Effects of a diabetes-specific care model for hip fractured older patients with diabetes: A randomized controlled trial.

OBJECTIVES: To examine the effects of a diabetes-specific care model for hip fractured elderly with diabetes mellitus (DM). METHODS: A randomized controlled trial was implemented in a 3000-bed medical center in northern Taiwan. Older adults (age ≥ 60) with DM who had hip-fracture surgery (N = 176) were recruited and randomly assigned to diabetes-specific care (n = 88) and usual care (n = 88). Usual care entailed one or two in-hospital rehabilitation sessions. Diabetes-specific care comprised an interdisciplinary care (including geriatric consultation, discharge planning, and in-home rehabilitation) and diabetes-specific care (including dietary and diabetes education, blood pressure control, dyslipidemia management, a glycemic treatment regimen, and rehabilitation exercises). Outcomes including heart rate variability; rehabilitation outcomes; activities of daily living and instrumental activities of daily living were assessed before discharge and 1, 3, 6, 12, 18, 24 months afterwards. RESULTS: Patients who received diabetes-specific care had significantly higher hip-flexion range of motion (b = 5.24, p < .01), peak-force quadriceps strength of the affected limb (b = 2.13, p < .05), higher total heart rate variability in terms of the time-domain parameter for the mean squared difference between two adjacent normal R-R intervals (b = 11.35, p < .05), and frequency-domain parameters, such as low frequency (b = 42.17, p < .05), and the high frequency-to-low frequency ratio (b = 0.11, p < .01). CONCLUSIONS: Our diabetes-specific care model enhanced hip-flexion range of motion, peak quadriceps strength of the affected limb, and overall heart rate variability, indicating dynamic responses to environmental changes during the 24 months following hospital discharge, above and beyond the effects of usual care.

Trajectories in postoperative recovery of elderly hip-fracture patients at risk for depression: A follow-up study.

OBJECTIVES: This secondary-analysis study aimed to identify distinct developmental depressive-symptom trajectories among elderly hip-fracture patients at risk for depression, examine the associations of trajectories with potential risk factors and care models, and explore the effect of trajectory membership on recovery outcomes. METHOD: Longitudinal data were obtained for 179 patients in a randomized controlled trial. These patients were included if their Geriatric Depression Scale short form scores were ≥ 5 before discharge or 1, 3, 6, or 12 months following discharge. Individuals who followed similar developmental depressive-symptom trajectories were identified by group-based trajectory modeling. Associations between trajectory-group membership and postoperative outcomes over the 12 months following discharge were evaluated by the generalized estimating equations method. RESULTS: We identified a progressively lower-risk group and a fluctuating higher-risk group. Patients' membership in the progressively lower-risk group was associated with receiving a comprehensive care model featuring psychological and physical interventions. Membership in this group was associated with better postoperative outcomes and fewer emergency department visits or hospital readmissions. Patients were more likely to belong to the fluctuating higher-risk group if they had more comorbidities or worse prefracture mobility. Patients in the fluctuating higher-risk group not only had higher levels of depressive symptoms, but also a greater likelihood of poor postoperative recovery outcomes. CONCLUSIONS: Depressive symptoms in elderly hip-fracture patients may be alleviated by postoperative comprehensive care that features both psychological and physical interventions. Patients with increasing depressive status should be targeted for early interventions. (PsycINFO Database Record

Effects of interventions on trajectories of health-related quality of life among older patients with hip fracture: a prospective randomized controlled trial.

BACKGROUND: Health-related quality of life (HRQoL) has been used to assess subjects' prognosis and recovery following hip fracture. However, evidence is mixed regarding the effectiveness of interventions to improve HRQoL of elders with hip fracture. The purposes of this study were to identify distinct HRQoL trajectories and to evaluate the effects of two care models on these trajectories over 12 months following hip-fracture surgery. METHODS: For this secondary analysis, data came from a randomized controlled trial of subjects with hip fracture receiving three treatment care models: interdisciplinary care (n = 97), comprehensive care (n = 91), and usual care (n = 93). Interdisciplinary care consisted of geriatric consultation, discharge planning, and 4 months of in-home rehabilitation. Comprehensive care consisted of interdisciplinary care plus management of malnutrition and depressive symptoms, fall prevention, and 12 months of in-home rehabilitation. Usual care included only in-hospital rehabilitation and occasional discharge planning, without geriatric consultation and in-home rehabilitation. Mental and physical HRQoL were measured at 1, 3, 6, and 12 months after discharge by the physical component summary scale (PCS) and mental component summary scale (MCS), respectively, of the Medical Outcomes Study Short Form 36, Taiwan version. Latent class growth modeling was used to identify PCS and MCS trajectories and to evaluate how they were affected by the interdisciplinary and comprehensive care models. RESULTS: We identified three quadratic PCS trajectories: poor PCS (n = 103, 36.6 %), moderate PCS (n = 96, 34.2 %), and good PCS (n = 82, 29.2 %). In contrast, we found three linear MCS trajectories: poor MCS (n = 39, 13.9 %), moderate MCS (n = 84, 29.9 %), and good MCS (n = 158, 56.2 %). Subjects in the comprehensive care and interdisciplinary care groups were more likely to experience a good PCS trajectory (b = 0.99, odds ratio [OR] = 2.69, confidence interval [CI] = 7.24-1.00, p = 0.049, and b = 1.32, OR = 3.75, CI = 10.53-1.33, p = 0.012, respectively) than those who received usual care. However, neither care model improved MCS. CONCLUSIONS: The interdisciplinary and comprehensive care models improved recovery from hip fracture by increasing subjects' odds for following a trajectory of good physical functioning after hospitalization. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT01350557 ).

