Study protocol of a quasi-experimental trial to compare two models of home care for older people in the primary setting.

BACKGROUND: Preventive home visits are suited for patients with reduced mobility, such as older people. Healthcare needs for older patients are expected to increase due to the extended life expectancy estimated in coming years. The implementation of low-cost, patient-centered methodologies may buffer this rise in health care costs without affecting the quality of service. In order to find the best home care model with less investment, this paper describes a study protocol comparing two models of home care for older people. METHODS: We describe a quasi-experimental study that compares the outcome of two different home care models already implemented in two primary care centers in Badalona (Barcelona, Spain). The traditional model (control model) is integrated in the sense that is continuous, the same primary care center team looks after its assigned patients both at the center and in preventive home visits. The new functional home care model (study model), consisting of a highly trained team, is specifically designed to meet patient needs and give total attention to preventive home interventions. The study will start and end on the expected dates, June 2018 to October 2020, and include all patients over 65 years old already enrolled in the home care programs of the primary care centers selected. The primary endpoint assessed will be the difference in hospitalization days between patients included in both home care programs. Other variables regarding health status, quality of care and resource utilization will also be compared between the two models. DISCUSSION: The study in progress will assess whether a functional and highly trained home care team will meet the ever-aging population needs in terms of cost and health outcomes better than a traditional, integrated one. Lessons learned from this pilot study will provide guidelines for a future model of home care based on the IHI Triple Aim: better care, better health, and lower costs. TRIAL REGISTRATION: Registered in ClinicalTrials.gov (Identifier: NCT03461315; March 12, 2018).

Predictors of mortality among elderly dependent home care patients.

BACKGROUND: The purpose of this study is to identify which variables--among those commonly available and used in the primary care setting--best predict mortality in a cohort of elderly dependent patients living at home (EDPLH) that were included in a home care program provided by Primary Care Teams (PCT). Additionally, we explored the risk of death among a sub-group of these patients that were admitted to hospital the year before they entered the home care program. METHODS: A one-year longitudinal cohort study of a sample of EDPLH patients included in a home care programme provided by 72 PCTs. Variables collected from each individual patient included health and social status, carer's characteristics, carer's burden of care, health and social services received. RESULTS: 1,001 patients completed the study (91.5%), 226 were admitted to hospital the year before inclusion. 290 (28.9%) died during the one-year follow-up period. In the logistic regression analysis women show a lower risk of death [OR= 0.67 (0.50-0.91)]. The risk of death increases with comorbidity [Charlson index OR= 1.14 (1,06-1.23)], the number of previous hospital admissions [OR= 1,16 (1.03-1.33)], and with the degree of pressure ulcers [ulcers degree 1-2 OR = 2.94 (1.92-4.52); ulcers degree 3-4 OR = 4.45 (1.90-10.92)]. The logistic predictive model of mortality for patients previously admitted to hospital identified male sex, comorbidity, degree of pressure ulcers, and having received home care rehabilitation as independent variables that predict death. CONCLUSIONS: Comorbidity, hospital admissions and pressure ulcers predict mortality in the following year in EDPLH patients. The subgroup of patients that entered home care programs with a previous record of hospital admission and a high score in our predictive model might be considered as candidates for palliative care.

Factores asociados a ingreso hospitalario en una cohorte de pacientes ancianos incorporados a un programa de atención domiciliaria / Factors associated with hospitalization in a cohort of elderly patients included in a home care program

Fundamento y objetivo: Identificar los factores que se asocian a que exista un ingreso hospitalario durante el año siguiente en pacientes ancianos dependientes que viven en su domicilio (ADD), visitados por equipos de atención primaria. Pacientes y método: Estudio longitudinal de una cohorte de pacientes ADD incluidos en un programa de atención domiciliaria. En el momento del reclutamiento se realizó una evaluación global (nivel de salud y situación social, cuidados formales e informales recibidos y utilización previa de servicios sanitarios). Durante el año de seguimiento se registraron las visitas a domicilio, así como el uso de servicios sociales, de urgencias y hospitalarios, incluyendo ingresos. Resultados: Se incluyó un total de 1.093 pacientes. Doscientos cincuenta y ocho pacientes (23,6%) fueron ingresados en el hospital y 170 (15,6%) fueron perdidos durante el seguimiento. Se observó que los pacientes hospitalizados habían recibido el mismo volumen de atención primaria y social domiciliarias que los no hospitalizados. Como factores independientes predictivos de ingreso se encontraron: utilizar las urgencias telefónicas centralizadas (061) (odds ratio [OR] 2,50, intervalo de confianza del 95% [IC 95%] 1,56-4,01) y comorbilidad evaluada por el índice de Charlson al reclutamiento (OR 1,16, IC 95% 1,06-1,27). Por el contrario, el sexo femenino (OR 0,59, IC 95% 0,40-0,85) y una alta valoración subjetiva del estado físico de salud medida por el cuestionario SF-12 (OR 0,97, IC 95% 0,95-0,99), predecían un bajo riesgo de hospitalización. Conclusiones: Los ingresos hospitalarios de pacientes ADD se relacionan con el sexo, la comorbilidad, el estado de salud subjetiva al reclutamiento y la falta de continuidad en la información y protocolos asistenciales entre niveles asistenciales, más que con la atención sanitaria recibida durante el seguimiento (AU)

