The effectiveness of intermediate care including transitional care interventions on function, healthcare utilisation and costs: a scoping review.

BACKGROUND AND AIM: Intermediate care describes services, including transitional care, that support the needs of middle-aged and older adults during care transitions and between different settings. This scoping review aimed to examine the effectiveness of intermediate care including transitional care interventions for middle-aged and older adults on function, healthcare utilisation, and costs. DESIGN: A scoping review of the literature was conducted including studies published between 2002 and 2019 with a transitional care and/or intermediate care intervention for adults aged ≥ 50. Searches were performed in CINAHL, Cochrane Library, EMBASE, Open Grey and PubMed databases. Qualitative and quantitative approaches were employed for data synthesis. RESULTS: In all, 133 studies were included. Interventions were grouped under four models of care: (a) Hospital-based transitional care (n = 8), (b) Transitional care delivered at discharge and up to 30 days after discharge (n = 70), (c) Intermediate care at home (n = 41), and (d) Intermediate care delivered in a community hospital, care home or post-acute facility (n = 14). While these models were associated with a reduced hospital stay, this was not universal. Intermediate including transitional care services combined with telephone follow-up and coaching support were reported to reduce short and long-term hospital re-admissions. Evidence for improved ADL function was strongest for intermediate care delivered by an interdisciplinary team with rehabilitation at home. Study design and types of interventions were markedly heterogenous, limiting comparability. CONCLUSIONS: Although many studies report that intermediate care including transitional care models reduce hospital utilisation, results were mixed. There is limited evidence for the effectiveness of these services on function, institutionalisation, emergency department attendances, or on cost-effectiveness.

Defining the characteristics of intermediate care models including transitional care: an international Delphi study.

BACKGROUND: Although there is growing utilisation of intermediate care to improve the health and well-being of older adults with complex care needs, there is no international agreement on how it is defined, limiting comparability between studies and reducing the ability to scale effective interventions. AIM: To identify and define the characteristics of intermediate care models. METHODS: A scoping review, a modified two-round electronic Delphi study involving 27 multi-professional experts from 13 countries, and a virtual consensus meeting were conducted. RESULTS: Sixty-six records were included in the scoping review, which identified four main themes: transitions, components, benefits and interchangeability. These formed the basis of the first round of the Delphi survey. After Round 2, 16 statements were agreed, refined and collapsed further. Consensus was established for 10 statements addressing the definitions, purpose, target populations, approach to care and organisation of intermediate care models. DISCUSSION: There was agreement that intermediate care represents time-limited services which ensure continuity and quality of care, promote recovery, restore independence and confidence at the interface between home and acute services, with transitional care representing a subset of intermediate care. Models are best delivered by an interdisciplinary team within an integrated health and social care system where a single contact point optimises service access, communication and coordination. CONCLUSIONS: This study identified key defining features of intermediate care to improve understanding and to support comparisons between models and studies evaluating them. More research is required to develop operational definitions for use in different healthcare systems.

European Collaborative and Interprofessional Capability Framework for Prevention and Management of Frailty-a consensus process supported by the Joint Action for Frailty Prevention (ADVANTAGE) and the European Geriatric Medicine Society (EuGMS).

BACKGROUND: Interprofessional collaborative practice (ICP) is currently recommended for the delivery of high-quality integrated care for older people. Frailty prevention and management are key elements to be tackled on a multi-professional level. AIM: This study aims to develop a consensus-based European multi-professional capability framework for frailty prevention and management. METHODS: Using a modified Delphi technique, a consensus-based framework of knowledge, skills and attitudes for all professions involved in the care pathway of older people was developed within two consultation rounds. The template for the process was derived from competency frameworks collected in a comprehensive approach from EU-funded projects of the European Commission (EC) supported best practice models for health workforce development. RESULTS: The agreed framework consists of 25 items structured in 4 domains of capabilities. Content covers the understanding about frailty, skills for screening and assessment as well as management procedures for every profession involved. The majority of items focused on interprofessional collaboration, communication and person-centred care planning. DISCUSSION: This framework facilitates clarification of professionals' roles and standardizes procedures for cross-sectional care processes. Despite a lack of evidence for educational interventions, health workforce development remains an important aspect of quality assurance in health care systems. CONCLUSIONS: The multi-professional capability framework for frailty prevention and management incorporated interprofessional collaborative practice, consistent with current recommendations by the World Health Organization, Science Advice for Policy by European Academies and the European Commission.

Factors Associated with Perception of the Quality of Physicians' End-of-life Communication in Long-Term Care Facilities: PACE Cross-Sectional Study.