Enhanced interdisciplinary care improves self-care ability and decreases emergency department visits for older Taiwanese patients over 2 years after hip-fracture surgery: A randomised controlled trial.

BACKGROUND: Little evidence is available on the longer-term effects (beyond 12 months) of intervention models consisting of hip fracture-specific care in conjunction with management of malnutrition, depression, and falls. OBJECTIVE: To compare the relative effects of an interdisciplinary care, and a comprehensive care programme with those of usual care for elderly patients with a hip fracture on self-care ability, health care use, and mortality. DESIGN: Randomised experimental trial. SETTING: A 3000-bed medical centre in northern Taiwan. PARTICIPANTS: Patients with hip fracture aged 60 years or older (N=299). METHOD: Patients were randomly assigned to three groups: comprehensive care (n=99), interdisciplinary care (n=101), and usual care (control) (n=99). Usual care entailed only one or two in-hospital rehabilitation sessions. Interdisciplinary care included not only hospital rehabilitation, but also geriatric consultation, discharge planning, and 4-month in-home rehabilitation. Building upon interdisciplinary care, comprehensive care extended in-home rehabilitation to 12 months and added management of malnutrition and depressive symptoms, and fall prevention. Patients' self-care ability was measured by activities of daily living and instrumental activities of daily living using the Chinese Barthel Index and Chinese version Instrumental Activities of Daily Living scale, respectively. Outcomes were assessed before discharge, and 1, 3, 6, 12, 18, 24 months following hip fracture. Hierarchical linear models were used to analyse health outcomes and health care utilisation, including emergency department visit and hospital re-admission. RESULTS: The comprehensive care group had better performance trajectories for both measures of activities of daily living and fewer emergency department visits than the usual care group, but no difference in hospital readmissions. The interdisciplinary care and usual care groups did not differ in trajectories of self-care ability and service utilisation. The three groups did not differ in mortality during the 2-year follow-up. CONCLUSION: Comprehensive care, with enhanced rehabilitation, management of malnutrition and depressive symptoms, and fall prevention, improved self-care ability and decreased emergency department visits for elders up to 2 years after hip-fracture surgery, above and beyond the effects of usual care and interdisciplinary care.

Comprehensive care improves physical recovery of hip-fractured elderly Taiwanese patients with poor nutritional status.

OBJECTIVES: The effects of nutritional management among other intervention components have not been examined for hip-fractured elderly persons with poor nutritional status. Accordingly, this study explored the intervention effects of an in-home program using a comprehensive care model that included a nutrition-management component on recovery of hip-fractured older persons with poor nutritional status at hospital discharge. DESIGN: A secondary analysis of data from a randomized controlled trial with 24-month follow-up. SETTING: A 3000-bed medical center in northern Taiwan. PARTICIPANTS: Subjects were included only if they had "poor nutritional status" at hospital discharge, including those at risk for malnutrition or malnourished. The subsample included 80 subjects with poor nutritional status in the comprehensive care group, 87 in the interdisciplinary care group, and 85 in the usual care group. INTERVENTIONS: The 3 care models were usual care, interdisciplinary care, and comprehensive care. Usual care provided no in-home care, interdisciplinary care provided 4 months of in-home rehabilitation, and comprehensive care included management of depressive symptoms, falls, and nutrition as well as 1 year of in-home rehabilitation. MEASUREMENTS: Data were collected on nutritional status and physical functions, including range of motion, muscle power, proprioception, balance and functional independence, and analyzed using a generalized estimating equation approach. We also compared patients' baseline characteristics: demographic characteristics, type of surgery, comorbidities, length of hospital stay, cognitive function, and depression. RESULTS: Patients with poor nutritional status who received comprehensive care were 1.67 times (95% confidence interval 1.06-2.61) more likely to recover their nutritional status than those who received interdisciplinary and usual care. Furthermore, the comprehensive care model improved the functional independence and balance of patients who recovered their nutritional status over the first year following discharge, but not of those who had not yet recovered. CONCLUSIONS: An in-home program using the comprehensive care model with a nutritional component effectively improved the nutritional status of hip-fractured patients with poor nutrition. This comprehensive care intervention more effectively improved recovery of functional independence and balance for patients with recovered nutritional status.

