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Mah JC, Stilwell C, Kubiseski M, Arora G, Nicholls K, Khan S, Veinot J, Eum L, Freter S, Koller K, von Maltzahn M, Rockwood K, Searle SD, Andrew MK, Marshall EG. Managing "socially admitted" patients in hospital: a qualitative study of health care providers' perceptions. CMAJ 2024; 196:E580-E590. [PMID: 38719223 PMCID: PMC11073828 DOI: 10.1503/cmaj.231430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Emergency departments are a last resort for some socially vulnerable patients without an acute medical illness (colloquially known as "socially admitted" patients), resulting in their occupation of hospital beds typically designated for patients requiring acute medical care. In this study, we aimed to explore the perceptions of health care providers regarding patients admitted as "social admissions." METHODS This qualitative study was informed by grounded theory and involved semistructured interviews at a Nova Scotia tertiary care centre. From October 2022 to July 2023, we interviewed eligible participants, including any health care clinician or administrator who worked directly with "socially admitted" patients. Virtual or in-person individual interviews were audio-recorded and transcribed, then independently and iteratively coded. We mapped themes on the 5 domains of the Quintuple Aim conceptual framework. RESULTS We interviewed 20 nurses, physicians, administrators, and social workers. Most identified as female (n = 11) and White (n = 13), and were in their mid to late career (n = 13). We categorized 9 themes into 5 domains: patient experience (patient description, provision of care); care team well-being (moral distress, hierarchy of care); health equity (stigma and missed opportunities, prejudices); cost of care (wait-lists and scarcity of alternatives); and population health (factors leading to vulnerability, system changes). Participants described experiences caring for "socially admitted" patients, perceptions and assumptions underlying "social" presentations, system barriers to care delivery, and suggestions of potential solutions. INTERPRETATION Health care providers viewed "socially admitted" patients as needing enhanced care but identified individual, institutional, and system challenges that impeded its realization. Examining perceptions of the people who care for "socially admitted" patients offers insights to guide clinicians and policy-makers in caring for socially vulnerable patients.
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Affiliation(s)
- Jasmine C Mah
- Department of Medicine (Mah, Eum), and Faculties of Health (Stilwell) and Medicine (Kubiseski, Arora), Dalhousie University; Frailty and Elder Care Network (Nicholls), Care Coordination Centre (Khan), and Queen Elizabeth II Halifax Infirmary Emergency Department (Veinot), Nova Scotia Health; Division of Geriatric Medicine (Freter, Koller, von Maltzahn, Rockwood, Searle, Andrew), Department of Medicine, and Department of Family Medicine Primary Care Research Unit (Marshall), Dalhousie University, Halifax, NS
| | - Christie Stilwell
- Department of Medicine (Mah, Eum), and Faculties of Health (Stilwell) and Medicine (Kubiseski, Arora), Dalhousie University; Frailty and Elder Care Network (Nicholls), Care Coordination Centre (Khan), and Queen Elizabeth II Halifax Infirmary Emergency Department (Veinot), Nova Scotia Health; Division of Geriatric Medicine (Freter, Koller, von Maltzahn, Rockwood, Searle, Andrew), Department of Medicine, and Department of Family Medicine Primary Care Research Unit (Marshall), Dalhousie University, Halifax, NS
| | - Madeline Kubiseski
- Department of Medicine (Mah, Eum), and Faculties of Health (Stilwell) and Medicine (Kubiseski, Arora), Dalhousie University; Frailty and Elder Care Network (Nicholls), Care Coordination Centre (Khan), and Queen Elizabeth II Halifax Infirmary Emergency Department (Veinot), Nova Scotia Health; Division of Geriatric Medicine (Freter, Koller, von Maltzahn, Rockwood, Searle, Andrew), Department of Medicine, and Department of Family Medicine Primary Care Research Unit (Marshall), Dalhousie University, Halifax, NS
| | - Gaurav Arora
- Department of Medicine (Mah, Eum), and Faculties of Health (Stilwell) and Medicine (Kubiseski, Arora), Dalhousie University; Frailty and Elder Care Network (Nicholls), Care Coordination Centre (Khan), and Queen Elizabeth II Halifax Infirmary Emergency Department (Veinot), Nova Scotia Health; Division of Geriatric Medicine (Freter, Koller, von Maltzahn, Rockwood, Searle, Andrew), Department of Medicine, and Department of Family Medicine Primary Care Research Unit (Marshall), Dalhousie University, Halifax, NS
