scholarly journals 55 The Case for A Best-Interest Meeting Decision Toolkit to Guide Preferred Place of Care and Interventions For Community Dwelling Older People Who Lack Mental Capacity

2021 ◽  
Vol 50 (Supplement_1) ◽  
pp. i12-i42
Author(s):  
A Dar ◽  
R Wiltshire ◽  
P N Wright
Keyword(s):  
Decision Making ◽  
Older People ◽  
Hospital Setting ◽  
Community Services ◽  
Community Dwelling ◽  
Best Interest ◽  
Care Plans ◽  
Health And Social Care ◽  
Community Dwelling Older People ◽  
Patients Wishes

Abstract Introduction The Hammersmith and Fulham Community Independence Service (CIS), runs a “virtual ward” to allow people to remain independent in their own homes where possible. Place-of-care decisions made for community-dwelling older people who lack capacity are formulated in a best-interest meeting (BIM), involving health and social care professionals, family and carers. Often BIMs centre around beliefs and wishes of the patient or family but fail to objectively evaluate risks and mitigants of staying at home versus placement. We observed that BIMs were not being held on a consistent basis, and when held lacked the necessary structure for an effective decision-making forum. Even experienced professionals find it difficult to chair BIMs because of the complexity of the decision-making process. Not all involved parties may be represented. We found BIMs more likely to be held, attended and effective when structured to identify the major relevant considerations. Method The CIS “virtual ward” team developed a BIM decision toolkit, comprising: a check-list of risks and mitigants for home versus care home; a list of required attendees; who should document and chair the meeting; and who should action the interventions raised. From 6th January to 25th October 2019, BIMs were held for 48 patients on the CIS “virtual ward”. Results 234 interventions were carried out following toolkit-led BIMs. 1 month after BIM, 34 of 44 patients’ wishes (77%) were honoured (3 not recorded, 1 died). 3 months after BIM, 23 of 31 patients’ wishes (74%) were honoured (15 not recorded, 2 died). Case studies are included in the presentation. Conclusion We developed a toolkit to support decision-making for older community dwellers who lack capacity regarding their place of care. The toolkit assures standardisation and structure to minimise bias, whilst recognising personal beliefs and preferences. It enables any member of the multidisciplinary team to hold and lead a BIM, to reliably identify appropriate interventions and care plans which may not otherwise have been implemented or recognised. The majority of the patients reviewed using the BIM toolkit remained in their preferred place of care well after the team’s interventions. Further evaluation is required to compare CIS BIM toolkit-based outcomes against other community services which do not use this toolkit, and appraise the toolkit in a hospital setting.

scholarly journals Health-promoting and preventive interventions for community-dwelling older people published from inception to 2019: a scoping review to guide decision making in a Swedish municipality context

2020 ◽  
Vol 78 (1) ◽  
Author(s):  
Saranda Bajraktari ◽  
Marlene Sandlund ◽  
Magnus Zingmark
Keyword(s):  
Decision Making ◽  
Cost Effectiveness ◽  
Older People ◽  
Nordic Countries ◽  
Community Dwelling ◽  
Preventive Interventions ◽  
Positive Effects ◽  
Scoping Reviews ◽  
Health Promoting ◽  
Community Dwelling Older People

Abstract Background Despite the promising evidence of health-promoting and preventive interventions for maintaining health among older people, not all interventions can be implemented due to limited resources. Due to the variation of content in the interventions and the breadth of outcomes used to evaluate effects in such interventions, comparisons are difficult and the choice of which interventions to implement is challenging. Therefore, more information, beyond effects, is needed to guide decision-makers. The aim of this review was to investigate, to what degree factors important for decision-making have been reported in the existing health-promoting and preventive interventions literature for community-dwelling older people in the Nordic countries. Methods This review was guided by the PRISMA-ScR checklist (Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews), the methodological steps for scoping reviews described in the Arksey and O′Malley’s framework, and the Medical Research Council’s (MRC) guidance on complex interventions. Eligible studies for inclusion were randomised controlled trials (RCTs) concerning health promotion or primary prevention for community-dwelling older people implemented in the Nordic countries. Additionally, all included RCTs were searched for related papers that were reporting on additional factors. Eligible studies were searched in seven databases: PubMed, SCOPUS, CINAHL, Academic Search Elite, PsycINFO, SocINDEX, and SPORTDiscus. Results Eighty-two studies met the inclusion criteria (twenty-seven unique studies and fifty-five related studies). Twelve studies focused on fall prevention, eleven had a health-promoting approach, and four studies focused on preventing disability. All interventions, besides one, reported positive effects on at least one health outcome. Three studies reported data on cost-effectiveness, three on experiences of participants and two conducted feasibility studies. Only one intervention, reported information on all seven factors. Conclusions All identified studies on health-promoting and preventive interventions for older people evaluated in the Nordic countries report positive effects although the magnitude of effects and number of follow-ups differed substantially. Overall, there was a general lack of studies on feasibility, cost-effectiveness, and experiences of participants, thus, limiting the basis for decision making. Considering all reported factors, promising candidates to be recommended for implementation in a Nordic municipality context are ‘Senior meetings’, ‘preventive home visits’ and ‘exercise interventions’ on its own or combined with other components.

