[VIG-Express: Consensus on an express multidimensional/geriatric assessment system in Catalonia]. / VIG-Express: Consenso de un sistema de valoración multidimensional/geriátrica rápida en Cataluña.

OBJECTIVE: To reach a consensus on an rapid multidimensional/geriatric assessment (RMGA) tool for all health and social professionals of Catalonia as a shared and universal system to assess patients with multimorbidities, frailty, complexity or advanced conditions. DESIGN: Three-phase consensus of professionals, combining in-person sessions with telematics. LOCATION: Catalonia. PARTICIPANTS: A group of 27 interdisciplinary professionals from different care settings. METHOD: The Design Thinking methodology for an initial consensus on the characteristics of the RMGA tool (Phase 1) has been combined with the Lean Startup methodology to create a new RMGA tool (Phase 2), and then tested in a group of patients (Phase 3). RESULTS: In Phase 1, a consensus was reached that the perfect RMGA tool should allow for an ad hoc assessment of patients, be fast and flexible (<10 min), identify altered dimensions using trigger questions and facilitate the diagnosis of the condition (ideally quantified). In Phase 2, a prototype of a new RMGA tool containing 15 + 2 questions (VIG-Express) was developed, which was then tested in 35 patients in Phase 3. CONCLUSIONS: Based on preliminary results, the VIG-Express tool seems to facilitate a simple, rapid multidimensional assessment and the customization of interventions, as well as provide a unique look and shared narrative between professionals from different care settings. More studies will be required to corroborate these findings.

Clinical effectiveness of an intermediate care inpatient model based on integrated care pathways.

AIM: The aim of this study was to compare the clinical impact of two intermediate care pathways. METHODS: A prospective, uncontrolled before-after study was carried out to compare two non-synchronic intermediate care frameworks in Spain. Participants in the control group were transferred to the intermediate care center by hospital request, whereas those in the intervention group (Badalona Integrated Care Model [BICM]) were transferred based on a territory approach considering the assessment of an intermediate care team. The clinical characteristics of study participants were assessed at admission and discharge. RESULTS: Compared with participants in the control group, those in the BICM group were significantly older (mean age 81.6 years [SD 10.3] vs 78.3 years [10.1], P < 0.001) and had a lower Barthel score (mean score 32.8 [SD 25.9] vs 39.9 [28.4]; P < 0.001), and a higher proportion of participants with total dependence (38.4% vs 32.2%; P = 0.001). The length of stay in intermediate care was similar in both groups; however, stay in acute care was significantly shorter in the BICM group than in the control group (mean 21 days [SD 19.5] vs 25 days [SD 23]; P < 0.001). No significant differences were found regarding the Barthel Index at discharge, although participants in the BICM group had significantly higher functional gain. CONCLUSIONS: The implementation of a territory-based integrated care pathway in an intermediate care center shifted the profile of admitted patients toward higher complexity. Despite this, patients managed under the integrated care model reduced their dependency and the referral rate to an acute unit during their stay in the intermediate care center. Geriatr Gerontol Int 2020; 20: 366-372.

Evaluation of integrated care services in Catalonia: population-based and service-based real-life deployment protocols.

BACKGROUND: Comprehensive assessment of integrated care deployment constitutes a major challenge to ensure quality, sustainability and transferability of both healthcare policies and services in the transition toward a coordinated service delivery scenario. To this end, the manuscript articulates four different protocols aiming at assessing large-scale implementation of integrated care, which are being developed within the umbrella of the regional project Nextcare (2016-2019), undertaken to foster innovation in technologically-supported services for chronic multimorbid patients in Catalonia (ES) (7.5 M inhabitants). Whereas one of the assessment protocols is designed to evaluate population-based deployment of care coordination at regional level during the period 2011-2017, the other three are service-based protocols addressing: i) Home hospitalization; ii) Prehabilitation for major surgery; and, iii) Community-based interventions for frail elderly chronic patients. All three services have demonstrated efficacy and potential for health value generation. They reflect different implementation maturity levels. While full coverage of the entire urban health district of Barcelona-Esquerra (520 k inhabitants) is the main aim of home hospitalization, demonstration of sustainability at Hospital Clinic of Barcelona constitutes the core goal of the prehabilitation service. Likewise, full coverage of integrated care services addressed to frail chronic patients is aimed at the city of Badalona (216 k inhabitants). METHODS: The population-based analysis, as well as the three service-based protocols, follow observational and experimental study designs using a non-randomized intervention group (integrated care) compared with a control group (usual care) with a propensity score matching method. Evaluation of cost-effectiveness of the interventions using a Quadruple aim approach is a central outcome in all protocols. Moreover, multi-criteria decision analysis is explored as an innovative method for health delivery assessment. The following additional dimensions will also be addressed: i) Determinants of sustainability and scalability of the services; ii) Assessment of the technological support; iii) Enhanced health risk assessment; and, iv) Factors modulating service transferability. DISCUSSION: The current study offers a unique opportunity to undertake a comprehensive assessment of integrated care fostering deployment of services at regional level. The study outcomes will contribute refining service workflows, improving health risk assessment and generating recommendations for service selection. TRIALS REGISTRATION: NCT03130283 (date released 04/06/2018), NCT03768050 (date released 12/05/2018), NCT03767387 (date released 12/05/2018).