OBJECTIVE: To examine factors associated with perceived quality of communication with physicians by relatives of dying residents of long-term care facilities (LTCFs). DESIGN: A cross-sectional retrospective study in a representative sample of LTCFs conducted in 2015. In each LTCF, deaths of residents during the 3 months before the researcher's visit were reported. Structured questionnaires were sent to the identified relatives of deceased residents. SETTINGS AND PARTICIPANTS: A total of 736 relatives of deceased residents in 210 LTCFs (in Belgium, Finland, Italy, the Netherlands, and Poland). METHODS: The Family Perception of Physician-Family Communication scale (FPPFC) was used to assess the quality of end-of-life (EOL) communication with physicians as perceived by relatives. We applied multilevel linear regression models to find factors associated with the FPPFC score. RESULTS: The quality of EOL communication with physicians was perceived by relatives as higher when the relative spent more than 14 hours with the resident in the last week of the resident's life (b = 0.205; P = .044), and when the treating physician visited the resident at least 3 times in the last week of the resident's life (b = 0.286; P = .002) or provided the resident with palliative care (b = 0.223; P = .003). Relatives with higher emotional burden perceived the quality of EOL communication with physicians as lower (b = -0.060; P < .001). These results had been adjusted to countries and LTCF types with physicians employed on-site or off-site of the facility. CONCLUSION: The quality of EOL communication with physicians, as perceived by relatives of dying LTCF residents, is associated with the number of physician visits and amount of time spent by the relative with the resident in the last week of the resident's life, and relatives' emotional burden. IMPLICATIONS: LTCF managers should organize care for dying residents in a way that enables frequent interactions between physicians and relatives, and emotional support to relatives to improve their satisfaction with EOL communication.

Perception of the Quality of Communication With Physicians Among Relatives of Dying Residents of Long-term Care Facilities in 6 European Countries: PACE Cross-Sectional Study.

OBJECTIVE: To examine how relatives evaluate the quality of communication with the treating physician of a dying resident in long-term care facilities (LTCFs) and to assess its differences between countries. DESIGN: A cross-sectional retrospective study in a representative sample of LTCFs conducted in 2015. Relatives of residents who died during the previous 3 months were sent a questionnaire. SETTINGS AND PARTICIPANTS: 761 relatives of deceased residents in 241 LTCFs in Belgium, England, Finland, Italy, the Netherlands, and Poland. METHODS: The Family Perception of Physician-Family Communication (FPPFC) scale (ratings from 0 to 3, where 3 means the highest quality) was used to retrospectively assess how the quality of end-of-life communication with treating physicians was perceived by relatives. We applied multilevel linear and logistic regression models to assess differences between countries and LTCF types. RESULTS: The FPPFC score was the lowest in Finland (1.4 ± 0.8) and the highest in Italy (2.2 ± 0.7). In LTCFs served by general practitioners, the FPPFC score differed between countries, but did not in LTCFs with on-site physicians. Most relatives reported that they were well informed about a resident's general condition (from 50.8% in Finland to 90.6% in Italy) and felt listened to (from 53.1% in Finland to 84.9% in Italy) and understood by the physician (from 56.7% in Finland to 85.8% in Italy). In most countries, relatives assessed the worst communication as being about the resident's wishes for medical treatment at the end of life, with the lowest rate of satisfied relatives in Finland (37.6%). CONCLUSION: The relatives' perception of the quality of end-of-life communication with physicians differs between countries. However, in all countries, physicians' communication needs to be improved, especially regarding resident's wishes for medical care at the end of life. IMPLICATIONS: Training in end-of-life communication to physicians providing care for LTCF residents is recommended.

The systematic review of effective interventions to promote collaboration between families and social and health services.

The increasing need for support and the fragmented nature of the service system challenge us to develop services for children and their families. Child and family services are provided by the public, private and third sectors, which according to research have little or no reciprocal co-operation. The review produced information on co-operation interventions used by service providers in the field of health care, social care and education. The current evidence base is too heterogeneous and sparse to draw conclusions on the overall effectiveness of interventions to co-operation. Further high quality studies examining the effectiveness of co-operation interventions are required.

The cost-effectiveness of integrated home care and discharge practice for home care patients.

OBJECTIVES: To evaluate the effects of integrated home care and discharge practice (IHCaD-practice) on the use of services and cost-effectiveness. METHODS: A cluster randomised trial with Finnish municipalities (n=22) as the units of randomisation. At baseline the sample included 668 home care patients aged 65 years or over. Data consisted of interviews (discharge, 3-week, 6-month) and care registers. The intervention was a generic prototype of care/case management-practice that was tailored to each municipality's needs. The effects were evaluated in terms of the use and cost of health and social care services. Unit costs of services were calculated. Cost-effectiveness was calculated for changes in health-related quality of life using the Nottingham Health Profile (NHP) and the EQ-5D instruments. All analyses were based on intention-to-treat. RESULTS: At 6-month follow-ups, the patients in the trail group used less home care, doctor and laboratory services than patients in the non-trial group. Similar differences between groups were found regarding costs. According to the NHP instrument, the IHCaD-practice showed higher cost-effectiveness compared to the old practice. No evidence for cost-effectiveness was found with the EQ-5D instrument. CONCLUSIONS: The study suggests that the IHCaD-practice may be a cost-effective alternative to usual care.