Background and objective: The objective is to identify the features associated with next year hospital admissions among elderly dependent patients living at home (EDLH) and visited by primary care teams at their home setting. Patients and method: Longitudinal cohort study of a sample of EDLH patients admitted to a home care programme delivered by 72 primary care teams. A global health assessment was performed at recruitment in all patients (health and social status, informal and formal carer characteristics and burden of care). We further collected data on visits by primary care personnel and the use of social, emergency and hospital services by EDLH patients throughout one year after recruitment. Results: A sample of 1,093 EDLH patients was included. 258 (23,6%) patients were admitted to hospital during follow-up and 170 (15.6%) were lost to follow-up. Hospitalised patients received the same volume of primary care and social care services at home than those that were not hospitalised. Independent predictors of high risk of hospital admission were calling and using the after-hours emergency community services (odds ratio [OR]= 2.50, 95% confidence interval [95% CI] 1.56-4.01) and comorbidity as measured by the Charlson Index (OR= 1.16, 95% CI 1.06-1.27) at recruitment. Similarly, female sex (OR= 0.59, 95% CI 0.40-0.85) and high subjective physical health status scores as measured by the SF12 questionnaire (OR 0.97, 95% CI 0.95-0.99) predicted a low-risk of hospital admission. Conclusions: Hospital admission among EDLH patients is related to comorbidity, gender, subjective health status and the use of uncoordinated emergency services as measured at recruitment, rather than to the use of services during the one-year follow-up (AU)

[Factors associated with hospitalization in a cohort of elderly patients included in a home care program]. / Factores asociados a ingreso hospitalario en una cohorte de pacientes ancianos incorporados a un programa de atención domiciliaria.

BACKGROUND AND OBJECTIVE: The objective is to identify the features associated with next year hospital admissions among elderly dependent patients living at home (EDLH) and visited by primary care teams at their home setting. PATIENTS AND METHOD: Longitudinal cohort study of a sample of EDLH patients admitted to a home care programme delivered by 72 primary care teams. A global health assessment was performed at recruitment in all patients (health and social status, informal and formal carer characteristics and burden of care). We further collected data on visits by primary care personnel and the use of social, emergency and hospital services by EDLH patients throughout one year after recruitment. RESULTS: A sample of 1,093 EDLH patients was included. 258 (23,6%) patients were admitted to hospital during follow-up and 170 (15.6%) were lost to follow-up. Hospitalised patients received the same volume of primary care and social care services at home than those that were not hospitalised. Independent predictors of high risk of hospital admission were calling and using the after-hours emergency community services (odds ratio [OR]= 2.50, 95% confidence interval [95% CI] 1.56-4.01) and comorbidity as measured by the Charlson Index (OR= 1.16, 95% CI 1.06-1.27) at recruitment. Similarly, female sex (OR= 0.59, 95% CI 0.40-0.85) and high subjective physical health status scores as measured by the SF12 questionnaire (OR 0.97, 95% CI 0.95-0.99) predicted a low-risk of hospital admission. CONCLUSIONS: Hospital admission among EDLH patients is related to comorbidity, gender, subjective health status and the use of uncoordinated emergency services as measured at recruitment, rather than to the use of services during the one-year follow-up.

La atención a personas en situación de dependencia: aportaciones de la evidencia en la construcción de un modelo de atención compartida / Delivering Healthcare to Dependent Individuals: Towards a Joint Care Model using Evidence-based Contributions

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[Health problems also explain social services use in home care]. / Los problemas de salud también explican la utilización de servicios sociales en atención domiciliaria.

