Barriers and facilitators to health care access for people experiencing homelessness in four European countries: an exploratory qualitative study.

BACKGROUND: People experiencing homelessness (PEH) are known to be at higher risk of adverse health outcomes and premature mortality when compared to the housed population and often face significant barriers when attempting to access health services. This study aimed to better understand the specific health care needs of PEH and the barriers and facilitators associated with their timely and equitable access to health services in the European context. METHODS: We conducted an exploratory cross-national qualitative study involving people with lived experience of homelessness and health and social care professionals in Austria, Greece, Spain, and the UK. A total of 69 semi-structured interviews comprising 15 social care professionals, 19 health care professionals, and 35 PEH were completed, transcribed, and analysed thematically. RESULTS: Findings were organised into three overarching themes relating to the research question: (a) Health care needs of PEH, (b) Barriers to health care access, and (c) Facilitators to health care access. Overall, the general health of PEH was depicted as extremely poor, and mainstream health services were portrayed as ill-equipped to respond to the needs of this population. Adopting tailored approaches to care, especially involving trusted professionals in the delivery of care, was identified as a key strategy for overcoming existing barriers. CONCLUSIONS: The results of this study indicate there to be a high degree of consistency in the health care needs of PEH and the barriers and facilitators associated with their access to health care across the various European settings. Homelessness in itself is recognized to represent an essential social determinant of health, with PEH at risk of unequal access to health services. Changes are thus required to facilitate PEH's access to mainstream primary care. This can also be further complemented by investment in 'in-reach' services and other tailored and person-centred forms of health care. TRIAL REGISTRATION: This study was registered retrospectively on June 6, 2022, in the registry of ClinicalTrials.gov under the number NCT05406687.

Evaluation design of the patient-centred pathways of early palliative care, supportive ecosystems and appraisal standard (InAdvance): a randomised controlled trial.

BACKGROUND: Palliative care aims to contribute to pain relief, improvement with regard to symptoms and enhancement of health-related quality of life (HRQoL) of patients with chronic conditions. Most of the palliative care protocols, programmes and units are predominantly focused on patients with cancer and their specific needs. Patients with non-cancer chronic conditions may also have significantly impaired HRQoL and poor survival, but do not yet receive appropriate and holistic care. The traditional focus of palliative care has been at the end-of-life stages instead of the relatively early phases of serious chronic conditions. The 'Patient-centred pathways of early palliative care, supportive ecosystems and appraisal standard' (InAdvance) project implements and evaluates early palliative care in the daily clinical routine addressing patients with complex chronic conditions in the evolution towards advanced stages. The objective of the current study is to evaluate the acceptability, feasibility, effectiveness and cost-effectiveness of this novel model of palliative care in the relatively early phases in patients with chronic conditions. METHODS: In this study, a single blind randomised controlled trial design will be employed. A total of 320 participants (80 in each study site and 4 sites in total) will be randomised on a 1:1 basis to the Palliative Care Needs Assessment (PCNA) arm or the Care-as-Usual arm. This study includes a formative evaluation approach as well as a cost-effectiveness analysis with a within-trial horizon. Study outcomes will be assessed at baseline, 6 weeks, 6 months, 12 months and 18 months after the implementation of the interventions. Study outcomes include HRQoL, intensity of symptoms, functional status, emotional distress, caregiving burden, perceived quality of care, adherence to treatment, feasibility, acceptability, and appropriateness of the intervention, intervention costs, other healthcare costs and informal care costs. DISCUSSION: The InAdvance project will evaluate the effect of the implementation of the PCNA intervention on the target population in terms of effectiveness and cost-effectiveness in four European settings. The evidence of the project will provide step-wise guidance to contribute an increased evidence base for policy recommendations and clinical guidelines, in an effort to augment the supportive ecosystem for palliative care. TRIAL REGISTRATION: ISRCTN, ISRCTN24825698 . Registered 17/12/2020.

[Application of the Community Assessment Risk Screen in Primary Care centres of the Valencia Health System]. / Aplicación de The Community Assessment Risk Screen en centros de atención primaria del Sistema Sanitario Valenciano.

