Using structured implicit review to assess quality of care in the Program of All-Inclusive Care for the Elderly (PACE)

Efficacy of Government-Sponsored Community Health Programs for Older Adults: A Systematic Review of Published Evaluation Studies

Objective: Population aging is an ongoing challenge for global health policy and is expected to have an increasing impact on developing economies in years to come. A variety of community health programs have been developed to deliver health services to older adults, and evaluating these programs is crucial to improving service delivery and avoiding barriers to implementation. This systematic review examines published evaluation research relating to public and community health programs aimed at older adults throughout the world.

Methods: A literature search using standardized criteria yielded 58 published articles evaluating 46 specific programs in 14 countries.

Results: Service models involving sponsorship of comprehensive facilities providing centralized access to multiple types of health services were generally evaluated the most positively, with care coordination programs appearing to have generally more modest success, and educational programs having limited effectiveness. Lack of sufficient funding was a commonly-cited barrier to successful program implementations.

Conclusion: It is important to include program evaluation as a component of future community and public health interventions aimed at aging populations to better understand how to improve these programs.

A case for revisiting peer review: Implications for professional self-regulation and quality improvement

Background

Quality improvement in healthcare has often been promoted as different from and more valuable than peer review and other professional self-regulation processes. In spite of attempts to harmonize these two approaches, the perception of dichotomous opposition has persisted. A sequence of events in the troubled California prison system fortuitously isolated workforce interventions from more typical quality improvement interventions. Our objectives were to (1) evaluate the relative contributions of professional accountability and quality improvement interventions to an observed decrease in population mortality and (2) explore the organizational dynamics that potentiated positive outcomes.

Methods

Our retrospective mixed-methods case study correlated time-series analysis of mortality with the timing of reform interventions. Quantitative and qualitative evidence was drawn from court documents, public use files, internal databases, and other archival documents.

Results

Change point analysis reveals with 98% confidence that a significant improvement in age-adjusted natural mortality occurred in 2007, decreasing from 138.7 per 100,000 in the 1998–2006 period to 106.4 in the 2007–2009 period. The improvement in mortality occurred after implementation of accountability processes, prior to implementation of quality improvement interventions. Archival evidence supports the positive impact of physician competency assessments, robust peer review, and replacement of problem physicians.

Conclusions

Our analysis suggests that workforce accountability provides a critical quality safeguard, and its neglect in scholarship and practice is unjustified. As with quality improvement, effective professional self-regulation requires systemic implementation of enabling policies, processes, and staff resources. The study adds to evidence that the distribution of physician performance contains a heterogeneous left skew of dyscompetence that is associated with significant harm and suggests that professional self-regulation processes such as peer review can reduce that harm. Beyond their responsibility for direct harm, dyscompetent professionals can have negative impacts on group performance. The optimal integration of professional accountability and quality improvement systems merits further investigation.

Effects of a Community Care Station Program With Structured Exercise Intervention on Physical Performance and Balance in Community-Dwelling Older Adults: A Prospective 2-Year Observational Study

The Taiwanese government has developed community care stations (CCSs) for community-based older adult care. We investigated the effects of a structured exercise intervention, applied at CCS for 6 months, on physical performance and balance in community-dwelling older adults, including a 2-year reassessment. Fifty-eight participants (aged 76.9 ± 6.3 years) participated in the study. The Elderly Mobility Scale, Short Physical Performance Battery (SPPB), Timed Up and Go (TUG), gait speed, functional reach, one-leg-stance (OLS), and flexibility were evaluated at baseline, 6 months, and 2 years. Compared with baseline, the participants improved significantly in the SPPB (0.93 points), TUG (1.94 s), gait speed (0.13 m/s), and right and left OLS (2.56 and 3.12 s) at 6 months. Furthermore, these significant effects, except for OLS, were maintained at the 2-year reassessment according to repeated-measures ANOVA (p < .01). Our preliminary data suggest that adding a structured exercise program can benefit older adults participating in Taiwanese CCSs.