OBJECTIVE: To identify which social and health variables are associated with receiving social services in patients included in home care programmes with the implementation of the Dependence Law. DESIGN: Cross-sectional study. SETTING: 72 primary health care teams in Catalonia. PATIENTS: Patients over 64 years old with chronic diseases in home care programmes in Catalonia. MEASUREMENTS: Health status variables: Charlson, Barthel, Pfeiffer, Braden and Gijon, data from their carer (Zarit), self perception of health (SF-12), health professional visits, as well as: emergency visits, temporary admissions, and final results such as death or definitive admission in a nursing home or a hospital. RESULTS: A total of 1068 patients were included, 46.8% of the patients received some kind of social service, public or private. We observed that the variables related to receive some kind of social services are: high dependence (Barthel test), pressure sores and home care rehabilitation. Barthel test is highly associated with having social problems (Gijon test), living without an informal carer, more than 2 GP visits and having additional private health care. CONCLUSIONS: To be more fair, the evaluation of the provisions of the Dependence Law should also consider the health status of the patient. With the implementation of this law we can observe difficulties in access to social services for middle class patients. These patients do not have access to public social assistance and cannot pay for a private one. Social services are still an alternative to family care.

Los problemas de salud también explican la utilización de servicios sociales en atención domiciliaria / Health problems also explain social services use in home care

Objetivo: identificar las variables relacionadas con el hecho de recibir servicios sociales de carácter público o privado antes de la implantación de la Ley de Dependencia en pacientes recluidos en sus domicilios. Diseño: estudio descriptivo transversal. Emplazamiento: 72 equipos de atención primaria de Cataluña (EAP). Participantes: pacientes mayores de 64 años, no institucionalizados atendidos por un programa de atención domiciliaria de los EAP. Mediciones principales: de cada paciente se registraron: comorbilidad, estado funcional, estado cognitivo, si tenía úlceras por presión, salud subjetiva, valoración social, utilización de servicios sociales y sanitarios formales e informales, sobrecarga del cuidador, ingresos en residencias, hospitales o urgencias, además del número de visitas de profesionales santiarios. Resultados: participan 1.068 pacientes, el 46,8% recibe algún servicio social. Las variables relacionadas con la prestación de servicios sociales son: el grado de dependencia (Barthel), las úlceras por presión y recibir rehabilitación a domicilio. El test de Barthel está firmemente asociado a la problemática social (Gijón), carecer de cuidador informal, más de dos visitas de médico de familia y tener sanidad privada adicional. Conclusiones: para ser más equitativa, la valoración de las prestaciones de la Ley de Dependencia debería considerar también el estado de salud. Antes de la aplicación de esta ley se intuye una dificultad de acceso a los servicios sociales formales para las clases medias que no acceden a las prestaciones públicas ni pueden pagarlas. Las prestaciones sociales son todavía una alternativa a la atención familiar(AU)

Objective: To identify which social and health variables are associated with receiving social services in patients included in home care programmes with the implementation of the Dependence Law. Design: Cross-sectional study. Setting: 72 primary health care teams in Catalonia. Patients: Patients over 64 years old with chronic diseases in home care programmes in Catalonia. Measurements: Health status variables: Charlson, Barthel, Pfeiffer, Braden and Gijon, data from their carer (Zarit), self perception of health (SF-12), health professional visits, as well as: emergency visits, temporary admissions, and final results such as death or definitive admission in a nursing home or a hospital. Results: A total of 1068 patients were included, 46.8% of the patients received some kind of social service, public or private. We observed that the variables related to receive some kind of social services are: high dependence (Barthel test), pressure sores and home care rehabilitation. Barthel test is highly associated with having social problems (Gijon test), living without an informal carer, more than 2 GP visits and having additional private health care. Conclusions: To be more fair, the evaluation of the provisions of the Dependence Law should also consider the health status of the patient. With the implementation of this law we can observe difficulties in access to social services for middle class patients. These patients do not have access to public social assistance and cannot pay for a private one. Social services are still an alternative to family care(AU)

[Monitoring a home care cohort]. / Seguimiento de una cohorte de atención domiciliaria.

