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.

New horizons in systems engineering and thinking to improve health and social care for older people.

Existing models for the safe, timely and effective delivery of health and social care are challenged by an ageing population. Services and care pathways are often optimised for single-disease management, while many older people are presenting with multiple long-term conditions and frailty. Systems engineering describes a holistic, interdisciplinary approach to change that is focused on people, system understanding, design and risk management. These principles are the basis of many established quality improvement (QI) tools in health and social care, but implementation has often been limited to single services or condition areas. Newer engineering techniques may help reshape more complex systems. Systems thinking is an essential component of this mindset to understand the underlying relationships and characteristics of a working system. It promotes the use of tools that map, measure and interrogate the dynamics of complex systems. In this New Horizons piece, we describe the evolution of systems approaches while noting the challenges of small-scale QI efforts that fail to address whole-system problems. The opportunities for novel soft-systems approaches are described, along with a recent update to the Systems Engineering Initiative for Patient Safety model, which includes human-centred design. Systems modelling and simulation techniques harness routine data to understand the functioning of complex health and social care systems. These tools could support better-informed system change by allowing comparison of simulated approaches before implementation, but better effectiveness evidence is required. Modern systems engineering and systems thinking techniques have potential to inform the redesign of services appropriate for the complex needs of older people.

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.

Factors that affect the implementation of an integrated care programme for older people with different frailty levels: a qualitative study of commissioners and provider stakeholders.

INTRODUCTION: The NHS has made it mandatory for General Practices in England to proactively identify and manage older people with moderate and severe frailty since the GMS contract of 2017/2018. In Luton, stakeholders developed the Luton Framework of Frailty (LFF) to implement this national policy. The aim of this study was to explore the factors that affect the implementation of this national policy at a local level. METHODS: In-depth interviews were conducted with 18 commissioners and service providers, all of whom were involved in providing services for older people with different frailty levels (OPDFL). Purposive and snowball sampling methods were used, with thematic analysis used for data analysis. RESULTS: Two main themes with several sub-themes were found. The first theme was the tension within existing national policy initiatives to provide integrated care services for OPDFL, which illuminated their strengths and limitations. Participants felt that new initiatives, such as the development of Primary Care Networks and Enhanced Health in Care Homes, have improved primary care coordination. However, the traditional reactive approach for managing older people who are frail was thought to be counterproductive, when an approach that focused on prevention and early intervention would have been better. The second theme concerned the contextual factors that affect implementation of integrated care. These included having key leaders at a local level, the requirement for more funding, as well as the need for good working relationships among service providers. However, the lack of awareness about the care pathways among GPs was thought to be a reason for the variation in the implementation of the LFF. The COVID-19 pandemic was perceived as a challenge for the implementation of the LFF. Finally, polices were thought to succeed only if more resources are provided, while the term frailty should be used with caution due to the negative connotations of OPDFL towards this term. CONCLUSION: The implementation of an integrated care programme for OPDFL can be affected by several factors. Having proactive national policies that facilitate coordination and, having key leaders locally, the need for more funding, and good working relationships, are some of the contextual factors that could facilitate a successful implementation. In contrast, the lack of awareness of the care pathways that have been introduced locally, insufficient resources to deliver the programmes efficiently and a lack of careful consideration of how the term frailty is used could hinder this being put into practice.

Co-producing and co-assessing a new service solution for enhancing health and social care integration: a participatory research protocol.

BACKGROUND: This paper describes a study protocol for co-producing and co-assessing a new sustainable and scalable service solution that enhances health and social integration by involving providers and volunteers delivering services for elderly people in the province of Cremona (Italy), where the elderly population will reach 27% in 2023. METHODS: This upcoming study involves mixed-method participatory research and is structured in three study phases and related objectives. First, it will co-produce a new, accessible and sustainable service solution using an iterative design and management method, Plan-Do-Check-Act by involving professionals and volunteers of a heterogeneous group of health, social and third sector organizations located in the city of Cremona (Italy). Second, the study protocol will co-assess the outcomes of the new service solution using a mixed-method approach for measuring the outcomes on: professionals and volunteers (micro level) and their health, social and third sector organizations (meso level). Third, this study will co-investigate the scalability of the new solution promoting health and social integration in other similar urban areas of the Province of Cremona via the Intervention Scalability Assessment Tool (macro level). The data will be collected through the analysis of official documents, websites, policies and participatory workshops. DISCUSSION: This protocol proposes an innovative intervention, a novel participatory approach, and an unexplored scalability assessment tool in the context of health and social care integration. This study aims to support professionals from health and social care service providers and volunteers from third-sector organizations to collaborate and integrate each other's resources. In doing so, the participatory approach will facilitate the co-creation of an effective response to the need of health and social integration, and the development of trustful relationships between health and social care service providers. Moreover, the adoption of Plan-Do-Check-Act and Intervention Scalability Assessment Tool will ensure the quality, scalability and sustainability of the new service solution in other settings.

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.

Older people's challenges accessing health services in central Nepal: a qualitative study using the domain of access framework.

