Typology of patients with mental health disorders and perceived continuity of care.

Background: While multiple socio-demographic, clinical and service use variables have been associated with continuity of care (CoC) in patients diagnosed with mental health disorders (MHDs), little is known about how these variables may inform clinical practice and service planning.Aim: This article identified profiles of patients with MHDs to better understand their perceptions of CoC.Method: The sample for this cross-sectional study comprised 327 patients recruited by staff or self-referred from four local health networks in Quebec (Canada). Data were collected using standardized instruments, and patient medical records. A three-factor conceptual framework based on Andersen's Behavioral Model was used, integrating predisposing, needs and enabling factors.Results: Cluster analyses identified five patient profiles. Profiles that included relatively more patients with common MHDs reported less continuity than those with patients primarily affected by severe MHDs.Conclusions: Service planning and delivery should be better adapted to patient profiles in order to improve CoC, and increased access to services prioritized.

Chronic kidney disease monitoring in Australian general practice.

BACKGROUND AND OBJECTIVES: Kidney Health Australia recommends regular monitoring of patients with chronic kidney disease (CKD) to reduce progression and prevent complications such as cardiovascular disease. The objective of this study was to examine how practice aligns with the recommendations in Kidney Health Australia's CKD guidelines. METHOD: Australian general practice data from the NPS MedicineWise MedicineInsight program (1 January 2013 - 1 June 2016) for 19,712 adults with laboratory evidence of stage 3 CKD were analysed. Complete monitoring in these individuals was defined as having at least one recorded assessment of blood pressure, urine albumin-to-creatinine ratio, estimated glomerular filtration rate and serum lipids over an 18-month period. RESULTS: Complete monitoring was performed for 25% of the cohort; 54.9% among patients with concomitant diabetes and 14.1% among patients without diabetes. Patients with diabetes, hypertension and a documented diagnosis of CKD were more likely to have complete monitoring. DISCUSSION: There is room for improvement in monitoring of patients with stage 3 CKD, particularly for albuminuria, which was monitored in fewer than 50% of these patients.

Continuidad asistencial y terapéutica tras la excarcelación: un problema urgente que precisa soluciones. El modelo aplicado en las prisiones de Cataluña / Continuity of care and treatment after release from prison: an urgent problem that requires solutions. The model applied in Catalonian prisons

Los déficits en salud tras la excarcelación son habituales, incluso con mayor riesgo de muerte. En estos casos, la principal causa de muerte es el uso de heroína y de otros opioides, pero hay otras posibles causas, muchas de ellas potencialmente prevenibles. Los grupos más vulnerables al incremento de la morbimortalidad tras la excarcelación son los consumidores de drogas, los enfermos mentales y los internos extranjeros que proceden de países con pocos recursos económicos. Es urgente implementar intervenciones que optimicen el acceso a los dispositivos sanitarios después de la excarcelación, eviten interrupciones de la continuidad de la atención y del tratamiento prescrito en prisión, y reduzcan la morbimortalidad. Para ello, se precisa coordinar de forma efectiva la atención dentro y fuera de la prisión y aplicar medidas de apoyo. En este trabajo, se presenta el proyecto implementado en las prisiones de Cataluña, que ha utilizado el "enfermero de enlace" (EE) como figura clave del proceso, y el procedimiento interno y externo utilizado para facilitar el adecuado traspaso de información sanitaria y terapéutica, vincular a los pacientes excarcelados a los dispositivos sanitarios y asegurarse de que estos los reciben en el tiempo y la forma adecuados

Deficits in health after being released are common, and even include a higher risk of death. In these cases, the main cause of death is the use of heroin and other opioids, but there are other causes and most of them are potentially preventable. The most vulnerable groups to the increase in post-release morbidity and mortality are drug users, the mentally ill and foreign inmates from countries with fewer economic resources. What is urgently needed is to implement interventions that optimize access to health devices after prison release, avoid interruptions in the continuity of care and treatment prescribed in prison and reduce morbidity and mortality. To achieve this, it is necessary to coordinate effective forms of care inside and outside prison and apply support measures. We present the project implemented in prisons in Catalonia, where the "liaison nurse" was used as a key figure in the process. We also present the internal and external procedure used to facilitate the transfer of sanitary and therapeutic information, to link released patients to health devices and to ensure that they are received in a timely and appropriate manner

Continuity of care: Vital, but how do we measure and promote it?

