Facilitators and barriers to implementing an acute geriatric community hospital in the Netherlands: a qualitative study.

BACKGROUND: there is a trend across Europe to enable more care at the community level. The Acute Geriatric Community Hospital (AGCH) in the Netherlands in an acute geriatric unit situated in a skilled nursing facility (SNF). It provides hospital-level care for older adults with acute medical conditions. The aim of this study is to identify barriers and facilitators associated with implementing the AGCH in a SNF. METHODS: semi-structured interviews (n = 42) were carried out with clinical and administrative personnel at the AGCH and university hospital and stakeholders from the partnering care organisations and health insurance company. Data were analysed using thematic analysis. RESULTS: facilitators to implementing the AGCH concept were enthusiasm for the AGCH concept, organising preparatory sessions, starting with low-complex patients, good team leadership and ongoing education of the AGCH team. Other facilitators included strong collaboration between stakeholders, commitment to shared investment costs and involvement of regulators.Barriers to implementation were providing hospital care in an SNF, financing AGCH care, difficulties selecting patients at the emergency department, lack of protocols and guidelines, electronic health records unsuited for hospital care, department layout on two different floors and complex shared business operations. Furthermore, transfer of acute care to the community care meant that some care was not reimbursed. CONCLUSIONS: the AGCH concept was valued by all stakeholders. The main facilitators included the perceived value of the AGCH concept and enthusiasm of stakeholders. Structural financing is an obstacle to the expansion and continuation of this care model.

Effectiveness of transmural team-based palliative care in prevention of hospitalizations in patients at the end of life: A systematic review and meta-analysis.

BACKGROUND: Team-based palliative care interventions have shown positive results for patients at the end of life in both hospital and community settings. However, evidence on the effectiveness of transmural, that is, spanning hospital and home, team-based palliative care collaborations is limited. AIM: To systematically review whether transmural team-based palliative care interventions can prevent hospital admissions and increase death at home. DESIGN: Systematic review and meta-analysis. DATA SOURCES: MEDLINE (Ovid), Embase (Ovid), CINAHL (Ebsco), PsychINFO (Ovid), and Cochrane Library (Wiley) were systematically searched until January 2021. Studies incorporating teams in which hospital and community professionals co-managed patients, hospital-based teams with community follow-up, and case-management interventions led by palliative care teams were included. Data was extracted by two researchers independently. RESULTS: About 19 studies were included involving 6614 patients, of whom 2202 received an intervention. The overall pooled odds ratio of at least one hospital (re)admissions was 0.46 (95% confidence interval (CI) 0.34-0.68) in favor of the intervention group. The highest reduction in admission was in the hospital-based teams with community follow-up: OR 0.21 (95% CI 0.07-0.66). The pooled effect on home deaths was 2.19 (95% CI 1.26-3.79), favoring the intervention, with also the highest in the hospital-based teams: OR 4.77 (95% CI 1.23-18.47). However, studies had high heterogeneity regarding intervention, study population, and follow-up time. CONCLUSION: Transmural team-based palliative care interventions, especially hospital-based teams that follow-up patients at home, show an overall effect on lowering hospital admissions and increasing the number of patients dying at home. However, broad clinical and statistical heterogeneity of included studies results in uncertainty about the effect size.

Implementing online group model building to unravel complex geriatric problems, a methodological description.

BACKGROUND: Group model building (GMB), is a qualitative focus group like study design from the field of system dynamics, that leads a group of topic experts (often key stakeholders of a problem), through a set of scripted activities to create a conceptual model of their shared view on this problems' key contributing factors and their interactions. By offering a specific step wise approach to the complexity of a problem, GMB has provided better understanding and overview of complex problems across different scientific domains, in addition to traditional research methods. As the development of geriatric syndromes and organization of geriatric care are often complex issues that are difficult to research, understand and resolve, GMB might be a useful methodology to better address these issues. This study aimed to describe the methodology of online GMB using a geriatric case study. METHODS: Four online GMB sessions were designed by two clinician researchers. A GMB methodology expert was consulted for optimal design. Scriptapedia scripts formed the core of the sessions. These scripts were adapted to the online format. Experts were recruited purposefully and included seven local health care professionals, one patient representative and one healthcare insurance data analyst. The outcome was a conceptual model of older adults' emergency department visits, which was discussed in a separate article. RESULTS: During implementation of these four sessions, the sessions were adjusted and two extra (non-scripted) sessions were added because defining unambiguous contributing factors to the geriatric case was challenging for the experts. Paraphrasing, categorizing, iterative plenary reflection, and reserving extra time were used to help experts overcome this challenge. All sessions were held in April and May 2021. CONCLUSION: This study shows that GMB can help unravel complex problems in geriatrics, both pathophysiological as organizational, by creating step wise overview of their key contributing factors and interactions. Furthermore, it shows that GMB can be used by clinicians, researchers and health policy makers to better understand complex geriatric problems. Moreover, this paper can help to overcome specific implementational challenges in the geriatric field.

