scholarly journals 211 A Novel Integrated Care Approach: Supporting Older Persons to Remain at Home

2019 ◽  
Vol 48 (Supplement_3) ◽  
pp. iii1-iii16
Author(s):  
Sarah Tormey ◽  
Laura Binions ◽  
Aoife Dunne ◽  
Josephine Soh ◽  
Marie O'Connor ◽  
...  
Keyword(s):  
Primary Care ◽  
Integrated Care ◽  
Older Persons ◽  
Care Team ◽  
Resource Utilisation ◽  
Day Hospital ◽  
Clinical Frailty Scale ◽  
Integrated Network ◽  
Rapid Access ◽  
Co Morbidity

Abstract Background An Integrated Care Team (ICT) was established within our Day Hospital in September 2018 serving a catchment of older persons encompassing 3 Community Healthcare Organisations. The geographical spread of our patients poses challenges to the ICT in establishing an integrated network of services for patients. Provided here is a descriptive analysis of our patient cohort including basic demographics, co-morbidities, interventions and outcomes. Methods The team comprises of a Senior Physiotherapist, Occupational Therapist and Medical Social Worker supported by two Geriatricians. Referrals to the ICT are via the Day Hospital with a weekly multi-disciplinary team (MDT) meeting where they are discussed and prioritised. Interventions offered include domiciliary and day hospital based assessments. Following assessment appropriate targeted therapeutic intervention is provided which includes rapid access to enabling equipment, access to community supports and rapid access Geriatrician review. Additionally the ICT communicate with the acute and primary care services to identify existing or previous resource utilisation. Results In the inaugural 15 weeks of the service,132 referrals were received. This cohort had a mean age of 81,range (60-102) years; 58% female, 42%male. The Charlson Co-morbidity Index (CCI) score ranged from 2-9 with a mean score of 5. Of these, 50% had a Dementia diagnosis, 33% had a Falls history and 17% had a Stroke diagnosis. The mean Rockwood Clinical Frailty Scale score was 5; range ( 2-7). 62% of referrals were reviewed by both Physiotherapy and Occupational therapy, 58% by Medical Social Work. 34/132 required input from all 3 disciplines. Conclusion The ICT service has augmented the existing Day Hospital with timely multi-disciplinary assessment and treatment enabling older persons’ independence within their home in addition to forward planning if dependency levels increase. Additional benefits include reduction of primary care team waiting lists and forging links with our community and local rehab services. Future ambitions include recruitment of specialist nursing and direct referral pathways from our community colleagues.

scholarly journals 216 Integrated Day Hospital for Older Persons in a Primary Care Centre

2019 ◽  
Vol 48 (Supplement_3) ◽  
pp. iii17-iii65
Author(s):  
Fiona McGrath ◽  
Sarah Ronayne ◽  
Karen McHugh ◽  
Mary McDonnell ◽  
Elnsari Muataz ◽  
...  
Keyword(s):  
Primary Care ◽  
Emergency Department ◽  
Older Persons ◽  
Blood Pressure Monitoring ◽  
Rapid Assessment ◽  
Population Data ◽  
Shared Vision ◽  
Primary Care Centre ◽  
Day Hospital ◽  
Care Centre

Abstract Background To progress with integrated care, for older persons, it was proposed to establish a Day Hospital in a Primary Care Centre. Population data for Co Mayo shows the percentage of those over 65 years, (17.6%), to be significantly higher than the national average In 2018 there were 39,092 attendances to the Emergency Department and approximately 500, per month, were over 75 years. The aim was to develop a pathway from the Emergency Department to the Day Hospital for those 75 years and over who had experienced a fall. Additionally, this included an Early Supported Discharge for hip fracture patients. Methods The Day Hospital was operational 1 day per week with an allocation of funding for a Consultant, Occupational Therapist and assigned Project Manager. Holter and Blood pressure monitoring equipment was purchased. The Home First Team were reassigned to the front door of the hospital and worked with a cANP and a Medical Registrar. A weekly multi-disciplinary forum, inclusive of all stakeholders, developed working relationships, built a shared vision and standardised the approach for the patient cohort. Frailty training was provided specifically to Emergency Department staff. Results The Home First Team saw 541 patients (Jan-Apr 2019) and in collaboration with the Geriatrician streamed those suitable for management to primary care. The Integrated Day Hospital, 1 day per week (Jan-Apr 2019) delivered 55 new assessments plus follow-up appointments. Patient feedback is very positive and specifically highlights ease of access in primary care. Conclusion Establishing a Day Hospital in a Primary Care Centre is an innovative approach and shifts the focus of intervention from acute to primary care. The location is ideal due to a range of disciplines on site, PHN, Dietetics, Psychiatry This is the initial phase, with some pathways in place, and the overall aim is to provide GP access to rapid assessment in Primary Care and thus ensure hospital avoidance where possible.

