Older persons and relatives’ experience of coordinated care planning via a video meeting

COVID-19 has highlighted the reality of an impending serious illness for many, particularly for older persons. Those faced with severe COVID-19 infection or other serious illness will be faced with decisions regarding admission to intensive care and use of mechanical ventilation. Past research has documented substantial medical errors regarding the use or non-use of life-sustaining treatments in older persons. While some experts advocate that advance care planning may be a solution to the problem, I argue that the prevailing understanding and current practice of advance care planning perpetuates the problem and results in patients not receiving optimal patient-centered care. Much of the problem centers on the framing of advance care planning around end of life care, the lack of use of decision support tools, and inadequate language that does not support shared decision-making. I posit that a new approach and new terminology is needed. Advance Serious Illness Preparations and Planning (ASIPP) consists of discrete steps using evidence-based tools to prepare people for future clinical decision-making in the context of shared decision-making and informed consent. Existing tools to support this approach have been developed and validated. Further dissemination of these tools is warranted.

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Evaluating Coordinated Care: Complex Problems do not Have Simple Solutions

Australian Journal of Primary Health ◽

10.1071/py99031 ◽

1999 ◽

Vol 5 (3) ◽

pp. 32 ◽

Cited By ~ 1

Author(s):

Libby Kalucy

Keyword(s):

Health Care ◽

Health Service ◽

Health Services ◽

Service Delivery ◽

Chronic Conditions ◽

Health Service Delivery ◽

Care Planning ◽

Coordinated Care ◽

Supportive Environments ◽

Personal Skills

The current trials of coordinated health care are aimed at changing health service delivery to be more patient-focussed, through care planning and funds pooling. The strategies being implemented with patients with a variety of chronic conditions include creating more supportive environments, developing personal skills and re-orientation of health services.

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Baseline evaluation of the patient-centered oncology care model.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.30_suppl.50 ◽

2014 ◽

Vol 32 (30_suppl) ◽

pp. 50-50

Author(s):

Manasi A. Tirodkar ◽

Sarah Hudson Scholle

Keyword(s):

Patient Centered Care ◽

Care Planning ◽

Coordinated Care ◽

Motivation To Change ◽

Care Model ◽

Patient Centered ◽

Centered Care ◽

Oncology Care ◽

The Impact ◽

The Way

50 Background: The patient-centered medical home (PCMH) model of care is being widely adopted as a way to provide accessible, proactive, coordinated care and self-care through primary care practices. During active treatment for cancer, the oncology practice is often the primary setting supporting the patient and coordinating cancer treatment. For this project, we are implementing a Patient-centered Oncology Care model in five oncology practices and evaluating the impact on cost, quality, and patient experiences. Methods: To determine the structures and processes present in the practices at baseline, we conducted a self-assessment on the standards, followed with an on-site “audit” for compliance with the standards. To get a sense for organizational culture and motivation to change, we conducted site visits which included interviews with providers, staff and patients and observation of clinical encounters and workflow. Results: Among the highest priority structures and processes, the most common were telephone triage, symptom management, advance care planning, and the use of evidence-based guidelines. The least common were patient/family orientation, availability of same day appointments, discussion and documentation of goals of therapy, symptom assessment, and tracking of appointments. All of the practices had made patient-centered care a priority and staff were motivated to change. There was variation in the way providers and the care team used health information technology during clinical workflow. There was also variation in which staff coordinated care for patients and whether or not financial counseling was offered. All of the practices stated that they needed to work on implementing survivorship care planning, shared decision-making, and patient engagement in quality improvement and practice transformation Conclusions: The pilot oncology practices have many structures and processes in common. However, there is little standardization within practices in the way these processes are established and documented. Practices vary in how they are implementing patient-centered care processes. However, with motivation to change, staff and providers are actively engaged in the transformation process.

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Quality of care plans in long‐term care facilities for the older persons—How well is information from RAI assessments utilised in care planning?

International Journal of Older People Nursing ◽

10.1111/opn.12442 ◽

2021 ◽

Author(s):

Suvi Kuha ◽

Katriina Niemelä ◽

Pia Vähäkangas ◽

Anja Noro ◽

Sinikka Lotvonen ◽

...