Post-discharge light physical activity indicates recovery in acutely hospitalized older adults - the Hospital-ADL study.

BACKGROUND: Physical activity (PA) levels might be a simple overall physical function indicator of recovery in acutely hospitalized older adults; however it is unknown which amount and level of PA is associated with recovery. Our objective was to evaluate the amount and level of post discharge PA and its optimum cut-off values associated with recovery among acutely hospitalized older adults and stratified for frailty. METHODS: We performed a prospective observational cohort study including acutely hospitalized older adults (≥ 70 years). Frailty was assessed using Fried's criteria. PA was assessed using Fitbit up to one week post discharge and quantified in steps and minutes light, moderate or higher intensity. The primary outcome was recovery at 3-months post discharge. ROC-curve analyses were used to determine cut-off values and area under the curve (AUC), and logistic regression analyses to calculate odds ratios (ORs). RESULTS: The analytic sample included 174 participants with a mean (standard deviation) age of 79.2 (6.7) years of whom 84/174 (48%) were frail. At 3-months, 109/174 participants (63%) had recovered of whom 48 were frail. In all participants, determined cut-off values were 1369 steps/day (OR: 2.7, 95% confidence interval [CI]: 1.3-5.9, AUC 0.7) and 76 min/day of light intensity PA (OR: 3.9, 95% CI: 1.8-8.5, AUC 0.73). In frail participants, cut-off values were 1043 steps/day (OR: 5.0, 95% CI: 1.7-14.8, AUC 0.72) and 72 min/day of light intensity PA (OR: 7.2, 95% CI: 2.2-23.1, AUC 0,74). Determined cut-off values were not significantly associated with recovery in non-frail participants. CONCLUSIONS: Post-discharge PA cut-offs indicate the odds of recovery in older adults, especially in frail individuals, however are not equipped for use as a diagnostic test in daily practice. This is a first step in providing a direction for setting rehabilitation goals in older adults after hospitalization.

More older adults died at their preferred place after implementation of a transmural care pathway for older adults at the end of life: a before-after study.

BACKGROUND: To improve transmural palliative care for older adults acutely admitted to hospital, the PalliSupport intervention, comprising an educational programme and transmural palliative care pathway, was developed. This care pathway involves timely identification of palliative care needs, advance care planning, multidisciplinary team meetings, warm handover, and follow-up home visits. With this study, we evaluate changes in patient-related outcomes and transmural collaboration after implementation of the care pathway. METHODS: We conducted a before-after study, in which we compared 1) unplanned hospital admission and death at place of preference and 2) transmural collaboration before implementation, up to six months, and six to 18 months after implementation. Data from palliative care team consultations were collected between February 2017 and February 2020 in a teaching hospital in the Netherlands. RESULTS: The palliative care team held 711 first-time consultations. The number of consultation, as well as the number of consultations for patients with non-malignant diseases, and consultations for advance care planning increased after implementation. The implementation of the pathway had no statistically significant effect on unplanned hospitalization but associated positively with death at place of preference more than six months after implementation (during/shortly after adjusted OR: 2.12; 95% CI: 0.84-5.35; p-value: 0.11, long term after adjusted OR: 3.14; 95% CI: 1.49-6.62; p-value: 0.003). Effects on transmural collaboration showed that there were more warm handovers during/shortly after implementation, but not on long term. Primary care professionals attended multidisciplinary team meetings more often during and shortly after implementation, but did not more than six months after implementation. CONCLUSIONS: The pathway did not affect unplanned hospital admissions, but more patients died at their place of preference after implementation. Implementation of the pathway increased attention to- and awareness for in-hospital palliative care, but did not improve transmural collaboration on long-term. For some patients, the hospital admissions might helped in facilitating death at place of preference.