BACKGROUND: Continuity of care is a fundamental element of traditional general practice linked, via an expanding evidence base, with important patient and system outcomes. It is of particular importance as populations age and live increasingly with significant, ongoing lifestyle and chronic disease challenges. OBJECTIVES: The aim of this article is to examine the challenges in measuring and promoting continuity of care in Australia. DISCUSSION: Appropriate measurement is challenging and the choice of tool requires careful consideration. This should include scope, length, validation testing, accessibility of the tool, alignment with the initiative requiring evaluation, and application to local and system-level analysis. As our healthcare system looks to major reform in the near future, we must ensure that it supports and incentivises continuity of care in its policy development, care models, payment method, training, data analytics, and community consultation and messaging.

Medicare Beneficiaries With Advanced Lung Cancer Experience Diverse Patterns Of Care From Diagnosis To Death.

Characterizations of average end-of-life care for people with cancer can obscure important differences in patients' experiences. Using Medicare claims data for 14,257 patients diagnosed with extensive-stage small-cell lung cancer in the period 1995-2009, we used latent class analysis to identify classes of people with different care patterns. We characterized care trajectories from diagnosis to death using time spent in five care settings-home, hospital inpatient unit (acute), hospital intensive care unit (ICU), postacute skilled nursing facility, and hospice-and transitions across these settings. We identified four classes of patients: 66 percent spent the time primarily at home, 11 percent were primarily in hospice, 17 percent were largely in an acute setting, and 6 percent were largely in an ICU. Patients in these classes differed significantly in terms of baseline clinical characteristics, survival length, time spent in hospice, site of death, and spending. The findings show substantial heterogeneity in patterns of care for patients with advanced cancer, which should be accounted for in efforts to improve end-of-life care.

Assessing the Validity of a Continuum-of-care Survey: A Rasch Measurement Approach.

Satisfied patients are more likely to be compliant, have better outcomes, and are more likely to return to the same provider or institution for future care. The Satisfaction with a Continuum of Care survey (SCC) was designed to improve patient care using measures of patient satisfaction and facilitate a cultural shift from a "silos-of-care" to a "continuum-of-care" mentality by fostering inter-departmental communication as patients moved between environments of care at a Midwestern rehabilitation hospital. This study provides a Rasch measurement framework for investigating issues related to survey reliability and validity. The results indicate that although certain aspects of the survey seem to function in a psychometrically sound manner, the questions are too easy to endorse and provide little information to help improve patient care. Suggestions for future revisions to this survey instrument are provided.

Prevalence, Geographic Variation, and Trends in Hospital Services Relevant to the Care of Older Adults: Development of the Senior Care Services Scale and Examination of Measurement Properties.

BACKGROUND: The availability of hospital services for older adults nationwide is not well understood. OBJECTIVE: To present the development of the Senior Care Services Scale (SCSS) through: (1) identification of hospital services relevant to the care of older adults; (2) development of a taxonomy classifying these services; and (3) description of prevalence, geographic variation, and trends in service provision in US hospitals over time. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of US hospitals in 1999 and 2006 rounds of American Hospital Association Annual Survey of Hospitals (n=4998 and 4831 hospitals, respectively). Exploratory factor analysis was used to create the SCSS, and confirmatory factor analysis was used to examine services over time. The paper reports prevalence of services nationwide. RESULTS: The SCSS consisted of 2 service groups: (1) Inpatient Specialty Care (IP): geriatrics, palliative care, psychiatric geriatrics, pain management, social work, case management, rehabilitation, and hospice; and (2) Postacute Community Care (PA): skilled nursing, intermediate care, other long-term care, assisted living, retirement housing, adult day care, and home health services. Over time, hospitals offered more IP services and fewer PA services. The distribution of services did not mirror the distribution of where older adults reside in the United States. CONCLUSIONS: The development of the SCSS provides important information about senior care services before the passage of the Affordable Care Act. The apparent mismatch of hospital services and demographic trends suggests that many US hospitals may not provide a seamless continuum of care for an increasing population of older adults.