Keyword(s):

Quality Of Care ◽

Older Persons ◽

Long Term Care ◽

Care Planning ◽

Term Care ◽

Care Plans ◽

Care Facilities

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Advance Care Planning for Care-Dependent Older Persons Living at Home: A Cluster-Randomized Controlled Trial

Innovation in Aging ◽

10.1093/geroni/igaa057.2301 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 665-665

Author(s):

Sascha Köpke ◽

Katharina Silies ◽

Rieke Schnakenberg ◽

Änne Kirchner ◽

Juliane Köberlein-Neu ◽

...

Keyword(s):

Advance Care Planning ◽

Older Persons ◽

Controlled Trial ◽

Patient Activation ◽

Cluster Randomised Controlled Trial ◽

Care Planning ◽

Term Care ◽

Systems Research ◽

Advance Care ◽

At Home

Abstract Advance Care Planning (ACP) for care-dependent older persons living at home is an important part of care, but remains difficult to implement, mostly due to access barriers. The aim of this trial is to increase patient activation, family communication and surrogate designation through an ACP-intervention delivered by trained nurses to care-dependent clients in their homes. The intervention is evaluated in a cluster-randomised controlled trial in Germany (DRKS00016886). Primary outcome is patient activation (PAM-13); secondary outcomes cover institutionalisation, ACP-engagement and prevalence of ACP-documents. 28 home care services (HCS) with 20 trained nurses and about 340 participants have been included. First results show that patients and caregivers judged the topic and the discussion with trusted persons as important and seized the opportunity for communication. In conclusion, established relationships can be built upon to ensure access to ACP and thus to avoid involuntary treatment in situations of decisional incapacity. Part of a symposium sponsored by Systems Research in Long-Term Care Interest Group.

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Communication patterns in coordinated care planning conferences with older patients

Journal of Nursing Education and Practice ◽

10.5430/jnep.v3n10p35 ◽

2013 ◽

Vol 3 (10) ◽

Author(s):

Tyra Graaf ◽

Annica Kihlgren ◽

Margareta Ehnfors ◽

Karin Blomberg

Keyword(s):

Older Patients ◽

Communication Patterns ◽

Care Planning ◽

Coordinated Care

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Dementia and the risk of short-term readmission and mortality after a pneumonia admission

PLoS ONE ◽

10.1371/journal.pone.0246153 ◽

2021 ◽

Vol 16 (1) ◽

pp. e0246153

Author(s):

Susanne Boel Graversen ◽

Henrik Schou Pedersen ◽

Annelli Sandbaek ◽

Catherine Hauerslev Foss ◽

Victoria Jane Palmer ◽

...

Keyword(s):

Older Persons ◽

Medication Use ◽

Independent Effect ◽

Sociodemographic Characteristics ◽

Care Planning ◽

Short Term ◽

Related Factors ◽

Short Term Mortality ◽

Essential Knowledge ◽

Rate Ratios

Background At time of discharge after a pneumonia admission, care planning for older persons with dementia is essential. However, care planning is limited by lack of knowledge on the short-term prognosis. Aim To investigate 30-day mortality and readmission after hospital discharge for pneumonia in persons with versus without dementia, and to investigate how these associations vary with age, time since discharge, and medication use. Methods Using the Danish registries, we investigated 30-day mortality and readmission in persons (+65 years) discharged after pneumonia in 2000–2016 (N = 298,872). Adjusted mortality rate ratios (aMRRs) and incidence rate ratios (aIRRs) were calculated for persons with versus without dementia, and we investigated if these associations varied with use of benzodiazepines, opioids, and antipsychotics, and with age and time since discharge. Results Among 25,948 persons with dementia, 4,524 died and 5,694 were readmitted within 30 days. The risk of 30-day mortality was 129% higher (95% CI 2.21–2.37) in persons with versus without dementia after adjustment for sociodemographic characteristics, admission-related factors, and comorbidities. Further, the highest mortality risk was found in persons with both dementia and use of antipsychotics (aMRR: 3.39, 95% CI 3.19–3.59); 16% of deaths in this group could not be explained by the independent effect of each exposure. In those with dementia, the highest aMRRs were found for the youngest and for the first days after discharge. The risk of 30-day readmission was 7% higher (95% CI 1.04–1.10) in persons with versus without dementia. In those with dementia, the highest aIRRs were found for the first days after discharge. Conclusions Dementia was associated with higher short-term mortality after pneumonia, especially in users of antipsychotics, and with slightly higher readmission, especially in the first days after discharge. This is essential knowledge in the care planning for persons with dementia who are discharged after a pneumonia admission.

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