Effectiveness of a Nurse-Led Tele-Homecare Program for Patients With Multiple Chronic Illnesses and a High Risk for Readmission: A Randomized Controlled Trial.

PURPOSE: Multiple chronic illnesses, such as those associated with advanced age, are leading causes of poor health, disability, death, and high healthcare expenditures. Tele-homecare is a novel method for providing home care to patients with chronic illnesses. The purpose of this study was to evaluate the effectiveness of an integrated nurse-led tele-homecare program for patients with multiple chronic illnesses and a high risk for readmission. DESIGN: A randomized controlled trial. METHODS: Two hundred patients from a regional hospital who were scheduled to receive home care after discharge were randomly assigned to the intervention group (n = 100) or the control group (n = 100). The patients in the intervention group participated in an integrated tele-homecare program. For outcome evaluation, primary outcomes included the number of emergency department (ED) visits as well as readmittance and mortality. Secondary outcomes included patients' medication adherence, activities of daily living, health status, and quality of life (QOL). Data were collected at three time points: pretest baseline (T0), 3 months after intervention (T3), and 6 months after intervention (T6). A generalized estimating equation model was used to compare changes and evaluate the effect of differences between the two groups over time. FINDINGS: For primary outcome evaluation, we found that the tele-homecare program significantly reduced mortality and ED visits, whereas no significant effect on readmission was observed. For secondary outcome evaluation, patients' QOL indicated significant improvement. CONCLUSIONS AND CLINICAL RELEVANCE: The nurse-led tele-homecare program involves daily 24-hr remote monitoring and surveillance. In this study, the system detected patients' physical changes early and provided timely and appropriate management, consequently reducing ED visits and mortality. Additionally, it improved patients' QOL. On the basis of our findings, nurses' independent roles and functions revealed that the effectiveness of this nurse-led tele-homecare program strengthened the care of patients with multiple chronic illnesses.

The Metabolomic Underpinnings of Symptom Burden in Patients With Multiple Chronic Conditions.

Over 25% of the adult population in the United States suffers from multiple chronic conditions, with numbers continuing to rise. Those with multiple chronic conditions often experience symptoms or symptom clusters that undermine their quality of life and ability to self-manage. Importantly, symptom severity in those with even the same multiple chronic conditions varies, suggesting that the mechanisms driving symptoms in patients with multiple chronic conditions are not fixed but may differ in ways that could make them amenable to targeted interventions. In this manuscript we describe at a metabolic level, the symptom experience of persons with multiple chronic conditions, including how symptoms may synergize or cluster across multiple chronic conditions to augment one's symptom burden. To guide this discussion, we consider the metabolites and metabolic pathways known to span multiple adverse health conditions and associate with severe symptoms of fatigue, depression, and anxiety and their cluster. We also describe how severe versus mild symptoms, and their associated metabolites and metabolic pathways, may vary, depending on the presence of covariates; two of which, sex as a biological variable and the contribution of gut microbiota dysbiosis, are discussed in additional detail. Intertwining metabolomics and symptom science into nursing research, offers the unique opportunity to better understand how the metabolites and metabolic pathways affected in those with multiple chronic conditions may initiate or exacerbate symptom presence within a given individual, ultimately allowing clinicians to develop targeted interventions to improve the health quality of patients their families.

Atención a domicilio a ancianos crónicos complejos. Una gran responsabilidad para las enfermeras del presente y del futuro / No disponible

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Abordajes para la intervención desde enfermería en la Díada en condiciones de cronicidad / Approaches for the intervention of nursing in the Dyad in chronic conditions

