Integrating Care for Older People: New Care for Old - A Systems Approach

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Enhancing interdisciplinary collaboration in primary health care initiatives. Preparing for change: Social work in primary health care, November Chew-Graham, C. Why may older people with depression not present to primary care? Messages from secondary analysis of qualitative data. Cooper, A. What future? Organisational form, relationship-based social work practice and the changing world order. Ruch, D. Ward Eds. London: Jessica Kingsley. Counsell, S.

Geriatric care management for low-income seniors: A randomised controlled trial. Journal of the American Medical Association, 22 , Craig, T. Social work in primary health care: A New Zealand study. Christchurch: Health Planning and Research Unit. Davey J. Social Policy Journal of New Zealand, 27, Dwyer, M.

Factors affecting the ability of older people to live independently. Wellington: Ministry of Social Policy. Foote, C. Integrating care for older people. New care for old — a systems approach. Foster, S. An analysis of the skills and knowledge base for needs assessment and service coordination. Unpublished Masters of Social Work thesis.

Frew, C. How do primary healthcare practitioners respond to elder abuse? Unpublished Master of Health Sciences thesis. University of Auckland, Auckland, New Zealand. Giles, R. Clinical priorities: Strengthening social work practice in health. Australian Social Work, 60 2 , Hawkes Bay District Health Board Health Workforce New Zealand.

Wellington: Ministry of Health. Irish Association of Social Workers. Primary care social work: Definition and role. Keefe, B. Integrating social workers into primary care: Physician and nurse perceptions of roles, benefits, and challenges. Social Work in Health Care, 48, Lilly, M. Holtzman, S. Can we move beyond burden and burnout to sup- port the health and wellness of family caregivers to persons with dementia? Evidence from British Columbia, Canada. Health and Social Care in the Community, 20 1 , Maher, P.

A study of social work practitioners and their needs when intervening in cases of elder abuse and neglect. Unpublished Master of Social Work thesis. University of Canterbury, Christchurch, New Zealand. Midlands Health Network. Integrated family health centres. Waikato: Waikato District Health Board. Ministry of Health a. Family violence intervention guidelines: Elder abuse and neglect.

Ministry of Health Primary health care strategy: Key directions for the information environment. Ministry of Health. Better, sooner, more convenient health care in the community. Murray, C. The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries and risk factors in and projected to Boston: Harvard University Press.

Nuthall, J. Players or spectators in the new public health? Social Work Review, 2 1 , The ecological systems metaphor in Australasia. Nash, R. Opie, A.

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Beyond good intentions: Support work with older people. Wellington, N. Social Work Review, 7 4 , Pack, M. Social Work Review, 20 3 , Phillips, R. Value-added social work: Value-added service delivery enhances hospital social work practice. Social Work Review, 11 2 , Richmond, D. Auckland: North Health. Rinfrette, E. In economic evaluations of healthcare approaches that are aimed at improving well-being, it is recommended to use well-being instruments alongside the more conventional health-related quality of life instruments [ ].


QALYs focus mainly on health and to a lesser degree on well-being in general [ ]. With respect to evaluating primary care approaches aimed at frail older people, it is crucial to have outcome measures that also go beyond health and evaluate a wider range of benefits for older people [ ]. Due to the lack of preference scores or utilities for well-being, a cost-effectiveness analysis is conducted with incremental effectiveness expressed as the difference in mean SPF-IL scores.

Scores on the four-point scale of the multidimensional SPF-IL instrument range from never 1 to always 4. Higher mean scores indicate a greater well-being [ 34 ]. Intervention costs, healthcare costs, and patient-related costs are considered relevant for the economic evaluation. Intervention costs consist of all costs that can be attributed to the delivery of the FFF approach, excluding the research-specific costs e.

Examples are costs that are associated with the proactive case finding of frail elderly in the community and multidisciplinary consultations in GP practices. We assess the average amount of time for each of the activities related to the FFF approach using time registrations of healthcare professionals and by registering time during observations.

Healthcare costs relate to telephone consultations with GPs and practice nurses, emergency GP, admissions to hospitals, nursing homes or homes for the elderly, homecare services, day care, nursing care, visits to paramedics, psychosocial care, and prescribed medications. Only consultations that are not already part of the FFF integrated care approach are included.

