Healthcare providers' experiences in supporting community-living older adults to manage multiple chronic conditions: a qualitative study.

BACKGROUND: Living with multiple chronic conditions (MCC), the coexistence of two or more chronic conditions, is becoming more prevalent as the population ages. Primary care and home care providers play key roles in caring for older adults with MCC such as facilitating complex care decisions, shared decision-making, and access to community health and support services. While there is some research on the perceptions and experiences of these providers in caring for this population, much of this literature is focused specifically on family physicians. Little is known about the experiences of other primary care and home care providers from multiple disciplines who care for this vulnerable group. The purpose of this study was to explore the experiences of primary and home care healthcare providers in supporting the care of older adults with MCC living in the community, and identify ways of improving care delivery and outcomes for this group. METHODS: The study used an interpretive descriptive design. A total of 42 healthcare providers from two provinces in Canada (Ontario and Alberta) participated in individual semi-structured, face-to-face 60-min interviews. Participants represented diverse disciplines from primary care and home care settings. Inductive thematic analysis was used for data analysis. RESULTS: The experiences and recommendations of healthcare providers managing care for older adults with MCC were organized into six major themes: (1) managing complexity associated with MCC, (2) implementing person-centred care, (3), supporting caregivers, (4) using a team approach for holistic care delivery, (5) encountering challenges and rewards, and (6) recommending ways to address the challenges of the healthcare system. Healthcare providers identified the need for a more comprehensive, integrated system of care to improve the delivery of care and outcomes for older adults with MCC and their family caregivers. CONCLUSIONS: Study findings suggest that community-based healthcare providers are using many relevant and appropriate strategies to support older adults living with the complexity of MCC, such as implementing person-centred care, supporting caregivers, working collaboratively with other providers, and addressing social determinants of health. However, they also identified the need for a more comprehensive, integrated system of care.

Explaining experiences of community-dwelling older adults with a pro-active comprehensive geriatric assessment program - a thorough evaluation by interviews.

INTRODUCTION: Pro-active assessment programs are increasingly used to improve care for older adults. These programs include comprehensive geriatric tailored to individual patient preferences. Evidence for the effects of these programs on patient outcomes is nevertheless scarce or ambiguous. Explaining these dissatisfying results is difficult due to the multi-component nature of the programs. The objective of the current study was to explore and explain the experience of older adults participating in a pro-active assessment program, to help to clarify the effects. METHODS: Semi-structured in-depth interviews were held with 25 participants of a pro-active assessment program for frail community-dwelling adults aged 65+. This study was part of an evaluation study on the effects of the program. Transcripts were analysed with thematic analysis and cross-case analysis. RESULTS: The participants' mean age was 78.5 (SD 6.9) and 56% was female. The majority of the participants were satisfied with the program but based this on communication aspects, since only a few of them expressed real program benefits. Participant experiences could be clustered in six themes: (1) All participants expressed the need for a holistic view which was covered in the program, (2) the scope of the CGA was broader than expected or unclear, (3) the program delivered unexpected but valued help, (4) participants described a very low sense of ownership, (5) timing of the program implementation or the CGA was difficult and(6), participants and care workers had a different view on what to consider as a problem. These experiences could be explained by three program components: the degree of (the lack of) integration of the program within usual care, the pro-active screening method and the broader than expected, but appreciated multi-domain approach. CONCLUSION: Older adults' need for a holistic view is covered by this outpatient assessment program. However, their engagement and the correct timing of the program are hampered by the pro-active recruitment and the limited integration of the program within existing care. Furthermore, satisfaction seems an insufficient guiding factor when evaluating CGA programs for older adults because it does not reflect the impact of the program.

Evaluating an integrated primary care approach to improve well-being among frail community-living older people: A theory-guided study protocol.