scholarly journals Filling the gaps in the characterization of the clinical management of COVID-19: 30-day hospital admission and fatality rates in a cohort of 118 150 cases diagnosed in outpatient settings in Spain

2020 ◽  
Author(s):  
Daniel Prieto-Alhambra ◽  
Elisabet Balló ◽  
Ermengol Coma ◽  
Núria Mora ◽  
María Aragón ◽  
...  
Keyword(s):  
Primary Care ◽  
Polymerase Chain Reaction ◽  
Hospital Admission ◽  
Nursing Home Residents ◽  
Outcome Studies ◽  
Day Hospital ◽  
Chain Reaction ◽  
Co Morbidity ◽  
Polymerase Chain ◽  
Outpatient Settings

Abstract Background Currently, there is a missing link in the natural history of COVID-19, from first (usually milder) symptoms to hospitalization and/or death. To fill in this gap, we characterized COVID-19 patients at the time at which they were diagnosed in outpatient settings and estimated 30-day hospital admission and fatality rates. Methods This was a population-based cohort study.   Data were obtained from Information System for Research in Primary Care (SIDIAP)—a primary-care records database covering >6 million people (>80% of the population of Catalonia), linked to COVID-19 reverse transcriptase polymerase chain reaction (RT-PCR) tests and hospital emergency, inpatient and mortality registers. We included all patients in the database who were ≥15 years old and diagnosed with COVID-19 in outpatient settings between 15 March and 24 April 2020 (10 April for outcome studies). Baseline characteristics included socio-demographics, co-morbidity and previous drug use at the time of diagnosis, and polymerase chain reaction (PCR) testing and results.   Study outcomes included 30-day hospitalization for COVID-19 and all-cause fatality. Results We identified 118 150 and 95 467 COVID-19 patients for characterization and outcome studies, respectively. Most were women (58.7%) and young-to-middle-aged (e.g. 21.1% were 45–54 years old). Of the 44 575 who were tested with PCR, 32 723 (73.4%) tested positive. In the month after diagnosis, 14.8% (14.6–15.0) were hospitalized, with a greater proportion of men and older people, peaking at age 75–84 years. Thirty-day fatality was 3.5% (95% confidence interval: 3.4% to 3.6%), higher in men, increasing with age and highest in those residing in nursing homes [24.5% (23.4% to 25.6%)]. Conclusion COVID-19 infections were widespread in the community, including all age–sex strata. However, severe forms of the disease clustered in older men and nursing-home residents. Although initially managed in outpatient settings, 15% of cases required hospitalization and 4% died within a month of first symptoms. These data are instrumental for designing deconfinement strategies and will inform healthcare planning and hospital-bed allocation in current and future COVID-19 outbreaks.

scholarly journals The Integrated Care Team Approach of the Department of Veterans Affairs (VA): Geriatric Primary Care

2018 ◽  
Vol 33 (3) ◽  
pp. 280-289 ◽  
Author(s):  
Donna Rasin-Waters ◽  
Valerie Abel ◽  
Lisa K Kearney ◽  
Antonette Zeiss
Keyword(s):  
Primary Care ◽  
Integrated Care ◽  
Veterans Affairs ◽  
Care Team ◽  
Team Approach ◽  
Department Of Veterans Affairs

scholarly journals 131Developing the Physiotherapist’s Role on an Integrated Care Team for Older Persons