Healthcare utilization is assessed by means of extracting data from electronic health records within GP practices and homecare organizations.

References currently unavailable

Patients indicate at baseline T0 and 12 month follow-up T1 what type of care they received and how often e. Patient-related costs include costs that are covered by frail older people themselves, like purchasing assistive aids e. This data is collected during the interviews with older persons. For the valuation of the healthcare costs, the latest version of the Dutch manual for costing in healthcare is used [ ]. We multiply volumes of resource use e. FFF approach and care as usual. When these standardized costs per unit of resource use are not available, costs are estimated using true economic costs, average reimbursement fees or literature.

The economic evaluation includes calculations of the cost-effectiveness and cost-utility ratios. For comparing the costs and effectiveness of the FFF approach and usual care, incremental cost-effectiveness ratios are calculated ICERs. In this way, the additional costs and effects of the FFF approach compared with usual care are determined. In the ratio, the numerator includes the difference in costs and the denominator the difference in effects [ ]. Sensitivity analysis is performed to assess the robustness of a series of predefined assumptions.

A cost-effectiveness plane and an acceptability curve are added. We aim to include frail older patients patients of intervention GP practices and patients of control GP practices. Accordingly, we expect patients at T1 in the intervention and control groups. Descriptive statistics are used to describe the study population at the two time points in the evaluation study baseline and 12 month follow-up.

Baseline variables are compared to detect differences between patients and professionals in the intervention group FFF approach and control group care as usual. Effect analyses are performed based on the intention-to-treat principle. Analyses of outcomes are performed by means of univariate, multivariate, and multilevel methods to account for the nested structure of the data. To analyze the differences in outcomes between the intervention group and control group, we employ linear mixed model with random effects multilevel analysis.

To estimate the effects of the FFF approach after 12 months a difference in differences model will be used followed by a sensitivity analysis method specifically developed for difference in differences model based on more general methods of bounds developed by Rosenbaum [ ]. Potential confounding and effect modification is accounted for when performing the analyses and, if necessary, adjustments for baseline differences are made. To handle missing data multiple imputation techniques will be used. Ultimate goals of these analyses are to test the assumptions of the theoretical framework with the instruments described in the study protocol.

Finally, we will assess clinical relevance of improvements made in cognitions and behaviors among both patients and professionals. Integration of health services is increasingly advocated as a means to develop more effective models of care and improve patient outcomes [ 37 ]. Much research in the field of integrated care for community-dwelling older adults has been conducted, however, these innovative interventions have had mixed effects on patient outcomes and there is a need for in-depth evaluations.

This underlines the importance of sound theory-based evaluations of integrated primary care approaches. Consequently, in efforts to evaluate the effects of innovative integrated care approaches, insight into the underlying mechanisms explaining the lack of effectiveness of these complex multicomponent interventions is crucial. The present paper describes the design of a theory-based evaluation of a proactive integrated primary care approach to improve well-being among frail community-living older adults.

A major strength of the study is the comprehensive and rigorous evaluation of the complex multicomponent integrated care approach FFF. Selected outcome measures are based on the theoretical model, which facilitates a sound theory-based evaluation. We ultimately may reveal crucial underlying mechanisms of this integrated care approach.

Therefore, the theory-based evaluation study is expected to contribute to the existing evidence on improvements in quality of care and patient outcomes, and a better understanding of explanatory mechanisms underlying integrated primary care approaches. The proposed evaluation study has potential limitations and challenges. First, the absence of randomization makes the design more susceptible to bias [ ].

Especially selection bias is a major concern in non-randomized studies.

Older people's community mental health team

Systematic differences between the groups result in incomparable groups which ultimately may lead to biased estimates of the intervention effect [ ]. To reduce the impact of this bias on the outcome measures studied, we aim to control for important factors in the analysis of the data and by means of matching [ ]. To ensure that the intervention and control groups are similar for key covariables, we use one-to-one matching to balance groups instead of matching on a higher level at healthcare practice level. Moreover, when necessary we use case-mix adjustments to take into account important dissimilarities.

