scholarly journals Improving care coordination for community-dwelling older Australians: a longitudinal qualitative study

2017 ◽  
Vol 41 (2) ◽  
pp. 144 ◽  
Author(s):  
Desley Harvey ◽  
Michele Foster ◽  
Edward Strivens ◽  
Rachel Quigley
Keyword(s):  
Older People ◽  
Care Transitions ◽  
Care Transition ◽  
Complex Care ◽  
Coordinated Care ◽  
Model Of Care ◽  
Care Needs ◽  
Levels Of Care ◽  
Transition Experiences ◽  
Complex Care Needs

Objective The aim of the present study was to describe the care transition experiences of older people who transfer between subacute and primary care, and to identify factors that influence these experiences. A further aim of the study was to identify ways to enhance the Geriatric Evaluation and Management (GEM) model of care and improve local coordination of services for older people. Methods The present study was an exploratory, longitudinal case study involving repeat interviews with 19 patients and carers, patient chart audits and three focus groups with service providers. Interview transcripts were coded and synthesised to identify recurring themes. Results Patients and carers experienced care transitions as dislocating and unpredictable within a complex and turbulent service context. The experience was characterised by precarious self-management in the community, floundering with unmet needs and holistic care within the GEM service. Patient and carer attitudes to seeking help, quality and timeliness of communication and information exchange, and system pressure affected care transition experiences. Conclusion Further policy and practice attention, including embedding early intervention and prevention, strengthening links between levels of care by building on existing programs and educative and self-help initiatives for patients and carers is recommended to improve care transition experiences and optimise the impact of the GEM model of care. What is known about the topic? Older people with complex care needs experience frequent care transitions because of fluctuating health and fragmentation of aged care services in Australia. The GEM model of care promotes multidisciplinary, coordinated care to improve care transitions and outcomes for older people with complex care needs. What does this paper add? The present study highlights the crucial role of the GEM service, but found there is a lack of systemised linkages within and across levels of care that disrupts coordinated care and affects care transition experiences. There are underutilised opportunities for early intervention and prevention across the system, including the emergency department and general practice. What are the implications for practitioners? Comprehensive screening, assessment and intervention in primary and acute care, formalised transition processes and enhanced support for patients and carers to access timely, appropriate care is required to achieve quality, coordinated care transitions for older people.

scholarly journals Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study (Preprint)

2020 ◽  
Author(s):  
Carolyn Steele Gray ◽  
Terence Tang ◽  
Alana Armas ◽  
Mira Backo-Shannon ◽  
Sarah Harvey ◽  
...  
Keyword(s):  
Older Adults ◽  
Phase 1 ◽  
Care Transitions ◽  
Self Management ◽  
Complex Care ◽  
Phase 2 ◽  
Care Needs ◽  
Centered Care ◽  
Hospital To Home ◽  
Complex Care Needs

BACKGROUND Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home. OBJECTIVE This protocol outlines the plan for the development, implementation, and evaluation of a Digital Bridge co-designed to support person-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional communication in hospital, and the electronic Patient-Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning and self-management in primary care settings. This project poses three overarching research questions that focus on adapting the technology to local contexts, evaluating the impact of the Digital Bridge in relation to the quadruple aim, and exploring the potential to scale and spread the technology. METHODS The study includes two phases: workflow co-design (phase 1), followed by implementation and evaluation (phase 2). Phase 1 will include iterative co-design working groups with patients, caregivers, hospital providers, and primary care providers to develop a transition workflow that will leverage the use of Care Connector and ePRO to support communication through the transition process. Phase 2 will include implementation and evaluation of the Digital Bridge within two hospital systems in Ontario in acute and rehab settings (600 patients: 300 baseline and 300 implementation). The primary outcome measure for this study is the Care Transitions Measure–3 to assess transition quality. An embedded ethnography will be included to capture context and process data to inform the implementation assessment and development of a scale and spread strategy. An Integrated Knowledge Translation approach is taken to inform the study. An advisory group will be established to provide insight and feedback regarding the project design and implementation, leading the development of the project knowledge translation strategy and associated outputs. RESULTS This project is underway and expected to be complete by Spring 2024. CONCLUSIONS Given the real-world implementation of Digital Bridge, practice changes in the research sites and variable adherence to the implementation protocols are likely. Capturing and understanding these considerations through a mixed-methods approach will help identify the range of factors that may influence study results. Should a favorable evaluation suggest wide adoption of the proposed intervention, this project could lead to positive impact at patient, clinician, organizational, and health system levels. CLINICALTRIAL ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192 INTERNATIONAL REGISTERED REPORT PRR1-10.2196/20220

