[A new playing field emerges in care and welfare]. / Het nieuwe speelveld van de zorg.

Two distinct changes in Dutch care provisions coincide. On the one hand emancipated civilians want to take, or are stimulated to take, more responsibility, on the other budget cuts restrict access to and the quality of care. Self-help and informal care are back on the agenda. As a consequence a new playing field emerges that requires politicians and professionals to balance their care responsibilities with the demands of informal care, social networks, housing, financial capacities, formal public care provisions, and the mechanism that are able to craft and calibrate these different demands. As a result of this new emerging playing field more and more civilians are organizing themselves in voluntary care associations, which are based on the principles of reciprocity and mutuality. They contribute to the dynamics of the new playing field by forcing national and local politicians and care professionals to reconsider their positions and policies. Their demand for more tailored care services requires a pro-active, risk taking, and innovative attitude of those responsible.

Joint geriatric and psychiatric wards: a review of the literature.

Joint geriatric/psychiatric wards are a potential solution to improving care of older patients with both psychiatric and medical illnesses in acute hospitals. A literature search using Medline, PsycINFO, Embase and CINAHL between 1980 and 2010 was carried out for information about joint wards for older people. Thirteen relevant papers were identified. These wards share common characteristics and there is evidence that they may reduce length of stay and be cost-effective, but there are no high-quality randomised controlled trials. Further research is needed, particularly regarding cost-effectiveness.

The HOME Study: Statistical and economic analysis plan for a randomised controlled trial comparing the addition of Proactive Psychological Medicine to usual care, with usual care alone, on the time spent in hospital by older acute hospital inpatients.

BACKGROUND: Prolonged acute hospital stays are a problem for older people and for health services. Failure to effectively manage the psychological and social aspects of illness is an important cause of prolonged hospital stay. Proactive Psychological Medicine (PPM) is a new way of providing psychiatry services to medical wards which is proactive, focussed, intensive and integrated with medical care. The primary aim of PPM is to reduce the time older people spend in hospital because of unmanaged psychological and social problems. The HOME Study will test the effectiveness and cost-effectiveness of PPM. METHODS/DESIGN: The study is a two-arm, parallel-group, randomised, controlled superiority trial with linked health economic analysis and an embedded process evaluation. The target population is people aged 65 years and older admitted to acute hospitals. Participants will be randomly allocated to either usual care plus PPM or usual care alone. The primary outcome is the number of days spent as an inpatient in a general hospital in the month following randomisation. Secondary outcomes include quality of life, cognitive function, independent functioning, symptoms of anxiety and depression, and experience of hospital stay. The cost-effectiveness of usual care plus PPM compared with usual care alone will be assessed using quality-adjusted life-years as an outcome as well as costs from the NHS perspective. DISCUSSION: This update to the published trial protocol gives a detailed plan of the statistical and economic analysis of The HOME Study. TRIAL REGISTRATION: ISRCTN registry, ISRCTN86120296. Registered on 3 January 2018.

[Trends in the utilization of Dutch mental health services by older adults between 1990-2004]. / Trends in het gebruik van geestelijke gezondheidszorg door ouderen in de periode 1990-2004.

AIM: Because the Dutch population has a growing number of older people, an increasing burden on mental health services is expected. To facilitate policy making for the future, it is important to know what changes there have been in use of mental health services by elderly in the past. This study investigates changes in the use of mental health services by older adults in the period 1990-2004. METHODS: Information about the use of mental health services by older adults was retrieved from the Dutch Psychiatric Case Registers. Population size in these register areas and the unit costs of the different mental health services were taken into account. RESULTS: In total there was an increase in the number of older adults that used mental health services in the period mentioned above. The costs, however, showed a decrease, which was caused by the decrease of expensive inpatient care and the increase of less expensive outpatient care. This was mainly the case until 2002. From this year on the ratio between inpatient and outpatient care stabilized. CONCLUSION: Deinstitutionalization of mental health care for older adults was shown in the period 1990-2002. This means that expensive inpatient care is partly replaced by less expensive outpatient care. As a consequence more older adults can be treated with no rise in costs. Since 2002 deinstitutionalization came to a halt. Because a growing number of older adults will be using mental health services in the future, new forms of outpatient care should be explored.