2017 ◽  
Vol 46 (Suppl_3) ◽  
pp. iii13-iii59
Author(s):  
Clare Mullarkey ◽  
Sean Kennelly ◽  
Desmond O’Neill
Keyword(s):  
Integrated Care ◽  
Older Persons ◽  
Care Team

scholarly journals OPEN ARCH: integrated care at the primary–secondary interface for the community-dwelling older person with complex needs

2020 ◽  
Vol 26 (2) ◽  
pp. 104
Author(s):  
Jennifer Mann ◽  
Rachel Quigley ◽  
Desley Harvey ◽  
Megan Tait ◽  
Gillian Williams ◽  
...  
Keyword(s):  
Primary Care ◽  
Integrated Care ◽  
Older Persons ◽  
Healthcare Delivery ◽  
Community Dwelling ◽  
Ageing Population ◽  
Preventative Care ◽  
Older Person ◽  
Complex Needs ◽  
Open Arch

Optimal care of community-dwelling older Australians with complex needs is a national imperative. Suboptimal care that is reactive, episodic and fragmented, is costly to the health system, can be life threatening to the older person and produces unsustainable carer demands. Health outcomes would be improved if services (health and social) are aligned towards community-based, comprehensive and preventative care. Integrated care is person-focussed in outlook and defies a condition-centric approach to healthcare delivery. Integration is a means to support primary care, with the volume and complexity of patient needs arising from an ageing population. Older Persons Enablement and Rehabilitation for Complex Health Conditions (OPEN ARCH) is a targeted model of care that improves access to specialist assessment and comprehensive care for older persons at risk of functional decline, hospitalisation or institutionalised care. OPEN ARCH was developed with primary care as the central integrating function and is built on four values of quality care: preventative health care provided closer to home; alignment of specialist and generalist care; care coordination and enablement; and primary care capacity building. Through vertical integration at the primary–secondary interface, OPEN ARCH cannot only improve the quality of care for clients, but improves the capacity of primary care to meet the needs of this population.

scholarly journals Evaluating integrated care for people with complex needs

2020 ◽  
Vol 26 (1) ◽  
pp. 46-53
Author(s):  
Panagiotis Kasteridis ◽  
Anne Mason ◽  
Andrew Street
Keyword(s):  
Primary Care ◽  
Integrated Care ◽  
Models Of Care ◽  
Care Team ◽  
Future Research ◽  
Complex Care ◽  
Care Needs ◽  
Complex Needs ◽  
Care Models ◽  
Integrated Care Models

Objectives As part of the Vanguard programme, two integrated care models were introduced in South Somerset for people with complex care needs: the Complex Care Team and Enhanced Primary Care. We assessed their impact on a range of utilization measures and mortality. Methods We used monthly individual-level linked primary and secondary care data from April 2014 to March 2018 to assess outcomes before and after the introduction of the care models. The analysis sample included 564 Complex Care Team and 841 Enhanced Primary Care cases that met specific criteria. We employed propensity score methods to identify out-of-area control patients and difference-in-differences analysis to isolate the care models’ impact. Results We found no evidence of significantly reduced utilization in any of the Complex Care Team or Enhanced Primary Care cohorts. The death rate was significantly lower only for those in the first Enhanced Primary Care cohort. Conclusions The integrated care models did not significantly reduce utilization nor consistently reduce mortality. Future research should test longer-term outcomes associated with the new models of care and quantify their contribution in the context of broader initiatives.

scholarly journals Using a new matrix to describe real-life integrated care innovation for older persons in primary care

2018 ◽  
Vol 18 (s2) ◽  
pp. 334
Author(s):  
Antonius J Poot ◽  
Claudia S De Waard ◽  
Annet W Wind ◽  
Monique AA Caljouw ◽  
Jacobijn Gussekloo
Keyword(s):  
Primary Care ◽  
Integrated Care ◽  
Older Persons ◽  
Real Life ◽  
Care Innovation