BACKGROUND: Low- and middle-income countries face rapid population aging. However, the health system has remained largely unprepared to deliver health services to an aging population. As the population is rapidly aging in Nepal, their challenges and experience should be the focus for health care providers to address these issues. There is a paucity of evidence on barriers and facilitators to accessing health care services among older people in Nepal. The aim of this study was to investigate the challenges that older people experience while accessing health services in central Nepal. METHODS: This qualitative study was conducted between April and June 2023. In-depth interviews were conducted among older people of a municipality in central Nepal, which were analysed thematically using a deductive-inductive approach based on the theory of access. RESULTS: Hypertension and diabetes were the most common health problems among the participants. The affordability of health services was a major issue, although there is a health insurance scheme and a major focus on universal health coverage from the Government of Nepal. Other issues included poor acceptability, poor communication between older people and health staff, and poor accommodation due to a lack of elderly-friendly services, including long wait times in the clinic. Living with family was a major facilitator of access to health care services and was interrelated with multiple domains of access. CONCLUSIONS: This study identified barriers to accessing health care services for older adults in Nepal. We found that the affordability of health services, poor acceptability, poor communication between older people and doctors, and a lack of elderly-friendly services are the key challenges experienced by older people. Older people felt that these barriers were easier to overcome when they had family support. Therefore, for those living with their children, family support was reported as the major facilitator.

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.

[Geragogic support for status passages in old age : Challenge and opportunity of a new care for older people]. / Geragogische Begleitung bei Statuspassagen im Alter : Herausforderung und Chance einer neuen Altenhilfe.

BACKGROUND: With the continuous increase in the average age, the temporal perspective for the phase of old age is also significantly expanding. This results in an individual need for reorientation for the aging person with respect to a meaningful shaping of this long period of time, which as a progressive process leads to the end of life. In the context of the status passages to the third, fourth and fifth ages, there is a special relevance for this; however, the so-called care for older people (§ 71 Social Security Code, SGB XII) has so far largely ignored these important aspects. Rethinking in a needs-oriented way, the facilitation of the necessary reorientation of life in old age through learning and education must therefore be given greater consideration. AIM OF THE ARTICLE: The article gives a necessary update of the existing care for older persons, which takes greater account of a needs-oriented design of a society of long life. Furthermore, the role and significance of the necessary educational processes in the sense of geragogy are outlined and also how they can contribute to successful aging. MATERIAL AND METHODS: With reference to current research work and publications on the topic, the possibilities of geragogic support as a challenge and opportunity for new care for older persons are worked out. RESULTS AND DISCUSSION: The learning and educational processes of the aging person can be aimed at various concerns, if nothing else differentiated according to the challenges associated with the social age categories, i.e., the third, fourth or fifth age; however, learning and educational processes also address very different dimensions, each focusing on the question of how older people can tackle and cope with such necessary adaptation and change processes.

[Development of innovations for neighborhood care-Contribution of social innovation laboratories]. / Innovationsentwicklung für die Pflege im Quartier ­ Beitrag von sozialen Innovationslaboren.

The article demonstrates the contributions of the innovation program "D-Care Lab Baden-Württemberg 2023" to the development of innovative solutions for neighborhood care. The effects of the program are reconstructed on the basis of initial research findings pertaining to the innovation program. A distinctive aspect of the laboratory is its cross-sectoral collaborative structure. The levels of impact can be defined as follows: the acquisition of skills by the participants, the connection between skills acquisition and learning arrangement, the changes observed as a result of participation and the innovative solutions developed for care in the neighborhood. The initial results are presented in accordance with the theoretical research design and research methods previously outlined. The results demonstrate alterations in the competence profiles of the participants and the impact of the cooperative laboratory setting on the development of solutions. Based on these findings, the function of innovation programs becomes evident, thereby highlighting the necessity for mid-term to long-term impact analysis.

[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.

Challenges and opportunities in the Polish healthcare sector from the implementation of telemedicine solutions in the field of gerontology and geriatric medicine: own experience.

OBJECTIVE: Aim: To analyze and summarize the implementation of telemedical solutions in geriatrics and gerontology within the Polish healthcare sector, aiming to develop innovative strategies for improving elderly care through telemedical technologies. PATIENTS AND METHODS: Materials and Methods: An interdisciplinary pilot project in geriatrics was implemented, focusing on health, organizational, and technological areas. The project involved continuous monitoring of health parameters, remote consultations, and the use of telemedical devices and platforms. Key data collection tools included digital clinimetric outcomes from the FRA-MNA-SARC model, with data transmitted to a telemedical platform. RESULTS: Results: The pilot project demonstrated significant positive outcomes for senior participants. Continuous monitoring of health parameters allowed for early detection and timely intervention, leading to noticeable improvements in chronic disease management. This proactive approach reduced emergency hospital visits and enhanced overall health stability. The medication adherence support system, with automated reminders, ensured patients took their medications as prescribed, resulting in improved compliance and health outcomes. Telemedical solutions efficiently reduced the need for frequent in-person visits, allowing healthcare providers to monitor progress and adjust therapies in real-time. The project also effectively engaged patients and caregivers, increasing confidence in health management and providing valuable support and real-time information. CONCLUSION: Conclusions: Implementing telemedical solutions in geriatrics within the Polish healthcare sector shows significant potential to improve elderly care. Telemedicine can effectively support chronic disease management, enhance seniors' quality of life through continuous health monitoring, and provide a practical framework for personalized and efficient healthcare delivery.

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.