OBJECTIVES: To evaluate home care by primary care teams for people over 65 years old with chronic conditions, in order to identify improvement opportunities. To identify patient and care variables associated with cognitive and functional impairment, nursing home admission, attendance at casualty units, hospital admission and death. DESIGN: Analytic study of the follow-up of a cohort for 3 years. SETTING: Primary health care teams in Catalonia, Spain. PATIENTS: One thousand three hundred patients over 65 with chronic pathologies and cared for by home care programmes in Catalonia. MAIN MEASUREMENTS: The following will be recorded annually: health status (Charlson, Barthel, Pfeiffer, Braden, and Gijón), data on the carer (Zarit), care received (social and health), self-perception of health (SF-12), Casualty attendance, short-term admissions and the final results, i.e. death or definitive admission to a nursing home or hospital. The statistical analyses will be based on logistic regression and a survival analysis. CONCLUSIONS: The study should reveal patient characteristics with prognostic value, as well as identify the social and health factors related to better survival and lower consumption of health and social resources.

Seguimiento de una cohorte de atención domiciliaria

Objetivo: Buscar oportunidades de mejora mediante la evaluación de la atención domiciliaria que ofrecen los equipos de atención primaria en nuestro entorno a las personas > 65 años de edad con enfermedades crónicas. Identificar cuáles son las variables del paciente y del servicio que recibe que se asocian con el deterioro funcional y cognitivo, ingreso en una residencia geriátrica, visita a urgencias, ingreso hospitalario o muerte. Diseño: Estudo analítico de seguimiento de una cohorte durante 3 años. Emplazamiento: Equipos de atención primaria de Cataluña. Participantes: En total, 1.300 pacientes > 65 años con enfermedades crónicas incluidos en el Programa de Atención Domiciliaria. Mediciones principales: Se recoge anualmente su estado de salud (Charlson, Barthel, Pfeiffer, Braden y Gijón), datos sobre el cuidador (Zarit), atenciones recibidas (social y sanitaria), sallud subjetiva (SF-12), visitas a urgencias, ingresos temporales y el resultado final: muerte, ingreso en residencias geriátricas u hospital. Los análisis principales se basarán e regresiones logísticas y una análisis de supervivencia. Discusión: El estudio permitirá identificar las características del paciente que tengan valor pronóstico, así como conocer las práticas de atención social y sanitaria que se asocian con una mejor supervivencia y un menor consumo de recursos sociosanitários(AU)

Seguimiento de una cohorte de atención domiciliaria / Monitoring a home care cohort

Objetivo. Buscar oportunidades de mejora mediante la evaluación de la atención domiciliaria que ofrecen los equipos de atención primaria en nuestro entorno a las personas > 65 años de edad con enfermedades crónicas. Identificar cuáles son las variables del paciente y del servicio que recibe que se asocian con el deterioro funcional y cognitivo, ingreso en una residencia geriátrica, visita a urgencias, ingreso hospitalario o muerte. Diseño. Estudio analítico de seguimiento de una cohorte durante 3 años. Emplazamiento. Equipos de atención primaria de Cataluña. Participantes. En total, 1.300 pacientes > 65 años con enfermedades crónicas incluidos en el Programa de Atención Domiciliaria. Mediciones principales. Se recoge anualmente su estado de salud (Charlson, Barthel, Pfeiffer, Braden y Gijón), datos sobre el cuidador (Zarit), atenciones recibidas (social y sanitaria), salud subjetiva (SF-12), visitas a urgencias, ingresos temporales y el resultado final: muerte, ingreso en residencias geriátricas u hospital. Los análisis principales se basarán en regresiones logísticas y una análisis de supervivencia. Discusión. El estudio permitirá identificar las características del paciente que tengan valor pronóstico, así como conocer las prácticas de atención social y sanitaria que se asocian con una mejor supervivencia y un menor consumo de recursos sociosanitarios

Objectives. To evaluate home care by primary care teams for people over 65 years old with chronic conditions, in order to identify improvement opportunities. To identify patient and care variables associated with cognitive and functional impairment, nursing home admission, attendance at casualty units, hospital admission and death. Design. Analytic study of the follow-up of a cohort for 3 years. Setting. Primary health care teams in Catalonia, Spain. Patients. One thousand three hundred patients over 65 with chronic pathologies and cared for by home care programmes in Catalonia. Main measurements. The following will be recorded annually: health status (Charlson, Barthel, Pfeiffer, Braden, and Gijón), data on the carer (Zarit), care received (social and health), self-perception of health (SF-12), Casualty attendance, short-term admissions and the final results, i.e. death or definitive admission to a nursing home or hospital. The statistical analyses will be based on logistic regression and a survival analysis. Conclusions. The study should reveal patient characteristics with prognostic value, as well as identify the social and health factors related to better survival and lower consumption of health and social resources

Luces y sombras de la atención domiciliaria preventiva

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