Protocol for a mixed-methods and multi-site assessment of the implementation process and outcomes of a new community-based frailty programme.

BACKGROUND: Frailty is increasing in prevalence internationally with population ageing. Frailty can be managed or even reversed through community-based interventions delivered by a multi-disciplinary team of professionals, but to varying degrees of success. However, many of these care models' implementation insights are contextual and may not be applicable in different cultural contexts. The Geriatric Service Hub (GSH) is a novel frailty care model in Singapore that focuses on identifying and managing frailty in the community. It includes key components of frailty care such as comprehensive geriatric assessments, care coordination and the assembly of a multi-disciplinary team. This study aims to gain insights into the factors influencing the development and implementation of the GSH. We also aim to determine the programme's effectiveness through patient-reported health-related outcomes. Finally, we will conduct a healthcare utilisation and cost analysis using a propensity score-matched comparator group. METHODS: We will adopt a mixed-methods approach that includes a qualitative evaluation among key stakeholders and participants in the programme, through in-depth interviews and focus group discussions. The main topics covered include factors that affected the development and implementation of each programme, operations and other contextual factors that influenced implementation outcomes. The quantitative evaluation monitors each programme's care process through quality indicators. It also includes a multiple-time point survey study to compare programme participants' pre- and post- outcomes on patient engagement, healthcare services experiences, health status and quality of life, caregiver burden and societal costs. A retrospective cohort study will compare healthcare and cost utilisation between participants of the programme and a propensity score-matched comparator group. DISCUSSION: The GSH sites share a common goal to increase the accessibility of essential services to frail older adults and provide comprehensive care. This evaluation study will provide invaluable insights into both the process and outcomes of the GSH and inform the design of similar programmes targeting frail older adults. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT04866316 . Date of Registration April 26, 2021. Retrospectively registered.

Health outcomes and implementation barriers and facilitators of comprehensive geriatric assessment in community settings: a systematic integrative review [PROSPERO registration no.: CRD42021229953].

BACKGROUND: Comprehensive geriatric assessment (CGA) addresses the bio-psycho-social needs of older adults through multidimensional assessments and management. Synthesising evidence on quantitative health outcomes and implementation barriers and facilitators would inform practice and policy on CGA for community-dwelling older adults. METHODS: We systematically searched four medical and social sciences electronic databases for quantitative, qualitative, and mixed methods studies published from 1 January 2000 to 31 October 2020. Due to heterogeneity of articles, we narratively reviewed the synthesis of evidence on health outcomes and implementation barriers and facilitators. RESULTS: We screened 14,151 titles and abstracts and 203 full text articles, and included 43 selected articles. Study designs included controlled intervention studies (n = 31), pre-post studies without controls (n = 4), case-control (n = 1), qualitative methods (n = 3), and mixed methods (n = 4). A majority of articles studied populations aged ≥75 years (n = 18, 42%). CGAs were most frequently conducted in the home (n = 25, 58%) and primary care settings (n = 8, 19%). CGAs were conducted by nurses in most studies (n = 22, 51%). There was evidence of improved functional status (5 of 19 RCTs, 2 of 3 pre-post), frailty and fall outcomes (3 of 6 RCTs, 1 of 1 pre-post), mental health outcomes (3 of 6 RCTs, 2 of 2 pre-post), self-rated health (1 of 6 RCTs, 1 of 1 pre-post), and quality of life (4 of 17 RCTs, 3 of 3 pre-post). Barriers to implementation of CGAs involved a lack of partnership alignment and feedback, poor acceptance of preventive work, and challenges faced by providers in operationalising and optimising CGAs. The perceived benefits of CGA that served to facilitate its implementation included the use of highly skilled staff to provide holistic assessments and patient education, and the resultant improvements in care coordination and convenience to the patients, particularly where home-based assessments and management were performed. CONCLUSION: There is mixed evidence on the quantitative health outcomes of CGA on community-dwelling older adults. While there is perceived positive value from CGA when carried out by highly skilled staff, barriers such as bringing providers into a partnership, greater acceptance of preventive care, and operational issues could impede its implementation.

Evaluating the Outcomes of a Hospital-to-Community Model of Integrated Care for Dementia.

