The influence of health literacy, anxiety and education on shared decision making and decisional conflict in older adults, and the mediating role of patient participation: A video observational study.

OBJECTIVE: To explore the relationship between personal characteristics of older adults with multiple chronic conditions (MCCs) and perceived shared decision making (SDM) resp. decisional conflict. METHODS: In a video-observational study (N = 213) data were collected on personal characteristics. The main outcomes were perceived level of SDM and decisional conflict. The mediating variable was participation in the SDM process. A twostep mixed effect multilinear regression and a mediation analysis were performed to analyze the data. RESULTS: The mean age of the patients was 77.3 years and 56.3% were female. Health literacy (ß.01, p < .001) was significantly associated with participation in the SDM process. Education (ß = -2.43, p = .05) and anxiety (ß = -.26, p = .058) had a marginally significant direct effect on the patients' perceived level of SDM. Education (ß = 12.12, p = .002), health literacy (ß = -.70, p = .005) and anxiety (ß = 1.19, p = .004) had a significant direct effect on decisional conflict. The effect of health literacy on decisional conflict was mediated by participation in SDM. CONCLUSION: Health literacy, anxiety and education are associated with decisional conflict. Participation in SDM during consultations plays a mediating role in the relationship between health literacy and decisional conflict. PRACTICE IMPLICATIONS: Tailoring SDM communication to health literacy levels is important for high quality SDM.

Current practice of hospital-based palliative care teams: Advance care planning in advanced stages of disease: A retrospective observational study.

BACKGROUND: Specialist palliative care teams are consulted during hospital admission for advice on complex palliative care. These consultations need to be timely to prevent symptom burden and maintain quality of life. Insight into specialist palliative care teams may help improve the outcomes of palliative care. METHODS: In this retrospective observational study, we analyzed qualitative and quantitative data of palliative care consultations in a six-month period (2017 or 2018) in four general hospitals in the northwestern part of the Netherlands. Data were obtained from electronic medical records. RESULTS: We extracted data from 336 consultations. The most common diagnoses were cancer (54.8%) and organ failure (26.8%). The estimated life expectancy was less than three months for 52.3% of all patients. Within two weeks after consultation, 53.2% of the patients died, and the median time until death was 11 days (range 191) after consultation. Most patients died in hospital (49.4%) but only 7.5% preferred to die in hospital. Consultations were mostly requested for advance care planning (31.6%). End-of-life preferences focused on last wishes and maintaining quality of life. CONCLUSION: This study provides detailed insight into consultations of palliative care teams and shows that even though most palliative care consultations were requested for advance care planning, consultations focus on end-of-life care and are more crisis-oriented than prevention-oriented. Death often occurs too quickly after consultation for end-of-life preferences to be met and these preferences tend to focus on dying. Educating healthcare professionals on when to initiate advance care planning would promote a more prevention-oriented approach. Defining factors that indicate the need for timely palliative care team consultation and advance care planning could help timely identification and consultation.

A case vignette study to refine the target group of an intermediate care model: the Acute Geriatric Community Hospital.

PURPOSE: To refine the admission criteria of the Acute Geriatric Community Hospital (AGCH) by defining its target group boundaries with (geriatric) hospital care and other bed-based intermediate care models in the Netherlands. METHODS: A qualitative study consisting of a three-phase refinement procedure with case vignettes. Physicians, medical specialists, nurse practitioners, and physician assistants in hospitals (n = 10) or intermediate care facilities (n = 10) in the Netherlands participated. They collected case vignettes from clinical practice (phase one). The referral considerations and decisions for each case were then documented through surveys (phase two) and two focus groups (phase 3). For thematic data analysis, inductive and deductive approaches were used. RESULTS: The combination of medical specialist care (MSC) and medical generalist care (MGC), is unique for the AGCH compared to other intermediate care models in the Netherlands. Compared to (geriatric) hospital care, the AGCH offers a more limited scope of MSC. Based on these findings, 13 refined admission criteria were developed such as 'The required diagnostic tests to monitor the effectiveness of treatment are available at the AGCH'. Besides admission criteria, additional clinical and organizational considerations played a role in referral decision-making; 10 themes were identified. CONCLUSION: This case vignette study defined the target group boundaries between the AGCH and other care models, allowing us to refine the AGCH admission criteria. Our findings may help to determine the required competencies of the interdisciplinary AGCH team and to develop triage instruments. The identified consideration themes can be used as conceptual framework in further research. The findings may also be of interests for healthcare systems outside the Netherlands who aspire to design integrated care for older people closer to home.