scholarly journals Demand for community-based Case Management in Austria - a qualitative analysis

BMC Nursing ◽  
2022 ◽  
Vol 21 (1) ◽  
Author(s):  
Alessandra Schirin Gessl ◽  
Angela Flörl ◽  
Eva Schulc
Keyword(s):  
Case Management ◽  
Focus Groups ◽  
Care Management ◽  
Qualitative Content Analysis ◽  
Community Setting ◽  
Complex Care ◽  
Care Providers ◽  
Coordinated Care ◽  
Care Needs ◽  
Complex Care Needs

Abstract Background The number of people with complex nursing and care needs living in their own homes is increasing. The implementation of Case and Care Management has shown to have a positive effect on unmet care needs. Research on and implementation of Case and Care Management in the community setting in Austria is limited. This study aimed to understand the changes and challenges of changing care needs by mobile nurses and to evaluate the need for Case Management in mobile care organizations by investigating the evolution of mobile care nurses‘task profiles and the challenges in working in a dynamic field with changing target groups and complexifying care needs. Methods A qualitative study with reductive-interpretative data analysis consisting of semi-structured focus groups was conducted. Community care nurses, head nurses, and managers of community mobile care units as well as discharge managers of a community hospital (n = 24) participated in nine qualitative, semi-structured focus groups. The recorded focus groups were transcribed and analyzed using qualitative content analysis. Results The analysis revealed three main categories: the complexity of the case, innerinstitutional frameworks, and interinstitutional collaboration, which influence the perception of need for further development in the direction of Case and Care Management. Feelings of overwhelmedness among nurses were predominantly tied to cases that presented with issues beyond healthcare such as legal, financial, or social that necessitated communication and collaboration across multiple care providers. Conclusions Care institutions need to adapt to changing and increasingly complex care needs that necessitate cooperation between organizations within and across the health and social sectors. A key facilitator for care coordination and the adequate service provision for complex care needs are multidisciplinary institutional networks, which often remain informal, leaving nurses in the role of petitioner without equal footing. Embedding Case and Care Management in the community has the potential to fill this gap and facilitate flexible, timely, and coordinated care across multiple care providers.

Service Coordinators in the NECC Trial: An RDNS perspective

2000 ◽  
Vol 6 (4) ◽  
pp. 104
Author(s):  
Megan Kerr ◽  
Janine Cramond ◽  
Maggie Scott
Keyword(s):  
Complex Care ◽  
Coordinated Care ◽  
Care Needs ◽  
Nursing Service ◽  
The North ◽  
Improved Outcomes ◽  
Service Coordinators ◽  
North Eastern ◽  
Complex Care Needs

The Royal District Nursing Service (RDNS) became involved in the North-Eastern Coordinated Care Trial in October 1997. The purpose of this was to assist the trial in exploring the hypothesis, that for people with chronic or complex care needs, care coordination will provide improved outcomes at the same or a reduced cost. There are a number of areas, which help to clarify the process involved in the trial and the benefits for clients: how the coordinators were chosen; the role of the Care and Service Coordinators: benefits experienced by the professionals; benefits experienced by clients: and discussion points.