El objetivo de esta investigación fue describir la forma en que se ha abordado e intervenido a la Diada desde Enfermería en condiciones crónicas y pluripatología. Se empleó la metodología de Revisión integrativa siguiendo los pasos de Whittemore y Knafl, los buscadores empleados fueron: Ovid Nursing, Science Direct, BVS y el metabuscador Ebsco (de éste último se emplearon: Medline, Medline Complete, Academic Search Complete y OmniFile Full Text Mega (H.W. Wilson). Se identificaron 5.530 piezas investigativas en todas las bases de datos, de las cuales al proceso de depurar por título y resumen quedaron 1.022 piezas. De estas al revisar el texto completo arrojó la revisión para el estudio de 70 piezas. Los hallazgos más significativos están relacionados con las bases de datos y el aporte que tuvo cada una de ellas, donde EBSCO tuvo una participación significativamente mayor que las demás, los países de los que más investigaciones se tuvieron en cuenta también fue un resultado importante, por el lugar que tiene Colombia en este, puesto que, solo es superado por Estados Unidos y España, las patologías que más se estudiaron fueron: en primer lugar fue la Enfermedad Pulmonar Obstructiva Crónica, el cáncer en sus diferentes clasificaciones, la Enfermedad Renal Crónica, la Insuficiencia Cardíaca, la Diabetes Mellitus y el Alzheimer. Las investigaciones realizadas con abordaje de diada representan el 41.66% de todas las investigaciones, lo que demuestra la importancia que tiene abordar a ambos miembros de la misma, pues dichas investigaciones tienen mayor impacto en la sociedad, y la mayoría busca no solo caracterizarlos sino que, también buscan mejorar la calidad de vida de ambos individuos. La representatividad del año de publicación, muestra que los investigadores han puesto sus ojos en los pacientes crónicos y en la Díada, pues a partir del 2013 el aumento ha sido cada vez mayor y su pico se da en el año 2016, y el 2017 también aporta gran parte de los estudios, pues se ha evidenciado lo importante que es entender a la Díada, y generar cambios en ella para mejorar su calidad de vida. De los 5.530 documentos revisados, solo uno habla de pluripatología, pues es un concepto relativamente nuevo, aun así, ya se encuentra ese término en la literatura mundial, pues si bien es cierto que la multimorbilidad continúa siendo un término empleado con bastante frecuencia, también es cierto que ambos conceptos tienen diferencias significativas, particularmente en que los primeros pueden tener comorbilidades y en la pluripatología, todas las entidades patológicas son independientes unas de otras. La díada se ha intervenido principalmente desde el aspecto educativo, con el fin de brindar las herramientas necesarias para que continúen con su proceso de cuidado, en cuanto al abordaje, en la mayoría de los casos se aborda solo al cuidador, en otra gran proporción se abordan ambos miembros de la díada y en un pequeño porcentaje se hace solo con el paciente, esto en términos generales de cronicidad, pues solo un estudio develó pluripatología.

The objective of this investigation was to describe the way in which the Dyad has been approached and intervened from Nursing in chronic conditions and pluripathology. The methodology of Integrative Review was used, following the steps of Whittemore and Knafl. The search engines used were: Ovid Nursing, Science Direct, VHL and the Ebsco metasearch engine (the latter were used: Medline, Medline Complete, Academic Search Complete and OmniFile Full Text Mega (HW Wilson). 5,530 pieces of research were identified in all the databases, of which 1,022 pieces were left in the process of debugging by title and summary, and when reviewing the full text the published review for the study was 70 pieces. The most significant findings are related to the databases and the contribution that each of them had, where EBSCO had a significantly higher participation than the others. The countries from which more research was taken into account was also an important result, the place that Colombia has in this, since it is only surpassed by the United States and Spain, the pathologies that were studied the most were: first, Chronic Obstructive Pulmonary Disease, cancer in its different classifications, Chronic Kidney Disease, Heart Failure, Diabetes Mellitus and Alzheimer's. The investigations approach out in Dyads represent 41.66% of all the investigations, which shows the importance of addressing both members of the same, since such investigations have a greater impact on society, and most of them seek not only to characterize them but also seek to improve the quality of life of both individuals. The representativeness of the year of publication, shows that the researchers have set their eyes on chronic patients and on the Dyad, since as of 2013 the increase has been increasing and its peak occurs in 2016, and the 2017 also contributes a large part of the studies, since it has become clear how important it is to understand the Dyad, and generate changes in it to improve their quality of life. Of the 5,530 documents reviewed, only one speaks of pluripathology, as it´s a relatively new concept, even so, that term is already found in world literature, although it is true that multi morbidity continues to be a term used quite frequently, also it is true that concepts have significant differences, particularly in the first they may have comorbidities and in pluripathology entities are independent of each other. The dating has been intervened mainly from the educational aspect, in order to provide the necessary tools to continue with their care process, in terms of the approach, in most cases only the caregivers is addressed, in another large proportion the two members a dyad and in a small percentage it is done only with the patient, this in general term of chronicity, as only a study of development of pluripathology.

Managing health changes for people with a learning disability in a residential care home setting.