Atención a las personas con demencia en el entorno de la cronicidad / No disponible

En Cataluña, con una población de 7.512.982 habitantes, se ha producido un incremento de la esperanza de vida, en la actualidad de 82,5 años, con una tendencia al envejecimiento de la población. Se trata de un hecho positivo, como consecuencia, en parte, de los avances científicos en medicina, pero que obliga a realizar actuaciones para dar una atención más eficiente a una población que va a vivir más años y la prevalencia de enfermedades crónicas va a ser elevada. En nuestro entorno hay estudios epidemiológicos que han encontrado una prevalencia del 9,6% en las personas de más de 70 años. Los sistemas sanitarios están evolucionando adaptando su funcionamiento a la prevención y atención de la cronicidad. De hecho en Cataluña, a partir del año 1986 se empezó a trabajar con un modelo de atención integral y se crearon estructuras específicas para dar atención a personas mayores con enfermedades crónicas, con enfermedad de Alzheimer y otras demencias, con enfermedades neurodegenerativas y/o con necesidad de cuidados paliativos. Desde entonces hasta la actualidad se han desarrollado diferentes unidades diagnósticas específicas, además de plazas de hospitalización de media y larga estancia psicogeriátricas, y también plazas de hospital de día de psicogeriatría

In Catalonia, with a population of 7,512,982 people, there has been an increase in life expectancy, currently 82.5 years, with a trend towards an aging population. This is a positive development, as a result, in part, of scientific advances in medicine, but it is necessary to perform actions to provide more efficient care to a population that will live longer and the prevalence of chronic diseases will be high. In our environment there are epidemiological studies that have found a prevalence of 9.6% in people over 70 years. Health systems are evolving to adapt its purpose to the prevention and chronicity care. In fact, in Catalonia, since 1986, a model of integrated care and specific structures were created to provide care to seniors with chronic diseases, Alzheimer’s disease and other dementias, neurodegenerative diseases and / or needs for palliative care. Until now, different specific diagnostic units have been developed, in addition to hospitalization medium and long stay psychogeriatric beds and also psychogeriatric day hospital places

A rule-based method for continuity of care identification in discharge summaries.

Discharge summaries are an important clinical narrative as they include the continuity of care information. Identification of data contained in their text is a difficult task due to its freeform text and lack of consensus on essential content. This research proposes a rule-based method to verify the presence of information about continuity of care in Portuguese texts, applying Natural Language Processing (NLP) techniques, and based on an annotated medical corpus. After the experiments, 4 rules were defined and applied in the text of 200 summaries to identify if they have or not the continuity of care information. This process had resulted in Precision value of 84%, Recall value of 70%, Specificity value of 97% and F-Measure value of 76% related to algorithm evaluation.

Lack of active follow-up of cancer patients in Chennai, India: implications for population-based survival estimates.

OBJECTIVE: To measure the bias in absolute cancer survival estimates in the absence of active follow-up of cancer patients in developing countries. METHODS: Included in the study were all incident cases of the 10 most common cancers and corresponding subtypes plus all tobacco-related cancers not ranked among the top 10 that were registered in the population-based cancer registry in Chennai, India, during 1990-1999 and followed through 2001. Registered incident cases were first matched with those in the all-cause mortality database from the vital statistics division of the Corporation of Chennai. Unmatched incident cancer cases were then actively followed up to determine their survival status. Absolute survival was estimated by using an actuarial method and applying different assumptions regarding the survival status (alive/dead) of cases under passive and active follow-up. FINDINGS: Before active follow-up, matches between cases ranged from 20% to 66%, depending on the site of the primary tumour. Active follow-up of unmatched incident cases revealed that 15% to 43% had died by the end of the follow-up period, while the survival status of 4% to 38% remained unknown. Before active follow-up of cancer patients, 5-year absolute survival was estimated to be between 22% and 47% higher, than when conventional actuarial assumption methods were applied to cases that were lost to follow-up. The smallest survival estimates were obtained when cases lost to follow-up were excluded from the analysis. CONCLUSION: Under the conditions that prevail in India and other developing countries, active follow-up of cancer patients yields the most reliable estimates of cancer survival rates. Passive case follow-up alone or applying standard methods to estimate survival is likely to result in an upward bias.

Risk factors for follow-up interruption of HIV patients in French Guiana.

