Effectiveness of integrated person-centered interventions for older people's care: Review of Swedish experiences and experts' perspective.

Older adults have multiple medical and social care needs, requiring a shift toward an integrated person-centered model of care. Our objective was to describe and summarize Swedish experiences of integrated person-centered care by reviewing studies published between 2000 and 2023, and to identify the main challenges and scientific gaps through expert discussions. Seventy-three publications were identified by searching MEDLINE and contacting experts. Interventions were categorized using two World Health Organization frameworks: (1) Integrated Care for Older People (ICOPE), and (2) Integrated People-Centered Health Services (IPCHS). The included 73 publications were derived from 31 unique and heterogeneous interventions pertaining mainly to the micro- and meso-levels. Among publications measuring mortality, 15% were effective. Subjective health outcomes showed improvement in 24% of publications, morbidity outcomes in 42%, disability outcomes in 48%, and service utilization outcomes in 58%. Workshop discussions in Stockholm (Sweden), March 2023, were recorded, transcribed, and summarized. Experts emphasized: (1) lack of rigorous evaluation methods, (2) need for participatory designs, (3) scarcity of macro-level interventions, and (4) importance of transitioning from person- to people-centered integrated care. These challenges could explain the unexpected weak beneficial effects of the interventions on health outcomes, whereas service utilization outcomes were more positively impacted. Finally, we derived a list of recommendations, including the need to engage care organizations in interventions from their inception and to leverage researchers' scientific expertise. Although this review provides a comprehensive snapshot of interventions in the context of Sweden, the findings offer transferable perspectives on the real-world challenges encountered in this field.

The impact of ageing-in-place reforms on the provision of home care packages for older Australians, 2008-21: a repeated cross-sectional study.

OBJECTIVES: To assess changes following the 2013-21 Home Care Package (HCP) reforms in the rate of HCPs provided to Australians aged 65 years or older, the characteristics of people who have received HCPs, and the capacity of the program to meet demand for its services during 2018-21. STUDY DESIGN: Repeated cross-sectional population-based study; analysis of Australian Institute of Health and Welfare GEN Aged Care and Australian Department of Health Home Care Packages program data. SETTING, PARTICIPANTS: HCPs provided to non-Indigenous Australians aged 65 years or older, 2008-09 to 2020-21. MAIN OUTCOME MEASURES: Changes in age- and sex-standardised HCP rates (number per 1000 older people) and changes in proportions of recipients for selected characteristics, 2013-14 to 2020-21, overall and by care level; correspondence of proportional HCP supply and demand, 2018-19 to 2020-21, by care level. RESULTS: A total of 490 276 HCPs were provided during 2008-21. The age- and sex-standardised HCP rate rose from 9.23 per 1000 people aged 65 years or more in 2013-14 to 16.4 per 1000 older people in 2020-21. The increases in age- and sex-standardised HCP rate between 2013-14 and 2020-21 were greatest for level 1 (from 0.19 to 5.05 per 1000 older people) and level 3 HCPs (from 0.35 to 3.62 per 1000 older people); the rate for level 2 HCPs declined from 6.75 to 5.82 per 1000 older people, and that for level 4 HCPs did not change. The proportion of culturally and linguistically diverse recipients rose from 10.8% to 16.2%; the overall proportion of recipients living outside major cities rose slightly, from 28.1% to 28.7%, but declined for higher care level HCPs (level 3: from 30.8% to 27.8%; level 4: from 29.6% to 25.2%). During 2018-19 to 2020-21, the proportions of lower level (1 and 2) HCPs generally exceeded demand, while the supply of higher level (3 and 4) HCPs generally fell short of demand. CONCLUSIONS: Despite the increased overall availability of HCPs, the supply of higher care level HCPs is still lower than the demand, probably contributing to suboptimal support for the ageing-in-place preferences of older Australians, especially in regional and remote areas.

Development of the Community-based complex Interventions to sustain Independence in Older People (CII-OP) typology: a qualitative synthesis of interventions in randomised controlled trials.