scholarly journals Multi-Morbidity and Polypharmacy in Older People: Challenges and Opportunities for Clinical Practice

2020 ◽  
Author(s):  
Pritti Aggarwal ◽  
Stephen Woolford ◽  
Harnish Patel
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Older People ◽  
Social Care ◽  
Population Ageing ◽  
Care Plans ◽  
Health And Social Care ◽  
Challenges And Opportunities ◽  
Care Systems ◽  
Global Population

Multi-morbidity and polypharmacy are common in older people and pose a challenge for health and social care systems especially in context of global population ageing. They are complex and interrelated concepts in the care of older people that require early detection and patient centred decision making that are underpinned by the principles of multidisciplinary led comprehensive geriatric assessment (CGA). Personalised care plans need to remain responsive and adaptable to the needs of a patient, enabling an individual to maintain their independence.

scholarly journals Using Participatory Observation to Understand Older People’s Experiences: Lessons from the Field

2015 ◽  
Author(s):  
Josephine Tetley
Keyword(s):  
Older People ◽  
Qualitative Methods ◽  
Research Study ◽  
Social Care ◽  
Participant Observation ◽  
Community Dwelling ◽  
Care Services ◽  
Health And Social Care ◽  
Community Dwelling Older People ◽  
Participatory Observation

This article describes how participant observation and a reflective diary were used in a study that aimed to explore how three different groups of community dwelling older people experienced and made choices about using, or refusing, a range of health and social care services. The roles of these qualitative methods are highlighted to demonstrate how they enhanced the insights gained during the course of a research study.

scholarly journals Effect of an integrated care model for pre-frail and frail older people living in community

2020 ◽  
Vol 49 (6) ◽  
pp. 1048-1055
Author(s):  
Ruby Yu ◽  
Cecilia Tong ◽  
Jean Woo
Keyword(s):  
Health Services ◽  
Older People ◽  
Integrated Care ◽  
Intervention Group ◽  
Community Dwelling ◽  
Control Group ◽  
Care Model ◽  
Health And Social Care ◽  
Community Dwelling Older People

Abstract Objectives to evaluate the effect of an integrated care model for pre-frail and frail community-dwelling older people. Design a quasi-experimental design. Setting and participants we enrolled people aged ≥60 years from a community care project. An inclusion criterion was pre-frailty/frailty, as measured by a simple frailty questionnaire (FRAIL) with a score of ≥1. Methods we assigned participants to an intervention group (n = 183) in which they received an integrated intervention (in-depth assessment, personalised care plans and coordinated care) or a control group (n = 270) in which they received a group education session on frailty prevention. The outcomes were changes in frailty, individual domains of frailty (‘fatigue’, ‘resistance’, ‘ambulation’, ‘illnesses’ and ‘loss of weight’) and health services utilisation over 12 months. Assessments were conducted at baseline and at the 12-month follow-up. Results the mean age of the participants (n = 453) at baseline was 76.1 ± 7.5 years, and 363 (80.1%) were women. At follow-up, the intervention group showed significantly greater reductions in FRAIL scores than the control group (P < 0.033). In addition, 22.4% of the intervention and 13.7% of the control participants had reverted from pre-frail/frail to robust status, with the difference reaching significance when the intervention was compared with the control group (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.0–2.4) after adjustments for age, sex, living arrangement/marital status and hypercholesterolemia. For individual domains of frailty, the adjusted OR for improved ‘resistance’ was 1.7 (95% CI 1.0–2.8). However, no effects were found on reducing use of health services. Conclusion the integrated health and social care model reduced FRAIL scores in a combined population of pre-frail/frail community-dwelling older people attending older people’s centres.