Assessing dynamical resilience indicators in older adults: a prospective feasibility cohort study.

PURPOSE: Measuring dynamical resilience indicators based on time series data may improve the prediction of health deterioration in older adults after hospital discharge. We examined the feasibility of an intensive prospective cohort study examining dynamical resilience indicators based on time series data of symptoms and physical activity in acutely ill older adults who visited the Emergency Department (ED). METHODS: This is a prospective cohort study with time series data from symptom questionnaires and activity trackers. Thirty older adults (aged 75.9 ± 5.5 years, 37% female) who were discharged from the ED of a tertiary hospital in the Netherlands were included in the study. We monitored self-reported symptoms using a daily online questionnaire, and physical activity using an activity tracker for 30 days. Descriptive data on participant eligibility and adherence to and acceptability of the assessments were collected. RESULTS: Of 134 older patients visiting the ED, 109/134 (81%) were eligible for inclusion and 30/109 (28%) were included. Twenty-eight (93%) of the included participants completed follow-up. Regarding the adherence rate, 78% of participants filled in the questionnaire and 80% wore the activity tracker. Three (10%) participants completed fewer than three questionnaires. Most participants rated the measurements as acceptable and seven (23%) participants experienced an adverse outcome in the 30 days after discharge. CONCLUSION: Such an intensive prospective cohort study examining dynamical resilience indicators in older adults was feasible. The quality of the collected data was sufficient, some adjustments to the measurement protocol are recommended. This study is an important first step to study resilience in older adults.

Investigating the Effectiveness of Care Delivery at an Acute Geriatric Community Hospital for Older Adults in the Netherlands: A Prospective Controlled Observational Study.

OBJECTIVES: Hospital admission in older adults is associated with unwanted outcomes such as readmission, institutionalization, and functional decline. To reduce these outcomes, the Netherlands introduced an alternative to hospital-based care: the Acute Geriatric Community Hospital (AGCH). The AGCH is an acute care unit situated outside of a hospital focusing on early rehabilitation and comprehensive geriatric assessment. The objective of this study was to evaluate if AGCH care is associated with decreasing unplanned readmissions or death compared with hospital-based care. DESIGN: Prospective cohort study controlled with a historic cohort. SETTING AND PARTICIPANTS: A (sub)acute care unit (AGCH) and 6 hospitals in the Netherlands; participants were acutely ill older adults. METHODS: We used inverse propensity score weighting to account for baseline differences. The primary outcome was 90-day readmission or death. Secondary outcomes included 30-day readmission or death, time to death, admission to long-term residential care, occurrence of falls and functioning over time. Generalized logistic regression models and multilevel regression analyses were used to estimate effects. RESULTS: AGCH patients (n = 206) had lower 90-day readmission or death rates [odds ratio (OR) 0.39, 95% CI 0.23-0.67] compared to patients treated in hospital (n = 401). AGCH patients had a lower risk of 90-day readmission (OR 0.38, 95% CI 0.21-0.67) but did not differ on all-cause mortality (OR 0.89, 95% CI 0.44-1.79) compared with the hospital control group. AGCH patients had lower 30-day readmission or death rates. Secondary outcomes did not differ. CONCLUSIONS AND IMPLICATIONS: AGCH patients had lower rates of readmission and/or death than patients treated in a hospital. Our results support further research on the implementation and cost-effectiveness of AGCH in the Netherlands and other countries seeking alternatives to hospital-based care.

More older adults died at their preferred place after implementation of a transmural care pathway for older adults at the end of life: a before-after study.