INTRODUCTION: Community-based services to sustain independence for older people have varying configurations. A typology of these interventions would improve service provision and research by providing conceptual clarity and enabling the identification of effective configurations. We aimed to produce such a typology. METHOD: We developed our typology by qualitatively synthesising community-based complex interventions to sustain independence in older people, evaluated in randomised controlled trials (RCTs), in four stages: (i) systematically identifying relevant RCTs; (ii) extracting descriptions of interventions (including control) using the Template for Intervention Description and Replication; (iii) generating categories of key intervention features and (iv) grouping the interventions based on these categories. PROSPERO registration: CRD42019162195. RESULTS: Our search identified 129 RCTs involving 266 intervention arms. The Community-based complex Interventions to sustain Independence in Older People (CII-OP) typology comprises 14 action components and 5 tailoring components. Action components include procedures for treating patients or otherwise intended to directly improve their outcomes; regular examples include formal homecare; physical exercise; health education; activities of daily living training; providing aids and adaptations and nutritional support. Tailoring components involve a process that may result in care planning, with multiple action components being planned, recommended or prescribed. Multifactorial action from care planning was the most common tailoring component. It involves individualised, multidomain assessment and management, as in comprehensive geriatric assessment. Sixty-three different intervention types (combinations) were identified. CONCLUSIONS: Our typology provides an empirical basis for service planning and evidence synthesis. We recommend better reporting about organisational aspects of interventions and usual care.

Development of person-centred quality indicators for aged care assessment services in Australia: A mixed methods study.

INTRODUCTION: This study developed a proposed set of person-centred quality indicators (PC-QIs) for services that assess older adults' care and support needs to determine their eligibility to receive government-funded aged care services in Australia. Individual proposed PC-QIs amenability for change within current organizational structures were explored. Barriers and opportunities to adapt service elements of the aged care assessment service to better align with the intent of the proposed PC-QIs were identified. METHODS: A mixed methods study was conducted over five phases. A scoping review identified domains of quality for aged care services as perceived by older adults. Service elements of an aged care assessment service were mapped alongside quality domains informing key attributes of each quality domain. Self-determination theory was used to formulate each proposed PC-QI to align with key attributes and quality domains. Consultation with a consumer group enabled revision of the proposed PC-QIs. A focus group with clinicians evaluated the amenability of each proposed PC-QI for change and identified barriers and opportunities to better align service elements with older adults' perceptions of quality. Results were informed by qualitative and quantitative data from a structured focus group. Focus group discussions were audio recorded and subsequently transcribed verbatim. Qualitative data were analyzed using a deductive thematic approach by two independent researchers. RESULTS: Twenty-four proposed PC-QIs were developed. Refinement to descriptors of the proposed PC-QIs were made by the consumer group (n = 18) and all were affirmed as being amenable to change by aged care assessors. Barriers in meeting the intent of the proposed PC-QIs were identified across five domains including: health care staff knowledge (18.7%; n = 3); clear communication (31%; n = 5); person-centred approach (18.7%; n = 3); respect for client (18.7%; n = 3); and collaborative partnership with client (12%; n = 2). Participants made 21 recommendations. Of the five service elements in delivering an aged care assessment service, barriers in meeting the intent of the proposed PC-QIs were identified at the intake and booking of an assessment and during the assessment. CONCLUSIONS: Recommendations identified provide assessment services guidance on ways to adapt service elements to better align with older adults' perceptions of quality. PATIENT AND PUBLIC CONTRIBUTION: Patients and carers were involved as collaborators in this project at the protocol stage which included participating in discussions regarding the refining and modification of the protocol, refinement of the proposed PC-QIs, data collection forms and supplementary information for participants.

The evaluation of health, disability and aged care-sector engagement with resources designed to support optimisation of the allied health assistant workforce: a qualitative study.