Effects of a shared decision making intervention for older adults with multiple chronic conditions: the DICO study.

BACKGROUND: To evaluate the effects of a shared decision making (SDM) intervention for older adults with multiple chronic conditions (MCCs). METHODS: A pragmatic trial evaluated the effects of the SDMMCC intervention, existing of SDM training for nine geriatricians in two hospitals and a preparatory tool for patients. A prospective pre-intervention post-intervention multi-center clinical study was conducted in which an usual care group of older patients with MCC and their informal caregivers was included before the implementation of the intervention and a new cohort of patients and informal caregivers after the implementation of the intervention. SDM was observed using the OPTIONMCC during video-recorded consultations. Patient- and caregivers reported outcomes regarding their role in SDM, involvement, perceived SDM and decisional conflict were measured. The differences between groups regarding the level of observed SDM (OPTIONMCC) were analyzed with a mixed model analysis. Dichotomous patient-reported outcomes were analyzed with a logistic mixed model. RESULTS: From two outpatient geriatric clinics 216 patients with MCCs participated. The mean age was 77.3 years, and 56.3% of patients were female. No significant difference was found in the overall level of SDM as measured with the OPTIONMCC or in patient-reported outcomes. However, at item level the items discussing 'goals', 'options', and 'decision making' significantly improved after the intervention. The items discussing 'partnership' and 'evaluating the decision-making process' showed a significant decrease. Fifty-two percent of the patients completed the preparatory tool, but the results were only discussed in 12% of the consultations. CONCLUSION: This study provides scope for improvement of SDM in geriatrics. Engaging older adults with MCCs and informal caregivers in the decision making process should be an essential part of SDM training for geriatricians, beyond the SDM steps of explaining options, benefits and harms. More attention should be paid to the integration of preparatory work in the consultation.

Effects of a transitional care programme on medication adherence in an older cardiac population: A randomized clinical trial.

AIMS: Medication non-adherence post-discharge is common among patients, especially those suffering from chronic medical conditions, and contributes to hospital admissions and mortality. This study aimed to evaluate the effect of the Cardiac Care Bridge (CCB) intervention on medication adherence post-discharge. METHODS: We performed a secondary analysis of the CCB randomized single-blind trial, a study in patients ≥70 years, at high risk of functional loss and admitted to cardiology departments in six hospitals. In this multi-component intervention study, community nurses performed medication reconciliation and observed medication-related problems (MRPs) during post-discharge home visits, and pharmacists provided recommendations to resolve MRPs. Adherence to high-risk medications was measured using the proportion of days covered (PDC), using pharmacy refill data. Furthermore, MRPs were assessed in the intervention group. RESULTS: For 198 (64.7%) of 306 CCB patients, data were available on adherence (mean age: 82 years; 58.9% of patients used a multidose drug dispensing [MDD] system). The mean PDC before admission was 92.3% in the intervention group (n = 99) and 88.5% in the control group (n = 99), decreasing to 85.2% and 84.1% post-discharge, respectively (unadjusted difference: -2.6% (95% CI -9.8 to 4.6, P = .473); adjusted difference -3.3 (95% CI -10.3 to 3.7, P = .353)). Post-hoc analysis indicated that a modest beneficial intervention effect may be restricted to MDD non-users (Pinteraction = .085). In total, 77.0% of the patients had at least one MRP post-discharge. CONCLUSIONS: Our findings indicate that a multi-component intervention, including several components targeting medication adherence in older cardiac patients discharged from hospital back home, did not benefit their medication adherence levels. A modest positive effect on adherence may potentially exist in those patients not using an MDD system. This finding needs replication.

Patients' preferred place of death: patients are willing to consider their preferences, but someone has to ask them.

