How is complexity measured and detected among community dwelling older people aged 65 years and over? A scoping review

Clinical Pharmacist and Clinical Nurse Specialist led medicine optimisation and medication adherence via eArly identifiCation advanCed gEriatric aSsesSment (ACCESS) tool in Senior Adult Oncology Programme (SAOP)

BACKGROUND

Comprehensive geriatric assessment evaluates key health domains for older adults, focusing on medicine optimisation and medication adherence to improve tolerability and quality of life for older adults on systematic anticancer therapy. The Royal Marsden (RM) Senior Adult Oncology Programme (SAOP) provides multidisciplinary geriatric assessment and interventions for patients ≥ 70 undergoing systematic anticancer therapy.

AIM

We designed an ACCESS (eArly identifiCation advanCed gEriatric aSsesSment) tool to enhance efficiency of SAOP outpatient clinics by facilitating geriatric assessment including medications, nutrition, social support, mood, and functional assessments.

SETTING

SAOP at RM NHS Foundation Trust, London, UK.

DEVELOPMENT

Developed by SAOP pharmacist and clinical nurse specialist with input from SAOP multidisciplinary team, the ACCESS tool includes medication review patient counselling deprescribing, and comorbidity management, aligning with the Royal Pharmaceutical Society Advanced Pharmacy Framework.

IMPLEMENTATION

From January to December 2022, ACCESS was implemented in three steps: screening with Senior Adult Oncology Programme v 3 (SAOP3) questionnaire, remote consultation based on results, and medication review and patient counselling for complex medication needs, enhancing patient engagement and treatment understanding.

EVALUATION

The practice was audited through the implementation process. Quantitative data from staff and 100 patients who were users of the SAOP service and ACCESS tool revealed higher medication adherence, improved identification of inappropriate medications, and enhanced confidence in managing complex geriatric oncology cases.

CONCLUSION

The ACCESS tool, led by clinical pharmacist and clinical nurse specialist has improved outpatient clinic efficiency, patient satisfaction, and healthcare coordination. It allows personalised follow-up plans for older adults with complex health issues on anticancer therapy. Regular multidisciplinary team meetings and digital health records enhance care coordination and decision-making for older adults with cancer.

Determinants of Nurses' Caring Behaviours: Cultural Adaptation and Psychometric Testing of the Turkish Version-A Methodologic Study

BACKGROUND

Understanding the factors influencing nurses' caring behaviour is imperative for advancing care quality.

AIM

This study aims to translate and culturally adapt the Determinants of Nurses' Caring Behaviours (DNCB) instrument into Turkish and assess its psychometric properties. The original DNCB consists of 35 items and six subscales, designed to identify and measure the factors that influence nurses' caring behaviours in clinical practice.

METHOD

This methodological study followed the guidelines for outcome measurement instruments established by COSMIN. The translation process followed the guidelines of the Patient-Reported Outcome (PRO) Consortium, which involved forward and back translation, reconciliation, cognitive interviewing, and expert panel review. A sample of 351 nurses was recruited from adult units at a university-affiliated hospital in Istanbul. Face validity and Content Validity Index (CVI) were assessed by an expert panel. Cronbach's alpha was used to evaluate internal consistency. Construct validity was assessed using Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA), along with model fit evaluations, using SPSS version 25 and AMOS 26.

RESULTS

The EFA revealed that 55% of the total variance was explained by 33 factors. Six distinct factors emerged, labelled as Nurses' Practice and Educational Background, Characteristics of Nurses, Challenge in Nursing Care and Identity, Professional Engagement, Satisfaction with Workplace, and Patient Characteristics. Following refinement, the model demonstrated significant enhancements, with improved indices: Normed Fit Index (NFI) at 0.921, Incremental Fit Index (IFI) at 0.979, and Tucker-Lewis Index (TLI) at 0.951. Additionally, the Comparative Fit Index (CFI) improved to 0.957, with a reduced RMSEA value of 0.053 (90% CI [0.046, 0.055]), indicating a more accurate representation of the data's underlying structure.