BACKGROUND: Allied health assistants (AHAs) support allied health professionals (AHPs) to meet workforce demands in modern healthcare systems. In an Australian context historically, AHAs have been sub-optimally utilised. Prior research has identified that AHAs and AHPs working in health, disability and aged care sectors, and the Vocational Education and Training (VET) industry, may benefit from access to resources to support the optimisation of the AHA workforce. As a part of a Victorian department of health funded project, several resources were developed in line with workforce recommendations for use in each of the above sectors. Recommendations and resources covered the broad areas of pre-employment training, workforce planning and governance, consumer-centred therapy and supports, recruitment and induction and workplace training and development. This study aimed to evaluate the engagement with these newly designed resources to support optimisation of AHAs in the Victorian context. METHODS: Semi-structured interviews were conducted to evaluate engagement with resources, from the perspective of AHAs, AHPs and allied health leaders (AHLs) in the health, aged care or disability sectors, and educators and managers of allied health assistance training. Thematic analysis was conducted using team-based framework analysis. RESULTS: Thematic framework analysis of the interview data identified four themes; Why participants accessed the resources; How participants engaged with the resources; What (if any) changes in practice occurred as a result of engaging with the resources in a participant's local context, How did participants envision the resources being utilised for AHA workforce optimisation in the future. Responses were mapped to the AHA workforce career pathway at the career preparation, career development and career trajectory tiers. CONCLUSIONS: Appetite for AHA workforce development and optimal utilisation is evident across Victoria, Australia. Readily accessible resources that inform AHA role and scope of practice, delegation practice, or improve the ability for an AHA to state their own development needs, were identified as useful by participants. The potential for these resources to assist in the optimal utilisation and development of AHA workforces across the career continuum differs according to the role, sector and geographical location of the resource user. Further study is needed to investigate the transferability of these resources to national and global contexts.

Mapping the way: functional modelling for community-based integrated care for older people.

BACKGROUND: Healthcare system sustainability is challenged by several critical issues; one of the most pressing is the ageing population. Traditional, episodic care delivery models are not designed for older people who are medically complex and frail. These individuals would benefit from health and social care that is more comprehensive, coordinated, person-centred and accessible in the communities in which they live. Delivering this is a challenging endeavour. Community-based health and social care professionals are siloed, dispersed across various locations and sectors, each with their own mental models, electronic health information systems, and means of communication. To move away from fragmented care delivery models and towards a more integrated approach to care, an analysis of the process of community-based comprehensive geriatric assessment was conducted in an urban location in Atlantic Canada. The purpose of the study was to identify where in the community-based comprehensive geriatric assessment process challenges and opportunities existed for moving towards a more integrated model of care delivery. METHOD: The functional resonance analysis method (FRAM) and dynamic FRAM (DynaFRAM) modelling were used to model the community-based health and social care system and create a hypothetical patient journey scenario. Data collected to inform modelling consisted of document review, focus groups, and semi-structured interviews with health and social care professionals providing care and service to older people in the community setting. FINDINGS: Challenges and opportunities for implementing integrated care in the local context were identified. Findings from the FRAM and DynaFRAM analysis informed the co-design of multi-level process improvement recommendations that aim to move the local community-based comprehensive geriatric assessment process towards a more integrated model of care. CONCLUSIONS: A transformative redesign of community-based health and social care in the local context is necessary but cannot be accomplished without an understanding of how health and social care professionals conduct their work and how older people may receive care under the dynamic conditions. The FRAM and DynaFRAM modelling provided an enhanced understanding of system operations and functionality and demonstrated a critical step that should not be overlooked for decision-makers in their efforts to implement a more integrated model of care.

[Priority needs of the older generation in social (digital) services.]

The social service approach for the elderly that emerged in the USSR in the late 1980s and was introduced within the framework of a federal law in 1995 was oriented towards care and service provision. However, various authors have noted that the needs of the elderly and the availability of services often do not coincide, and this gap is growing with the change of generations of the elderly. The modern approach, the founder of which was the Polish demographer E.Rosset, reflected in a number of international documents, prioritizes supporting employment and maintaining independence for the elderly for as long as possible. However, there is still little research clarifying the specific services needed by the elderly themselves. The aim of this article is to demonstrate that the needs and capabilities of the «older generation¼ are changing noticeably, and the existing approach to the provision of social services, which largely took shape in the 1990s, is outdated. Our research question is: do the digital ecosystems (services) being developed by the Information and Analytical Center of St. Petersburg Government correspond to the needs of the elderly on the one hand, and the provisions enshrined in the Madrid Plan on the other? The study employed qualitative methods: an analysis of a pilot survey of users of the «Active Longevity¼ service and the opinions of participants in a focus group (age of informants 60-75 years) of elderly individuals conducted on 16.03.2024.

