban city of Basel. We received support from local stakeholders, policy makers and media through using a broad combination of marketing channels and targeting our community partners who have a strong relationship with our target audience.

CONCLUSIONS

Although recruiting older adults in research is challenging, our study shows that a high response rate can be achieved by developing the survey through expert input and by involving all important stakeholders, including older adults, throughout the entire process.

Higher Medicare Expenditures Are Associated With Better Integrated Care as Perceived by Patients

BACKGROUND

Integrated care that is continuous, coordinated and patient-centered is vital for Medicare beneficiaries, but its relationship to health care expenditures remains unclear.

RESEARCH OBJECTIVE

This study explores-for the first time-the relationship between integrated care, as measured from the patient's perspective, and health care expenditures.

METHODS

Subjects include a sample of continuously eligible fee-for-service Medicare beneficiaries (n=8807) in 2015. Analyses draw on 7 previously validated measures of patient-perceived integrated care from the 2015 Medicare Current Beneficiary Survey. These data are combined with 2015 administrative utilization data that measure health care expenditures. Relationships between patient-perceived integrated care and costs are assessed using generalized linear models with comprehensive control measures.

RESULTS

Patients who perceive more integrated care have higher expenditures for many, but not all, cost categories examined. Aspects of integrated care pertaining to primary provider and specialist care are associated with higher costs in several areas (particularly inpatient costs associated with specialist knowledge of the patient). Office staff members' knowledge of the patient's medical history is associated with lower home health costs.

CONCLUSIONS

Patients who experience their care as more integrated may have higher expenditures on average. Thoughtful policy choices, further research, and innovations that enable patients to perceive integrated care at lower or neutral cost are needed.

General practitioners' views on the influence of long-term care reforms on integrated elderly care in the Netherlands: a qualitative interview study

This study explores the long-term care (LTC) reform in the Netherlands and its relation to the day-to-day integrated care for frail elderly people, from the perspective of general practitioners (GPs). We assessed GP perspectives regarding which elements of the LTC reform have promoted and hindered the provision of person-centred, integrated care for elderly people in the Netherlands. We performed case studies conducted by semi-structured interviews, using the Healthy Alliances (HALL) framework as a framework for thematic analysis. GPs reported that the ideals of the LTC reform (self-reliance) were largely achievable and listed a number of positive effects, including increased healthcare professional engagement and the improved integration of the medical and social domains through the close involvement of social support teams. The reported negative implications were a lack of co-ordination in the implementation of the reforms by the municipality, insufficient funding for multidisciplinary team meetings and the reinforced fragmentation of home care. In particular, the implementation of the system reforms took place with little regard for the local context. We suggest that the implementation of national care reforms should be aligned with factors operating at the micro level and make the following recommendations: use one central location for primary health and social services, integrate regional ICT structures to improve the exchange of patient information, and reduce fragmentation in home care.

Untangling the inter-relatedness within integrated care programmes for community-dwelling frail older people: a rapid realist review

OBJECTIVE

To identify the relationships between the context in which integrated care programmes (ICPs) for community-dwelling frail older people are applied, the mechanisms by which the programmes do (not) work and the outcomes resulting from this interaction by establishing a programme theory.

DESIGN

Rapid realist review.

INCLUSION CRITERIA

Reviews and meta-analyses (January 2013-January 2019) and non-peer-reviewed literature (January 2013-December 2019) reporting on integrated care for community-dwelling frail older people (≥60 years).

ANALYSIS

Selection and appraisal of documents was based on relevance and rigour according to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards criteria. Data on context, mechanisms, programme activities and outcomes were extracted. Factors were categorised into the five strategies of the WHO framework of integrated people-centred health services (IPCHS).

RESULTS

27 papers were included. The following programme theory was developed: it is essential to establish multidisciplinary teams of competent healthcare providers (HCPs) providing person-centred care, closely working together and communicating effectively with other stakeholders. Older people and informal caregivers should be involved in the care process. Financial support, efficient use of information technology and organisational alignment are also essential. ICPs demonstrate positive effects on the functionality of older people, satisfaction of older people, informal caregivers and HCPs, and a delayed placement in a nursing home. Heterogeneous effects were found for hospital-related outcomes, quality of life, healthcare costs and use of healthcare services. The two most prevalent WHO-IPCHS strategies as part of ICPs are 'creating an enabling environment', followed by 'strengthening governance and accountability'.

CONCLUSION

Currently, most ICPs do not address all WHO-IPCHS strategies. In order to optimise ICPs for frail older people the interaction between context items, mechanisms, programme activities and the outcomes should be taken into account from different perspectives (system, organisation, service delivery, HCP and patient).

A Contextual Analysis and Logic Model for Integrated Care for Frail Older Adults Living at Home: The INSPIRE Project

INTRODUCTION

Implementation science methods and a theory-driven approach can enhance the understanding of whether, how, and why integrated care for frail older adults is successful in practice. In this study, we aimed to perform a contextual analysis, develop a logic model, and select preliminary implementation strategies for an integrated care model in newly created information and advice centers for older adults in Canton Basel-Landschaft, Switzerland.

METHODS

We conducted a contextual analysis to determine factors which may influence the integrated care model and implementation strategies needed. A logic model depicting the overall program theory, including inputs, core components, outputs and outcomes, was designed using a deductive approach, and included stakeholders' feedback and preliminary implementation strategies.