BACKGROUND: People with learning disability (LD) have complex comorbidities that develop at an earlier age than the general population and with which they are now living longer. Identification, assessment and management of these conditions is important but challenging. AIM: To develop resources with care staff to enable them to recognise and manage changes and decline in the health of a person with a LD. METHODS: Two resources (PIP-LD and CIRC) were developed through undertaking a literature review; networking with experts; and collaborating with staff in the care homes for people with a LD. Care staff then used these resourcesto review their residents. FINDINGS: The PIP-LD and CIRC were used in 39 care homes. The PIP-LD empowered staff to meet people's immediate health needs, and the CIRC helped them to recognise changes or a decline. CONCLUSIONS: The combined use of the PIP-LD and the CIRC enabled care staff to recognise the signs and symptoms of each person's comorbidities early, and to identify and manage changes when their health declined.

A Mixed-Methods Evaluation of a Nurse-Led Community-Based Health Home for Ethnically Diverse Older Adults With Multimorbidity in the Adult Day Health Setting.

Multimorbidity affects 75% of older adults (aged 65 years and older) in the United States and increases risk of poor medical outcomes, especially among the poor and underserved. The creation of a Medicaid option allowing states to establish health homes under the Affordable Care Act was intended to enhance coordinated care for Medicaid beneficiaries with multimorbidity. The Community-Based Health Home (CBHH) model uses the infrastructure of the Adult Day Health Center (ADHC) to serve as a health home to improve outcomes for medically complex vulnerable adults. Between 2017 and 2018, we used a sequential explanatory mixed-methods approach to (a) quantitatively examine changes in depression, fall risk, loneliness, cognitive function, nutritional risk, pain classification, and health care utilization over the course of 12 months in the program and (b) qualitatively explore the perspectives of key stakeholders (registered nurse navigators, participants, ADHC administrators, and caregivers) to identify the most effective components of CBHH. Using data integration techniques, we identified components of CBHH that were most likely driving outcomes. After 12 months in CBHH, our racially diverse sample (N = 126), experienced statistically significant (p < .05) reductions in loneliness, depression, nutritional risk, poorly controlled pain, and emergency department utilization. Stakeholders who were interviewed (n = 40) attributed positive changes to early clinical intervention by the registered nurse navigators, communication with providers across settings, and a focus on social determinants of health, in conjunction with social stimulation and engagement provided by the ADHC. CBHH positions the ADHC as the locus of an effective health home site and is associated with favorable results. CBHH also demonstrates the unique capacity and skill of registered nurses in integrating health and social services across community settings. Continued exploration of CBHH among diverse populations with multimorbidity is warranted.

The return home of the hospitalized elderly: the nurse in the preparation of the caregiver

Preparing for hospital discharge is a care activity inserted in the hospitalization phase, in order to provide care providers with knowledge, skills and responsibili-ty in the management of the health condition and daily activities of nursing. The objective is to identify the strategies performed in the preparation of discharge of the elderly to the informal caregivers in order to enable them to manage the care to be provided. Descriptive, cross-sectional, correlational and quantitative study. Collection of information by questionnaire. Non-probabilistic sample for convenience, composed by 30 nurses, in a Medicine Service. The results suggest that the effectiveness of the discharge planning is indica-ted by 26.7% of the participants, and 33.3% say that it is performed by the doctor. It coincides with the onset of hospitalization in 83.3% of cases, including a set of interventions addressing patients real problems and needs to 96.7%. For patients with autonomic deficit, 100% of the participants mention that the presence of family member or caregiver in the preparation of discharge is promoted. The use of scales, that measure the degree of dependence is only used by 33.3%. The study concludes that the time of professional experience of the participants does not interfere with the activities of planning of the discharge. Training do not introduce changes in the preparation of discharge, and no significant statistical di-fferences were found. To establish a customized, assertive and adjusted planning to the patient's real needs, we suggest the use of protocols and the implement of procedures to systematize the nurse's role

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Mental health and reactions to caregiving among next of kin of older people (65+) with multi-morbidity discharged home after hospitalization.

