Reliable integrative assessment of health care needs in elderly persons: the INTERMED for the Elderly (IM-E).

OBJECTIVE: With the increasing prevalence of multiple conditions in older age, the high prevalence of mental disorders, and the many social challenges facing elderly people, a high-risk patient group in need of interdisciplinary (biological, psychological, and social) care is emerging. The INTERMED interview is an integrative assessment method that identifies patients with complex health care needs. The aim of this study was to develop and evaluate the INTERMED for the Elderly (IM-E), specifically for use in populations of elderly persons. METHODS: In focus groups conducted with the authors of the original INTERMED, the variables and anchor points that had to be adjusted to the needs and situation of the elderly and to the demands of a population-based study were discussed and altered. The final version of the IM-E was conducted with 42 elderly persons. Participants were doubly scored by two trained raters; the interrater reliability [intraclass correlation coefficient (ICC) (2,1)] was calculated. RESULTS: The IM-E was well accepted by the elderly persons interviewed. ICCs for the various domains of the IM-E ranged between .87 and .95, while the ICC for the sum score was .95. Regarding the cutoff point of 20/21 for patients with complex health care needs, a κ of .75 was achieved. CONCLUSIONS: The IM-E is a reliable integrative assessment instrument. It is well suited for epidemiological settings to adequately describe the percentage of elderly patients with complex health care needs. In clinical settings, it can be used to identify elderly patients in need of interdisciplinary care.

Psychiatrists for medically complex patients: bringing value at the physical health and mental health/substance-use disorder interface.

BACKGROUND: In their current configuration, traditional reactive consultation-liaison services see a small percentage of the general-hospital patients who could benefit from their care. These services are poorly reimbursed and bring limited value in terms of clinical improvement and reduction in health-service use. METHOD: The authors examine models of cross-disciplinary, integrated health services that have been shown to promote health and lower cost in medically-complex patients, those with complicated admixtures of physical, mental, social, and health-system difficulties. CONCLUSION: Psychiatrists who specialize in the treatment of medically-complex patients must now consider a transition from traditional consultation to proactive, value-added programs and bill for services from medical, rather than behavioral, insurance dollars, since the majority of health-enhancement and cost-savings from these programs occur in the medical sector. The authors provide the clinical and financial arguments for such program-creation and the steps that can be taken as psychiatrists for medically-complex patients move to the next generation of interdisciplinary service.

[Early prediction of psychosocial intervention needs in pneumology patients after nurses' evaluation]. / Predicción temprana de necesidades de intervención psicosocial especializada en pacientes con enfermedades pulmonares a partir de evaluaciones por enfermeras.

BACKGROUND AND OBJECTIVE: This study was aimed to verify whether it is possible to detect at hospital admission, by means of INTERMED, pneumonology patients at risk of "complexity" and of specialized psychosocial intervention. PATIENTS AND METHOD: With the Spanish version of INTERMED (for detection of risk for complexity of care) 144 patients were interviewed at admission by a standardized nurse. At discharge, patients were reassessed blindly with standardized Spanish versions of instruments including the Hospital Anxiety and Depression Scale (HADS). Somatic illness variables were independently documented, and severity was assessed by means of the Cumulative Illness Rating Scale. All variables were operationalized including complex (IM+; INTERMED>20) and non-complex patients (IM-), and probable need of psychosocial treatment/intervention. Statistical analysis included multivariate logistic regression. RESULTS: A complex course was documented in 9.6% of patients, and 28.8% had complex discharge. Significantly higher proportions of severe anxiety and/or depression were documented in IM+ cases (12.1%) when compared to IM- cases (0.9%), and the need of psychosocial treatment/intervention was also significantly more frequent among the former (24.2% versus 6.3% respectively). Furthermore, in the multivariate analysis and controlling for medical and sociodemographic confounders INTERMED was significantly associated with the variable need of psychosocial intervention. CONCLUSIONS: In support of the clinical utility of the INTERMED method (Spanish version), this is the first report in the international literature documenting that standardized nurses are able to detect at admission those medical patients who will eventually need specialized psychosocial intervention.

Cost-effectiveness of a nurse-led case management intervention in general medical outpatients compared with usual care: an economic evaluation alongside a randomized controlled trial.