Clients' and workers' perceptions on clients' functional ability and need for help: home care in municipalities.

The aim of the study was to compare clients' and named home care (HC) workers' perceptions of clients' functional ability (FA) and need for help and to analyse which client- and municipality-related factors are associated with perceptions of client's FA. The total of 686 Finnish HC clients was interviewed in 2001. Further, the questionnaire was sent to 686 HC workers. FA was assessed by activities of daily living (ADL), which included both basic/physical (PADL) and instrumental (IADL) activities. The association between client's FA and municipality-related variables was analysed by using hierarchical logistic regression models. The findings indicated that clients' and HC-workers' perceptions about what the clients were able to do were similar in the PADL functions, but perceptions differed when it comes to the IADL functions for mobility and in climbing stairs. A smaller proportion of clients compared with HC workers assessed themselves to be in need of help in all ADL functions. Use of home help and bathing services increased the probability of belonging to the 'poor' FA class while living alone and small size of municipality decreased the probability. The study indicates that although clients and workers assessed client's FA fairly similarly, there were major differences in perceptions concerning clients' needs for help in ADL functions. Clients' and workers' shared view of need for help forms a basis for high-quality care. Therefore, the perception of both the clients and workers must be taken into account when planning care and services. There was also variation in clients' FA between municipalities, although only the size of municipality had some association with the variation. The probability that clients with a lower FA are cared for in HC is higher if the clients live in large- rather than small-sized municipalities. This may reflect a better mix of services and resources in large-sized municipalities.

Home-care clients' need for help, and use and costs of services.

The aims of the study were to describe (1) the need for help as well as the use and costs of services of home help and/or home nursing (home care) and (2) to identify the variables associated with the use and costs of health and social care services. A total of 721 Finnish home-care clients were interviewed in 2001. The need for help was assessed by basic and instrumental activities of daily Living (ADL) and in terms of pain and illness, rest and sleep, psychosocial well-being and social and environment variables. The Anderson-Newman model was used to study predictors of use of services, including visits of home-care personnel and visits to the doctor, nurse, physiotherapist, laboratory and hospital. Weekly costs of services were calculated. Data were analyzed using multivariate analyses. The clients had poor functional ability and they needed help at least once a week with, on average, 6 out of 15 ADL functions, and 5 out of 13 items relating to pain and illnesses, rest and sleep, psychosocial well-being and social and environment items. The enabling and need variables, particularly the variables "living alone" and "perceived need for help", were important predictors for the use of services. Social care constituted more than half of the average weekly costs of municipalities. The perceived need for help with basic ADL was associated with higher costs. To ensure the quality of life among home-care clients while keeping costs reasonable is a challenge for municipalities.

The effects of integrated home care and discharge practice on functional ability and health-related quality of life: a cluster-randomised trial among home care patients.

OBJECTIVES: The aim was to evaluate the effects of integrated home care and discharge practice on the functional ability (FA) and health-related quality of life (HRQoL) of home care patients. METHODS: A cluster randomised trial (CRT) with Finnish municipalities (n=22) as the units of randomisation. At baseline the sample included 669 patients aged 65 years or over. Data consisted of interviews (at discharge, and at 3-week and 6-month follow-up), medical records and care registers. The intervention was a generic prototype of care/case management-practice (IHCaD-practice) that was tailored to municipalities needs. The aim of the intervention was to standardize practices and make written agreements between hospitals and home care administrations, and also within home care and to name a care/case manager pair for each home care patient. The main outcomes were HRQoL-as measured by a combination of the Nottingham Health Profile (NHP) and the EQ-5D instrument for measuring health status-and also Activities of Daily Living (ADL). All analyses were based on intention-to-treat. RESULTS: At baseline over half of the patient population perceived their FA and HRQoL as poor. At the 6-month follow-up there were no improvements in FA or in EQ-5D scores, and no differences between groups. In energy, sleep, and pain the NHP improved significantly in both groups at the 3-week and at 6-month follow-up with no differences between groups. In the 3-week follow-up, physical mobility was higher in the trial group. CONCLUSIONS: Although the effects of the new practice did not improve the patients' FA and HRQoL, except for physical mobility at the 3-week follow-up, the workers thought that the intervention worked in practice. The intervention standardised practices and helped to integrate services. The intervention was focused on staff activities and through the changed activities also had an effect on patients. It takes many years to achieve permanent changes in every worker's individual practice and it is also likely that changes in working practices would be visible before effects on patients. The use of other outcome measures, such as the use of services, may be clearer in showing a positive impact of the intervention rather than FA or HRQoL.