BACKGROUND: To improve transmural palliative care for older adults acutely admitted to hospital, the PalliSupport intervention, comprising an educational programme and transmural palliative care pathway, was developed. This care pathway involves timely identification of palliative care needs, advance care planning, multidisciplinary team meetings, warm handover, and follow-up home visits. With this study, we evaluate changes in patient-related outcomes and transmural collaboration after implementation of the care pathway. METHODS: We conducted a before-after study, in which we compared 1) unplanned hospital admission and death at place of preference and 2) transmural collaboration before implementation, up to six months, and six to 18 months after implementation. Data from palliative care team consultations were collected between February 2017 and February 2020 in a teaching hospital in the Netherlands. RESULTS: The palliative care team held 711 first-time consultations. The number of consultation, as well as the number of consultations for patients with non-malignant diseases, and consultations for advance care planning increased after implementation. The implementation of the pathway had no statistically significant effect on unplanned hospitalization but associated positively with death at place of preference more than six months after implementation (during/shortly after adjusted OR: 2.12; 95% CI: 0.84-5.35; p-value: 0.11, long term after adjusted OR: 3.14; 95% CI: 1.49-6.62; p-value: 0.003). Effects on transmural collaboration showed that there were more warm handovers during/shortly after implementation, but not on long term. Primary care professionals attended multidisciplinary team meetings more often during and shortly after implementation, but did not more than six months after implementation. CONCLUSIONS: The pathway did not affect unplanned hospital admissions, but more patients died at their place of preference after implementation. Implementation of the pathway increased attention to- and awareness for in-hospital palliative care, but did not improve transmural collaboration on long-term. For some patients, the hospital admissions might helped in facilitating death at place of preference.

Implementing online group model building to unravel complex geriatric problems, a methodological description.

BACKGROUND: Group model building (GMB), is a qualitative focus group like study design from the field of system dynamics, that leads a group of topic experts (often key stakeholders of a problem), through a set of scripted activities to create a conceptual model of their shared view on this problems' key contributing factors and their interactions. By offering a specific step wise approach to the complexity of a problem, GMB has provided better understanding and overview of complex problems across different scientific domains, in addition to traditional research methods. As the development of geriatric syndromes and organization of geriatric care are often complex issues that are difficult to research, understand and resolve, GMB might be a useful methodology to better address these issues. This study aimed to describe the methodology of online GMB using a geriatric case study. METHODS: Four online GMB sessions were designed by two clinician researchers. A GMB methodology expert was consulted for optimal design. Scriptapedia scripts formed the core of the sessions. These scripts were adapted to the online format. Experts were recruited purposefully and included seven local health care professionals, one patient representative and one healthcare insurance data analyst. The outcome was a conceptual model of older adults' emergency department visits, which was discussed in a separate article. RESULTS: During implementation of these four sessions, the sessions were adjusted and two extra (non-scripted) sessions were added because defining unambiguous contributing factors to the geriatric case was challenging for the experts. Paraphrasing, categorizing, iterative plenary reflection, and reserving extra time were used to help experts overcome this challenge. All sessions were held in April and May 2021. CONCLUSION: This study shows that GMB can help unravel complex problems in geriatrics, both pathophysiological as organizational, by creating step wise overview of their key contributing factors and interactions. Furthermore, it shows that GMB can be used by clinicians, researchers and health policy makers to better understand complex geriatric problems. Moreover, this paper can help to overcome specific implementational challenges in the geriatric field.

Acute hospital use in older adults following the 2015 Dutch reform of long-term care: an interrupted time series analysis.