[Focusing on intersectorality-strategies and current research projects for the care of geriatric people]. / Intersektoralität im Fokus ­ Strategien und aktuelle Forschungsprojekte zur Versorgung geriatrischer Personen.

In view of the demographic change, the need for intersectoral care of the aging population has already been identified. The strategies for implementation are diverse and address different approaches, each of which requires different sectors to overlap. This article provides an overview of already completed and ongoing projects for the care of geriatric patients. It becomes apparent that the development of networks as an indispensable basis for intersectoral care cannot be measured in terms of direct intervention effects and therefore makes it difficult to prove the cost-benefit. It is also evident that some research projects fail to be implemented into standard care due to financial and staff shortages.Do we need a rethinking in Germany or less innovation-related funding lines for better implementation and research of existing concepts? International role models such as Japan show that cost reduction for the care of the aging population should be considered in the long term, which requires increased financial volumes in the short term. For a sustainable implementation of cross-sectoral approaches into everyday life, research should therefore reorganize tight and/or entrenched structures, processes, and financing. By linking the countless existing projects and integrating ideas from different sectors, future demands of intersectoral geriatric care may be achieved.

[Cooperation of geriatrics and trauma surgery in certified geriatric trauma centers : Insights into different care models and the implementation of requirements resulting from certification]. / Zusammenarbeit von Geriatrie und Unfallchirurgie in zertifizierten alterstraumatologischen Zentren : Einblicke in unterschiedliche Versorgungsmodelle und in die Umsetzung von Anforderungen, die sich aus der Zertifizierung ergeben.

BACKGROUND: In Germany, different models of orthogeriatric co-management have been implemented in certified geriatric trauma centers. So far, it is not clear how the different models are implemented and what influence the certification has on the structures and processes within the centers. The present study examined the extent of cooperation between surgery and geriatrics and if the quality of care had changed since the certification of the centers. METHODS: In this study 4 guided focus group interviews (FGI) were conducted in different teams of certified geriatric trauma centers in 3 federal states with 16 participants. To specify the content of the FGI, two additional interviews were conducted with system auditors. Both types of interview were analyzed by content analysis. RESULTS: The certification supported the implementation of structures and processes in the different orthogeriatric models; however, the quality of care and cooperation between surgery and geriatrics depends on the spatial proximity and the orthogeriatric care model in the geriatric trauma centers. Simultaneously, challenges in the area of geriatric syndromes and the recruitment of skilled staff became relevant. DISCUSSION: The results can help to reflect processes in the certified geriatric trauma centers and to treat geriatric syndromes more effectively. In the future, the challenge will be to establish geriatric care under the existing shortage of skilled staff.

Excess mortality for care home residents during the first 23 weeks of the COVID-19 pandemic in England: a national cohort study.

BACKGROUND: To estimate excess mortality for care home residents during the COVID-19 pandemic in England, exploring associations with care home characteristics. METHODS: Daily number of deaths in all residential and nursing homes in England notified to the Care Quality Commission (CQC) from 1 January 2017 to 7 August 2020. Care home-level data linked with CQC care home register to identify home characteristics: client type (over 65s/children and adults), ownership status (for-profit/not-for-profit; branded/independent) and size (small/medium/large). Excess deaths computed as the difference between observed and predicted deaths using local authority fixed-effect Poisson regressions on pre-pandemic data. Fixed-effect logistic regressions were used to model odds of experiencing COVID-19 suspected/confirmed deaths. RESULTS: Up to 7 August 2020, there were 29,542 (95% CI 25,176 to 33,908) excess deaths in all care homes. Excess deaths represented 6.5% (95% CI 5.5 to 7.4%) of all care home beds, higher in nursing (8.4%) than residential (4.6%) homes. 64.7% (95% CI 56.4 to 76.0%) of the excess deaths were confirmed/suspected COVID-19. Almost all excess deaths were recorded in the quarter (27.4%) of homes with any COVID-19 fatalities. The odds of experiencing COVID-19 attributable deaths were higher in homes providing nursing services (OR 1.8, 95% CI 1.6 to 2.0), to older people and/or with dementia (OR 5.5, 95% CI 4.4 to 6.8), amongst larger (vs. small) homes (OR 13.3, 95% CI 11.5 to 15.4) and belonging to a large provider/brand (OR 1.2, 95% CI 1.1 to 1.3). There was no significant association with for-profit status of providers. CONCLUSIONS: To limit excess mortality, policy should be targeted at care homes to minimise the risk of ingress of disease and limit subsequent transmission. Our findings provide specific characteristic targets for further research on mechanisms and policy priority.