| | - Karen Nicholls
- Department of Medicine (Mah, Eum), and Faculties of Health (Stilwell) and Medicine (Kubiseski, Arora), Dalhousie University; Frailty and Elder Care Network (Nicholls), Care Coordination Centre (Khan), and Queen Elizabeth II Halifax Infirmary Emergency Department (Veinot), Nova Scotia Health; Division of Geriatric Medicine (Freter, Koller, von Maltzahn, Rockwood, Searle, Andrew), Department of Medicine, and Department of Family Medicine Primary Care Research Unit (Marshall), Dalhousie University, Halifax, NS
| | - Sheliza Khan
- Department of Medicine (Mah, Eum), and Faculties of Health (Stilwell) and Medicine (Kubiseski, Arora), Dalhousie University; Frailty and Elder Care Network (Nicholls), Care Coordination Centre (Khan), and Queen Elizabeth II Halifax Infirmary Emergency Department (Veinot), Nova Scotia Health; Division of Geriatric Medicine (Freter, Koller, von Maltzahn, Rockwood, Searle, Andrew), Department of Medicine, and Department of Family Medicine Primary Care Research Unit (Marshall), Dalhousie University, Halifax, NS
| | - Jonathan Veinot
- Department of Medicine (Mah, Eum), and Faculties of Health (Stilwell) and Medicine (Kubiseski, Arora), Dalhousie University; Frailty and Elder Care Network (Nicholls), Care Coordination Centre (Khan), and Queen Elizabeth II Halifax Infirmary Emergency Department (Veinot), Nova Scotia Health; Division of Geriatric Medicine (Freter, Koller, von Maltzahn, Rockwood, Searle, Andrew), Department of Medicine, and Department of Family Medicine Primary Care Research Unit (Marshall), Dalhousie University, Halifax, NS
| | - Lucy Eum
- Department of Medicine (Mah, Eum), and Faculties of Health (Stilwell) and Medicine (Kubiseski, Arora), Dalhousie University; Frailty and Elder Care Network (Nicholls), Care Coordination Centre (Khan), and Queen Elizabeth II Halifax Infirmary Emergency Department (Veinot), Nova Scotia Health; Division of Geriatric Medicine (Freter, Koller, von Maltzahn, Rockwood, Searle, Andrew), Department of Medicine, and Department of Family Medicine Primary Care Research Unit (Marshall), Dalhousie University, Halifax, NS
| | - Susan Freter
- Department of Medicine (Mah, Eum), and Faculties of Health (Stilwell) and Medicine (Kubiseski, Arora), Dalhousie University; Frailty and Elder Care Network (Nicholls), Care Coordination Centre (Khan), and Queen Elizabeth II Halifax Infirmary Emergency Department (Veinot), Nova Scotia Health; Division of Geriatric Medicine (Freter, Koller, von Maltzahn, Rockwood, Searle, Andrew), Department of Medicine, and Department of Family Medicine Primary Care Research Unit (Marshall), Dalhousie University, Halifax, NS
| | - Katalin Koller
- Department of Medicine (Mah, Eum), and Faculties of Health (Stilwell) and Medicine (Kubiseski, Arora), Dalhousie University; Frailty and Elder Care Network (Nicholls), Care Coordination Centre (Khan), and Queen Elizabeth II Halifax Infirmary Emergency Department (Veinot), Nova Scotia Health; Division of Geriatric Medicine (Freter, Koller, von Maltzahn, Rockwood, Searle, Andrew), Department of Medicine, and Department of Family Medicine Primary Care Research Unit (Marshall), Dalhousie University, Halifax, NS
| | - Maia von Maltzahn
- Department of Medicine (Mah, Eum), and Faculties of Health (Stilwell) and Medicine (Kubiseski, Arora), Dalhousie University; Frailty and Elder Care Network (Nicholls), Care Coordination Centre (Khan), and Queen Elizabeth II Halifax Infirmary Emergency Department (Veinot), Nova Scotia Health; Division of Geriatric Medicine (Freter, Koller, von Maltzahn, Rockwood, Searle, Andrew), Department of Medicine, and Department of Family Medicine Primary Care Research Unit (Marshall), Dalhousie University, Halifax, NS
| | - Kenneth Rockwood
- Department of Medicine (Mah, Eum), and Faculties of Health (Stilwell) and Medicine (Kubiseski, Arora), Dalhousie University; Frailty and Elder Care Network (Nicholls), Care Coordination Centre (Khan), and Queen Elizabeth II Halifax Infirmary Emergency Department (Veinot), Nova Scotia Health; Division of Geriatric Medicine (Freter, Koller, von Maltzahn, Rockwood, Searle, Andrew), Department of Medicine, and Department of Family Medicine Primary Care Research Unit (Marshall), Dalhousie University, Halifax, NS