OBJECTIVE: Application of The Community Assessment Risk Screen (CARS) tool for detection of chronic elderly patients at risk of hospital readmission and the viability study for its inclusion in health information systems. DESIGN: Retrospective cohort study. LOCATION: Health Departments 6, 10, and 11 from the Valencia Community. PARTICIPANTS: Patients of 65 and over seen in 6 Primary Care centres in December 2008. The sample consisted of 500 patients (sampling error=±4.37%, sampling fraction=1/307). VARIABLES: The CARS tools includes 3items: Diagnostics (heart diseases, diabetes, myocardial infarction, stroke, COPD, cancer), number of prescribed drugs and hospital admissions or emergency room visits in the previous 6months. The data came from SIA-Abucasis, GAIA and MDS, and were compared by Primary Care professionals. The end-point was hospital admission in 2009. RESULTS: CARS risk levels are related to future readmission (P<.001). The value of sensitivity and specificity is 0.64; the tool accurately identifies patients with low probability of being hospitalized in the future (negative predictive value=0.91, diagnostic efficacy=0.67), but has a positive predictive value of 0.24. CONCLUSIONS: CARS does not properly identify the population at high risk of hospital readmission. However, if it could be revised and the positive predictive value improved, it could be incorporated into the Primary Care computer systems and be useful in the initial screening and grouping of chronic patients at risk of hospital readmission.

Self-efficacy as a mediator between frailty and falls among community-dwelling older citizens.

Frailty is one of the most challenging issues among older adults, and the relationship between frailty and falls has already been assessed numerous times in literature. In the present study, we explored the mediating role of self-efficacy related to falls (FSe) in the relationship between frailty and fall risk. In a cross-sectional design, 1080 community-dwelling older adults from Rotterdam (Netherlands) and Valencia (Spain) completed a questionnaire and data were then analyzed via mediation analysis using a bootstrapping approach. Results show that higher frailty is associated with higher fall incidence, and higher FSe is a partial mediator of this association, with a confidence interval for the indirect effect of 0.131-0.247. Moreover, results showed gender differences in FSe levels; women had lower FSe scores. Deepening research on the construct of FSe may give potential explanations that account for the emerged gender differences, and it could be more targeted in fall prevention programs.

User-centred design of a clinical decision support system for palliative care: Insights from healthcare professionals.

Objective: Although clinical decision support systems (CDSS) have many benefits for clinical practice, they also have several barriers to their acceptance by professionals. Our objective in this study was to design and validate The Aleph palliative care (PC) CDSS through a user-centred method, considering the predictions of the artificial intelligence (AI) core, usability and user experience (UX). Methods: We performed two rounds of individual evaluation sessions with potential users. Each session included a model evaluation, a task test and a usability and UX assessment. Results: The machine learning (ML) predictive models outperformed the participants in the three predictive tasks. System Usability Scale (SUS) reported 62.7 ± 14.1 and 65 ± 26.2 on a 100-point rating scale for both rounds, respectively, while User Experience Questionnaire - Short Version (UEQ-S) scores were 1.42 and 1.5 on the -3 to 3 scale. Conclusions: The think-aloud method and including the UX dimension helped us to identify most of the workflow implementation issues. The system has good UX hedonic qualities; participants were interested in the tool and responded positively to it. Performance regarding usability was modest but acceptable.

Access to cancer preventive care and program considerations for people experiencing homelessness across four European countries: an exploratory qualitative study.

Background: People experiencing homelessness (PEH) have a higher prevalence of adverse health outcomes and premature mortality compared to the non-homeless population. These include a higher burden of cancer and cancer-specific morbidity and mortality-outcomes that may be a consequence of significant barriers to accessing primary and secondary prevention and community health services. This study aimed to better comprehend the health needs and barriers to accessing preventive cancer care for PEH across four European countries as well as necessary considerations for developing interventions around cancer prevention for this population. Methods: In this exploratory qualitative study, 69 semi-structured interviews were conducted across Austria, Greece, Spain, and the UK, with a sample comprising 15 professionals working in homelessness support services, 19 health professionals, and 35 PEH. Interviews took place between August 1 and October 31, 2021, and data were analysed inductively and iteratively following a thematic approach. Findings: Findings were organised into two overarching themes: (1) Experiences and understanding of cancer prevention and treatment and (2) Considerations for program interventions. While cancer was a significant worry among PEH across all settings, they generally had minimal knowledge and understanding of cancer symptoms and prevention. Specific programs for cancer prevention for PEH were described as almost non-existent. Health professionals in some settings indicated that cancer in PEH was often missed in the early stages and instead diagnosed when the severity of symptoms intensified. Interpretation: Overall, our findings indicate many commonalities in the health needs of PEH and the barriers they face when they seek access to cancer-specific healthcare services in the European context. Funding: This study received funding from the European Union's Horizon 2020 Research and Innovation Programme under GA 965351.

Barriers and facilitators for an effective palliative care communication with older people: A systematic review.