Influence of demographic and clinical characteristics of elderly patients with a hip fracture on mortality: A retrospective, total cohort study in North-East Spain.

IMPORTANCE: The increased mortality after hip fracture (HF) is caused by multiple factors, and large samples are needed to assess the weight of each factor. To date, few studies have investigated these factors through a total cohort approach, and the complexity of underlying medical conditions has not been considered. OBJECTIVE: To investigate the influence of demographic and clinical characteristics on increased mortality risk in elderly patients with hip fracture (HF). DESIGN: Retrospective, total cohort study collecting 4-year data. SETTING: All hospitals and primary care units owned by, or associated with, Catalonia's local health department (CatSalut) (north-east Spain). PARTICIPANTS: All patients aged ≥65 years, admitted to Catalan hospitals from CatSalut because of a HF between 1st January 2012 and 31st December 2015. EXPOSURE: Hip fracture. MAIN OUTCOME MEASURES: The main outcome was survival. Measures regarding demographic and clinical characteristics at the moment of hospital admission included age, sex, osteoporosis treatment, previous fractures, type of intervention, nutritional status, and comorbidities. Patients were stratified using the Adjusted Morbidity Groups (GMA) risk assessment tool. RESULTS: Of the 30,552 patients included in the study sample, 10,439 (34%) died during follow-up, 6821 (22%) within the first year after hospital admission. Mean (SD) age was 84 (7) years; 75% were female. Baseline factors with greater influence on survival were age (HRs 1.44 [95% CI 1.22-1.70], 2.38 [2.03-2.79], and 4.38 [3.73-5.15] for age groups 70-79, 80-89, and >89, respectively), underweight (HR 1.65 [1.36-2.01]), lack of surgical intervention (HR 2.64 [2.47-2.83]), and very high risk stratum of GMA risk (HR 1.58 [1.45-1.73]). Vitamin D/calcium supplementation and osteoporosis treatment showed a significant but moderate influence on mortality (HRs 0.84 (0.79-0.88) and 0.92 [0.85-0.99], respectively). CONCLUSIONS AND RELEVANCE: In elderly patients with HF, age and health status factors at hospital admission have the greatest impact on mortality risk after hospital admission. Our findings encourage a comprehensive intervention aimed at improving underlying medical conditions of HF patients.

Nuevo modelo de atención integrada orientada a ancianos ingresados en Unidades de Atención Intermedia en Cataluña: protocolo de un estudio cuasiexperimental / New integrated care model for older people admitted to Intermediate Care Units in Catalonia: a quasi-experimental study protocol

Objetivo. Evaluar la efectividad clínica de un modelo de atención intermedia basado en un sistema de atención centrado en procesos clínicos integrados (integrated care pathways) respecto al modelo de atención sociosanitario tradicional en Cataluña (atención habitual). Pacientes y métodos. Estudio cuasiexperimental pre-pos no aleatorizado con grupo control no sincrónico y período de lavado. El grupo control lo conforman pacientes incluidos en programas de atención habitual sociosanitaria. De forma posterior durante el período de lavado se desarrolla el modelo de atención intermedia con sus procesos de atención integrada y se llevará a cabo la segunda parte del estudio con el grupo intervención basado en un sistema integrado ya evaluado (Intermediate Care británico). Dicha intervención se caracterizará por el desarrollo e implementación de rutas asistenciales integradas y la creación de equipos interdisciplinares especializados en cada uno de los procesos. Los dos grupos se compararán para variables demográficas, clínicas al ingreso y al alta, síndromes geriátricos y de consumo de recursos. Discusión. Este estudio cuasiexperimental, de carácter eminentemente pragmático, pretende valorar el impacto clínico de la transformación de un modelo de atención sociosanitario tradicional a un modelo de atención intermedia basado en atención por procesos integrados en el marco de una organización sanitaria integral. Creemos que los resultados del presente estudio podrán ser útiles para futuros estudios aleatorizados y controlados (AU)