BACKGROUND: In 2015, the Dutch government implemented a long-term care (LTC) reform primarily designed to promote older adults to age-in-place. Increased proportions of older adults living in the community might have resulted in more and longer acute hospitalisations. The aims of this study were to evaluate whether the Dutch 2015 LTC reform was associated with immediate and longitudinal increases in the monthly rate of acute clinical hospitalisation and monthly average hospital length of stay (LOS) in adults aged 65 years or older. METHODS: In this interrupted time series analysis of national hospital data (2009-18), we evaluated the association of the Dutch 2015 LTC reform with the monthly rate of acute clinical hospitalisation and monthly average LOS for older adults (aged ≥65 years). Patient-level episodic hospital data were provided by Dutch Hospital Data. Records were included that were defined as an acute clinical hospital admission for which a medical specialist decided treatment was necessary within 24 h. The analysis controlled for population growth (Dutch population data was provided by Statistics Netherlands) and seasonality, and calculated adjusted incident rate ratios (IRR). FINDINGS: Before the 2015 LTC reform, the rate of acute monthly hospitalisation was increasing (IRR 1·002 [95% CI 1·001-1·002]). A positive average reform effect was observed (1·116 [1·070-1·165]), accompanied by a negative change in trend (0·997 [0·996-0·998]) that resulted in a decreasing trend over the post-reform period (0·998 [0·998-0·999]). The pre-reform trend of LOS was decreasing (0·998 [0·997-0·998]), and the 2015 reform exhibited a positive change in trend (1·002 [1·002-1·003]) that resulted in a stabilisation of LOS in the post-reform period (0·999 [0·999-1·000]). INTERPRETATION: Our findings suggest that the increase in the rate of acute hospitalisation after the reform implementation was temporary, whereas the increase in LOS post-reform appeared to last longer than expected. These results have the potential to inform policy makers about effects of ageing-in-place LTC strategies on health and curative care. FUNDING: The Netherlands Organization for Health Research and Development, the Yale Claude Pepper Center, and the National Center for Advancing Translational Sciences, National Institutes of Health. TRANSLATION: For the Dutch translation of the abstract see Supplementary Materials section.

A causal loop diagram of older persons' emergency department visits and interactions of its contributing factors: a group model building approach.

PURPOSE: Understanding the etiology of older persons' emergency department (ED) visits is highly needed. Many contributing factors have been identified, however, the role their interactions play remains unclear. Causal loop diagrams (CLDs), as conceptual models, can visualize these interactions and therefore may elucidate their role. This study aimed to better understand why people older than 65 years of age visit the ED in Amsterdam by capturing the interactions of contributing factors as perceived by an expert group in a CLD through group model building (GMB). METHODS: Six qualitative online focus group like sessions, known as GMB, were conducted with a purposefully recruited interdisciplinary expert group of nine that resulted in a CLD that depicted their shared view. RESULTS: The CLD included four direct contributing factors, 29 underlying factors, 66 relations between factors and 18 feedback loops. The direct factors included, 'acute event', 'frailty', 'functioning of the healthcare professional' and 'availability of alternatives for the ED'. All direct factors showed direct as well as indirect contribution to older persons' ED visits in the CLD through interaction. CONCLUSION: Functioning of the healthcare professional and availability of alternatives for the ED were considered pivotal factors, together with frailty and acute event. These factors, as well as many underlying factors, showed extensive interaction in the CLD, thereby contributing directly and indirectly to older persons' ED visits. This study helps to better understand the etiology of older persons' ED visits and in specific the way contributing factors interact. Furthermore, its CLD can help to find solutions for the increasing numbers of older adults in the ED.

Avoiding Hospital Admissions and Delayed Transfers of Care by Improved Access to Intermediate Care: A Simulation Study.

OBJECTIVE: The current waiting times for intermediate care in the Netherlands prohibit timely access, leading to unwanted and costly hospital admissions. We propose alternative policies for improvement of intermediate care and estimate the effects on the waiting times, hospitalization, and the number of patient replacements. DESIGN: Simulation study. SETTING AND PARTICIPANTS: For our case study, data were used of older adults who received intermediate care in Amsterdam, the Netherlands, in 2019. For this target group, in- and outflows and patient characteristics were identified. METHODS: A process map of the main pathways into and out of the intermediate care was obtained and a discrete event simulation (DES) was built. We demonstrate the use of our DES for intermediate care by evaluating possible policy changes for a real-life case study in Amsterdam. RESULTS: By means of a sensitivity analysis with the DES, we show that in Amsterdam the waiting times are not a result of a lack in bed capacity but are due to an inefficient triage and application process. Older adults have to wait a median of 1.8 days for admission, leading to hospitalization. If the application process becomes more efficient and evening and weekend admissions are allowed, we find that unwanted hospitalization can be decreased substantially. CONCLUSION AND IMPLICATIONS: In this study, a simulation model is developed for intermediate care that can serve as a basis for policy decisions. Our case study shows that the waiting times for health care facilities are not always solved by increasing bed capacity. This underlines the necessity for a data-driven approach to identify logistic bottlenecks and find the best ways to solve them.