Comprehensive care improves health outcomes among elderly Taiwanese patients with hip fracture.

BACKGROUND: Few studies have investigated the effects of care models that combine interdisciplinary care with nutrition consultation, depression management, and fall prevention in older persons with hip fracture. The purpose of this study was to compare the effects of a comprehensive care program with those of interdisciplinary care and usual care for elderly patients with hip fracture. METHODS: A randomized experimental trial was used to explore outcomes for 299 elderly patients with hip fracture receiving three treatment care models: interdisciplinary care (n = 101), comprehensive care (n = 99), and usual care (n = 99). Interdisciplinary care included geriatric consultation, continuous rehabilitation, and discharge planning with post-hospital services. Comprehensive care consisted of interdisciplinary care plus nutrition consultation, depression management, and fall prevention. Usual care included only in-hospital rehabilitation without geriatric consultation, in-home rehabilitation, and home environmental assessment. RESULTS: Participants in the comprehensive care group had better self-care ability (odds ratio, OR = 3.19, p < .01) and less risk of depression (OR = 0.48, p < .01) than those who received usual care. The comprehensive care group had less risk of depression (OR = 0.51, p < .05) and of malnutrition (OR = 0.48, p < .05) than the interdisciplinary care group during the first year following discharge. Older persons with hip fracture benefitted more from the comprehensive care program than from interdisciplinary care and usual care. CONCLUSIONS: Older persons with hip fracture benefitted more from comprehensive care including interdisciplinary care and nutrition consultation, depression management, and fall prevention than simply interdisciplinary care.

Comprehensive and subacute care interventions improve health-related quality of life for older patients after surgery for hip fracture: a randomised controlled trial.

BACKGROUND: Elderly patients with hip fracture have been found to benefit from subacute care interventions that usually comprise usual care with added geriatric intervention, early rehabilitation, and supported discharge. However, no studies were found on the effects of combining subacute care and health-maintenance interventions on health outcomes for elders with hip fracture. OBJECTIVES: To compare the effects of an interdisciplinary comprehensive care programme with those of subacute care and usual care programmes on health-related quality of life (HRQoL) for elderly patients with hip fracture. DESIGN: Randomised controlled trial. SETTINGS: A 3000-bed medical centre in northern Taiwan. PARTICIPANTS: Patients with hip fracture (N=299) were randomised into three groups: subacute care (n=101), comprehensive care (n=99), and usual care (n=99). METHODS: Subacute care included geriatric consultation, continuous rehabilitation, and discharge planning. Comprehensive care consisted of subacute care plus health-maintenance interventions to manage depressive symptoms, manage malnutrition, and prevent falls. Usual care included only 1-2 in-hospital rehabilitation sessions, discharge planning without environmental assessment, no geriatric consultation, and no in-home rehabilitation. HRQoL was measured using the Medical Outcomes Study Short-Form 36 Taiwan version at 1, 3, 6, and 12 months after discharge. RESULTS: Participants in the comprehensive care group improved more in physical function, role physical, general health and mental health than those in the usual care group. The subacute care group had greater improvement in physical function, role physical, vitality, and social function than the usual care group. The intervention effects for both comprehensive and subacute care increased over time, specifically from 6 months after hip fracture onward, and reached a maximum at 12 months following discharge. CONCLUSIONS: Both comprehensive care and subacute care programmes may improve health outcomes of elders with hip fracture. Our results may provide a reference for health care providers in countries using similar programmes with Chinese/Taiwanese immigrant populations.

[The expanding role of home care nurses in long-term care].

This article was developed to discuss the expanding role of home care nurses in long-term care. Home care recipients included in the study were elderly, had chronic illness conditions, were experiencing ADL and IADL impairment, had been discharged from hospital, lived alone and tended to use home care services. Home care services funding from the National Health Care Insurance is limited to those clients with wounds, stomy, and indwelled catheters. Thus, home care nurses mainly provide technical care rather than care addressing psychological, spiritual and social needs. The present care model deviates from the concept of holistic care. Besides, a lack of proper case management training and community resources utilization constrains nurses from providing social care to the clients. The article can serve as a reference for education institutes and nursing professional association to justify relevant training programs in order to facilitate the professional development of home care nurses.