[Long-duration home hospitalization: the impacts of socio-demographic and clinical factors and care pathways]. / Séjours longs en hospitalisation à domicile : impacts des facteurs sociodémographiques, cliniques et des parcours de soins.

INTRODUCTION: Although considerable literature exists concerning duration of stay in hospital settings, particularly for long-duration patients, we have little or no information about those hospitalized at home (HAH). We have studied the socio-demographic, clinical characteristics and care pathways of patients having undergone long-duration HAH. METHODS: One hundred and twenty-eight non-obstetric patients having undergone at least seven months of home hospitalization in 2018 and 2019 under the aegis of Assistance publique-Hôpitaux de Paris (AP-HP) were included and compared with 12381 shorter-duration patients. Data came from the French medicalized information system program (PMSI). A multivariate logistic regression model was developed and a descriptive analysis was carried out. RESULTS: Advanced age, residing in a nursing home, living alone, having several caregivers and being socially disadvantaged were associated with long-duration home hospitalization (HAH). These patients more often required complex dressings and palliative care, had more severe functional disability and were more frequently readmitted to hospital or died during the same period. In the multivariate model, advanced age, functional disability and transfer to HAH from conventional hospitalization were associated with increasingly lengthier home hospitalization. CONCLUSION: Long-duration home hospitalization was associated with a number of socio-demographic, clinical and care pathway-related factors. Further study of the advantages and drawbacks of HAH is called for.

[Use of social and health primary care services for older people with complex needs: Comparison of three types of gerontological coordination]. / Utilisation des services d'aide et de soins à domicile pour les personnes âgées en situations complexes : comparaison entre trois types de coordination gérontologique.

BACKGROUND: Older people with complex needs live mainly at home. Several types of gerontological coordinations have been established on the French territory to meet their needs and to implement social and primary health care services. But we do not have any information on the use of these services at home as a function of the coordination method used. METHODS: We compared the use of home care services for older people with complex needs in three types of coordination with 12 months' follow-up. The three coordinations regrouped a gerontological network with case management (n=105 persons), a nursing home service (SSIAD) with a nurse coordination (n=206 persons) and an informal coordination with a non-professional caregiver (n=117 persons). RESULTS: At t0, the older people addressed to the gerontological network had less access to the services offered at home; those followed by the SSIAD had the highest number of services and of weekly interventions. Hours of weekly services were two-fold higher in those with the informal coordination. At t12, there was an improvement in access to services for the network group with case management and an overall increase in the use of professional services at home with no significant difference between the three groups. CONCLUSION: The use of social and primary health care services showed differences between the three gerontological coordinations. The one-year evolution in the use of home services was comparable between the groups without an explosion in the number of services in the network group with case management.

[Factors facilitating and impairing implementation of integrated care]. / Intégration des services: obstacles et facteurs facilitant leur implantation.

BACKGROUND: Better integration of healthcare is the focus of many current reforms in Western countries. The goal is to reduce fragmentation of health and social care delivery for patients with chronic diseases. In France, Alzheimer autonomy integration experimentations (Maison Autonomie Intégration Alzheimer [MAIA]) were introduced as part of the 2008-2012 National Alzheimer Plan. To date, implementation of such organizations remains challenging. It is thus paramount to identify factors obstructing, and on the contrary facilitating, implementation of integrated care. METHODS: After an in-depth literature review of qualitative studies published from January 1995 to December 2010. We selected 10 qualitative studies on health care professionals' perceptions of barriers and facilitators to the implementation of integrated care. RESULTS: Barriers and facilitating factors linked to the implementation of integrated care were identified at several levels: leadership; collaboration between services and clinicians; and funding and policy making. The operative strategy applied to change care delivery and the role of the leading pilot are key elements during the implementation phase. CONCLUSION: Strong leadership and active involvement of a broad spectrum of professionals from clinical practitioners to healthcare managers is crucial for a successful implementation of integrated care services.

[The participation of primary care physicians in integrated health services network: United States experiences]. / Participation des médecins généralistes dans les réseaux de santé : expériences en Amérique du Nord.