Post-discharge light physical activity indicates recovery in acutely hospitalized older adults - the Hospital-ADL study.

BACKGROUND: Physical activity (PA) levels might be a simple overall physical function indicator of recovery in acutely hospitalized older adults; however it is unknown which amount and level of PA is associated with recovery. Our objective was to evaluate the amount and level of post discharge PA and its optimum cut-off values associated with recovery among acutely hospitalized older adults and stratified for frailty. METHODS: We performed a prospective observational cohort study including acutely hospitalized older adults (≥ 70 years). Frailty was assessed using Fried's criteria. PA was assessed using Fitbit up to one week post discharge and quantified in steps and minutes light, moderate or higher intensity. The primary outcome was recovery at 3-months post discharge. ROC-curve analyses were used to determine cut-off values and area under the curve (AUC), and logistic regression analyses to calculate odds ratios (ORs). RESULTS: The analytic sample included 174 participants with a mean (standard deviation) age of 79.2 (6.7) years of whom 84/174 (48%) were frail. At 3-months, 109/174 participants (63%) had recovered of whom 48 were frail. In all participants, determined cut-off values were 1369 steps/day (OR: 2.7, 95% confidence interval [CI]: 1.3-5.9, AUC 0.7) and 76 min/day of light intensity PA (OR: 3.9, 95% CI: 1.8-8.5, AUC 0.73). In frail participants, cut-off values were 1043 steps/day (OR: 5.0, 95% CI: 1.7-14.8, AUC 0.72) and 72 min/day of light intensity PA (OR: 7.2, 95% CI: 2.2-23.1, AUC 0,74). Determined cut-off values were not significantly associated with recovery in non-frail participants. CONCLUSIONS: Post-discharge PA cut-offs indicate the odds of recovery in older adults, especially in frail individuals, however are not equipped for use as a diagnostic test in daily practice. This is a first step in providing a direction for setting rehabilitation goals in older adults after hospitalization.

Recommendations for an exercise intervention and core outcome set for older patients after hospital discharge: Results of an international Delphi study.

For older adults, acute hospitalization is a high-risk event with poor health outcomes, including functional decline. In absence of practical guidelines and high quality randomized controlled trials, this Delphi study was conducted. The aim of this study was to obtain consensus on an exercise intervention program, a core outcome set (COS) and handover information to prevent functional decline or restore physical function in acutely hospitalized older patients transitioning from hospital to home. An internal panel of experts in the field of exercise interventions for acutely hospitalized older adults were invited to join the study. In the Delphi study, relevant topics were recognized, statements were formulated and ranked on a 9-point Likert scale in two additional rounds. To reaching consensus, a score of 7-9 was classified as essential. Results were expressed as median and semi-interquartile range (SIQR), and consensus threshold was set at SIQR≤0.5. Fifteen international experts from eight countries participated in the panel. The response rate was 93%, 93% and 80% for the three rounds respectively. After three rounds, consensus was reached on 167 of the 185 (90.3%) statements, of which ninety-five (51.4%) were ranked as essential (median Likert-score ≥7.0, SIQR ≤0.5). This Delphi study provides starting points for developing an exercise intervention, a COS and handover information. The results of this Delphi study can assist physical therapists to provide a tailored exercise intervention for older patients with complex care needs after hospital discharge, to prevent functional decline and/or restore physical function.

Effects of a shared decision making intervention for older adults with multiple chronic conditions: the DICO study.