French Guiana is the region of France where the HIV epidemic is most prevalent. To determine the risk factors for being lost for follow-up, we followed a cohort of 1,213 patients between 1992 and 2002 and determined which variables were related to two definitions of being lost to follow-up: permanently disappearing from HIV clinics and coming back after more than 1 year of missed appointments. The incidence rate for permanent follow-up interruption was 17.2 per 100 person-years. The median time to lost to follow-up was 4.3 years (interquartile range = 1.4-8.4 years). Cox modeling showed that the younger age groups, foreigners, patients with initial CD4 counts at the time of HIV diagnosis less than 500/mm3, and patients followed before the availability of highly active antiretroviral therapy (HAART) were significantly more likely to be permanently lost to follow-up, suggesting that some of the patients may have died. When looking at temporary loss to follow-up, younger age groups, untreated patients, patients consulting before the availability of HAART, and patients with CD4 counts more than 500/mm3 were more likely to not come back for a period of more than 1 year.

The Diabetes Continuity of Care Scale: the development and initial evaluation of a questionnaire that measures continuity of care from the patient perspective.

The purpose of the present study was to develop and pilot test a questionnaire to assess continuity of care from the perspective of patients with diabetes. Seven patient and two healthcare-provider focus groups were conducted. These focus groups generated 777 potential items. This number was reduced to 56 items after item reduction, face validity testing and readability analysis, and to 47 items after a preliminary factor analysis. Readability was assessed as requiring 7-8 years of schooling. Sixty adult patients with diabetes completed the draft Diabetes Continuity of Care Scale (DCCS) at a single point in time to assess the validity of the instrument. Patients completed the draft DCCS again 2 weeks later to assess test-retest reliability. A provisional factor analysis and grouping according to clinical sense yielded five domains: access and getting care, care by doctor, care by other healthcare professionals, communication between healthcare professionals, and self-care. The internal consistency (Cronbach's alpha) for the whole scale was 0.89. The test-retest reliability was r = 0.73. The DCCS total score was moderately correlated with some of the measures used to establish construct validity. The DCCS could differentiate between patients who did and did not achieve specific process and clinical indicators of good diabetes care (e.g. Hba1c tested within 6 months). The development of the DCCS was centred on the patient's perspective and revealed that the patient perspective regarding continuity of care extends beyond the concept of seeing one doctor. Initial testing of this instrument demonstrates that it has promise as a reliable and valid measure in this area.

Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs.

Persons with continuous complex care needs frequently require care in multiple settings. During transitions between settings, this population is particularly vulnerable to experiencing poor care quality and problems of care fragmentation. Despite how common these transitions have become, the challenges of improving care transitions have received little attention from policy makers, clinicians, and quality improvement entities. This article begins with a definition of transitional care and then discusses the nature of the problem, its prevalence, manifestations of poorly executed transitions, and potentially remediable barriers. Necessary elements for effective transitions are then presented, followed by promising new directions for quality improvement at the level of the delivery system, information technology, and national health policy. The article concludes with a proposed research agenda designed to advance the science of high-quality transitional care.

Determining service variations between and within ASAM levels of care.

The American Society of Addiction Medicine (ASAM) Criteria Validity Study at Massachusetts General Hospital and Harvard Medical School randomized patients between programs in two levels of care. It therefore became critical to determine the extent to which programs met ASAM level of care (LOC) descriptions. Quantitative surveys (checklist) and qualitative case studies (field observation, key informant interviews) documented care variation within and between two ASAM LOCs in 12 substance abuse treatment units. These LOCs were: Level II (Intensive Outpatient Treatment) and Level III (Medically Monitored Residential Treatment). The Level II and Level III programs, as a group, met ASAM LOC criteria, but data showed major within-level variation by hours per day and number and type of skilled treatment services. Observational data suggest considerable within-level variation due to managed care and staff training. In multi-site PPC validity studies, it will be crucial to examine within-LOC variation and take into account payment sources and staff training when assessing patient outcomes.

Gestión por procesos asistenciales integrados en el sistema sanitario público de Andalucía

No disponible

Construction of a GP integration model.

There are frequent calls to improve integration of health services, within and between primary and secondary care sectors. In Australia, general medical practitioners (GPs) are central to these endeavours. This paper aims to better conceptualise GP integration and to develop a model and index based on this. A conceptualisation of integration is proposed based on integration fundamentally as an activity or process not structure. Integration process is the frequency and quality of episodes of information exchange involving the GP and another practitioner or patient and aimed at fulfilling the objectives of the health care system with regard to patient care. These are both direct responses to structural forces and emergent GP capacities and dispositions. The content of this typology was studied using Concept Mapping in 11 groups of GPs, consumers and other practitioners. Clusters of related statements within thematic domains were used as the basis for a provisional model. This was tested using confirmatory factor analysis in a data set derived from a national probability sample of 501 GPs. Some re-specification of the model was necessary, with three integration process factors needing to be subdivided. One factor congeneric model assumptions were used to identify the constituent items for these factors. The result was a model in which 50 items measured nine integration process factors and 20 items measured five enabling factors. Two distinct but correlated higher order factors, relating to individual patient care and public (or community) health--in contrast to a single higher order factor for integration--were identified. The re-specified model was tested with a new sample of 151 GPs and exhibited strong psychometric properties. Reliability and validity were acceptable to this stage of the indices' development. Further testing of the index is necessary to demonstrate factor invariance of the indices in other contexts as well as their utility in cross-structural analysis. That said, the indices have immediate uses.