Consultant Pharmacist Case Management of Older People in Intermediate Care: a New Innovative Model

2016 ◽  
Vol 4 (1) ◽  
pp. 46 ◽  
Author(s):  
Ruth Miller ◽  
Carmel M Darcy ◽  
Anne Friel ◽  
Michael G Scott ◽  
Stephen B Toner
Keyword(s):  
Case Management ◽  
Older People ◽  
Cost Savings ◽  
Community Services ◽  
Rank Test ◽  
Intermediate Care ◽  
Clinical Interventions ◽  
Care Plans ◽  
Health And Social Care ◽  
Medication Appropriateness

Rationale, Aims and Objectives: In 2011, ‘Transforming Your Care’ outlined the remodelling of Health and Social Care in Northern Ireland (HSCNI) UK, specifically recommending better integration of hospital and community services for older people. This work aimed to evaluate consultant pharmacist case management for older patients admitted from acute to intermediate care continuing back into the community setting, given the importance of such a transition to person-centered healthcare.  Method: On transfer to intermediate care, the consultant pharmacist determined the Medication Appropriateness Index (MAI) for each drug prescribed. Individualised pharmaceutical care plans were implemented with clinical interventions recorded and graded using Eadon criteria. Cost savings resulting from interventions which prevent medication errors/Adverse Drug Events (ADEs) have been estimated using the model as described by the University of Sheffield School of Health and Related Research (ScHARR); these were applied. Drugs stopped/started were costed using the NHS dictionary of medicines and devices (dm+d). Case management continued via communication with GPs and/or community pharmacists and post-discharge patient telephone calls/home visits.  Results: Three hundred and fifty-five patients had 3674 drugs assessed for medication appropriateness; both individual and total drug MAI scores on admission to and discharge from intermediate care, were significantly reduced (Wilcoxon signed rank test, p<0.001, n=355). An average of 2.5 clinical interventions per patient were made, with 84% being self-graded as Eadon ≥ Grade 4 (significant interventions resulting in improved care standards). Clinical interventions yielded potential savings of £63-144k pa whilst annual drug cost savings were £68k. Conclusion: This project demonstrated consultant pharmacist case management results in both cost savings and more appropriate prescribing with safer, seamless and more person-centered care.

scholarly journals “To be seen” – older adults and their relatives’ care experiences given by a geriatric mobile team (GerMoT)

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Iréne Ericsson ◽  
Anne W. Ekdahl ◽  
Ingrid Hellström
Keyword(s):  
Health Care ◽  
Older People ◽  
Usual Care ◽  
Health Care Professionals ◽  
Intervention Group ◽  
Community Dwelling ◽  
World Health ◽  
Secondary Outcome ◽  
Health And Social Care ◽  
Community Dwelling Older People

Abstract Background The proportion of older people in the population has increased globally and has thus become a challenge in health and social care. There is good evidence that care based on comprehensive geriatric assessment (CGA) is superior to the usual care found in acute hospital settings; however, the evidence is scarcer in community-dwelling older people. This study is a secondary outcome of a randomized controlled trial of community-dwelling older people in which the intervention group (IG) received CGA-based care by a geriatric mobile geriatric team (GerMoT). The aim of this study is to obtain a better understanding, from the patients’ perspective, the experience of being a part of the IG for both the participants and their relatives. Methods Qualitative semistructured interviews of twenty-two community dwelling participants and eleven of their relatives were conducted using content analysis for interpretation. Results The main finding expressed by the participants and their relatives was in the form of feelings related to safety and security and being recognized. The participants found the care easily accessible, and that contacts could be taken according to needs by health care professionals who knew them. This is in accordance with person-centred care as recommended by the World Health Organisation (WHO) for older people in need of integrated care. Other positive aspects were recurrent health examinations and being given the time needed when seeking health care. Not all participants were positive as some found the information about the intervention to be unclear especially regarding whom to contact when in different situations. Conclusions CGA-based care of community-dwelling older people shows promising results as the participants in GerMoT found the care was giving a feeling of security and safety. They found the care easily accessible and that it was provided by health care professionals who knew them as a person and knew their health care problems. They found this to be in contrast to the usual care provided, but GerMoT care did not fulfill some people’s expectations.