Expensive detour or a way forward? The experience of routine outcome measurement in an aged care psychiatry service.

OBJECTIVE: This paper describes and reflects upon the experience of a small, integrated aged care psychiatry service that has utilized the National Outcomes Casemix Collection (NOCC) routine outcome measurements within clinical practice, service management and evaluation. The goals of the NOCC initiative are reviewed in light of this experience. CONCLUSION: Routine outcome measurement has the potential to significantly improve aged care psychiatric service delivery. The service described has developed a model that the authors believe demonstrates the potential for routine outcome measures to improve the monitoring of patient progress, care planning, team communication, management and the understanding of service effectiveness - goals that are consistent with NOCC philosophy. However, this requires both ongoing development of infrastructure support and the willingness of clinicians to explore their utility.

A survey of memory clinics in New Zealand.

OBJECTIVE: The aim of this survey was to identify all the publicly funded memory clinics in the 21 District Health Boards (DHBs) in New Zealand. METHOD: Information on the provision of memory clinics was obtained by emailing the old age psychiatrists' group and making telephone contact with clinicians working in old age psychiatry/geriatric services. A brief structured questionnaire was completed by the memory clinic lead clinicians. RESULTS: There are eight memory clinics in New Zealand, funded equally between mental health services and geriatric medicine. However, there is variability in the provision of memory clinics in the medium and smaller sizedDHBs and inconsistency in the level of funded staff across DHBs. CONCLUSIONS: Acknowledgement of the value of memory clinics within a national service framework is needed, with appropriate benchmarking of funding. This would ensure improved access, including for rural and remote areas of New Zealand.

Development of a cost-efficient psychogeriatrics service.

Various cost-efficient and space-efficient methods were used to expand outpatient services to the elderly at a teaching hospital's psychiatry clinic over a 2-year period. During this time the active treatment census of elderly patients more than doubled, to 185 patients. Only one enrolled patient required psychiatric hospitalization, and none required nursing home placement in the 2 years. Except for the geriatrics service director, no new paid staff and no extra space were required to form the service. The authors review the methods that seemed most beneficial to the service.

Clinicoeconomics in geropsychiatry.

The question becomes, who will manage managed care and what will be used as a basis for rational decision making? It has been suggested that a policy-regulating body composed of health care providers, payors, and patients be formed to oversee the process of health care reform and to discourage profit-driven managed care practices. It is particularly appealing to incorporate health care consumers into this process as representatives of evolving societal values. To make rational decisions, the proposed regulatory body will need data. In this regard the discipline of clinicoeconormics could provide information on the effectiveness and relative value of health care interventions. Geropsychiatrists must be willing to join the effort to learn about and participate in clinicoeconomics to shift the debate from the bottom line of a balance sheet to the preservation of quality care for the elderly and mentally ill.

Reduction of psychiatric inpatient stay for older adults by intensive case management.

An intensive case management program was offered for a 5-month period to all older persons admitted to a county inpatient unit. A quasiexperimental design was used for program evaluation with comparison to a preintervention baseline period and to younger adults on the inpatient unit during both baseline and intervention periods. Length of stay was reduced from 27 days during baseline to 12 days during intervention. For the younger patient group, length of stay changed from 11 to 12 days. Contrary to expectation, older patients were the young-old, mostly first admissions, and with mostly functional rather than organic diagnoses. This reduction in length of stay would save about $6,750 per geriatric admission.

Inpatient psychiatric treatment of elderly Medicare beneficiaries.