Research in hospital discharge procedures addresses gaps in care continuity in the community, but leaves gaping holes for people with dementia: a review of the literature

AIM

To examine the literature on the impact of the discharge experience of patients with dementia and their continuity of care.

METHODS

Peer-reviewed and grey literature published in the English language between 1995 and 2014 were systematically searched using Medline, CINAHL, PubMed, PsycINFO and Cochrane library databases, using a combination of the search terms Dementia, Caregivers, Integrated Health Care Systems, Managed Care, Patient Discharge. Also reviewed were Department of Health and Ageing and Alzheimer's Australia research reports between 2000 and 2014.

RESULTS

The review found a wide range of studies that raise concerns in relation to the quality of care provided to people with dementia during hospital discharge and in transitional care.

CONCLUSION

Discharge planning and transitional care for patients with dementia are not adequate and are likely to lead to readmission and other poor health outcomes.

Models of home care services for persons with dementia: a narrative review

BACKGROUND

Worldwide trends of increasing dementia prevalence, have put economic and workforce pressures to shifting care for persons with dementia from residential care to home care.

METHODS

We reviewed the effects of the four dominant models of home care delivery on outcomes for community-dwelling persons with dementia. These models are: case management, integrated care, consumer directed care, and restorative care. This narrative review describes benefits and possible drawbacks for persons with dementia outcomes and elements that comprise successful programs.

RESULTS

Case management for persons with dementia may increase use of community-based services and delay nursing home admission. Integrated care is associated with greater client satisfaction, increased use of community based services, and reduced hospital days however the clinical impacts on persons with dementia and their carers are not known. Consumer directed care increases satisfaction with care and service usage, but had little effect on clinical outcomes. Restorative models of home care have been shown to improve function and quality of life however these trials have excluded persons with dementia, with the exception of a pilot study.

CONCLUSIONS

There has been a little research into models of home care for people with dementia, and no head-to-head comparison of the different models. Research to inform evidence-based policy and service delivery for people with dementia needs to evaluate both the impact of different models on outcomes, and investigate how to best deliver these models to maximize outcomes.

Quality-of-care processes in geriatric assessment units: principles, practice, and outcomes

OBJECTIVES

To assess quality-of-care processes and to examine whether care processes are associated with short-term postdischarge outcomes in older vulnerable hospitalized patients.

DESIGN

Retrospective study.

SETTING

Forty-nine Geriatric Assessment Units.

PARTICIPANTS

Patients aged 65 and older who were admitted to a Geriatric Assessment Unit for a fall with trauma.

MEASUREMENTS

Three care processes (comprehensiveness, informational continuity, patient-centered care) assessed through chart audit; three-month postdischarge outcomes (emergency department visit, hospital readmission, and death) obtained from national databases.

RESULTS

A total of 934 hospitalization records were included. Mean comprehensiveness and informational continuity scores were 55% ± 12% and 42% ± 16%, respectively. Items related to geriatric global assessment (eg, functional autonomy) were particularly overlooked. Patient-centered care was poorly provided, with only 24% of hospitalization records showing evidence of advance care directives and at least one patient/family meeting with the physician to discuss clinical evolution. For the three care processes, a large variability among Geriatric Assessment Units was observed. Better comprehensiveness of care was associated with lowered short-term mortality (OR = 0.73, 95% CI = 0.55-0.96, P = .023), whereas higher scores on informational continuity was associated with fewer emergency department visits (OR = 0.91, 95% CI = 0.82-1.00, P = .046), hospital readmissions (OR = 0.84, 95% CI = 0.74-0.94, P = .003), and mortality (OR = 0.72, 95% CI = 0.59-0.88, P = .002). Patient-centered care was not associated with any of the postdischarge outcomes.

CONCLUSION

A large gap between geriatric care principles and practice in Geriatric Assessment Units has been observed. Our results show that improvement in care processes may be translated to decreased short-term health services use and mortality.