BACKGROUND: end-of-life care is not always in line with end-of-life preferences, so patients do not always die at their preferred place of death (PPD). This study aims to identify factors associated with patients' PPD and changes in PPD. METHODS: we prospectively collected data on PPD at four time points within 6 months from 230 acutely hospitalised older patients who were part of the control group in a stepped-wedge randomised controlled trial. Associations between patient characteristics and preferences were calculated using multivariable (multinomial) logistic regression analysis. RESULTS: the mean age of participants was 80.7 years. 47.8% of the patients had no PPD at hospital admission. Patients previously admitted to hospital preferred to die at home (home versus no preference: odds ratio [OR] 2.38, 95% confidence interval [CI] 1.15-4.92; home versus healthcare facility: OR 3.25, 95% CI 1.15-9.16). Patients with more chronic diseases preferred the healthcare facility as their PPD (healthcare facility versus no preference: OR 1.33, 95% CI 1.09-1.61; healthcare facility versus home: OR 1.21, 95% CI 1.00-1.47). 32 of 65 patients changed their preference during follow-up, and most of these had no PPD at hospital admission (home versus no preference: OR 0.005, 95% CI ≤0.001-0.095) and poorer self-rated well-being (OR 1.82, 95% CI 1.07-3.08). CONCLUSIONS: almost half of the patients had no PPD at baseline. Previous hospital admission, having more chronic diseases and living alone are associated with having a PPD. Introducing PPD could make older people aware of PPD and facilitate optimal palliative care.

'Patients come with two garbage bags full of problems and we have to sort them.' A qualitative study of the experiences of healthcare professionals on patients admitted to short-term residential care in the Netherlands.

BACKGROUND: Short-term residential care (STRC) facilities were recently implemented in the Netherlands to provide temporary care to older adults with general health problems. The aim of STRC is to allow the individual to return home. However, 40% of patients are discharged to long-term care facilities. In-depth data about characteristics of patients admitted and challenges in providing STRC are missing. OBJECTIVE: To obtain perspectives of STRC professionals on the patient journey from admission to discharge. DESIGN: Qualitative study. SETTING: Eight nursing homes and three hospitals. SUBJECTS: A total of 28 healthcare professionals. METHODS: A total of 13 group interviews with in-depth reviews of 39 pseudonymised patient cases from admission to discharge. Interviews were analysed thematically. RESULTS: Many patients had complex problems that were underestimated at handover, making returning to home nearly impossible. The STRC eligibility criteria that patients have general health problems and can return home do not fit with current practice. This results in a mismatch between patient needs and the STRC that is provided. Therefore, planning care before and after discharge, such as advance care planning, social care and home adaptations, is important. CONCLUSIONS: STRC is used by patients with complex health problems and pre-existing functional decline. Evidence-based guidelines, appropriate staffing and resources should be provided to STRC facilities. We need to consider the environmental context of the patient and healthcare system to enable older adults to live independently at home for longer.

The nurse-coordinated cardiac care bridge transitional care programme: a randomised clinical trial.

BACKGROUND: after hospitalisation for cardiac disease, older patients are at high risk of readmission and death. OBJECTIVE: the cardiac care bridge (CCB) transitional care programme evaluated the impact of combining case management, disease management and home-based cardiac rehabilitation (CR) on hospital readmission and mortality. DESIGN: single-blind, randomised clinical trial. SETTING: the trial was conducted in six hospitals in the Netherlands between June 2017 and March 2020. Community-based nurses and physical therapists continued care post-discharge. SUBJECTS: cardiac patients ≥ 70 years were eligible if they were at high risk of functional loss or if they had had an unplanned hospital admission in the previous 6 months. METHODS: the intervention group received a comprehensive geriatric assessment-based integrated care plan, a face-to-face handover with the community nurse before discharge and follow-up home visits. The community nurse collaborated with a pharmacist and participants received home-based CR from a physical therapist. The primary composite outcome was first all-cause unplanned readmission or mortality at 6 months. RESULTS: in total, 306 participants were included. Mean age was 82.4 (standard deviation 6.3), 58% had heart failure and 92% were acutely hospitalised. 67% of the intervention key-elements were delivered. The composite outcome incidence was 54.2% (83/153) in the intervention group and 47.7% (73/153) in the control group (risk differences 6.5% [95% confidence intervals, CI -4.7 to 18%], risk ratios 1.14 [95% CI 0.91-1.42], P = 0.253). The study was discontinued prematurely due to implementation activities in usual care. CONCLUSION: in high-risk older cardiac patients, the CCB programme did not reduce hospital readmission or mortality within 6 months. TRIAL REGISTRATION: Netherlands Trial Register 6,316, https://www.trialregister.nl/trial/6169.