BACKGROUND: Older people with multi-morbidity are major users of healthcare and are often discharged from hospital with ongoing care needs. This care is frequently provided by informal caregivers and the time immediately after discharge is challenging for caregivers with new and/or additional tasks, resulting in anxiety and stress. AIM: This study aimed to describe mental health, with particular reference to anxiety and depression and reactions to caregiving, and to investigate any associations between the two, in next of kin of older people with multi-morbidity after hospitalisation. It also aimed to explore the association between the demographic characteristics of the study group and mental health and reactions to caregiving. METHODS: This was a cross-sectional questionnaire study using the Hospital Anxiety and Depression Scale and the Caregiver Reaction Assessment. The study group consisted of 345 next of kin of older people (65+) with multi-morbidity discharged home from 13 medical wards in Sweden. Data were analysed using descriptive and analytical statistics. To identify whether reactions to caregiving and next of kin characteristics were associated with anxiety and depression, a univariate logistic regression analysis was performed. RESULTS: More than one quarter of respondents showed severe anxiety and nearly one in 10 had severe depressive symptoms. The frequencies of anxiety and depression increased significantly with increased negative reactions to caregiving and decreased significantly with positive reactions to caregiving. Regarding caregiving reactions, the scores were highest for the positive domain Caregiver esteem, followed by the negative domain Impact on health. Women scored significantly higher than men on Impact on health and spouses scored highest for Impact on schedule and Caregiver esteem. CONCLUSIONS: Nurses and other healthcare professionals may need to provide additional support to informal caregivers before and after discharging older people with significant care needs from hospital. This might include person-centred information, education and training.

Walking and talking activities as nursing therapy for improving quality of life among older adults

Objective: The most prominent problem resulting from decreased body function in older adults is declining quality of life. Walking and talking among older adults in peer group may become a nursing therapy to improve their quality of life. The objective of this study was to identify the impact of walking and talking intervention of quality of life among community dwelling older adults in Depok, Indonesia. Method: This study applied quasi-experimental design with 43 and 40 older adults in the intervention and control group, respectively. The participants were selected using multistage random sampling method. Results: Based on t test, the average quality of life score of older adults improved more significantly in the intervention group than that in the control group, with p value of 0.003, its mean p value < α, respectively. An ANCOVA analysis was used to detect confounding factors. The result showed that all characteristics have a p value of > 0.05, which means there were no confounding factors warranting further investigation. Conclusions: It was concluded that walking and talking therapy in peer group significantly increase the quality of life of older adults

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Impacto de las intervenciones enfermeras en la atención a la cronicidad en España. Revisión sistemática / Population impact of nurses in care interventions chronicity in Spain. Systematic review

Fundamentos: Las proyecciones epidemiológicas para las próximas décadas sugieren que la mayor parte de las patologías crónicas incrementarán su prevalencia. Se han desarrollado diferentes modelos de atención para afrontar el reto que supone la cronicidad; todas las iniciativas implementadas señalan a la atención primaria de salud y especialmente a la enfermera comunitaria como los garantes de la atención al paciente crónico, su familia y la comunidad, si bien las políticas sanitarias no lo refrendan. El objetivo de esta revisión fue evaluar el impacto de las distintas intervenciones enfermeras incluidas en la estrategia de atención a la cronicidad en España. Métodos: Revisión sistemática de la literatura sobre la aportación enfermera en la atención a la cronicidad en pacientes adultos en España. La búsqueda se realizó en las bases de datos Medline / Pubmed, Cochrane, EMBASE, LILACS, CINAHL, IME y CUIDEN. Criterios de inclusión: artículos escritos en castellano e inglés publicados entre 2007-2016, que incluyesen pacientes con enfermedad crónica en todas las etapas del ciclo vital. Se evaluó la calidad de los estudios siguiendo los criterios Prisma y los niveles de evidencia y recomendación CEBM. Resultados: Las intervenciones enfermeras de mayor impacto en la estrategia de atención a la cronicidad en España fueron la gestión de casos y la práctica avanzada (50%), los programas de atención domiciliaria desde atención primaria (41,7%) y la telemonitorización (8,3%). Conclusiones: Las intervenciones enfermeras demuestran resultados favorables en efectividad y satisfacción. Se necesitan más estudios que evidencien la eficiencia de la aportación enfermera en la cronicidad