BACKGROUND: To evaluate the effects of a shared decision making (SDM) intervention for older adults with multiple chronic conditions (MCCs). METHODS: A pragmatic trial evaluated the effects of the SDMMCC intervention, existing of SDM training for nine geriatricians in two hospitals and a preparatory tool for patients. A prospective pre-intervention post-intervention multi-center clinical study was conducted in which an usual care group of older patients with MCC and their informal caregivers was included before the implementation of the intervention and a new cohort of patients and informal caregivers after the implementation of the intervention. SDM was observed using the OPTIONMCC during video-recorded consultations. Patient- and caregivers reported outcomes regarding their role in SDM, involvement, perceived SDM and decisional conflict were measured. The differences between groups regarding the level of observed SDM (OPTIONMCC) were analyzed with a mixed model analysis. Dichotomous patient-reported outcomes were analyzed with a logistic mixed model. RESULTS: From two outpatient geriatric clinics 216 patients with MCCs participated. The mean age was 77.3 years, and 56.3% of patients were female. No significant difference was found in the overall level of SDM as measured with the OPTIONMCC or in patient-reported outcomes. However, at item level the items discussing 'goals', 'options', and 'decision making' significantly improved after the intervention. The items discussing 'partnership' and 'evaluating the decision-making process' showed a significant decrease. Fifty-two percent of the patients completed the preparatory tool, but the results were only discussed in 12% of the consultations. CONCLUSION: This study provides scope for improvement of SDM in geriatrics. Engaging older adults with MCCs and informal caregivers in the decision making process should be an essential part of SDM training for geriatricians, beyond the SDM steps of explaining options, benefits and harms. More attention should be paid to the integration of preparatory work in the consultation.

Facilitators and barriers to implementing an acute geriatric community hospital in the Netherlands: a qualitative study.

BACKGROUND: there is a trend across Europe to enable more care at the community level. The Acute Geriatric Community Hospital (AGCH) in the Netherlands in an acute geriatric unit situated in a skilled nursing facility (SNF). It provides hospital-level care for older adults with acute medical conditions. The aim of this study is to identify barriers and facilitators associated with implementing the AGCH in a SNF. METHODS: semi-structured interviews (n = 42) were carried out with clinical and administrative personnel at the AGCH and university hospital and stakeholders from the partnering care organisations and health insurance company. Data were analysed using thematic analysis. RESULTS: facilitators to implementing the AGCH concept were enthusiasm for the AGCH concept, organising preparatory sessions, starting with low-complex patients, good team leadership and ongoing education of the AGCH team. Other facilitators included strong collaboration between stakeholders, commitment to shared investment costs and involvement of regulators.Barriers to implementation were providing hospital care in an SNF, financing AGCH care, difficulties selecting patients at the emergency department, lack of protocols and guidelines, electronic health records unsuited for hospital care, department layout on two different floors and complex shared business operations. Furthermore, transfer of acute care to the community care meant that some care was not reimbursed. CONCLUSIONS: the AGCH concept was valued by all stakeholders. The main facilitators included the perceived value of the AGCH concept and enthusiasm of stakeholders. Structural financing is an obstacle to the expansion and continuation of this care model.

Effectiveness of transmural team-based palliative care in prevention of hospitalizations in patients at the end of life: A systematic review and meta-analysis.

BACKGROUND: Team-based palliative care interventions have shown positive results for patients at the end of life in both hospital and community settings. However, evidence on the effectiveness of transmural, that is, spanning hospital and home, team-based palliative care collaborations is limited. AIM: To systematically review whether transmural team-based palliative care interventions can prevent hospital admissions and increase death at home. DESIGN: Systematic review and meta-analysis. DATA SOURCES: MEDLINE (Ovid), Embase (Ovid), CINAHL (Ebsco), PsychINFO (Ovid), and Cochrane Library (Wiley) were systematically searched until January 2021. Studies incorporating teams in which hospital and community professionals co-managed patients, hospital-based teams with community follow-up, and case-management interventions led by palliative care teams were included. Data was extracted by two researchers independently. RESULTS: About 19 studies were included involving 6614 patients, of whom 2202 received an intervention. The overall pooled odds ratio of at least one hospital (re)admissions was 0.46 (95% confidence interval (CI) 0.34-0.68) in favor of the intervention group. The highest reduction in admission was in the hospital-based teams with community follow-up: OR 0.21 (95% CI 0.07-0.66). The pooled effect on home deaths was 2.19 (95% CI 1.26-3.79), favoring the intervention, with also the highest in the hospital-based teams: OR 4.77 (95% CI 1.23-18.47). However, studies had high heterogeneity regarding intervention, study population, and follow-up time. CONCLUSION: Transmural team-based palliative care interventions, especially hospital-based teams that follow-up patients at home, show an overall effect on lowering hospital admissions and increasing the number of patients dying at home. However, broad clinical and statistical heterogeneity of included studies results in uncertainty about the effect size.