Delivering Community Emergency Medicine during the COVID-19 pandemic: the Physician Response Unit.

The COVID-19 pandemic has presented significant challenges to services providing emergency care, in both the community and hospital setting. The Physician Response Unit (PRU) is a Community Emergency Medicine model, working closely with community, hospital and pre-hospital services. In response to the pandemic, the PRU has been able to rapidly introduce novel pathways designed to support local emergency departments (EDs) and local emergency patients. The pathways are (1) supporting discharge from acute medical and older people's services wards into the community; (2) supporting acute oncology services; (3) supporting EDs; (4) supporting palliative care services. Establishing these pathways have facilitated a number of vulnerable patients to access patient-focussed and holistic definitive emergency care. The pathways have also allowed EDs to safely discharge patients to the community, and also mitigate some of the problems associated with trying to maintain isolation for vulnerable patients within the ED. Community Emergency Medicine models are able to reduce ED attendances and hospital admissions, and hence risk of crowding, as well as reducing nosocomial risks for patients who can have high-quality emergency care brought to them. This model may also provide various alternative solutions in the delivery of safe emergency care in the postpandemic healthcare landscape.

A rapid response and treatment service for care homes: a case study.

Rapid response services provide opportunities for older people living with frailty to remain in their own homes during an episode of deteriorating health. The government has announced additional funding to increase capacity and responsiveness for these services through the Ageing Well programme as part of the NHS Long Term Plan. Older people living with frailty are particularly at risk of the adverse effects of a hospital admission and evidence is emerging of the benefits of enhanced healthcare support to allow them to remain in their own home. The Hospital at Home model offers short-term, targeted interventions at acute hospital level care that can provide a truly person-centred experience within the home. This article describes a Rapid Response and Treatment service for older people living in care homes in Berkshire West and shares Sid's story to demonstrate how such a service is delivered. The COVID-19 pandemic has presented additional challenges and opportunities that highlight the ongoing need for the development of services that will support older people to prioritise what matters to them most.

Beliefs regarding geriatrics primary care topics among medical students and internal medicine residents.

This study evaluated beliefs regarding 25 content areas essential to the primary care of older adults and attitudes toward aging held by first-yearmedical students and Internal Medicine residents. A survey of 136 medical students and 61 Internal Medicine residents was conducted at an academic health-center. Beliefs were assessed by the 25-item Geriatrics Clinician-Educator Survey. Gap scores reflecting the difference in ratings between self-rated importance and knowledge were calculated. Attitudes toward aging was assessed by the Images of Aging Scale. Students and residents expressed similar beliefs about the importance of content areas, but students provided lower ratings in knowledge. Students reported larger gap scores in areas that reflected general primary care (e.g., chronic conditions, medications), whereas residents reported larger gap scores in areas that reflected specialists' expertise (e.g., driving risk, cognition, psychiatric symptoms). Attitudes toward aging did not differ appreciably between students and residents. Our findings suggest that primary care topics applicable for any age demographic were rated as most important by first-year medical students and Internal Medicine residents. Topics relevant to older populations--particularly those requiring specialists' knowledge of or requiring sensitive discussion with older adults-were rated as less important and were less well-mastered.

Ensuring contact: calling rural Appalachian older adults during the COVID-19 epidemic.