| | - Samuel D Searle
- Department of Medicine (Mah, Eum), and Faculties of Health (Stilwell) and Medicine (Kubiseski, Arora), Dalhousie University; Frailty and Elder Care Network (Nicholls), Care Coordination Centre (Khan), and Queen Elizabeth II Halifax Infirmary Emergency Department (Veinot), Nova Scotia Health; Division of Geriatric Medicine (Freter, Koller, von Maltzahn, Rockwood, Searle, Andrew), Department of Medicine, and Department of Family Medicine Primary Care Research Unit (Marshall), Dalhousie University, Halifax, NS
| | - Melissa K Andrew
- Department of Medicine (Mah, Eum), and Faculties of Health (Stilwell) and Medicine (Kubiseski, Arora), Dalhousie University; Frailty and Elder Care Network (Nicholls), Care Coordination Centre (Khan), and Queen Elizabeth II Halifax Infirmary Emergency Department (Veinot), Nova Scotia Health; Division of Geriatric Medicine (Freter, Koller, von Maltzahn, Rockwood, Searle, Andrew), Department of Medicine, and Department of Family Medicine Primary Care Research Unit (Marshall), Dalhousie University, Halifax, NS
| | - Emily Gard Marshall
- Department of Medicine (Mah, Eum), and Faculties of Health (Stilwell) and Medicine (Kubiseski, Arora), Dalhousie University; Frailty and Elder Care Network (Nicholls), Care Coordination Centre (Khan), and Queen Elizabeth II Halifax Infirmary Emergency Department (Veinot), Nova Scotia Health; Division of Geriatric Medicine (Freter, Koller, von Maltzahn, Rockwood, Searle, Andrew), Department of Medicine, and Department of Family Medicine Primary Care Research Unit (Marshall), Dalhousie University, Halifax, NS
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Baumstarck K, Hamouda I, Aim MA, Anzola AB, Khaldi-Cherif S, Felce A, Maincent K, Lind K, Auquier P, Billette de Villemeur T, Rousseau MC. Health care management adequacy among French persons with severe profound intellectual and multiple disabilities: a longitudinal study. BMC Health Serv Res 2024; 24:99. [PMID: 38238747 PMCID: PMC10795329 DOI: 10.1186/s12913-024-10552-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 01/03/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND The care organization of persons with profound intellectual and multiple disabilities (PIMD) varies by country according to the health care system. This study used a large sample of French individuals with severe PIMD/polyhandicap to assess: 1) the adequacy of care setting over a 5-year period and 2) health care consumption. METHODS The longitudinal study used data from the French EVALuation PoLyHandicap (EVAL-PLH) cohort of persons with severe PIMD/polyhandicap who were receiving managed in specialized care centres and residential facilities. Two assessments were performed: wave 1 (T1) in 2015-2016 and wave 2 (T2) in 2020-2021. The inclusion criteria were as follows: age > 3 years at the time of inclusion; age at onset of cerebral lesion younger than 3 years old; and severe PIMD. The adequacy of the care setting was based on the following: i) objective indicators, i.e., adequacy for age and adequacy for health status severity; ii) subjective indicators, i.e., self-perception of the referring physician about medical care adequacy and educational care adequacy. Health care consumption was assessed based on medical and paramedical care. RESULTS Among the 492 persons assessed at the 2 times, 50% of individuals at T1 and 46% of individuals at T2 were in an inadequate care setting based on age and severity. Regarding global subjective inadequacy, the combination of medical adequacy and educational adequacy, 7% of individuals at T1 and 13% of individuals at T2 were in an inadequate care setting. At T2, a majority of individuals were undermonitored by medical care providers (general practitioners, physical medicine rehabilitation physicians, neurologists, orthopaedists, etc.). Important gaps were found between performed and prescribed sessions of various paramedical care (physiotherapy, occupational therapy, psychomotor therapy, etc.). CONCLUSIONS This study revealed key elements of inadequate care management for persons with severe PIMD/polyhandicap in France. Based on these important findings, healthcare workers, familial caregivers, patients experts, and health decision-makers should develop appropriate care organizations to optimize the global care management of these individuals. TRIAL REGISTRATION NCT02400528, registered 27/03/2015.
