scholarly journals Correction: Associations between continuity of primary and specialty physician care and use of hospital-based care among community-dwelling older adults with complex care needs

PLoS ONE ◽  
2021 ◽  
Vol 16 (10) ◽  
pp. e0258708
Author(s):  
Aaron Jones ◽  
Susan E. Bronskill ◽  
Hsien Seow ◽  
Mats Junek ◽  
David Feeny ◽  
...  
Keyword(s):  
Older Adults ◽  
Community Dwelling ◽  
Complex Care ◽  
Care Needs ◽  
Physician Care ◽  
Complex Care Needs ◽  
Community Dwelling Older Adults

scholarly journals Associations between continuity of primary and specialty physician care and use of hospital-based care among community-dwelling older adults with complex care needs

PLoS ONE ◽  
2020 ◽  
Vol 15 (6) ◽  
pp. e0234205
Author(s):  
Aaron Jones ◽  
Susan E. Bronskill ◽  
Hsien Seow ◽  
Mats Junek ◽  
David Feeny ◽  
...  
Keyword(s):  
Older Adults ◽  
Community Dwelling ◽  
Complex Care ◽  
Care Needs ◽  
Physician Care ◽  
Complex Care Needs ◽  
Community Dwelling Older Adults

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 Exploring Community-Dwelling Older Adults’ Considerations About Values and Preferences for Future End-of-Life Care: A Study from Sweden

2020 ◽  
Vol 60 (7) ◽  
pp. 1332-1342 ◽  
Author(s):  
Malin Eneslätt ◽  
Gert Helgesson ◽  
Carol Tishelman
Keyword(s):  
Older Adults ◽  
End Of Life ◽  
Community Dwelling ◽  
Participatory Action ◽  
Action Research Project ◽  
Care Needs ◽  
Swedish Version ◽  
Using Data ◽  
Eol Care ◽  
Community Dwelling Older Adults

Abstract Background and Objectives There is a substantial body of research on advance care planning (ACP), often originating from English-speaking countries and focused on health care settings. However, studies of content of ACP conversations in community settings remain scarce. We therefore explore community-dwelling, older adults’ reasoning about end-of-life (EoL) values and preferences in ACP conversations. Research Design and Methods In this participatory action research project, planned and conducted in collaboration with national community-based organizations, we interviewed 65 older adults without known EoL care needs, about their values and preferences for future EoL care. Conversations were stimulated by sorting and ranking statements in a Swedish version of GoWish cards, called the DöBra cards, and verbatim transcripts were analyzed inductively. Results While participants shared some common preferences about EoL care, there was great variation among individuals in how they reasoned. Although EoL preferences and prioritizations could be identical, different individuals explained these choices very differently. We exemplify this variation using data from four participants who discussed their respective EoL preferences by focusing on either physical, social, existential, or practical implications. Discussion and Implications A previously undocumented benefit of the GoWish/DöBra cards is how the flexibility of the card statements support substantial discussion of an individual’s EoL preferences and underlying values. Such in-depth descriptions of participants’ reasoning and considerations are important for understanding the very individual nature of prioritizing EoL preferences. We suggest future users of the DöBra/GoWish cards consider the underlying reasoning of individuals’ prioritizations to strengthen person-centeredness in EoL conversations and care provision.

scholarly journals Geriatric Resource Teams: Equipping Primary Care Practices to Meet the Complex Care Needs of Older Adults

Geriatrics ◽  
2019 ◽  
Vol 4 (4) ◽  
pp. 59 ◽  
Author(s):  
Gwendolen Buhr ◽  
Carrissa Dixon ◽  
Jan Dillard ◽  
Elissa Nickolopoulos ◽  
Lynn Bowlby ◽  
...  
Keyword(s):  
Older Adults ◽  
Primary Care ◽  
Cognitive Impairment ◽  
Assessment Process ◽  
Complex Care ◽  
Care Needs ◽  
Care Practices ◽  
Primary Care Practices ◽  
Complex Care Needs ◽  
The Impact

Primary care practices lack the time, expertise, and resources to perform traditional comprehensive geriatric assessment. In particular, they need methods to improve their capacity to identify and care for older adults with complex care needs, such as cognitive impairment. As the US population ages, discovering strategies to address these complex care needs within primary care are urgently needed. This article describes the development of an innovative, team-based model to improve the diagnosis and care of older adults with cognitive impairment in primary care practices. This model was developed through a mentoring process from a team with expertise in geriatrics and quality improvement. Refinement of the existing assessment process performed during routine care allowed patients with cognitive impairment to be identified. The practice team then used a collaborative workflow to connect patients with appropriate community resources. Utilization of these processes led to reduced referrals to the geriatrics specialty clinic, fewer patients presenting in a crisis to the social worker, and greater collaboration and self-efficacy for care of those with cognitive impairment within the practice. Although the model was initially developed to address cognitive impairment, the impact has been applied more broadly to improve the care of older adults with multimorbidity.

scholarly journals Self-management in older adults: how to delineate self-management ability, self-management behavior, and self-management support?