Are presymptomatic SARS-CoV-2 infections in nursing home residents unrecognised symptomatic infections? Sequence and metadata from weekly testing in an extensive nursing home outbreak.

BACKGROUND: Sars-CoV-2 outbreaks resulted in a high case fatality rate in nursing homes (NH) worldwide. It is unknown to which extent presymptomatic residents and staff contribute to the spread of the virus. AIMS: To assess the contribution of asymptomatic and presymptomatic residents and staff in SARS-CoV-2 transmission during a large outbreak in a Dutch NH. METHODS: Observational study in a 185-bed NH with two consecutive testing strategies: testing of symptomatic cases only, followed by weekly facility-wide testing of staff and residents regardless of symptoms. Nasopharyngeal and oropharyngeal testing with RT-PCR for SARs-CoV-2, including sequencing of positive samples, was conducted with a standardised symptom assessment. RESULTS: 185 residents and 244 staff participated. Sequencing identified one cluster. In the symptom-based test strategy period, 3/39 residents were presymptomatic versus 38/74 residents in the period of weekly facility-wide testing (P-value < 0.001). In total, 51/59 (91.1%) of SARS-CoV-2 positive staff was symptomatic, with no difference between both testing strategies (P-value 0.763). Loss of smell and taste, sore throat, headache or myalga was hardly reported in residents compared to staff (P-value <0.001). Median Ct-value of presymptomatic residents was 21.3, which did not differ from symptomatic (20.8) or asymptomatic (20.5) residents (P-value 0.624). CONCLUSIONS: Symptoms in residents and staff are insufficiently recognised, reported or attributed to a possible SARS-CoV-2 infection. However, residents without (recognised) symptoms showed the same potential for viral shedding as residents with symptoms. Weekly testing was an effective strategy for early identification of SARS-Cov-2 cases, resulting in fast mitigation of the outbreak.

The performance of the Dutch Safety Management System frailty tool to predict the risk of readmission or mortality in older hospitalised cardiac patients.

BACKGROUND: Early identification of older cardiac patients at high risk of readmission or mortality facilitates targeted deployment of preventive interventions. In the Netherlands, the frailty tool of the Dutch Safety Management System (DSMS-tool) consists of (the risk of) delirium, falling, functional impairment, and malnutrition and is currently used in all older hospitalised patients. However, its predictive performance in older cardiac patients is unknown. AIM: To estimate the performance of the DSMS-tool alone and combined with other predictors in predicting hospital readmission or mortality within 6 months in acutely hospitalised older cardiac patients. METHODS: An individual patient data meta-analysis was performed on 529 acutely hospitalised cardiac patients ≥70 years from four prospective cohorts. Missing values for predictor and outcome variables were multiply imputed. We explored discrimination and calibration of: (1) the DSMS-tool alone; (2) the four components of the DSMS-tool and adding easily obtainable clinical predictors; (3) the four components of the DSMS-tool and more difficult to obtain predictors. Predictors in model 2 and 3 were selected using backward selection using a threshold of p = 0.157. We used shrunk c-statistics, calibration plots, regression slopes and Hosmer-Lemeshow p-values (PHL) to describe predictive performance in terms of discrimination and calibration. RESULTS: The population mean age was 82 years, 52% were males and 51% were admitted for heart failure. DSMS-tool was positive in 45% for delirium, 41% for falling, 37% for functional impairments and 29% for malnutrition. The incidence of hospital readmission or mortality gradually increased from 37 to 60% with increasing DSMS scores. Overall, the DSMS-tool discriminated limited (c-statistic 0.61, 95% 0.56-0.66). The final model included the DSMS-tool, diagnosis at admission and Charlson Comorbidity Index and had a c-statistic of 0.69 (95% 0.63-0.73; PHL was 0.658). DISCUSSION: The DSMS-tool alone has limited capacity to accurately estimate the risk of readmission or mortality in hospitalised older cardiac patients. Adding disease-specific risk factor information to the DSMS-tool resulted in a moderately performing model. To optimise the early identification of older hospitalised cardiac patients at high risk, the combination of geriatric and disease-specific predictors should be further explored.

Barriers and facilitators for shared decision making in older patients with multiple chronic conditions: a systematic review.