INTRODUCTION: Older adults, especially those aged 85 years or older, remain at significantly higher risk for COVID-19. This group, along with those with pre-existing heart and lung disease and diabetes, have accounted for 80% of hospitalizations and an even higher percentage of COVID-19 related deaths in the USA. West Virginia, the only state in the USA located completely within Appalachia, has a higher percentage of elderly than all but two states in the nation. Rural seniors are hesitant to use hospital emergency departments and attend routine care visits for fear of exposure to the virus. Restricted cell phone and internet service may limit effective technological outreach to more isolated rural older adults. More information is needed to develop effective, safe, and acceptable approaches to care for rural, isolated older adults. METHODS: Telephone interviews were conducted with 124 community-dwelling residents in four counties in rural Appalachia between 1 and 22 April 2020. Participants were aged 75 years or older. Descriptive statistics were calculated and Fisher's Exact Test was used to examine for associations among variables. RESULTS: Participants consisted of 86 (69.4%) women and 38 (30.6%) men with an average age of 82.5 years. Telephone contact was the preferred method of contact among all but four participants (96.8%). Seventeen calls (13.7%) resulted in some form of intervention, including arranging for emergent home repairs, treatment of severe hypertension, scheduling urgent laboratory testing, arranging for terminal care, treating acute conditions, and providing durable medical equipment. The 17 participants requiring intervention were significantly more likely to be aged 85 years or older (p=0.004), and report two or more chronic conditions (p<0.001). Those describing themselves as 'lonely' were significantly more likely to live alone (p=0.009) and describe themselves as 'anxious' or 'depressed' (p<0.001). CONCLUSION: A telephone call appears to be the most effective means of communication with patients in these rural Appalachian counties. Patients aged 85 years or older and those living alone should be given highest priority for regular outreach by healthcare providers. In this population, systematically calling rural elderly patients during the COVID-19 epidemic and its aftermath represents an effective strategy for providers who care for elderly rural patients.

The Politics of Aging under a Hybrid Regime: The Case of Democratization in Hong Kong.

Students of the politics of aging have mainly focused their research on the following: (1) elders' voting patterns and other forms of political participation, (2) the power and influence of older people as perceived, most notably, by politicians, and (3) the effectiveness of pressure/interest groups and lobbyists for older people. The context of their research has been large and growing national fiscal deficits and the projected growth in health care, long-term care, and age pension costs arising from population aging and the consequent calls for welfare state reform. However, an aspect of the relationship between aging and politics in which there has been little investment is that of the engagement of elders with issues and that do not bear narrowly on their own well-being or self-interest. This paper focuses upon the politics of aging in relation to the highly controversial issue of greater democratization in Hong Kong SAR, China. It seeks to provide some insight into the role played by Hong Kong's elders in shaping politics and policy under a quasi-democratic regime in order to move beyond, on the one hand, the focus by students of the politics of aging on liberal democracies and, on the other, their hitherto exclusive focus on the politics of aging in relation to old-age welfare state reform.

Geriatric Mental Health and COVID-19: An Eye-Opener to the Situation of the Arab Countries in the Middle East and North Africa Region.

While the detrimental ramifications of the COVID-19 outbreak on the mental wellbeing of the general public continue to unravel, older adults seem to be at high risk. As the geriatric population continues to grow in the Middle East and North Africa (MENA) region, it is essential to explore the influence of this outbreak on geriatric mental health, a topic often neglected. In this review, we depict the status of geriatric psychiatry in the Arab countries of the MENA region, exploring the variations from one nation to another. While some have a null exposure to the field, resources and expertise in other countries range from very limited to extensive. Furthermore, we highlight the measures implemented in the Arab region to address mental health during the COVID-19 outbreak; these tend to be insufficient when targeting the geriatric population. Finally, we provide short- and long-term recommendations to stakeholders that aim at enhancing the mental healthcare of older adults in the Arab countries of the MENA region, particularly during this pandemic.

COVID-19 outbreak: organisation of a geriatric assessment and coordination unit. A French example.

Older people are particularly affected by the COVID-19 outbreak because of their vulnerability as well as the complexity of health organisations, particularly in the often-compartmentalised interactions between community, hospital and nursing home actors. In this endemic situation, with massive flows of patients requiring holistic management including specific and intensive care, the appropriate assessment of each patient's level of care and the organisation of specific networks is essential. To that end, we propose here a territorial organisation of health care, favouring communication between all actors. This organisation of care is based on three key points: To use the basis of territorial organisation of health by facilitating the link between hospital settings and geriatric sectors at the regional level.To connect private, medico-social and hospital actors through a dedicated centralised unit for evaluation, geriatric coordination of care and decision support. A geriatrician coordinates this multidisciplinary unit. It includes an emergency room doctor, a supervisor from the medical regulation centre (Centre 15), an infectious disease physician, a medical hygienist and a palliative care specialist.To organise an ad hoc follow-up channel, including the necessary resources for the different levels of care required, according to the resources of the territorial network, and the creation of a specific COVID geriatric palliative care service. This organisation meets the urgent health needs of all stakeholders, facilitating its deployment and allows the sustainable implementation of a coordinated geriatric management dynamic between the stakeholders on the territory.