FRI0512 INTEGRATED CARE NETWORK AS A BUILDING STONE FOR SUSTAINABLE AND COMPREHENSIVE CARE FOR PATIENTS WITH ARTHRALGIA

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 855.1-855
Author(s):  
E. Van Delft ◽  
K. H. Han ◽  
J. Hazes ◽  
D. Lopes Barreto ◽  
A. Weel
Keyword(s):  
Primary Care ◽  
Usual Care ◽  
Integrated Care ◽  
Usual Care Group ◽  
Inflammatory Arthritis ◽  
Care Setting ◽  
Primary Care Setting ◽  
Care Group ◽  
Care Network ◽  
The Right

Background:Western countries experience an increasing demand for care, particularly for inflammatory arthritis (IA), while the healthcare budget decreases1. The innovative value-based primary care strategy2includes integrated care networks, where primary and secondary care bundle their expertise to improve patient value by providing the right care at the right place.General practitioners (GPs) have difficulties recognising IA, leading up to only 20% IA diagnoses of all newly referred arthralgia patients. However, since IA needs to be treated as early as possible to overcome progression, it is worthwhile to analyse whether integrated care networks have an impact on patient outcomes and cost-effectiveness. Triage by a rheumatologist in a primary care setting is one of the most promising integrated care networks for efficient referrals3.Objectives:To assess the effect of triage by a rheumatologist in a primary care setting in patients suspect for inflammatory arthritis.Methods:The present study follows a cluster randomized controlled trial design. The intervention, triage by a rheumatologist in a local primary care centre, will be compared to usual care. Usual care means that patients are referred to a rheumatology outpatient clinic based on the opinion of the general practitioner.The primary outcome is the frequency of IA diagnoses assessed by a rheumatologist. Patient reported outcome measures (PROMs (EQ-5D)) and costs (work productivity (iPCQ) and healthcare utilization (iMCQ)) were determined at baseline, after three, six and twelve months. The target was to include 267 patients for each study group (power level 0.8). Since this study is still ongoing we can only show first results on the efficiency of referrals.Results:In the period between February 2017 and December 2019 a total of 543 participants were included; 275 in the usual care group and 268 in the triage group. Mean age (51.3 ± 14.6 years) and percentage of men (23.6%) were comparable between groups (page=0.139; psex=0.330).The preliminary data show that the number of referred patients in the triage group is n=28 (10.5%) (Fig. 1). 32 patients (11.9%) were not referred directly but advice was given for additional diagnostics. Since all patients in the usual care group were referred there is a decrease of at least 77.6% in referrals when rheumatologists are participating in the integrated practice units.Preliminary data on diagnosis are available for all referred patients in the triage group and for n=137 (49.8%) in the usual care group at this point. In the triage group n=18 (64.2%) of referred patients were diagnosed with IA (6.7% of the total study population). In the usual care group this was n=52 (38.0%) of the patients yet diagnosed.Conclusion:These preliminary results of an integrated care network are promising. Approximately three-quarters of all patients can be withheld from expensive outpatient care. PROMs data and cost-effectiveness analysis will give clear answers in order to provide evidence whether this integrated care network can be implemented as a standard of care.References:[1] Rijksoverheid. (2018). Bestuurlijk akkoord medisch-specialistische zorg 2019 t/m 2022.https://www.rijksoverheid.nl/.[2] Porter ME, Pabo EA, Lee TH. (2013). Redesigning Primary Care: a strategic vision to improve value by organizing around patients’ needs. Health affairs, 32(3);516-525[3] Akbari A, et al. (2008). Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev, 4,CD005471.Disclosure of Interests:None declared

Improving Access to Integrated Behavioral Health in a Nurse-Led Federally Qualified Health Center

2021 ◽  
pp. 107839032199416
Author(s):  
Sarah Stalder ◽  
Aimee Techau ◽  
Jenny Hamilton ◽  
Carlo Caballero ◽  
Mary Weber ◽  
...  
Keyword(s):  
Primary Care ◽  
Quality Improvement ◽  
Behavioral Health ◽  
Behavioral Health Care ◽  
Primary Care Providers ◽  
Care Team ◽  
Psychiatric Nurse ◽  
Care Providers ◽  
Team Members ◽  
Task Forces