2020 ◽  
Author(s):  
Klaske Wynia ◽  
Karin Veldman ◽  
Sophie Spoorenberg ◽  
Maarten Lahr ◽  
Menno Reijneveld
Keyword(s):  
Older Adults ◽  
Integrated Care ◽  
Elderly Care ◽  
Self Management ◽  
Complex Care ◽  
Management Support ◽  
Care Needs ◽  
Risk Profiles ◽  
Management Ability ◽  
Complex Care Needs

Abstract Background: Self-management is a key element in person-centered and integrated care. It involves several related concepts, such as self-management ability, behavior, and support. These concepts are poorly delineated. The aim of this study was to examine hypothesized associations between self-management ability, behavior, and support in older adults (taking their frailty and complexity of care needs into account) and to examine underlying aspects of these concepts, if these hypotheses lacksupport.Methods: Cross-sectional data from the Embrace study, a stratified randomized controlled trial, evaluating person-centered and integrated care in Dutch community-living older adults, were used. Participants (n=537) were aged 75 and older, assigned to health-related risk profiles based on self-reported frailty and complexity of care needs. Ability was assessed with the Self-Management Ability Scale, behavior with the Partner in Health Scale for Older Adults, and support with the Patient Assessment of Integrated Elderly Care.Results: Ability and behavior were positively associated for participants with the risk profiles “Robust” and “Complex care needs” (betas are 0.38 and 0.46). Coping (an aspect of behavior) turned out to be a key element for participants with risk profiles “Robust” and “Complex care needs” (betas ranging from 0.13 to 0.45). Support was associated with aspects of behavior, varying per risk profile.Conclusion: We found no associations for self-management on the conceptual level, but the aspect coping did appear to play a major role. Improving coping strategies of older adults may be a promising way of enhancing self-management ability, and of reducing the need for self-management support.

scholarly journals CARE DEPENDENCY: EXPERIENCES AND EXPECTATIONS OF COMMUNITY-DWELLING OLDER ADULTS

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S624-S624
Author(s):  
Jan S Jukema ◽  
Sharon Oude Veldhuis ◽  
Jacqueline Van Alphen ◽  
Jopie Jorritsma ◽  
Frits De Lange
Keyword(s):  
Older Adults ◽  
Ethic Of Care ◽  
Influential Factors ◽  
Community Dwelling ◽  
Care Needs ◽  
Living Situation ◽  
Equal Distribution ◽  
Study Results ◽  
Diverse Groups ◽  
Community Dwelling Older Adults

Abstract “Not to be a burden” is a common phrase used by community-dwelling older adults in discussing their dependency on others in care for their daily life. This attitude may lead to conflicts with relatives, neighbors, or professionals when in their opinion, care is necessary and, ultimately, may result in unmet care needs. The goal of this study is to gain a better understanding of how older adults experience their increased dependency on others and to contribute to the development of an ethic of care. Thirty-two participants of a larger research sample (n=64) from a descriptive qualitative research were purposefully selected, resulting in an equal distribution of the following variables: gender, living situation, living with or without partner, and having children or not. From a multiphase qualitative analysis with five researchers, including two senior citizens four themes emerged: (1) relationships in the context of care; (2) experiences with giving, receiving and asking for care; (3) future perspectives towards receiving and asking for care; and (4) actual practices of caregiving and receiving. Our study clarifies how community-dwelling older adults deal with the changes in their dependency on others. The study results highlight particular dynamics which appear, at least, partly in contrast with current policy regarding care at home. Moreover, it contributes to an empirical refinement of the concepts of dependency and interdependency in an ethic of care. Further studies are needed to clarify the influential factors on asking for care in diverse groups of older adults and the response from their network.

scholarly journals Addressing Needs of Older Adults in Low-Income Independent Living Facilities in Community Health

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 328-329
Author(s):  
Lisa Rauch ◽  
Toby Adelman ◽  
Daryl Canham ◽  
Nancy Dudley
Keyword(s):  
Older Adults ◽  
Community Health ◽  
Low Income ◽  
Independent Living ◽  
Complex Care ◽  
Care Needs ◽  
Term Care ◽  
Undergraduate Nursing ◽  
Complex Care Needs ◽  
The Impact

Abstract Access to quality care in long-term care settings including independent living facilities is needed for a diverse high-risk aging U.S. population. There is an urgent need to assess and address complex care needs of older adults living longer with chronic conditions and serious illness. However, a system to assess and identify health problems, intervene, and evaluate outcomes is lacking. This session presents learnings from a pilot study developed in collaboration with Nurse Managed Centers at low-income independent living facilities for older adults and undergraduate nursing students in community health practice. We will discuss the adaptation of the Omaha System for provision of care in independent living facilities to address complex care needs. Finally, we will discuss the impact of this project and its potential for healthcare transformation in independent living facilities and transformation of education in undergraduate nursing programs.

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