Quality of care assessment in geriatric evaluation and management units: construction of a chart review tool for a tracer condition

Background

The number of elderly people requiring hospital care is growing, so, quality and assessment of care for elders are emerging and complex areas of research. Very few validated and reliable instruments exist for the assessment of quality of acute care in this field. This study's objective was to create such a tool for Geriatric Evaluation and Management Units (GEMUs).

Methods

The methodology involved a reliability and feasibility study of a retrospective chart review on 934 older inpatients admitted in 49 GEMUs during the year 2002–2003 for fall-related trauma as a tracer condition. Pertinent indicators for a chart abstraction tool, the Geriatric Care Tool (GCT), were developed and validated according to five dimensions: access to care, comprehensiveness, continuity of care, patient-centred care and appropriateness. Consensus methods were used to develop the content. Participants were experts representing eight main health care professions involved in GEMUs from 19 different sites. Items associated with high quality of care at each step of the multidisciplinary management of patients admitted due to falls were identified. The GCT was tested for intra- and inter-rater reliability using 30 medical charts reviewed by each of three independent and blinded trained nurses. Kappa and agreement measures between pairs of chart reviewers were computed on an item-by-item basis.

Results

Three quarters of 169 items identifying the process of care, from the case history to discharge planning, demonstrated good agreement (kappa greater than 0.40 and agreement over 70%). Indicators for the appropriateness of care showed less reliability.

Conclusion

Content validity and reliability results, as well as the feasibility of the process, suggest that the chart abstraction tool can gather standardized and pertinent clinical information for further evaluating quality of care in GEMU using admission due to falls as a tracer condition. However, the GCT should be evaluated in other models of acute geriatric units and new strategies should be developed to improve reliability of peer assessments in characterizing the quality of care for elderly patients with complex conditions.

PACE: has it changed the chronic care paradigm?

The Program of All-inclusive Care for the Elderly (PACE) grew out of a small community organization in San Francisco and has been replicated by non-profit organizations in a number of other communities across the country. The authors review the successes of PACE as reported in the literature and discuss reasons for its limited growth as well as its significant influence on state and federal long term care policy. They argue that PACE has significantly changed how we think of long term care through its pioneering work fully integrating medical and long term care. PACE has also provided an influential model for breaking down the funding silos that characterize the medical and long term care services arena. State Medicaid agencies and Medicare have learned from PACE. Health plans and private long term insurers may also still learn from PACE. However, the fact that only a little more than 10,000 elders have enrolled in PACE nationwide prevents the authors from finding that PACE has brought about significant structural change in a long term care industry dominated by for-profit nursing homes.

Older adults' satisfaction with integrated capitated health and long-term care

PURPOSE

The objective of this study is to develop an instrument to evaluate satisfaction with care for older adults in capitated environments. Although satisfaction with care is now widely accepted as an important outcome measure, there are relatively few satisfaction measures developed or validated on older persons. Because many older persons are unable to respond to surveys, separate instruments were developed for individuals and for their families.

DESIGN AND METHODS

There were 402 face-to-face interviews conducted at 11 PACE sites with PACE participants or their family members and a non-PACE group. Scales were constructed by use of factor analysis and were evaluated for internal-consistency reliability, validity, and ability to discriminate.

RESULTS

For the participant survey, three factors were identified, but only two exhibited adequate internal consistency (Perceived Access and Perceived Interpersonal Quality). For the family survey, all four identified factors had adequate internal consistency (Perceived Access, Family Pressure, Ease of Access, and Family Involvement). The participant survey discriminated between the PACE sites and the non-PACE sites, but the family-member survey did not.

IMPLICATIONS

The PACE Satisfaction Survey appears to have adequate reliability and validity for measuring the satisfaction of older persons and their family members with capitated care. The domains of satisfaction differ between individuals and family members.

Measuring Interdisciplinary Team Performance in a Long-Term Care Setting

OBJECTIVES

The objectives of this study were to test the reliability and the validity of a survey instrument for assessing interdisciplinary team performance in long-term care settings and to measure team performance in the Program of All-Inclusive Care for the Elderly (PACE).