OBJECTIVE: The objective of this study was to evaluate the cost-effectiveness of a nurse-led, home-based, case-management intervention (NHI) after hospital discharge in addition to usual care. METHODS: Economic evaluation alongside a randomized controlled trial after being discharged home with 24 weeks of follow-up. Patients discharged to their home from a general hospital were randomly assigned to NHI or usual care. Clinical outcomes were frequency of emergency readmissions, quality of life, and psychological functioning. Direct costs were measured by means of cost diaries kept by the patients and information obtained from the patients' pharmacists. RESULTS: A total of 208 patients were randomized, 61 patients dropped out, and 26 had incomplete data, leaving a total of 121 patients included in the final analysis. There were no statistically significant differences in emergency readmissions, quality of life, and psychological functioning. There was a substantial difference in total costs between the NHI group and the control group (4286 Euro; 95% CI, -41; 8026), but this difference was not statistically significant. CONCLUSION: NHI is not a cost-effective intervention. We do not recommend the implementation of this intervention in populations that do not consist of severely vulnerable and complex patients. Future studies should include complexity assessment on inclusion and evaluate the effectiveness and cost-effectiveness of this intervention in patients with more complex profiles.

Case and care complexity in the medically ill.

The authors have argued that complexity in general health care is increasingly prevalent because of the increase in patients who have multimorbid conditions, and the increased professional and technical possibilities of medicine. In the increasingly complex care systems, it is necessary-specifically when treating patients in need of integrated care by several providers-that an optimal match between case and care complexity be found in order to prevent poor outcomes in this vulnerable group. The authors discussed several approaches to case complexity that can be identified in the literature. Most of them seem unsuitable for adjusting case and care complexity, and inadequate for designing multidisciplinary care. Theoretic approaches to case complexity may be of interest, but did not result in clinically meaningful information. The INTERMED, which can be considered the first empirically based instrument to link case and care complexity, is an attempt to improve care delivery and outcomes for the complex medically ill.

A simple risk score predicts poor quality of life and non-survival at 1 year follow-up in dialysis patients.

BACKGROUND: Quality of life (QoL) in end-stage renal disease patients has become an important focus of attention in evaluating dialysis. We studied risk factors of poor QoL at 1 year follow-up. METHODS: Of a baseline sample of 80 dialysis patients, we contacted 60 patients who were alive at 1 year follow-up. QoL data were obtained for 46 (76.7%) of these patients. QoL measured with the SF-36 [physical health component score (PCS) and mental health component score (MCS)] at 1 year-follow-up was predicted by means of multivariate regression analysis by data collected at baseline using INTERMED-an observer-rated method to assess biopsychosocial care needs-and several indicators for disease severity and comorbidity. RESULTS: The regression models explained 32% of the variance in PCS and 40% in MCS. INTERMED score (P < 0.01) was the only independent risk factor for low MCS, while for low PCS, diabetic comorbidity (P = 0.02) and age (P = 0.03) were independent risk factors. A simple risk score consisting of INTERMED > or =21, diabetic comorbidity and age > or =65 was significantly correlated with non-survival (P = 0.02) and with PCS (P < 0.01) and MCS (P < 0.01) in surviving patients, although not with hospital admissions during follow-up. CONCLUSIONS: A simple risk score based on INTERMED, age (> or =65) and comorbid diabetes (yes/no) can be used to detect patients at risk of poor QoL and non-survival at an early stage of treatment.

Medical inpatients at risk of extended hospital stay and poor discharge health status: detection with COMPRI and INTERMED.

OBJECTIVE: To detect the patients in medical wards at risk of extended LOS and poor discharge health status with the use of complexity prediction instrument (COMPRI) and interdisciplinary medicine (INTERMED) instruments. METHODS: STUDY 1: In a sample of 275 consecutively admitted medical inpatients, a hierarchical cluster analysis on INTERMED variables was performed. The clusters were compared on length of hospital stay (LOS) and Short Form 36 (SF-36) at discharge. STUDY 2: Receiver operating characteristic (ROC) analysis was used to optimal cut-off points for the COMPRI and INTERMED. Patients detected with COMPRI and INTERMED were then compared with undetected patients on LOS and SF-36. RESULTS: STUDY 1: In concordance with previous findings, a cluster of patients with high biopsychosocial vulnerability was identified with significantly higher scores on LOS (p <.05) and lower scores on SF-36 (p <.001) than patients in other clusters. STUDY 2: A cut-off point for the COMPRI of 5/6 was found to detect patients at risk of long LOS. A cut off score for the INTERMED of 20/21 was found to detect patients at risk of poor discharge health status. Patients detected with COMPRI and INTERMED had a significantly longer LOS (p <.001) and a poorer discharge health status (SF-36 MCS: p <.001; SF-36 PCS: p =.05) than nondetected patients. Of the detected patients, 37% had an extended hospital stay and poor discharge health status; of the nondetected patients, this was only 7%. CONCLUSIONS: The COMPRI-INTERMED can help to detect complex patients admitted to medical wards within the first days of admission, and rule out those with a small chance of poor outcomes.