Background: Epidemiological projections for the coming decades suggest that most chronic diseases will increase its prevalence. Different models of care have been developed to meet the challenge of chronicity; all implemented initiatives point to primary health care and especially the community nurse as the guarantors of chronic patient care, family and community. However, health policies do not endorse facts. The objective of this review was to evaluate the impact of different nursing interventions in the care strategy to chronicity in Spain. Methods: Systematic review of the literature on the nurse contribution to address the chronicity in adult patients in Spain. The search was carried out in Medline / Pubmed, Cochrane, EMBASE, LILACS, CINAHL, IME and CUIDEN, databases. Inclusion criteria: written articles in Castilian and English published between 2007 and 2016 involving patients with chronic disease in all their life stages. The quality of the studies was assessed following Prisma criteria and the CEBM levels of evidence and recommendation. Results: The Nursing interventions with the highest impact on the strategy of chronicity care in Spain were cases management and advanced nursing practice (50%), the home-care program offered from Primary Care (41,7%) and Telemonitoring intervention (8,3%). Conclusions: Nurses interventions have shown favorable results in effectiveness and satisfaction more studies that demonstrate the efficiency of the nurse contribution to the chronicity are needed

The ACHRU-CPP versus usual care for older adults with type-2 diabetes and multiple chronic conditions and their family caregivers: study protocol for a randomized controlled trial.

BACKGROUND: Many community-based self-management programs have been developed for older adults with type-2 diabetes mellitus (T2DM), bolstered by evidence from randomized controlled trials (RCTs) that T2DM can be prevented and managed through lifestyle modifications. However, the evidence for their effectiveness is contradictory and weakened by reliance on single-group designs and/or small samples. Additionally, older adults with multiple chronic conditions (MCC) are often excluded because of recruiting and retention challenges. This paper presents a protocol for a two-armed, multisite, pragmatic, mixed-methods RCT examining the effectiveness and implementation of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP), a new 6-month interprofessional, nurse-led program to promote self-management in older adults (aged 65 years or older) with T2DM and MCC and support their caregivers (including family and friends). METHODS/DESIGN: The study will enroll 160 participants in two Canadian provinces, Ontario and Alberta. Participants will be randomly assigned to the control (usual care) or program study arm. The program will be delivered by registered nurses (RNs) and registered dietitians (RDs) from participating diabetes education centers (Ontario) or primary care networks (Alberta) and program coordinators from partnering community-based organizations. The 6-month program includes three in-home visits, monthly group sessions, monthly team meetings for providers, and nurse-led care coordination. The primary outcome is the change in physical functioning as measured by the Physical Component Summary (PCS-12) score from the short form-12v2 health survey (SF-12). Secondary client outcomes include changes in mental functioning, depressive symptoms, anxiety, and self-efficacy. Caregiver outcomes include health-related quality of life and depressive symptoms. The study includes a comparison of health care service costs for the intervention and control groups, and a subgroup analysis to determine which clients benefit the most from the program. Descriptive and qualitative data will be collected to examine implementation of the program and effects on interprofessional/team collaboration. DISCUSSION: This study will provide evidence of the effectiveness of a community-based self-management program for a complex target population. By studying both implementation and effectiveness, we hope to improve the uptake of the program within the existing community-based structures, and reduce the research-to-practice gap. TRIAL REGISTRATION: ClinicalTrials.gov, Identifier: NCT02158741 . Registered on 3 June 2014.

Nurses' role in Long-term conditions care.

Nurses have a key role to play in caring for those with long-term conditions. But a model of care used throughout the country and funded from the national health budget is needed.

Comparing multi-component chronic-disease programs to disease-specific programs

The provincial Chronic Disease Prevention and Management Strategy from 2008-12 (and then renewed until 2016) began with a focus on diabetes.(1) The strategy had a stated intention to expand beyond diabetes to a broader chronic-disease management approach. However, to determine whether it would be beneficial to evolve diabetes programs into more generalized chronic-disease prevention and management models, there is a need to review evidence that compares the effectiveness of general chronic-disease programs to disease-specific programs.

Identifying optimal treatment approaches for people with multimorbidity in Ontario

Multimorbidity is part of the daily life of a growing number of Ontarians who must manage multiple chronic conditions. As Fortin et al. observed, "patients with multiple conditions are the rule rather than the exception in primary care." Multimorbidity not only has a significant impact on healthcare utilization and costs, but it is expected to affect quality of life, ability to work, employability, disability, process of care and mortality.(3) Despite the burden of multimorbidity, patients often receive care that is "fragmented, incomplete, inefficient, and ineffective."(3) Thus, there have been growing calls for changes to health systems and clinical decision-making processes to more effectively and efficiently provide the complex care required by those with multimorbidity.