However, it is stated by Deeks and colleagues [ ] that the degree to which techniques can sufficiently adjust for differences between the groups is still unclear, which ultimately provides no guarantee for unbiased study results [ ]. In addition, unknown and unmeasured factors can still influence the outcome [ ]. Second, the design of the study makes it impossible to blind participating healthcare professionals and frail older patients. Knowledge of the status of the person receiving either the FFF approach or care as usual may have an influence on the responses and may affect compliance [ ].

Nevertheless, the interviewers that conduct the interviews with frail older persons are kept unaware of the group the person is in intervention or control GP practice , so that the interviewers collecting outcome data are not influenced by that knowledge.

Blinding of the interviewers aids to reduce differential outcome measurements information bias [ ]. Due to the nature of the evaluation study, however, it is possible that the patient inadvertently reveals his or her status during the interview e. Third, one of the core challenges of the evaluation study is the willingness of frail community-dwelling older patients to participate in the study, especially in the long-term.

Recruitment of appropriate numbers of patients requires a sufficiently long period [ ]. We aim to optimize participation in the evaluation study by means of home visits instead of interviews over the telephone, recruiting interviewers that live in the same region as the older adults, and sending letters to older patients on behalf of their own GP. Fourth, although control GP practices continue to provide usual care, GPs in the control group may start initiatives to improve care delivery for frail older patients.

We collect data on various interventions that are implemented to improve care for older adults and we monitor and describe the activities performed by the GPs. In contrast to the intervention GP practices, control practices are not supported financially by the health insurers to implement elements of the FFF approach. Fifth, recall bias may potentially affect our study findings. Earlier research using a 12 months period of asking patients about their healthcare visits show both under-reporting and over-reporting effects [ ].

Administrative data could be included to accurately capture resources for an economic evaluation if filled in correctly. Sixth, while we included patients and professionals in our theoretical framework and study protocol we did not include informal caregivers. Given their important role in supporting community-dwelling frail older people they are expected to influence the well-being of older persons as well.

Future research should look at the role of informal caregivers and their cognitions and behaviors as well. Assessment of Chronic Illness Care Short version. Chronic Care Model. Chronic Obstructive Pulmonary Disease. EuroQol 5 dimensions and 3 levels. Finding and Follow-up of Frail older persons. General practitioner s.

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Incremental cost-effectiveness ratio s. Katz Activities of Daily Living index.

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  7. Quality-Adjusted Life-Year s. Standard deviation. Self-Management Ability Scale Short version. Social Production Function Instrument for the Level of well-being. Tilburg Frailty Indicator. The authors acknowledge all GP practices that participate in the evaluation study. The funding bodies were not involved in the design of our study or in writing the manuscript.

    Also, the funding bodies will not be involved in the collection, analysis, and interpretation of data. Our theory-guided study protocol has not undergone peer-review by any of the funding bodies. Data sharing is not applicable to this theory-guided study protocol as no datasets were generated or analyzed during the current study.

    LV, JC and AN developed the theoretical model to facilitate the evaluation of integrated primary care approaches and drafted the manuscript. EB was consulted for the design of the economic evaluation, helped drafting the manuscript, and contributed to its refinement.

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    All authors read and approved the final version of the manuscript. Consent to participate in the evaluation study was obtained from all GP practices. In our theory-guided study protocol we do not report on any data relating to individual participants. Informed consent to participate in the study is obtained from all patients. Verbal informed consent to participate in the face-to-face interviews is obtained from all GPs. With respect to the research involving healthcare professionals, we explain in a letter that consent is implied upon return of a completed questionnaire.

    Consent to publish is not applicable as our theory-guided study protocol does not contain data from any individual person. The authors declare that they have no other competing interests related to this manuscript. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Evaluating an integrated primary care approach to improve well-being among frail community-living older people: A theory-guided study protocol.

    Nieboer 1. BMC Geriatrics 18 Abstract Background A major challenge in primary healthcare is the substantial increase in the proportion of frail community-dwelling older persons with long-term conditions and multiple complex needs. Methods The longitudinal evaluation study has a matched quasi-experimental design with one pretest and one posttest 12 month follow-up and is conducted in the Netherlands between and Discussion The proposed evaluation study will reveal insight into the cost effectiveness and underlying mechanisms of the proactive integrated primary care approach FFF.