BACKGROUND: The aim of this study was to describe barriers and facilitators for shared decision making (SDM) as experienced by older patients with multiple chronic conditions (MCCs), informal caregivers and health professionals. METHODS: A structured literature search was conducted with 5 databases. Two reviewers independently assessed studies for eligibility and performed a quality assessment. The results from the included studies were summarized using a predefined taxonomy. RESULTS: Our search yielded 3838 articles. Twenty-eight studies, listing 149 perceived barriers and 67 perceived facilitators for SDM, were included. Due to poor health and cognitive and/or physical impairments, older patients with MCCs participate less in SDM. Poor interpersonal skills of health professionals are perceived as hampering SDM, as do organizational barriers, such as pressure for time and high turnover of patients. However, among older patients with MCCs, SDM could be facilitated when patients share information about personal values, priorities and preferences, as well as information about quality of life and functional status. Informal caregivers may facilitate SDM by assisting patients with decision support, although informal caregivers can also complicate the SDM process, for example, when they have different views on treatment or the patient's capability to be involved. Coordination of care when multiple health professionals are involved is perceived as important. CONCLUSIONS: Although poor health is perceived as a barrier to participate in SDM, the personal experience of living with MCCs is considered valuable input in SDM. An explicit invitation to participate in SDM is important to older adults. Health professionals need a supporting organizational context and good communication skills to devise an individualized approach for patient care.

Older patients' perspectives on factors contributing to frequent visits to the emergency department: a qualitative interview study.

BACKGROUND: Older patients are at high risk of unplanned revisits to the emergency department (ED) because of their medical complexity. To reduce the number of ED visits, we need more knowledge about the patient-level, environmental, and healthcare factors involved. The aim of this study was to describe older patients' perspectives and experiences before and after an ED visit, and to identify factors that possibly contribute to frequent ED revisits. METHODS: This was a qualitative description study. We performed semi-structured individual interviews with older patients who frequently visited the ED and were discharged home after an acute visit. Patients were enrolled in the ED of a university medical centre using purposive sampling. Interviews were recorded, transcribed, and coded independently by two researchers. Theoretical analysis was used to identify recurring patterns and themes in the data. Interviews were conducted until thematic saturation was reached. RESULTS: In-depth interviews were completed with 13 older patients. Three main themes emerged: 1) medical events leading to feelings of crisis, 2) patients' untreated health problems, and 3) persistent problems in health and daily functioning post discharge. Participants identified problems before and after their ED visit that possibly contributed to further ED visits. These problems included increasing symptoms leading to feelings of crisis, the relationship with the general practitioner, incomplete discharge information at the ED, and inadequate follow-up and lack of recovery after an ED visit. CONCLUSIONS: This qualitative study identified multiple factors that may contribute to frequent ED visits among older patients. Older patients in need of acute care might benefit from hospital-at-home interventions, or acute care provided by geriatric emergency teams in the primary care setting. Identifying frailty in the ED is needed to improve discharge communication and adequate follow-up is needed to improve recovery after an acute ED visit.

Experiences of frail older cardiac patients with a nurse-coordinated transitional care intervention - a qualitative study.

BACKGROUND: Older cardiac patients are at high risk of readmission and mortality. Transitional care interventions (TCIs) might contribute to the prevention of adverse outcomes. The Cardiac Care Bridge program was a randomized nurse-coordinated TCI combining case management, disease management and home-based rehabilitation for hospitalized frail older cardiac patients. This qualitative study explored the experiences of patients' participating in this study, as part of a larger process evaluation as this might support interpretation of the neutral study outcomes. In addition, understanding these experiences could contribute to the design and application of future transitional care interventions for frail older cardiac patients. METHODS: A generic qualitative approach was used. Semi-structured interviews were performed with 16 patients ≥70 years who participated in the intervention group. Participants were selected by gender, diagnosis, living arrangement and hospital of inclusion. Data were analysed using thematic analysis. In addition, quantitative data about intervention delivery were analysed. RESULTS: Three themes emerged from the data: 1) appreciation of care continuity; 2) varying experiences with recovery and, 3) the influence of an existing care network. Participants felt supported by the transitional care intervention as they experienced post-discharge support and continuity of care. The perceived contribution of the program in participants' recovery varied. Some participants reported physical improvements while others felt impeded by comorbidities or frailty. The home visits by the community nurse were appreciated, although some participants did not recognize the added value. Participants with an existing healthcare provider network preferred to consult these providers instead of the providers who were involved in the transitional care intervention. CONCLUSION: Our results contribute to an explanation of the neutral study of a nurse-coordinated transitional care intervention. For future purpose, it is important to identify which patients might benefit most from TCIs. Furthermore, the intensity and content of TCIs could be more personalized by tailoring interventions to older cardiac patients' needs, considering their frailty, self-management skills and existing formal and informal caregiver networks.