Critical Care Recovery Center: a model of agile implementation in intensive care unit (ICU) survivors.

BACKGROUND: As many as 70% of intensive care unit (ICU) survivors suffer from long-term physical, cognitive, and psychological impairments known as post-intensive care syndrome (PICS). We describe how the first ICU survivor clinic in the United States, the Critical Care Recovery Center (CCRC), was designed to address PICS using the principles of Agile Implementation (AI). METHODS: The CCRC was designed using an eight-step process known as the AI Science Playbook. Patients who required mechanical ventilation or were delirious ≥48 hours during their ICU stay were enrolled in the CCRC. One hundred twenty subjects who completed baseline HABC-M CG assessments and had demographics collected were included in the analysis to identify baseline characteristics that correlated with higher HABC-M CG scores. A subset of patients and caregivers also participated in focus group interviews to describe their perceptions of PICS. RESULTS: Quantitative analyses showed that the cognitive impairment was a major concern of caregivers. Focus group data also confirmed that caregivers of ICU survivors (n = 8) were more likely to perceive cognitive and mental health symptoms than ICU survivors (n = 10). Caregivers also described a need for ongoing psychoeducation about PICS, particularly cognitive and mental health symptoms, and for ongoing support from other caregivers with similar experiences. CONCLUSIONS: Our study demonstrated how the AI Science Playbook was used to build the first ICU survivor clinic in the United States. Caregivers of ICU survivors continue to struggle with PICS, particularly cognitive impairment, months to years after discharge. Future studies will need to examine whether the CCRC model of care can be adapted to other complex patient populations seen by health-care professionals.

The influence of integrated geriatric outpatient clinics on the health care utilization of older people.

BACKGROUND: The number of people aged greater than 65 years is growing in many countries. Taiwan will be a superaged society in 2026, and health care utilization will increase considerably. Our study aimed to evaluate the efficacy of the geriatric integrated outpatient clinic model for reducing health care utilization by older people. METHODS: This was a retrospective case-control study. Patients aged greater than 65 years seen at the geriatric outpatient clinic (Geri-OPD) and non-geriatric outpatient clinic (non-Geri-OPD) at a single medical centre were age and sex matched. Data on the number of outpatient clinic visits, emergency department visits, hospitalizations and medical expenditures were collected during the first and second years. A subgroup analysis by Charlson comorbidity index (CCI) and older age (age≧80 years) was performed, and the results were compared between the Geri-OPD and non-Geri-OPD groups. RESULTS: A total of 6723 patients were included (3796 women and 2927 men). The mean age was 80.42 ± 6.39 years. There were 1291 (19.2%) patients in the Geri-OPD group and 5432 (80.8%) patients in the non-Geri-OPD group. After one year of regular follow-up, the Geri-OPD patients showed a significant reduction in the types of drugs included in each prescription (5.62 ± 10.85) and the number of clinic visits per year (18.18 ± 48.85) (P < 0.01). After a two-year follow-up, the number of clinic visits, emergency department visits, and hospitalizations and the annual medical costs were still decreased in the Geri-OPD patients. The Geri-OPD patients had more comorbidities and a higher rate of health care utilization than the non-Geri-OPD patients. In the subgroup analysis, patients with more comorbidities (CCI≧2) and an older age (≧80 years) in the Geri-OPD group showed a significant reduction in health care utilization. The Geri-OPD patients also showed a significant decrease in medical utilization in the second year compared with the non-Geri-POD patients. CONCLUSION: The Geri-OPD reduced medical costs, the number of drugs prescribed, and the frequency of outpatient clinic visits, emergency department visits and hospitalizations in older patients with complicated conditions. The effect was even better in the second year.