CONCLUSION

The Turkish version of the DNCB demonstrates strong internal consistency and validity, supported by robust psychometric properties. It can serve as an effective instrument for measuring and investigating the determinants of nurses' care behaviour both in Turkey and Northern Cyprus, with implications for nursing practice and future research.

Improving Quality of Care Through Detection of Complexity Among Community-Dwelling Older People Receiving District-Nurse Support: ImPaCt Study Randomised Controlled Trial

AIM

To examine the effect of implementing the patient complexity instrument (PCI) in addition to usual-care on complexity detection, clinical-care time allocation and referrals to supportive services compared to usual-assessment alone.

DESIGN

A parallel-group-blocked pragmatic randomised controlled trial.

METHODS

A mixed-method study conducted within a regional Australian community nursing service. Randomisation occurred at the initial client assessment following referral acceptance for community nursing support. Older people aged 65 years and over (client participants), referred to the service from 1st of July 2020 to 30th of September 2020, were eligible for Commonwealth Home Support Programme funding. A convenience sample of community nurses conducting client assessments was recruited. The intervention group included usual assessment plus the PCI, and the control group was usual assessment alone. Chi-square test independence compared complexity ratings (low, medium, high) between groups for the hypothesis that adding the PCI to usual assessment has no effect on nurses' complexity detection compared to usual assessment alone.

RESULTS

Compared to usual-assessment alone, adding the PCI did not change nurses' level detected complexity rating. However, for older people initially assessed with low levels of complexity, the PCI indicated a need for additional clinical-care-time. The nurses' contribution to process evaluation showed that the PCI was useful in providing prompts for aspects to consider during their assessment.

CONCLUSION

The addition of PCI to nurses' usual assessment did not improve levels of complexity ratings. However, the PCI enhanced complexity detection by pinpointing areas of care requiring referrals for additional care and extra time required. The ImPaCt trial demonstrated the PCI as a useful tool for enhancing care for older people receiving nursing support in the community. The PCI is a beneficial guidance resource for those new to the Community Nursing role caring for older people.

REPORTING METHOD

The study adhered to the updated guidelines for reporting parallel group randomised trials. Reporting was conducted according to the CONSORT checklist.

PATIENT OR PUBLIC CONTRIBUTION

This study was focused on the nurses' perspective of client complexity and how this complexity is detected. During the protocol development phase, a presentation about the study was made to a consumer group (older people) from the lead researcher's workplace. This presentation was well received, with five consumers in attendance. The protocol was also presented to the Board of the lead researcher's workplace, which was a large regional public health service. Four board members were in attendance and showed positive interest.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

This study underscores the merit of incorporating a care complexity assessment tool into community nursing care for older people, amplifying decision-making regarding patient complexity. Future studies should explore clients' perspectives, the PCI's effect on and implications for hospital (re)admissions and longevity at home.

TRIAL REGISTRATION

The trial was registered with the Australian and New Zealand Clinical Trials Registry (blinded for review).

Characteristics, care and support needs of older Victorians requiring a government-funded Home Care Package: An observational study

OBJECTIVES

To describe sociodemographic characteristics and comprehensive day-to-day care and support needs of older Victorians requiring government-funded home-based aged-care, and to explore associations between vulnerability factors and complexity indicators in this population.

METHODS

A population-based observational study was conducted using de-identified, routinely collected aged-care assessment data for Victorians approved for a Home Care Package (HCP) between January 2019 and June 2022.

RESULTS

The study population (n = 94,975 individuals), approved for one of four HCP levels (Levels 1 (5%), 2 (38%), 3 (34%) or 4 (24%)), was aged 82 years on average (SD 7.6), commonly born outside Australia (48%), with people of higher socio-economic status more likely to be approved for a high-level HCP. Advanced care and support needs such as for showering (53%) and dressing (43%) were common, with higher overall needs when cognitive and behavioural concerns such as short-term memory loss (75%) or agitation (21%) were present. 79% reported at least one vulnerability factor such as being socially isolated, culturally and linguistically diverse, or Aboriginal and Torres Strait Islander peoples, and 49% reported at least one complexity indicator. The three most prevalent complexity indicators were significant cognitive changes (29%), self-neglect (17%) and emotional/mental health issues (11%), which were generally positively associated with vulnerability factors.