scholarly journals Nursing Home Staff’s Perceptions of Healthcare Decision Making for Unbefriended Residents

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 384-384
Author(s):  
Hyejin Kim ◽  
Molly Perkins ◽  
Thaddeus Pope ◽  
Patricia Comer ◽  
Mi-Kyung Song
Keyword(s):  
Decision Making ◽  
Geographic Area ◽  
Care Physician ◽  
Healthcare Decision ◽  
Do Not Resuscitate ◽  
Best Interest ◽  
Care Plans ◽  
Course Of Action ◽  
Healthcare Decision Making ◽  
Facility Level

Abstract ‘Unbefriended’ adults are those who lack decision-making capacity and have no surrogates or advance care plans. Little data exist on nursing homes (NHs)’ healthcare decision-making practices for unbefriended residents. This study aimed to describe NH staff’s perceptions of healthcare decision making on behalf of unbefriended residents. Sixty-six staff including administrators, physicians, nurses, and social workers from three NHs in one geographic area of Georgia, USA participated in a 31-item survey. Their responses were analyzed using descriptive statistics and conventional content analysis. Of 66 participants, eleven had been involved in healthcare decision-making for unbefriended residents. The most common decision was do-not-resuscitate orders. Decisions primarily were made by relying on the resident’s primary care physician and/or discussing within a facility interdisciplinary team. Key considerations in the decision-making process included “evidence that the resident would not have wanted further treatment” and the perception that “further treatment would not be in the resident’s best interest”. Compared with decision making for residents with surrogates, participants perceived decision making for unbefriended residents to be equally-more difficult. Key barriers to making decisions included uncertainty regarding what the resident would have wanted in the given situation and concerns regarding the ethically and legally right course of action. Facilitators (reported by 52 participants) included some information/knowledge about the resident, an understanding regarding decision-making-related law/policy, and facility-level support. The findings highlight the complexity and difficulty of healthcare decision making for unbefriended residents and suggest more discussions among all key stakeholders to develop practical strategies to support decision-making practices in NHs.

Prioritization and management of calls from older people to GP out-of-hours services

2021 ◽  
Vol 33 (1) ◽  
Author(s):  
Suzanne Smith ◽  
Lucia Carragher
Keyword(s):  
Older People ◽  
Service Provision ◽  
Emergency Services ◽  
Oldest Old ◽  
Community Dwelling ◽  
Third Party ◽  
Older Person ◽  
Out Of Hours ◽  
Accident And Emergency ◽  
Community Dwelling Older People

Abstract Background Urgent out-of-hours medical care is necessary to ensure people can remain living at home into older age. However, older people experience multiple barriers to using out-of-hours services including poor awareness about the general practitioner (GP) out-of-hours (GPOOH) service and how to access it. In particular, older people are reluctant users of GPOOH services because they expect either their symptoms will not be taken seriously or they will simply be referred to hospital accident and emergency services. The aim of this study was to examine if this expectation was borne out in the manner of GPOOH service provision. Objective The objective was to establish the urgency categorization and management of calls to GPOOH , for community dwelling older people in Ireland. Methods An 8-week sample of 770 calls, for people over 65 years, to a GPOOH service in Ireland, was analysed using Excel and Nvivo software. Results Urgency categorization of older people shows 40% of calls categorized as urgent. Recognition of the severity of symptoms, prompting calls to the GPOOH service, is also reflected in a quarter of callers receiving a home visit by the GP and referral of a third of calls to emergency services. The findings also show widespread reliance on another person to negotiate the GPOOH system, with a third party making 70% of calls on behalf of the older person seeking care. Conclusion Older people are in urgent need of medical services when they contact GPOOH service, which plays an effective and patient-centred gatekeeping role, particularly directing the oldest old to the appropriate level of care outside GP office hours. The promotion of GPOOH services should be enhanced to ensure older people understand their role in supporting community living.

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