RESULTS

Contextual factors were identified (e.g., lack of integrated care regulations, existing community services, and a care pathway needed). Core components of the care model include screening, referral, assessment, care plan creation and coordination, and follow-up. Outcomes included person-centred coordinated care experiences, hospitalization rate and symptom burden, among others. Implementation strategies (e.g., nurse training and co-developing educational materials) were proposed to facilitate care model adoption.

CONCLUSION

Contextual understanding and a clear logic model should enhance the potential for successful implementation of the integrated care model.

Service Delivery Reforms for Asian Ageing Societies: A Cross-Country Study Between Japan, South Korea, China, Thailand, Indonesia, and the Philippines

INTRODUCTION

Japan's health policies to address the most advanced-aged society have been the target of focus in Asia, but no studies have investigated this issue using tools for cross-country comparisons.

THEORY AND METHODS

A cross-country study design was used to compare healthcare reform policies with a framework in Japan, Korea, Thailand, China, Indonesia, and the Philippines. Data were collected via document reviews and key informant interviews.

RESULTS

Three distinctions were identified. First, all countries except for the Philippines have policy decisions regarding reforms for the existing service delivery systems for healthcare, long-term care and welfare. Second, the most extensive service delivery reform is currently being implemented in Japan, whose system is shifting to primary health care. Third, the direction of the transformation of service delivery system is different between Thailand and China despite a similar level of ageing society. China has made progress on facility-based care integration between health and social care, whereas Thailand is focusing on home-based care.

CONCLUSIONS AND DISCUSSION

Doctor and hospital-based healthcare delivery system requires more drastic reform for an aged society. This fact implies that strengthening primary health care is not only useful for current health issues but also an investment for the aged society near future in low- and middle-income countries.

Proactive primary care model for frail older people in New Zealand delays aged-residential care: A quasi-experiment

BACKGROUND/OBJECTIVES

To determine the effect of a proactive primary care program on acute hospitalization and aged-residential care placement for frail older people.

DESIGN

Controlled before and after, and controlled after only quasi-experimental studies, with a comparison group created via propensity score matching. One-year follow-up.

SETTING

Nine general practices in Auckland, New Zealand.

PARTICIPANTS

Community-dwelling people aged 75 and older identified as at increased risk of hospitalization. One thousand and eighty five patients are compared with 3750 comparison patients matched by propensity score based on known risks.

INTERVENTION

Primary healthcare based, registered nurse-led, comprehensive geriatric assessment, goal-setting, care planning, and regular follow-up. Patients were also provided self-management education, health and social care navigation, and transitional care for hospital discharges. Practices received program support, workforce development, and mentoring of primary healthcare nurses by gerontology nurse specialists.

MEASUREMENTS

Outcomes from routinely collected administrative data. Primary: aged-residential care placement.

SECONDARY OUTCOMES

acute hospitalization, mortality, and other health service utilization.

RESULTS

Aged-residential care placement (odds ratio [OR] 0.66, 95% confidence interval (CI) = 0.48-0.91) and mortality (OR 0.66, 95% CI = 0.49-0.88) were significantly lower over the first year in Kare patients compared with matched controls. There was no difference in acute hospitalization (+0.06 admissions per year, 95% CI = -0.01-0.13). Support service use (allied health therapists and assessment for social support) was increased, and emergency department use decreased.

CONCLUSION

The Kare participants had lower aged-residential care placement and mortality in the first year, but no decrease in acute hospitalization. Because the design is nonexperimental caution is required in interpreting these results.

'What matters to you?' Normative integration of an intervention to promote participation of older patients with multi-morbidity - a qualitative case study

Background

Interventions in which individual older patients with multi-morbidity participate in formulating goals for their own care are being implemented in several countries. Successful service delivery requires normative integration by which values and goals for the intervention are shared between actors at macro-, meso- and micro-levels of health services. However, health services are influenced by multiple and different institutional logics, which are belief systems guiding actors’ cognitions and practices. This paper examines how distinct institutional logics materialize in justifications for patient participation within an intervention for patients with multi-morbidity, focusing on how variations in the institutional logics that prevail at different levels of health services affect vertical normative integration.

Methods

This qualitative case study of normative integration spans three levels of Norwegian health services. The macro-level includes a white paper and a guideline which initiated the intervention. The meso-level includes strategy plans and intervention tools developed locally in four municipalities. Finally, the micro-level includes four focus group discussions among 24 health professionals and direct observations of ten care-planning meetings between health professionals and patients. The content analysis draws on seven institutional logics: professional, market, family, community, religious, state and corporate.

Results

The particular institutional logics that justified patient participation varied between healthcare levels. Within the macro-level documents, seven logics justified patients’ freedom of choice and individualization of service delivery. At meso-level, the operationalization of the intervention into tools for clinical practice was dominated by a state logic valuing equal services for all patients and a medical professional logic in which patient participation meant deciding how to maintain patients’ physical abilities. At micro-level, these two logics were mixed with a corporate logic prioritizing cost-efficient service delivery.

Conclusion

Normative integration is challenging to achieve. The number of institutional logics in play was reduced downwards through the three levels, and the goals behind the intervention shifted from individualization to standardization. The study broadens our understanding of the dynamic between institutional logics and of how multiple sets of norms co-exist and guide action. Knowledge of mechanisms by which normative justifications are put into practice is important to achieve normative integration of patient participation interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06106-y.