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Affiliation(s)
- Karine Baumstarck
- EA 3279, CEReSS - Research Centre On Health Services and Quality of Life, Aix Marseille University, 27 Boulevard Jean-Moulin, 13385, Marseille, France.
- Epidemiology and Health Economy Department, Assistance Publique Hôpitaux de Marseille, 27, Boulevard Jean-Moulin, 13385, Marseille, France.
| | - Ilyes Hamouda
- EA 3279, CEReSS - Research Centre On Health Services and Quality of Life, Aix Marseille University, 27 Boulevard Jean-Moulin, 13385, Marseille, France
- Epidemiology and Health Economy Department, Assistance Publique Hôpitaux de Marseille, 27, Boulevard Jean-Moulin, 13385, Marseille, France
| | - Marie-Anastasie Aim
- UR 849, LPS - Social Psychology Laboratory, Aix-Marseille University, 29 Av. Robert Schuman, 13621, Aix-en-Provence, France
| | - Any Beltran Anzola
- EA 3279, CEReSS - Research Centre On Health Services and Quality of Life, Aix Marseille University, 27 Boulevard Jean-Moulin, 13385, Marseille, France
| | - Sherezad Khaldi-Cherif
- General Union Health Insurance Fund (Union Générale Caisse Assurance Maladie, UGECAM), 26-50 Avenue du Professeur-André-Lemierre, 75986, Paris, Ile de France, France
| | - Agnès Felce
- Hendaye Hospital, Route Corniche, 64700, Hendaye, Assistance Publique-Hôpitaux de Paris, France
| | - Kim Maincent
- Committee for Studies, Education and Care for People With Multiple Disabilities (Comité d'Études, d'Éducation Et de Soins Auprès Des Personnes Polyhandicapées, CESAP), 62 Rue de La Glacière, 75013, Paris, France
| | - Katia Lind
- General Union Health Insurance Fund (Union Générale Caisse Assurance Maladie, UGECAM), 26-50 Avenue du Professeur-André-Lemierre, 75986, Paris, Ile de France, France
| | - Pascal Auquier
- EA 3279, CEReSS - Research Centre On Health Services and Quality of Life, Aix Marseille University, 27 Boulevard Jean-Moulin, 13385, Marseille, France
- Epidemiology and Health Economy Department, Assistance Publique Hôpitaux de Marseille, 27, Boulevard Jean-Moulin, 13385, Marseille, France
| | - Thierry Billette de Villemeur
- Service de Polyhandicap Pédiatrique, Roche Guyon Hospital, Assistance Publique Hôpitaux de Paris, 1 Rue Justinien Blazy 95780, La Roche-Guyon, France
- Hospital Fédération Des Hôpitaux de Polyhandicap Et Multihandicap, San Salvadour Hospital, Assistance Publique Hôpitaux de Paris, 4312 Rte de L'Almanarre, 83400, Hyères, France
| | - Marie-Christine Rousseau
- EA 3279, CEReSS - Research Centre On Health Services and Quality of Life, Aix Marseille University, 27 Boulevard Jean-Moulin, 13385, Marseille, France
- Hospital Fédération Des Hôpitaux de Polyhandicap Et Multihandicap, San Salvadour Hospital, Assistance Publique Hôpitaux de Paris, 4312 Rte de L'Almanarre, 83400, Hyères, France
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Buta B, Friedman AB, Chung SE, Sheehan OC, Blinka MD, Gearhart SL, Xue QL. The combined effects of physical frailty and cognitive impairment on emergency department- versus direct-admission hospitalizations. BMC Geriatr 2022; 22:718. [PMID: 36042414 PMCID: PMC9429704 DOI: 10.1186/s12877-022-03397-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/12/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND We aimed to study whether physical frailty and cognitive impairment (CI) increase the risk of recurrent hospitalizations in older adults, independent of comorbidity, and disability. METHODS Two thousand five hundred forty-nine community-dwelling participants from the National Health and Aging Trends Study (NHATS) with 3 + years of continuous Medicare coverage from linked claims data were included. We used the marginal means/rates recurrent events model to investigate the association of baseline CI (mild CI or dementia) and physical frailty, separately and synergistically, with the number of all-source vs. Emergency Department (ED)-admission vs. direct admission hospitalizations over 2 years. RESULTS 17.8% of participants had at least one ED-admission hospitalization; 12.7% had at least one direct admission hospitalization. Frailty and CI, modeled separately, were both significantly associated with risk of recurrent all-source (Rate Ratio (RR) = 1.24 for frailty, 1.21 for CI; p < .05) and ED-admission (RR = 1.49 for frailty, 1.41 for CI; p < .05) hospitalizations but not direct admission, adjusting for socio-demographics, obesity, comorbidity and disability. When CI and frailty were examined together, 64.3% had neither (Unimpaired); 28.1% CI only; 3.5% Frailty only; 4.1% CI + Frailty. Compared to those Unimpaired, CI alone and CI + Frailty were predictive of all-source (RR = 1.20, 1.48, p < .05) and ED-admission (RR = 1.36, 2.14, p < .05) hospitalizations, but not direct admission, in our adjusted model. CONCLUSIONS Older adults with both CI and frailty experienced the highest risk for recurrent ED-admission hospitalizations. Timely recognition of older adults with CI and frailty is needed, paying special attention to managing cognitive impairment to mitigate preventable causes of ED admissions and potentiate alternatives to hospitalization.
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Affiliation(s)
- Brian Buta
- Department of Medicine Division of Geriatric Medicine and Gerontology, Center On Aging and Health, Johns Hopkins University, 2024 E. Monument Street, Suite 2-700, Baltimore, MD, 21205, USA
| | - Ari B Friedman
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, PA, Philadelphia, USA
| | - Shang-En Chung
- Department of Medicine Division of Geriatric Medicine and Gerontology, Center On Aging and Health, Johns Hopkins University, 2024 E. Monument Street, Suite 2-700, Baltimore, MD, 21205, USA
| | - Orla C Sheehan
- Department of Medicine Division of Geriatric Medicine and Gerontology, Center On Aging and Health, Johns Hopkins University, 2024 E. Monument Street, Suite 2-700, Baltimore, MD, 21205, USA
- Connolly Hospital Blanchardstown, Dublin, Ireland
| | - Marcela D Blinka
- Department of Medicine Division of Geriatric Medicine and Gerontology, Center On Aging and Health, Johns Hopkins University, 2024 E. Monument Street, Suite 2-700, Baltimore, MD, 21205, USA
| | - Susan L Gearhart
- Department of Medicine Division of Geriatric Medicine and Gerontology, Center On Aging and Health, Johns Hopkins University, 2024 E. Monument Street, Suite 2-700, Baltimore, MD, 21205, USA
| | - Qian-Li Xue
- Department of Medicine Division of Geriatric Medicine and Gerontology, Center On Aging and Health, Johns Hopkins University, 2024 E. Monument Street, Suite 2-700, Baltimore, MD, 21205, USA.
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