Objective. To evaluate the clinical effectiveness of an intermediate care model based on a system of care focused on integrated care pathways compared to the traditional model of geriatric care (usual care) in Catalonia. Patients and methods. The design is a quasi-experimental pre-post non-randomised study with non-synchronous control group. The intervention consists of the development and implementation of integrated care pathways and the creation of specialised interdisciplinary teams in each of the processes. The two groups will be compared for demographic, clinical variables on admission and discharge, geriatric syndromes, and use of resources. Discussion. This quasi-experimental study, aims to assess the clinical impact of the transformation of a traditional model of geriatric care to an intermediate care model in an integrated healthcare organisation. It is believed that the results of this study may be useful for future randomised controlled studies (AU)

Hospital-at-home Integrated Care Programme for the management of disabling health crises in older patients: comparison with bed-based Intermediate Care.

Objective: to analyse the clinical impact of a home-based Intermediate Care model in the Catalan health system, comparing it with usual bed-based care. Design: quasi-experimental longitudinal study. Setting: hospital Municipal de Badalona and El Carme Intermediate Care Hospital, Badalona, Catalonia, Spain. Participants: we included older patients with medical and orthopaedic disabling health crises in need of Comprehensive Geriatric Assessment (CGA) and rehabilitation. Methods: a CGA-based hospital-at-home Integrated Care Programme (acute care and rehabilitation) was compared with a propensity score matched cohort of contemporary patients attended by usual inpatient hospital care (acute care plus intermediate care hospitalisation), for the management of medical and orthopaedics processes. Main outcomes measures were: (a) Health crisis resolution (referral to primary care at the end of the intervention); (b) functional resolution: relative functional gain (functional gain/functional loss) ≥ 0.35; and (c) favourable crisis resolution (health + functional) = a + b. We compared between-groups outcomes using uni/multivariable logistic regression models. Results: clinical characteristics were similar between home-based and bed-based groups. Acute stay was shorter in home group: 6.1 (5.3-6.9) versus 11.2 (10.5-11.9) days, P < 0.001. The home-based scheme showed better results on functional resolution 79.1% (versus 75.2%), OR 1.62 (1.09-2.41) and on favourable crisis resolution 73.8% (versus 69.6%), OR 1.54 (1.06-2.22), with shorter length of intervention, with a reduction of -5.72 (-9.75 and -1.69) days. Conclusions: in our study, the extended CGA-based hospital-at-home programme was associated with shorter stay and favourable clinical outcomes. Future studies might test this intervention to the whole Catalan integrated care system.

Hospital-at-home Integrated Care Program for Older Patients With Orthopedic Processes: An Efficient Alternative to Usual Hospital-Based Care.

OBJECTIVE: To compare outcomes and costs for patients with orthogeriatric conditions in a home-based integrated care program versus conventional hospital-based care. DESIGN: Quasi-experimental longitudinal study. SETTING: An acute care hospital, an intermediate care hospital, and the community of an urban area in the North of Barcelona, in Southern Europe. PARTICIPANTS: In a 2-year period, we recruited 367 older patients attended at an orthopedic/traumatology unit in an acute hospital for fractures and/or arthroplasty. INTERVENTION: Patients were referred to a hospital-at-home integrated care unit or to standard hospital-based postacute orthogeriatric unit, based on their social support and availability of the resource. MEASUREMENTS: We compared home-based care versus hospital-based care for Relative Functional Gain (gain/loss of function measured by the Barthel Index), mean direct costs, and potential savings in terms of reduction of stay in the acute care hospital. RESULTS: No differences were found in Relative Functional Gain, median (Q25-Q75) = 0.92 (0.64-1.09) in the home-based group versus 0.93 (0.59-1) in the hospital-based group, P =.333. Total health service direct cost [mean (standard deviation)] was significantly lower for patients receiving home-based care: €7120 (3381) versus €12,149 (6322), P < .001. Length of acute hospital stay was significantly shorter in patients discharged to home-based care [10.1 (7)] than in patients discharged to the postacute orthogeriatric hospital-based unit [15.3 (12) days, P < .001]. CONCLUSION: The hospital-at-home integrated care program was suitable for managing older patients with orthopedic conditions who have good social support for home care. It provided clinical care comparable to the hospital-based model, and it seems to enable earlier acute hospital discharge and lower direct costs.