The implementation of a professional practice model to improve the nurse work environment in a Dutch hospital: A quasi-experimental study.

AIMS: To evaluate the effects of the implementation of a professional practice model based on Magnet principles on the nurse work environment in a Dutch teaching hospital. DESIGN: A quasi-experimental study. METHODS: Data were collected from registered nurses working on the clinical wards and outpatient clinics of the hospital in June/July 2016 (baseline) and in June/September 2019 (measurement of effects). Participants completed the Dutch Essentials of Magnetism II survey, which was used to measure their perception of their work environment. After baseline measurements were collected, interventions based on a professional practice model incorporating Magnet principles were implemented to improve the nurse work environment. Descriptive statistics and independent t-tests were conducted to examine differences between survey outcomes in 2016 and 2019. RESULTS: Survey outcomes revealed significant changes in the nurse work environment between 2016 and 2019. Seven of the eight subscales (essentials of magnetism) improved significantly. Score for overall job satisfaction increased from 7.3 to 8.0 and score for quality of care increased from 7.0 to 7.6. On unit level, 17 of the 19 units showed improvement in the nurse work environment. CONCLUSION: The implementation of a professional practice model positively affects the nurse work environment, job satisfaction and quality of care. IMPACT: Nowadays, the quality of care is threatened by workload pressure and the low autonomy experienced by nurses. Considering the global shortage of nurses and growing complexity of healthcare, it is important to invest in improving the nurse work environment. The Magnet concept created a work environment in which nurses can deliver optimal quality of care. Knowledge of how Magnet principles affect the nurse work environment in the Netherlands is missing. These study results, including the description of how the interventions were implemented, will assist other hospitals to develop improvement strategies by focusing on the nurse work environment.

The Cardiac Care Bridge randomized trial in high-risk older cardiac patients: A mixed-methods process evaluation.

AIM: To evaluate healthcare professionals' performance and treatment fidelity in the Cardiac Care Bridge (CCB) nurse-coordinated transitional care intervention in older cardiac patients to understand and interpret the study results. DESIGN: A mixed-methods process evaluation based on the Medical Research Council Process Evaluation framework. METHODS: Quantitative data on intervention key elements were collected from 153 logbooks of all intervention patients. Qualitative data were collected using semi-structured interviews with 19 CCB professionals (cardiac nurses, community nurses and primary care physical therapists), from June 2017 until October 2018. Qualitative data-analysis is based on thematic analysis and integrated with quantitative key element outcomes. The analysis was blinded to trial outcomes. Fidelity was defined as the level of intervention adherence. RESULTS: The overall intervention fidelity was 67%, ranging from severely low fidelity in the consultation of in-hospital geriatric teams (17%) to maximum fidelity in the comprehensive geriatric assessment (100%). Main themes of influence in the intervention performance that emerged from the interviews are interdisciplinary collaboration, organizational preconditions, confidence in the programme, time management and patient characteristics. In addition to practical issues, the patient's frailty status and limited motivation were barriers to the intervention. CONCLUSION: Although involved healthcare professionals expressed their confidence in the intervention, the fidelity rate was suboptimal. This could have influenced the non-significant effect of the CCB intervention on the primary composite outcome of readmission and mortality 6 months after randomization. Feasibility of intervention key elements should be reconsidered in relation to experienced barriers and the population. IMPACT: In addition to insight in effectiveness, insight in intervention fidelity and performance is necessary to understand the mechanism of impact. This study demonstrates that the suboptimal fidelity was subject to a complex interplay of organizational, professionals' and patients' issues. The results support intervention redesign and inform future development of transitional care interventions in older cardiac patients.