scholarly journals Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study

10.2196/20220 ◽  
2020 ◽  
Vol 9 (11) ◽  
pp. e20220
Author(s):  
Carolyn Steele Gray ◽  
Terence Tang ◽  
Alana Armas ◽  
Mira Backo-Shannon ◽  
Sarah Harvey ◽  
...  
Keyword(s):  
Older Adults ◽  
Phase 1 ◽  
Care Transitions ◽  
Self Management ◽  
Complex Care ◽  
Phase 2 ◽  
Care Needs ◽  
Centered Care ◽  
Hospital To Home ◽  
Complex Care Needs

Background Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home. Objective This protocol outlines the plan for the development, implementation, and evaluation of a Digital Bridge co-designed to support person-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional communication in hospital, and the electronic Patient-Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning and self-management in primary care settings. This project poses three overarching research questions that focus on adapting the technology to local contexts, evaluating the impact of the Digital Bridge in relation to the quadruple aim, and exploring the potential to scale and spread the technology. Methods The study includes two phases: workflow co-design (phase 1), followed by implementation and evaluation (phase 2). Phase 1 will include iterative co-design working groups with patients, caregivers, hospital providers, and primary care providers to develop a transition workflow that will leverage the use of Care Connector and ePRO to support communication through the transition process. Phase 2 will include implementation and evaluation of the Digital Bridge within two hospital systems in Ontario in acute and rehab settings (600 patients: 300 baseline and 300 implementation). The primary outcome measure for this study is the Care Transitions Measure–3 to assess transition quality. An embedded ethnography will be included to capture context and process data to inform the implementation assessment and development of a scale and spread strategy. An Integrated Knowledge Translation approach is taken to inform the study. An advisory group will be established to provide insight and feedback regarding the project design and implementation, leading the development of the project knowledge translation strategy and associated outputs. Results This project is underway and expected to be complete by Spring 2024. Conclusions Given the real-world implementation of Digital Bridge, practice changes in the research sites and variable adherence to the implementation protocols are likely. Capturing and understanding these considerations through a mixed-methods approach will help identify the range of factors that may influence study results. Should a favorable evaluation suggest wide adoption of the proposed intervention, this project could lead to positive impact at patient, clinician, organizational, and health system levels. Trial Registration ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192 International Registered Report Identifier (IRRID) PRR1-10.2196/20220

ASSOCIATIONS BETWEEN FRAILTY, COMPLEX CARE NEEDS AND QUALITY OF LIFE IN MULTI-MORBID OLDER PEOPLE

2014 ◽  
pp. 1-6
Author(s):  
N. BLEIJENBERG ◽  
V.H. TEN DAM ◽  
I. DRUBBEL ◽  
M.E. NUMANS ◽  
N.J. DE WIT ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Older People ◽  
The Elderly ◽  
Complex Care ◽  
Care Needs ◽  
Self Assessment ◽  
Primary Care Practices ◽  
Complex Care Needs ◽  
The Relationship

Background:Little is known regarding the complex care needs, level of frailty or quality of life ofmulti-morbid older patients. Objectives:The objective of this study was to determine the relationship betweenfrailty, complexity of care and quality of life in multi-morbid older people. Design:Cross-sectional study.Setting: Thirteen primary care practices in the Netherlands. Participants:1,150 multi-morbid older people livingin the community. Measurements:The level of frailty was assessed with the Groningen Frailty Indicator.Complexity of care needs was measured with the Intermed for the Elderly Self-Assessment. Quality of life (QoL)was measured with two items of the RAND-36. Results:In total, 758 out of 1,150 (65.9%) patients were frail,8.3% had complex care needs, and the mean QoL score was 7.1 (standard deviation 1.2). Correlations betweenfrailty and complexity, frailty and QoL, and complexity of care and QoL were 0.67, -0.51 and -0.52 (all p<0.001)respectively. All patients with complex care needs were frail, but, only 12.5% of the frail patients had complexcare needs. Problems at climbing up stairs was associated with higher levels of frailty and complexity of care butwith a lower QoL. Conclusions:Higher levels of frailty and complexity of care are associated with a lower QoLin multi-morbid older people. The results of this study contribute to a better understanding these concepts and arevaluable for the development of tailored interventions for older persons in the future.

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