INTRODUCTION: Living with dementia is challenging for persons with dementia (PWDs) and their families. Although multi-component intervention, underscored by the ethos of person-centred care, has been shown to maintain quality of life (QOL) in PWDs and caregivers, a lack of service integration can hinder effectiveness. METHODS: CARITAS, an integrated care initiative provided through a hospital-community care partnership, endeavours to provide person-centred dementia care through ambulatory clinic consults, case management, patient and caregiver engagement, and support. We evaluated CARITAS' clinical outcomes and cost-effectiveness with a naturalistic cross-sectional within-subject design. We assessed patients' function, QOL, and behavioural problems post-intervention. We estimated CARITAS' cost-effectiveness from a patient's perspective, benchmarking it against other dementia treatments and Singapore's Gross Domestic Product (GDP) per capita. RESULTS: CARITAS care significantly improved health utility (p < 0.001), reduced caregiver burden (p < 0.001), and improved PWDs' behavioural problems (p < 0.001) related to "memory" (p < 0.001), "disruption" (p = 0.017), and "depression" (p < 0.001). CARITAS' benefits (dRMBPC = 0.357, dEQ5D index = 0.328, dZBI = 0.361) were comparable to those of other pharmacological and non-pharmacological interventions for dementia. CARITAS costs SG$133,056.69 per quality-adjusted life years gain, yielding an incremental cost-effectiveness ratio of 1.31 and 1.49 against the cost of donepezil in patients with mild Alz-heimer's disease and Singapore's GDP per capita in 2019, respectively, falling within the cost-effectiveness threshold of 1.0-3.0. DISCUSSION: CARITAS integrated dementia care is a cost-effective intervention that showed promising outcomes for PWDs and their caregivers.

Mixed-method evaluation of CARITAS: a hospital-to-community model of integrated care for dementia.

OBJECTIVES: The capability and capacity of the primary and community care (PCC) sector for dementia in Singapore may be enhanced through better integration. Through a partnership involving a tertiary hospital and PCC providers, an integrated dementia care network (CARITAS: comprehensive, accessible, responsive, individualised, transdisciplinary, accountable and seamless) was implemented. The study evaluated the process and extent of integration within CARITAS. DESIGN: Triangulation mixed-methods design and analyses were employed to understand factors underpinning network mechanisms. SETTING: The study was conducted at a tertiary hospital in the northern region of Singapore. PARTICIPANTS: We recruited participants who were involved in the conceptualisation, design, development and implementation of the CARITAS Programme from a tertiary hospital and PCC providers. INTERVENTION: We used the Rainbow Model of Integrated Care-Measurement Tool (RMIC-MT) to assess integration from managerial perspectives. RMIC-MT comprises eight dimensions that play interconnected roles on a macro-level, meso-level and micro-level. We administered RMIC-MT to healthcare providers and conducted in-depth interviews with key CARITAS stakeholders. PRIMARY AND SECONDARY OUTCOME MEASURES: We assessed integration scores across eight dimensions of the RMIC-MT and factors underpinning network mechanisms. RESULTS: Compared with other dimensions, functional integration (mechanisms by which information and management modalities are linked) achieved the lowest mean score of 55. Other dimensions (eg, clinical, professional and organisational integration) scored about 70. Presence of inspiring clinical leaders and tacit interdependencies among partners strengthened the network. However, the lack of structured documentation and a shared information-technology platform hindered functional integration. CONCLUSION: CARITAS has reached maturity in micro-levels and meso-levels of integration, while macro-integration needs further development. Integration can be enhanced by assessing service gaps, increasing engagement with stakeholders and providing a shared communication system.

The Effectiveness of Horticultural Therapy on Older Adults: A Systematic Review.

OBJECTIVES: Although the therapeutic effects of horticulture on older adults have been widely investigated, a recent and comprehensive synthesis of available evidence on outcomes is lacking. We systematically reviewed evidence for the therapeutic effects of horticulture on older adults. DESIGN: A systematic search of PubMed, MEDLINE, Sage Journals, ProQuest, Science Direct, and CINAHL was conducted. Articles were selected if they were quantitative studies published in English from 2008 to 2018. SETTING AND PARTICIPANTS: Articles were selected if they included participants aged 60 years and older and used horticulture as the main intervention. MEASURES: Experimental studies were appraised using the Physiotherapy Evidence Database Scale. RESULTS: The systematic search yielded 20 articles. Significant pre-post improvement was reported in quality of life, anxiety, depression, social relations, physical effects, and cognitive effects. However, between-group results were lacking or nonsignificant. CONCLUSIONS AND IMPLICATIONS: There is evidence for benefits of horticulture among older adults, particularly in long-term care facilities. Nonetheless, as the robustness of evidence is lacking, more rigorous randomized controlled trials and between-group effects need to be investigated.