The course of readmission in frail older cardiac patients.

AIM: The aim of this study is to explore patients' and (in)formal caregivers' perspectives on their role(s) and contributing factors in the course of unplanned hospital readmission of older cardiac patients in the Cardiac Care Bridge (CCB) program. DESIGN: This study is a qualitative multiple case study alongside the CCB randomized trial, based on grounded theory principles. METHODS: Five cases within the intervention group, with an unplanned hospital readmission within six months after randomization, were selected. In each case, semi-structured interviews were held with patients (n = 4), informal caregivers (n = 5), physical therapists (n = 4), and community nurses (n = 5) between April and June 2019. Patients' medical records were collected to reconstruct care processes before the readmission. Thematic analysis and the six-step analysis of Strauss & Corbin have been used. RESULTS: Three main themes emerged. Patients experienced acute episodes of physical deterioration before unplanned hospital readmission. The involvement of (in)formal caregivers in adequate observation of patients' health status is vital to prevent rehospitalization (theme 1). Patients and (in)formal caregivers' perception of care needs did not always match, which resulted in hampering care support (theme 2). CCB caregivers experienced difficulties in providing care in some cases, resulting in limited care provision in addition to the existing care services (theme 3). CONCLUSION: Early detection of deteriorating health status that leads to readmission was often lacking, due to the acuteness of the deterioration. Empowerment of patients and their informal caregivers in the recognition of early signs of deterioration and adequate collaboration between caregivers could support early detection. Patients' care needs and expectations should be prioritized to stimulate participation. IMPACT: (In)formal caregivers may be able to prevent unplanned hospital readmission of older cardiac patients by ensuring: (1) early detection of health deterioration, (2) empowerment of patient and informal caregivers, and (3) clear understanding of patients' care needs and expectations.

Emergency department management of older people living with frailty: a guide for emergency practitioners.

Emergency Departments (EDs) are increasingly seeing more seriously unwell older people living with frailty. In the context of limited resources and increasing demand it's the ED practitioner's challenge to unpick this constellation of physical, psychological, functional and social issues.To properly assess older people living with frailty at the ED it is crucial to use an holistic approach. This consists of triage with algorithms sensitive to the higher risk of older people living with frailty, a frailty assessment, and an assessment with the help of the principles of Comprehensive Geriatric Assessment. Multi-disciplinary care, a tailor-made treatment plan, based on what the person values most, will help the ED practitioner to deliver appropriate and valuable care during the ED stay, but also in transition from hospital to home.

Motivational factors mediate the association of general self-efficacy and performance outcomes in acutely hospitalised older patients.

OBJECTIVES: To study (i) the association of general self-efficacy (GSE) on the course of subjective (i.e. basic and instrumental activities of daily living (ADLs and IADLs) and objective physical performance outcomes (short physical performance battery (SPPB)) among older persons from discharge up to 3 months post-discharge and (ii) the extent to whether motivational factors such as depressive symptoms, apathy and fatigue mediate this association. METHODS: Prospective multi-centre cohort of acutely hospitalised patients aged ≥70 (Hospital-ADL study). Structural equation modelling was used to analyse the structural relationships. RESULTS: The analytic sample included 236 acutely hospitalised patients. GSE had a significant total effect on the course of subjective and objective performance outcomes (ADLs: ß = -0.21, P < 0.001, IADLs: ß = -0.24, P < 0.001 and SPPB: ß = 0.17, P < 0.001). However, when motivational factors as mediator were included into the same model, motivational factors (IADLs: ß = 0.51, P < 0.001; SPPB: ß = 0.49, P < 0.001) but not GSE remained significantly associated with IADLs (ß = -0.06, P = 0.16) and SPPB (ß = 0.002, P = 0.97). Motivational factors partially mediated the relationship between GSE and ADLs (ß = -0.09, P = 0.04). The percentage of mediation was 55, 74 and 99% for ADLs, IADLs and SPPB, respectively. CONCLUSIONS: Motivational factors and GSE are both associated with subjective and objective performance outcomes. However, the relationship between GSE and subjective and objective performance outcomes was highly mediated by motivational factors. Taken together, this suggests that GSE is important to being physically active but not sufficient to becoming more physical active in acutely hospitalised older patients; motivation is important to improving both subjective and objective performance.