OBJECTIVE: The clinical characteristics and treatment patterns of elderly Medicare beneficiaries hospitalized for psychiatric disorders were examined. METHODS: Administrative data on all elderly Medicare beneficiaries in the United States hospitalized in a nonfederal hospital for a primary psychiatric disorder in 1990-1991 were used to calculate descriptive statistics on case-mix by age group, hospital type (psychiatric hospital, general hospital psychiatric unit, or general hospital nonpsychiatric unit), and primary diagnosis. Length of stay, costs, and discharge destination by hospital type and primary diagnosis were also determined. RESULTS: A total of .6 percent of elderly Medicare beneficiaries were hospitalized for a psychiatric disorder in 1990, accounting for more than 240,000 admissions and $1 billion in Medicare payments. The most common reasons for hospitalization were major depressive disorder (28.1 percent), dementia and other organic disorders (26.8 percent), and substance-related disorders (12.6 percent). Organic disorders were particularly prevalent among the oldest old, accounting for more than half of psychiatric admissions among those 85 and older. A total of 43 percent of the psychiatric admissions were to general hospital nonpsychiatric units, 38 percent to general hospital psychiatric units, and only 19 percent to psychiatric hospitals. Within each diagnostic category, patients admitted to general hospital nonpsychiatric units had the shortest average lengths of stay and the lowest average costs. Among beneficiaries with organic, affective, and psychotic disorders other than schizophrenia, those admitted to general hospitals had shorter lengths of stay, higher rates of discharge to nursing homes, and lower rates of discharge to self-care than those treated in psychiatric hospitals. CONCLUSIONS: Case-mix-adjusted treatment patterns varied substantially across hospital types, due to differences in either illness severity or treatment styles.

Hospice use for the patient with advanced Alzheimer's disease: the role of the geriatric psychiatrist.

Advanced Alzheimer's disease (AD) can place an immense burden on caregivers as they struggle to provide end-of-life (EOL) care for the patient. Palliative care, as delivered by hospice, provides a viable solution. Hospice maintains the patient's quality of life (QOL) and helps the family during the grieving process. However, many providers are not familiar with hospice and its care for advanced AD patients. Geriatric psychiatrists can be central in implementing hospice, and they can remain an important part of the care once it is in place. A principal clinical challenge is establishing the six-month prognosis for such patients, which is a prerequisite for initiating hospice admission.

[Inventory of geriatric psychiatry in Sweden. In short supply where demand does not determine resource allocation]. / Aldrepsykiatrin inventerad i Sverige. En bristvara där efterfrågan inte styr resurstilldelningen.

In 1999 The Swedish Society for Old Age Psychiatry conducted an investigation in all Swedish counties in order to survey existing organizations and resources for medical services intended for elderly people with psychiatric complaints. In some counties there were no out-patient units specifically aimed at elderly people with psychiatric diseases, while more than half had no out-patient units for the large group of elderly with psychiatric ailments other than dementia. The total number of beds was far less than international recommendations. Less than 5 per cent of the total number of Swedish psychiatrists and geriatricians hold positions exclusively for geriatric psychiatry. Access to geriatric psychiatry resources appears to be unevenly distributed, and may be found mainly in or near university cities.

[Troubled times in care of the elderly. Increasing number of the "oldest old" and demented, shortage of general practitioners and lack of clarity with regards to locating resources]. / Ansträngt läge för äldrevården. Fler "äldre äldre" och dementa, färre vårdplatser, brist på distriktsläkare och oklarhet om var resurserna finns.

The media image of general breakdown in care of the elderly, replete with portrayals of malpractice and maltreatment, is analyzed in the light of changes in demographics, care resources and care delivery systems during the past decades. A substantial increase in the number of people aged 80 years or more, increasing numbers of elderly persons with dementia, deinstitutionalization of health care, together with the present economic crisis, place a considerable burden on the care system, as illustrated by an increased nursing load, a decrease in the number of elderly persons receiving home services, and a concentration of support to the most impaired. The author calls attention to the need for refined methods for describing care delivery systems, longitudinal population based studies, and a national hospital plan. Primary health care, already pushed to the limit by dwindling resources and job vacancies, is hard put to shoulder the burden of responsibility for the elderly.

[Can the costs of future needs of health and social services for the elderly be calculated?]. / Kan kostnaderna för äldres framtida vård- och omsorgsbehov beräknas?

As a consequence of the increasing number of elderly people, the proportion of people of working age (20-65) vs. the oldest-old (80+) will decrease considerably. Today, the total annual cost for the care of the elderly (health care and social services) in Sweden is about SEK 110 billion (about 6% of the GNP). The costs of health care are better correlated with the number of remaining years of life than with number of years from birth. The cost of health care during the last year in life is higher for the oldest-old than for the young-old. Informal care of demented persons is about 4-5 times more extensive than formal care. There is a strong correlation between GNP per citizen and resources spent on health care.