    A theoretical model to facilitate the evaluation of integrated primary care approaches Many interventions to improve healthcare entail complex changes in daily routines and organization of healthcare, and collaboration among healthcare professionals of different disciplines.

    Moreover, changes in the behaviors of patients are necessary. It is important to incorporate theoretical assumptions in the development and evaluation of innovative approaches to improve patient care because it provides insight into the underlying mechanisms of integrated primary care approaches and insight into the complexity of changing healthcare practices [ 31 ].

    Therefore, a theory-guided evaluation of an innovative integrated primary care approach is proposed see Fig. In Fig. We assume that improvements in well-being are associated with high-quality care delivery as well as cognitions and behaviors of older people and healthcare professionals.

    The proposed concepts and their interrelations are explained in detail hereafter. Productive patient-professional interaction Well-designed healthcare systems should be able to meet the needs and preferences of frail community-dwelling older people by means of fostering productive interactions between these older patients and their team of healthcare professionals [ 45 , 46 ]. Cognitions and behaviors of frail older people Individuals take an active role in realizing well-being and aim to enhance their life situation by optimizing the universal goals of physical and social well-being [ 52 — 56 ].

    Cognitions and behaviors of healthcare professionals In addition to the behaviors and cognitions of frail older people, the behaviors and cognitions of healthcare professionals also drive effectiveness of integrated care approaches [ 39 — 41 , 43 ]. Proactive case finding With the aging of the population, an increasing trend in frailty is to be expected. Case management Case management is expected to improve quality of primary care for frail community-dwelling older people as well as delay or avoid institutionalization.

    Self-management support The FFF approach aims to improve self-management abilities and well-being among frail patients by incorporating different types of self-management support interventions, like skill building, educational materials, personal coaching, and the use of an individualized care plan. Multidisciplinary teams A strong team of professionals with different occupational backgrounds led by a GP is one of the core elements of the FFF approach in order to deliver high-quality care to frail elderly patients. Study design The longitudinal evaluation study has a mixed methods design in which a combination of quantitative and qualitative research methods are employed in order to evaluate the effectiveness, processes, and cost-effectiveness of the FFF approach.

    Ethics approval The research proposal has been reviewed by the medical ethics committee of the Erasmus Medical Centre in Rotterdam, the Netherlands study protocol number MEC Participants and recruitment of frail older people for the FFF approach The target population of the study consists of community-dwelling older persons aged 75 years and older registered at the 15 participating GP practices. Healthcare delivery: Intervention group and control group Frail older persons in the intervention group receive the proactive, integrated care approach FFF as was previously described in detail.

    Data collection and informed consent for the evaluation study Older persons in the intervention group and control group are interviewed at home at baseline T0 and 12 months thereafter T1. Outcome measures and measurement instruments To assess the effectiveness of the FFF integrated primary care approach in improving well-being of frail community-living older patients, we selected measurement instruments that are particularly relevant for measuring all the concepts incorporated in our proposed theoretical model.

    Secondary outcome measures Cognitive and behavioral components Productive patient-professional interaction To assess productive patient-professional interactions, we measure dimensions of communication and relationships among community-living frail older persons and their healthcare professionals using a validated relational coproduction instrument.

    Cognitions and behaviors of frail older people Cognitive and behavioral self-management abilities are measured by means of the short version of the Self-Management Ability Scale SMAS-S. Cognitions and behaviors of healthcare professionals Dimensions of communication and relationships among healthcare professionals i. Figure 2 shows a general timeline of the data collection among older adults and healthcare professionals, the analyses of the data and writing up the results of the evaluation study.

    Strengths and limitations A major strength of the study is the comprehensive and rigorous evaluation of the complex multicomponent integrated care approach FFF. Acknowledgements The authors acknowledge all GP practices that participate in the evaluation study. Availability of data and materials Data sharing is not applicable to this theory-guided study protocol as no datasets were generated or analyzed during the current study.

    Ethics approval and consent to participate The research proposal has been reviewed by the medical ethics committee of the Erasmus Medical Centre in Rotterdam, the Netherlands study protocol number MEC Consent for publication Consent to publish is not applicable as our theory-guided study protocol does not contain data from any individual person.

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    Integrating Care for Older People: New Care for Old - A Systems Approach Integrating Care for Older People: New Care for Old - A Systems Approach
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