RESEARCH DESIGN AND METHODS

The analysis is based on 1220 surveys completed by team members of 26 PACE programs. Cronbach's alphas, analysis of variance, and regression models were used to assess the reliability and the validity of the instrument. Multivariate regression analysis was used to examine factors associated with team performance in PACE.

RESULTS

Cronbach's alphas ranging from 0.76 to 0.89 demonstrate good-to-high reliability for all domains of the team process and performance (effectiveness). Construct validity is demonstrated through the results of the regression analysis showing that leadership, communication, coordination, and conflict management are positive and significant (P <0.001) predictors of team cohesion and team effectiveness. The data also support the appropriateness of aggregating individual-level responses to the unit level. Perceived team effectiveness significantly (P <0.05) increases with: age of the respondents; longer length of the team's professional work experience; shorter duration of the team's PACE experience; more ethnically diverse composition of the team; greater ethnic concordance between team members and the participants; and greater perceived resource availability.

CONCLUSIONS

Several of the factors influencing team effectiveness in PACE are potentially modifiable and, therefore, could offer insights for improving team practice.

Advanced practice nursing in the care of frail older adults

Models of care for frail older adults have increasingly used advanced practice nurses (APNs) to achieve outcomes. Knowledge of the common APN functions and skills that contribute to the success of these models could better inform education and evidence-based practice and guide further research, but published investigations associated with models of gerontologic care neither describe fully these functions and skills nor link the activities of the APN with specific outcomes. Using examples primarily from the University of Pennsylvania School of Nursing, this paper identifies, describes, and analyzes common functions and skills of APNs in published gerontologic care models; examines the strength of the evidence for the effect of APNs on outcomes of care; and identifies areas for further study.

Development of a method to identify seniors at high risk for high hospital utilization

BACKGROUND

A small percentage of older persons account for most Medicare costs. If persons at high risk for high health care utilization can be identified, resources can be directed to improve their health care and reduce utilization.

OBJECTIVE

To develop an efficient and economical approach to identifying older persons at risk for high future health care utilization.

DESIGN

Validation cohort.

SETTING

Three communities.

SUBJECTS

Five thousand one hundred thirty-eight community-dwelling persons aged 71 years or older.

MAIN OUTCOME MEASURES

High utilization (defined as >or=11 hospital days during 3 years) and overall Part A Medicare hospital costs during 3 years.

RESULTS

Predictive multivariable models were created that relied on prior hospitalization only, self-report only, and combined self-report and physical examination/lab data. Ten self-report items (hospitalizations in prior year and year before that, male gender, fair/poor health, not working, infrequent religious participation, needing help bathing, unable to walk 1/2 mile, diabetes, and taking loop diuretics) and two lab tests (low serum albumin and iron) remained as independent predictors of high utilization. Based upon these variables, approximately 1/4 of the population was identified as being at high risk (>or=0.28 probability) for high health care utilization and those identified accounted for approximately half of all Medicare Part A costs for the entire population. Finally, a two-phase strategy was developed in which tests are only administered to individuals whose risk cannot be adequately determined by self-report variables (approximately 1/4 of subjects).

CONCLUSIONS

Simple questions and laboratory tests can accurately and efficiently identify seniors at high risk for high health care utilization.

Challenges of systems of care for frail older persons: the United States of America experience

The concomitant demographic and economic imperatives of an increasingly aged and frail population in the United States provide a compelling rationale for the development of systems of care that provide greater integration and improved quality of care. After providing the supporting statistics that illuminate the challenges faced by this country, this article then examines the current organization and financing of services pertinent to the care of frail older adults. These individual services, however, comprise a continuum of care more by default than by design. Greater integration is needed to meet the needs of this population that requires care from different providers in multiple settings. Fortunately, innovations are being implemented that integrate acute care with chronic and long-term care, providing reason for hope that the health care system in the United States is responding to these imperatives.