BACKGROUND: A major challenge in primary healthcare is the substantial increase in the proportion of frail community-dwelling older persons with long-term conditions and multiple complex needs. Consequently, a fundamental transformation of current models of primary care by means of implementing proactive integrated care is necessary. Therefore, an understanding of the effects of integrated primary care approaches and underlying mechanisms is essential. This article presents the design of a theory-based evaluation of an integrated primary care approach to improve well-being among frail community-living older adults, which is called "Finding and Follow-up of Frail older persons" (FFF). First, we present a theoretical model to facilitate a sound theory-guided evaluation of integrated primary care approaches for frail community-dwelling older people. The model incorporates interrelated elements of integrated primary care approaches (e.g. proactive case finding and self-management support). Efforts to improve primary care should integrate these promising components to assure productive patient-professional interactions and to improve well-being. Moreover, cognitive and behavioral components of healthcare professionals and patients are assumed to be important. Second, we present the design of the study to evaluate the FFF approach which consists of the following key components: (1) proactive case finding, (2) case management, (3) medication review, (4) self-management support, and (5) working in multidisciplinary care teams. METHODS: The longitudinal evaluation study has a matched quasi-experimental design with one pretest and one posttest (12 month follow-up) and is conducted in the Netherlands between 2014 and 2017. Both quantitative and qualitative methods are used to evaluate effectiveness, processes, and cost-effectiveness. In total, 250 frail older persons (75 years and older) of 11 GP (general practitioner) practices that implemented the FFF approach are compared with 250 frail older patients of 4 GP practices providing care as usual. In addition, data are collected from healthcare professionals. Outcome measures are based on our theoretical model. DISCUSSION: The proposed evaluation study will reveal insight into the (cost)effectiveness and underlying mechanisms of the proactive integrated primary care approach FFF. A major strength of the study is the comprehensive evaluation based on a theoretical framework. The quasi-experimental design presents some challenges.

Evaluation design of Urban Health Centres Europe (UHCE): preventive integrated health and social care for community-dwelling older persons in five European cities.

BACKGROUND: Older persons often have interacting physical and social problems and complex care needs. An integrated care approach in the local context with collaborations between community-, social-, and health-focused organisations can contribute to the promotion of independent living and quality of life. In the Urban Health Centres Europe (UHCE) project, five European cities (Greater Manchester, United Kingdom; Pallini (in Greater Athens Area), Greece; Rijeka, Croatia; Rotterdam, the Netherlands; and Valencia, Spain) develop and implement a care template that integrates health and social care and includes a preventive approach. The UHCE project includes an effect and process evaluation. METHODS: In a one-year pre-post controlled trial, in each city 250 participants aged 75+ years are recruited to receive the UHCE approach and are compared with 250 participants who receive 'care as usual'. Benefits of UHCE approach in terms of healthy life styles, fall risk, appropriate medication use, loneliness level and frailty, and in terms of level of independence and health-related quality of life and health care use are assessed. A multilevel modeling approach is used for the analyses. The process evaluation is used to provide insight into the reach of the target population, the extent to which elements of the UHCE approach are executed as planned and the satisfaction of the participants. DISCUSSION: The UHCE project will provide new insight into the feasibility and effectiveness of an integrated care approach for older persons in different European settings. TRIAL REGISTRATION: ISRCTN registry number is ISRCTN52788952 . Date of registration is 13/03/2017.

Social and environmental predictors of walking among older adults.

BACKGROUND: Regular physical activity (PA) is a major factor in maintaining health in aging populations. This study examines the influences of sociodemographic, health, and environmental characteristics on older adults' walking behaviors, and the role physicians can play in promoting physical activity. METHODS: Online and paper surveys (n = 272) were distributed to community-dwelling older (age ≥ 60) adults from a large integrated healthcare system in two counties in Central Texas. Descriptive statistics were utilized to characterize participant's walking behaviors and places. Multivariate logistic regression was employed to predict being: 1) a frequent walker (i.e., walking at least three times a week); and 2) meeting the Centers for Disease Control and Prevention (CDC) PA recommendation through walking (i.e., walking ≥150 min per week), while considering sociodemographic, health, and environmental factors. RESULTS: Individuals had a median age of 69 years, were of both genders (50.37 % female), and were primarily non-Hispanic White (84.87 %). While the majority (59.55 %) walked at least three times a week, only 27.86 % walked ≥150 min a week. Factors associated with a lower likelihood of being frequent walkers included experiencing poor mental health in the past month (OR = 0.345, 95 % CI = 0.185-0.645) and residing in areas with low or moderate (versus high) perceived neighborhood cohesion (OR = 0.471, 95 % CI = 0.228-0.974), while those in Census Tracts reflecting populations with a lower median age were more likely to report frequent walking behavior (OR = 1.799, 95 % CI = 1.034-3.131). Factors associated with a lower likelihood of meeting the CDC PA recommendation included being 60-69 years (versus 70 years or older) (OR = 0.538, 95 % CI = 0.290-0.997), experiencing poor mental health in the past month (OR = 0.432, 95 % CI = 0.198-0.944), and lacking social support for walking (OR = 0.383, 95 % CI = 0.154-0.957). CONCLUSION: Given the health benefits, PA promotion must be seen as a national responsibility. In particular, physicians have a major role to play in communicating the importance of PA to their older patients and making discussions about strategies for overcoming barriers to walking an integral part of their clinical encounter with these patients.