BACKGROUND: Reforms of care and services have affected primary care physicians, but very little attention has been devoted to their actual participation in Integrated Health Services Network (IHSN). METHODS: From a literature review of articles published from January 1985 to December 2006, we selected 24 studies on physicians' participation in IHSN and their perceptions on practices. RESULTS: This literature review suggests that physicians' perceptions of IHSN are linked to their actual level of participation. Physicians who participated fully perceived improvements in all practice dimensions. Physicians who participated partially were dissatisfied with physician-patient relationships, perceived a loss of professional autonomy and increased gate-keeping constraints. They had however a positive perception of the overall quality of care. When physicians received capitation payments, they were overall dissatisfied. CONCLUSIONS: In order to improve primary care physicians' participation in IHSN, quality of care should be reinforced, capitation payment avoided and gate-keeping should be transformed into coordination of care.

[Evaluation of a multifaceted intervention for implementing national guidelines: the case of physical restraint in geriatric care]. / Evaluation d'une intervention multiple pour implanter des recommandations nationales: le cas de la contention physique passive en gériatrie.

BACKGROUND: There is a growing interest in developing guidelines. The French Agency for accreditation and Evaluation (Anaes) published in October 2000 guidelines on the use of restraint in geriatric care settings because in spite of the risks this practice remains widespread in that type of care setting. A multifaceted intervention was conducted in a Parisian geriatric hospital in order to improve the implementation of the published guidelines. An epidemiological study was conducted to assess the outcomes of this intervention. METHODS: The intervention consisted in distributing educational materials and a specific prescription sheet, and in staff training sessions. A time series study was used to assess outcomes. The three time points were: before the intervention, just after the end of the intervention and one year later. Two dimensions were studied: implementation of the guidelines using markers collected from patients' charts and restraining practices noted in an observational study of hospitalized patients. RESULTS: The results of the study suggest that five recommendations were followed better: restraint prescription (8.7 to 57.4%), writing in the patient chart the reasons for restraining (3.5 to 35.3%), follow-up prescription, assessment of potential benefits and risks for the patient and patient information (0% to 19-34%). Nevertheless, the prevalence of restraint and of devices employed (around 70%) remained unchanged after the intervention. The various outcomes of the intervention might be explained by the guidelines themselves, which were variably practical or precise. Moreover, the effect of certain factors directly related with the use of restraint, a routine practice strongly supported by myths about its efficacy, as well as factors related to intervention design may merely have prevented any decrease in the use of restraint practices. CONCLUSION: Multifaceted intervention can favour implementation of certain national guidelines such as prescribing restraint, but can also fail in stimulating the implementation of others such as decreasing the prevalence of restraint in geriatric practice. Therefore the next intervention should emphasize alternatives to physical restraint practices.

Predictive factors of rate of loss of autonomy in Alzheimer's disease patients. A prospective study of the REAL.FR Cohort.

Alzheimer's disease is characterised by a progressive loss of autonomy in activities of daily living. Many patients lose this autonomy rapidly with dramatic consequences for the patients and their relatives, and for health and social services. The aim of this study was to determine, in a large French cohort of community-living Alzheimer patients (REAL.FR), the factors underpinning different rates of loss of autonomy. Six hundred and eighty seven patients were recruited to this French cohort. Autonomy in activities of daily living was estimated with the IADL scale (Lawton). Patients were divided into three groups according to loss of autonomy during the first one-year follow-up period. Patients with a decrease in the IADL score had worse ADAS-cog score (Alzheimer's Disease Assessment Scale, cognitive subscale), Mini-Mental State Examination (MMSE), and Clinical Dementia Rating Scale scores. Up to a point, a marked decrease in the IADL score was less frequent among patients with a better ADAS-cog score (p < 0.10, bilateral test). At one-year evaluation, patients with a marked decline in autonomy were characterised by a greater decrease in Mini-Mental State score, faster progression of behavioural disturbance, and more hospitalisations. Further prospective studies, using established models, are needed to isolate the factors associated with a high rate of loss of autonomy in activities of daily living in Alzheimer patients.