Reduced Waiting Times by Preference-Based Allocation of Patients to Nursing Homes.

OBJECTIVES: The long waiting times for nursing homes can be reduced by applying advanced waiting-line management. In this article, we implement a preference-based allocation model for older adults to nursing homes, evaluate the performance in a simulation setting for 2 case studies, and discuss the implementation in practice. DESIGN: Simulation study. SETTING AND PARTICIPANTS: Older adults requiring somatic nursing home care, from an urban region (Rotterdam) and a rural region (Twente) in the Netherlands. METHODS: Data about nursing homes and capacities for the 2 case studies were identified. A set of preference profiles was defined with aims regarding waiting time preferences and flexibility. Guidelines for implementation of the model in practice were obtained by addressing the tasks of all stakeholders. Thereafter, the simulation was run to compare the current practice with the allocation model based on specified outcome measures about waiting times and preferences. RESULTS: We found that the allocation model decreased the waiting times in both case studies. Compared with the current practice policy, the allocation model reduced the waiting times until placement by at least a factor of 2 (from 166 to 80 days in Rotterdam and 178 to 82 days in Twente). Moreover, more of the older adults ended up in their preferred nursing home and the aims of the distinct preference profiles were satisfied. CONCLUSIONS AND IMPLICATIONS: The results show that the allocation model outperforms commonly used waiting-line policies for nursing homes, while meeting individual preferences to a larger extent. Moreover, the model is easy to implement and of a generic nature and can, therefore, be extended to other settings as well (eg, to allocate older adults to home care or daycare). Finally, this research shows the potential of mathematical models in the care domain for older adults to face the increasing need for cost-effective solutions.

[Home sweat hospital-at-home]. / Oost west, thuis toch echt het best?

This article discusses the outcomes of a randomized controlled trial by Shepperd et al in the UK on comprehensive geriatric assessment and hospital-at-home (HaH) for older adults, compared to hospitalization and the implications for the Dutch health care system. The authors found that older adults have comparable outcomes in terms of living at home and mortality at six months, but older adults were more satisfied with the HaH care, less often experienced a delirium and less older adults were admitted to the nursing home. The hospital-at-home model has some other advantages, as it minimizes transitions, older adults are more active in their own environment and experience more autonomy and self-management. To implement this model in the Netherlands it is important to sharply define the target group for HaH, to have a team with nurse practitioners and geriatrician who is able to provide the care 24/7 and to build an acute geriatric infrastructure in primary care, so the HaH is a serious alternative to hospital care.

The Cardiac Care Bridge transitional care program for the management of older high-risk cardiac patients: An economic evaluation alongside a randomized controlled trial.

OBJECTIVE: To evaluate the cost-effectiveness of the Cardiac Care Bridge (CCB) nurse-led transitional care program in older (≥70 years) cardiac patients compared to usual care. METHODS: The intervention group (n = 153) received the CCB program consisting of case management, disease management and home-based cardiac rehabilitation in the transition from hospital to home on top of usual care and was compared with the usual care group (n = 153). Outcomes included a composite measure of first all-cause unplanned hospital readmission or mortality, Quality Adjusted Life Years (QALYs) and societal costs within six months follow-up. Missing data were imputed using multiple imputation. Statistical uncertainty surrounding Incremental Cost-Effectiveness Ratios (ICERs) was estimated by using bootstrapped seemingly unrelated regression. RESULTS: No significant between group differences in the composite outcome of readmission or mortality nor in societal costs were observed. QALYs were statistically significantly lower in the intervention group, mean difference -0.03 (95% CI: -0.07; -0.02). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective was 0.31 at a Willingness To Pay (WTP) of €0,00 and 0.14 at a WTP of €50,000 per composite outcome prevented and 0.32 and 0.21, respectively per QALY gained. CONCLUSION: The CCB program was on average more expensive and less effective compared to usual care, indicating that the CCB program is dominated by usual care. Therefore, the CCB program cannot be considered cost-effective compared to usual care.