CONCLUSIONS

This population-based study provides evidence of the diverse sociodemographics, and often advanced day-to-day mobility, functional, physical, cognitive, behavioural, psychological and psychosocial care and support needs of people requiring home-based aged-care. It also highlights the multifaceted complexities within this population. Results could inform home care service-delivery models and workforce skill-mix requirements to efficiently and safely meet these needs.

The reliability and validity of triage tools in geriatric emergency departments: A scoping review

BACKGROUND

The nurse's ability to accurately identify urgent conditions and triage this vulnerable population tends to be complex and challenging. Little is known about the reliability and validity of common triage tools in geriatric patients.

AIM

To determine the reliability and validity of triage tools in geriatric emergency care and summarize the specific content of current triage tools for geriatric patients.

METHODS

The eligible literature was searched from the MEDLINE, CINAHL, EMBASE, and Cochrane Database using targeted search strategies. We defined the objectives and questions, set standards for article inclusion criteria, and conducted literature searching and screening. The mixed methods assessment tool (MMAT) appraised the article's quality. Finally, we extracted and analyzed the data from the included articles, summarizing the results. Endnote X9 was used for data extraction and collation.

RESULTS

Nine articles were eligible. These included six triage tools: CTAS, JTAS, KTAS, MTS, SETS, and ESI. The reliability of the CTAS was good when applied to triage geriatric patients. The SETS performed well in prehospital simulated triage. The ESI has moderate to excellent reliability. The CTAS has good to excellent validity, while the JTAS, KTAS, MTS, and ESI have fair to good results.

CONCLUSION

Several triage tools are useful in geriatrics, but the reliability and validity of these tools have mixed results. Applying triage tools to triage geriatric patients still has limitations.

Capturing the clinical complexity in young people presenting to primary mental health services: a data-driven approach

AIMS

The specific and multifaceted service needs of young people have driven the development of youth-specific integrated primary mental healthcare models, such as the internationally pioneering headspace services in Australia. Although these services were designed for early intervention, they often need to cater for young people with severe conditions and complex needs, creating challenges in service planning and resource allocation. There is, however, a lack of understanding and consensus on the definition of complexity in such clinical settings.

METHODS

This retrospective study involved analysis of headspace's clinical minimum data set from young people accessing services in Australia between 1 July 2018 and 30 June 2019. Based on consultations with experts, complexity factors were mapped from a range of demographic information, symptom severity, diagnoses, illness stage, primary presenting issues and service engagement patterns. Consensus clustering was used to identify complexity subgroups based on identified factors. Multinomial logistic regression was then used to evaluate whether these complexity subgroups were associated with other risk factors.

RESULTS

A total of 81,622 episodes of care from 76,021 young people across 113 services were analysed. Around 20% of young people clustered into a 'high complexity' group, presenting with a variety of complexity factors, including severe disorders, a trauma history and psychosocial impairments. Two moderate complexity groups were identified representing 'distress complexity' and 'psychosocial complexity' (about 20% each). Compared with the 'distress complexity' group, young people in the 'psychosocial complexity' group presented with a higher proportion of education, employment and housing issues in addition to psychological distress, and had lower levels of service engagement. The distribution of complexity profiles also varied across different headspace services.

CONCLUSIONS

The proposed data-driven complexity model offers valuable insights for clinical planning and resource allocation. The identified groups highlight the importance of adopting a holistic and multidisciplinary approach to address the diverse factors contributing to clinical complexity. The large number of young people presenting with moderate-to-high complexity to headspace early intervention services emphasises the need for systemic change in youth mental healthcare to ensure the availability of appropriate and timely support for all young people.