[New integrated care model for older people admitted to Intermediate Care Units in Catalonia: A quasi-experimental study protocol]. / Nuevo modelo de atención integrada orientada a ancianos ingresados en Unidades de Atención Intermedia en Cataluña: protocolo de un estudio cuasiexperimental.

OBJECTIVE: To evaluate the clinical effectiveness of an intermediate care model based on a system of care focused on integrated care pathways compared to the traditional model of geriatric care (usual care) in Catalonia. PATIENTS AND METHODS: The design is a quasi-experimental pre-post non-randomised study with non-synchronous control group. The intervention consists of the development and implementation of integrated care pathways and the creation of specialised interdisciplinary teams in each of the processes. The two groups will be compared for demographic, clinical variables on admission and discharge, geriatric syndromes, and use of resources. DISCUSSION: This quasi-experimental study, aims to assess the clinical impact of the transformation of a traditional model of geriatric care to an intermediate care model in an integrated healthcare organisation. It is believed that the results of this study may be useful for future randomised controlled studies.

Hospital-at-home integrated care programme for older patients with orthopaedic conditions: Early community reintegration maximising physical function.

OBJECTIVE: Older citizens with orthopaedic conditions need specialised care for the facilitation of early community reintegration and restitution of physical function. We introduced a new community care programme as an alternative to usual hospital rehabilitation for orthopaedic patients. STUDY DESIGN: This was an observational study of a cohort of older orthopaedic patients attending a hospital-at-home integrated care programme (HHU), compared with a contemporary cohort of users of a geriatric rehabilitation unit (GRU) in the urban area of Badalona, Catalonia, Spain. MAIN OUTCOMES MEASURES: Functional gain at discharge was measured using the Barthel Index (BI). Other outcomes were: length of intervention (days), rehabilitation efficiency and discharge destination. RESULTS: Over the 2 years of the study we assessed 270 patients (69 at HHU; 201 at GRU). We found no significant differences in baseline characteristics between HHU and GRU groups-mean (IQR) or % age 83 (79-87) vs. 84 (79-88), cognitive impairment 27.5% vs. 24.9%, functional decline 40 (31-48) vs. 43 (32-58). Overall, we found no statistically significant differences between HHU and GRU groups on functional gain: 35 (22-45) vs. 32 (18-46), and discharge home 85.5% vs. 86.1%. Length of intervention was shorter in the HHU group, 43 (32-56) vs. 57 (44-81); p<0.01, for hip fracture patients. In a multivariate analysis, the adjusted mean difference in rehabilitation efficiency between HHU and GRU groups in the hip fracture subgroup was 0.27 (0.09 to 0.46); p=0.004. CONCLUSIONS: This hospital-at-home service obtained similar clinical results to the usual hospital-based rehabilitation care, and for hip fracture patients attending that service, rehabilitation efficiency was better.

Proposals for enhanced health risk assessment and stratification in an integrated care scenario.

OBJECTIVES: Population-based health risk assessment and stratification are considered highly relevant for large-scale implementation of integrated care by facilitating services design and case identification. The principal objective of the study was to analyse five health-risk assessment strategies and health indicators used in the five regions participating in the Advancing Care Coordination and Telehealth Deployment (ACT) programme (http://www.act-programme.eu). The second purpose was to elaborate on strategies toward enhanced health risk predictive modelling in the clinical scenario. SETTINGS: The five ACT regions: Scotland (UK), Basque Country (ES), Catalonia (ES), Lombardy (I) and Groningen (NL). PARTICIPANTS: Responsible teams for regional data management in the five ACT regions. PRIMARY AND SECONDARY OUTCOME MEASURES: We characterised and compared risk assessment strategies among ACT regions by analysing operational health risk predictive modelling tools for population-based stratification, as well as available health indicators at regional level. The analysis of the risk assessment tool deployed in Catalonia in 2015 (GMAs, Adjusted Morbidity Groups) was used as a basis to propose how population-based analytics could contribute to clinical risk prediction. RESULTS: There was consensus on the need for a population health approach to generate health risk predictive modelling. However, this strategy was fully in place only in two ACT regions: Basque Country and Catalonia. We found marked differences among regions in health risk predictive modelling tools and health indicators, and identified key factors constraining their comparability. The research proposes means to overcome current limitations and the use of population-based health risk prediction for enhanced clinical risk assessment. CONCLUSIONS: The results indicate the need for further efforts to improve both comparability and flexibility of current population-based health risk predictive modelling approaches. Applicability and impact of the proposals for enhanced clinical risk assessment require prospective evaluation.