¿Funciona el flujo de información entre los niveles primario y especializado? Análisis de la continuidad asistencial en un área de salud* / Does the information flow between primary and specialized levels? The analysis of assistance continuity in a healthcare area

Objetivo: 1. Evaluar la continuidad asistencial mediante la información transmitida entre los dos niveles, primario y especializado, en una Área de Salud, tanto a través del documento de interconsulta, como en otros documentos escritos o transmitida verbalmente por el paciente. 2. Comparar la información existente sobre los mismos procesos en ambos niveles. Material y Método: Diseño del estudio: observacional, retrospectivo, utilizando criterios explícitos. Ámbito: un Área de Salud, con tres Centros de Especialidades y 31 Centros de Atención Primaria. Población de estudio: una muestra aleatoria de derivaciones de primer día, estratificada por el número de consultas atendidas en cada especialidad, n= 293 (e= ñ5 por ciento).Para conseguir los objetivos se revisaron tanto las historias de atención primaria como las de especializada, buscando en ellas la información correspondiente a las interconsultas que se evaluaban, éstas fueron extraídas de los listados de citaciones de los centros de especializada. Resultados: La existencia de copia del documento de interconsulta en atención primaria se constató en 87 (30,10 por ciento) y en atención especializada en 160 (55,36 por ciento). Los documentos de interconsulta con las tres copias localizados en las historias de especializada fueron 67 (41,87 por ciento).En las historias clínicas de atención primaria consta el diagnóstico del especialista en 107 casos (37,02 por ciento) y la pauta de actuación en 115 ocasiones (39,79 por ciento), mientras que en las historias del nivel especializado encontramos diagnóstico en 246 casos (85,12 por ciento) y pauta de actuación en 244 (84,42 por ciento).Conclusiones: Hay un elevado número de pacientes en los que el médico de atención primaria carece de información sobre los resultados de la derivación al especialista. Paradójicamente, se aprecian buenos niveles de cumplimentación de las variables estudiadas en dichos pacientes, en las historias de atención especializada, pero esta información no se transmite, lo que pone en evidencia que el déficit está en los mecanismos de comunicación que deben ser prioritariamente mejorados (AU)

Association of lower continuity of care with greater risk of emergency department use and hospitalization in children.

CONTEXT: The benefits of continuity of pediatric care remain controversial. OBJECTIVE: To determine whether there is an association between having a continuous relationship with a primary care pediatric provider and decreased risk of emergency department (ED) visitation and hospitalization. DESIGN: Retrospective cohort study. Setting and Population. We used claims data from 46 097 pediatric patients enrolled at Group Health Cooperative, a large staff-model health maintenance organization, between January 1, 1993, and December 31, 1998, for our analysis. To be eligible, patients had to have been continuously enrolled for at least a 2-year period or since birth and to have made at least 4 visits to one of the Group Health Cooperative clinics. MAIN EXPOSURE VARIABLE: A continuity of care (COC) index that quantifies the degree to which a patient has experienced continuous care with a provider. MAIN OUTCOME MEASURES: ED utilization and hospitalization. RESULTS: Compared with children with the highest COC, children with medium continuity were more likely to have visited the ED (hazard ratio [HR]: 1.28 [1.20-1.36]) and more likely to be hospitalized (HR: 1.22 [1.09-1.38]). Children with the lowest COC were even more likely to have visited the ED (HR: 1.58 [1.49-1.66]) and to be hospitalized (HR: 1.54 [1.33-1.75]). These risks were even greater for children on Medicaid and those with asthma. CONCLUSIONS: Lower continuity of primary care is associated with higher risk of ED utilization and hospitalization. Efforts to improve and maintain continuity may be warranted.