BACKGROUND: The specific aims of this project were to create a fully integrated, nurse-led model of a psychiatric nurse practitioner and behavioral health care team within primary care to facilitate (1) patients receiving an appropriate level of care and (2) care team members performing at the top of their scope of practice. METHOD: The guiding model for process implementation was Rapid Cycle Quality Improvement. Three task forces were established to develop interventions in the areas of Roles and Responsibilities, Training and Implementation, and the electronic health record. INTERVENTION: The four interventions that emerged from these task forces were (1) the establishment of patient tiers based on diagnosis, medications, and risk assessment; (2) the creation of process maps to engage care team members; (3) just-in-time education regarding psychiatric medication management for primary care providers; and (4) use of a registry to track patients. RESULTS: The process measures of referrals to the psychiatric care team and psychiatric assessment intakes performed as expected. Both measures were higher at the onset of the project and lower 1 year later. The outcome indicator, number of case reviews, increased dramatically over time. CONCLUSIONS: For psychiatric nurse practitioners, this quality improvement effort provides evidence that a consultative role can be effective in supporting primary care providers. Through providing education, establishing patient tiers, and establishing an effective workflow, more patients may have access to psychiatric services.

scholarly journals Cross-sectional study evaluating the association between integrated care and health-related quality of life (HRQOL) in Dutch primary care

BMJ Open ◽  
2021 ◽  
Vol 11 (4) ◽  
pp. e040781
Author(s):  
Pim P Valentijn ◽  
Marcel Kerkhoven ◽  
Jantien Heideman ◽  
Rosa Arends
Keyword(s):  
Primary Care ◽  
Integrated Care ◽  
Primary Care Practice ◽  
Anxiety And Depression ◽  
Care Practice ◽  
Cross Sectional ◽  
Practice Population ◽  
Related Quality ◽  
Health Related

ObjectivesThe aim of this study was to evaluate the association between integrated care and health-related quality of life (HRQOL) in a primary care practice population.DesignA cross-sectional survey study.SettingPrimary care practice population.ParticipantsA sample (n=5562) of patients in two general practitioner practices in the Netherlands.Primary outcome measuresThe Rainbow Model of Integrated Care Measurement Tool patient version and EQ-5D was used to assess integrated service delivery and HRQOL. The association between integrated care and HRQOL groups was analysed using multivariate logistic regression.ResultsOverall, 933 respondents with a mean age of 62 participated (20% response rate) in this study. The multivariate analysis revealed that positive organisational coordination experiences were linked to better HRQOL (OR=1.87, 95% CI 1.18 to 2.95), and less anxiety and depression problems (OR=0.36, 95% CI 0.20 to 0.63). Unemployment was associated with a poor HRQOL (OR=0.15, 95% CI 0.08 to 0.28). Ageing was associated with more mobility (OR=1.06, 95% CI 1.04 to 1.09), self-care (OR=1.06, 95% CI 1.02 to 1.11), usual activity (OR=1.03, 95% CI 1.01 to 1.05) and pain problems (OR=1.02, 95% CI 1.01 to 1.04). Being married improved the overall HRQOL (OR=1.60, 95% CI 1.13 to 2.26) and decreased anxiety and depression (OR=0.47, 95% CI 0.31 to 0.72). Finally, females had a poor overall HRQOL (OR=1.67, 95% CI 0.48 to 0.93) and more pain and discomfort problems (OR=1.47, 95% CI 1.11 to 1.95).ConclusionThis study shows for the first time that organisational coordination activities are positively associated with HROQL of adult patients in a primary care context, adding to the evidence of an association between integrated care and HRQOL. Also, unemployment, ageing and being female are accumulating risk factors that should be considered when designing integrated primary care programmes. Further research is needed to explore how various integration types relate to HRQOL for people in local communities.

Sign in / Sign up

Export Citation Format

Share Document