Implementation of a national testing policy in Dutch nursing homes during SARS-CoV-2 outbreaks.

BACKGROUND: To evaluate how a national policy of testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) regardless of symptoms was implemented during outbreaks in Dutch nursing homes in the second wave of the pandemic and to explore barriers and facilitators to serial testing. METHODS: We conducted a mixed-method study of nursing homes in the Netherlands with a SARS-CoV-2 outbreak after 15 September 2020. Direct care staff and management from 355 healthcare organizations were invited to participate in a digital survey. A total of 74 out of 355 (20.9%) healthcare organizations participated and provided information about 117 nursing homes. We conducted 26 in-depth interviews on the outbreak and the testing strategy used. We also conducted four focus group meetings involving managers, physicians, nurses, and certified health assistants. Recordings were transcribed and data were thematically analyzed. RESULTS: One hundred and four nursing homes (89%) tested residents regardless of their symptoms during the outbreak, and 85 nursing homes (73%) tested the staff regardless of their symptoms. However, interviews showed testing was sometimes implemented during later stages of the outbreak and was not always followed up with serial testing. Barriers to serial testing regardless of symptoms were lack of knowledge of local leaders with decisional making authority, lack of a cohort ward or skilled staff, and insufficient collaboration with laboratories or local public health services. Important facilitators to serial testing were staff willingness to undergo testing and the availability of polymerase chain reaction (PCR) tests. CONCLUSIONS: Serial testing regardless of symptoms was only partially implemented. The response rate of 21% of nursing home organizations gives a risk of selection bias. Barriers to testing need to be addressed. A national implementation policy that promotes collaboration between public health services and nursing homes and educates management and care staff is necessary.

Effects of a transitional care programme on medication adherence in an older cardiac population: A randomized clinical trial.

AIMS: Medication non-adherence post-discharge is common among patients, especially those suffering from chronic medical conditions, and contributes to hospital admissions and mortality. This study aimed to evaluate the effect of the Cardiac Care Bridge (CCB) intervention on medication adherence post-discharge. METHODS: We performed a secondary analysis of the CCB randomized single-blind trial, a study in patients ≥70 years, at high risk of functional loss and admitted to cardiology departments in six hospitals. In this multi-component intervention study, community nurses performed medication reconciliation and observed medication-related problems (MRPs) during post-discharge home visits, and pharmacists provided recommendations to resolve MRPs. Adherence to high-risk medications was measured using the proportion of days covered (PDC), using pharmacy refill data. Furthermore, MRPs were assessed in the intervention group. RESULTS: For 198 (64.7%) of 306 CCB patients, data were available on adherence (mean age: 82 years; 58.9% of patients used a multidose drug dispensing [MDD] system). The mean PDC before admission was 92.3% in the intervention group (n = 99) and 88.5% in the control group (n = 99), decreasing to 85.2% and 84.1% post-discharge, respectively (unadjusted difference: -2.6% (95% CI -9.8 to 4.6, P = .473); adjusted difference -3.3 (95% CI -10.3 to 3.7, P = .353)). Post-hoc analysis indicated that a modest beneficial intervention effect may be restricted to MDD non-users (Pinteraction = .085). In total, 77.0% of the patients had at least one MRP post-discharge. CONCLUSIONS: Our findings indicate that a multi-component intervention, including several components targeting medication adherence in older cardiac patients discharged from hospital back home, did not benefit their medication adherence levels. A modest positive effect on adherence may potentially exist in those patients not using an MDD system. This finding needs replication.