OBJECTIVES: The present mixed-method systematic review identifies facilitators and barriers in palliative care communication among health professionals and older people. METHODS: The review process was conducted by three reviewers who searched studies in four different databases (January 2009-January 2022), exploring experiences of communication among health professionals and older people without cognitive impairments. Relevant articles were quality assessed with a standardized tool. RESULTS: Twenty-eight articles were included and the following 5 clusters were identified: 1) training and education for health professionals, 2) team working and coordination among health professionals, 3) communication skills, 4) time and availability, 5) emotional, cultural and psychological factors. The articles highlighted the need for greater preparation of health professionals around the management of palliative care communication with older people. CONCLUSION: Palliative care communication among health professionals and older people are characterized by several challenges. However, there are facilitating aspects that may be considered to improve the quality of communication. PRACTICE IMPLICATIONS: Facilitators are promising approaches to support health professionals in providing high-quality palliative care communication to older people, developing a person-centred practice. Facilitators include palliative care training and educational opportunities for health professionals, like ELNEC Geriatric Curriculum, permitting them to develop specific competences in communication and aging.

Frailty as a Predictor of Adverse Outcomes among Spanish Community-Dwelling Older Adults.

Spain is one of the European countries with the oldest populations. The prevalence of frailty among Spanish older people ranges from 8.4 to 29.4% and currently, is one of the most relevant public health challenges. The Tilburg Frailty indicator (TFI) has been widely used in the community and in healthcare settings for assessing frailty. The objective of this study is to evaluate the predictive performance of the TFI for several adverse outcomes among Spanish community-dwelling older adults. The predictive performance was tested through linear regression analyses and receiver operating characteristics (ROC) curves. A total of 552 Spanish older adults composed the study sample. Participants were assessed at baseline and after 6 months. Main results showed that frailty was strongly and significantly correlated with disability, physical health, mental health and falls efficacy. The TFI score predicted most of these adverse outcomes. The ROC analyses confirmed the acceptable predictive performance of the total frailty. This study provides new evidence confirming that the TFI is a valid tool to predict several adverse outcomes in Spanish older adults, which may allow professionals to plan and activate health and social care resources to support frail patients' needs.

Palliative Care in Older People with Multimorbidities: A Scoping Review on the Palliative Care Needs of Patients, Carers, and Health Professionals.

Although numerous studies have been conducted previously on the needs of cancer patients at the end of their life, there is a lack of studies focused on older patients with non-oncological complex chronic multipathologies. Examining these needs would help to gain a greater understanding of the profile of this specific population within the palliative care (PC) pathway and how the health and care systems can address them. The aim of this review was to identify the needs influencing PC among older patients with multimorbidities, their relatives or informal caregivers, and the health professionals who provide care for these patients. A scoping literature review guided by the Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist was carried out with literature searched in the Medline, Embase, CINAHL, WoS, Cochrane Library, PsycINFO, and Scopus databases from 2009 to 2022. Eighty-one studies were included, demonstrating a great variety of unaddressed needs for PC among chronic older patients and the complexity in detecting those needs and how to refer them to PC pathways. This review also suggested a scarcity of tools and limited pathways for professionals to satisfy their needs for these patients and their families, who often felt ignored by the system. Substantial changes will be needed in health and care systems at the institutional level, providing more specialized PC environments and systematizing PC processes.

Complementary frailty and mortality prediction models on older patients as a tool for assessing palliative care needs.

Palliative care (PC) has demonstrated benefits for life-limiting illnesses. Bad survival prognosis and patients' decline are working criteria to guide PC decision-making for older patients. Still, there is not a clear consensus on when to initiate early PC. This work aims to propose machine learning approaches to predict frailty and mortality in older patients in supporting PC decision-making. Predictive models based on Gradient Boosting Machines (GBM) and Deep Neural Networks (DNN) were implemented for binary 1-year mortality classification, survival estimation and 1-year frailty classification. Besides, we tested the similarity between mortality and frailty distributions. The 1-year mortality classifier achieved an Area Under the Curve Receiver Operating Characteristic (AUC ROC) of 0.87 [0.86, 0.87], whereas the mortality regression model achieved an mean absolute error (MAE) of 333.13 [323.10, 342.49] days. Moreover, the 1-year frailty classifier obtained an AUC ROC of 0.89 [0.88, 0.90]. Mortality and frailty criteria were weakly correlated and had different distributions, which can be interpreted as these assessment measurements are complementary for PC decision-making. This study provides new models that can be part of decision-making systems for PC services in older patients after their external validation.

The Experiences and Views on Palliative Care of Older People with Multimorbidities, Their Family Caregivers and Professionals in a Spanish Hospital.

The increasing prevalence of complex chronic diseases in the population over 65 years of age is causing a major impact on health systems. This study aims to explore the needs and preferences of the multimorbid patient and carers to improve the palliative care received. The perspective of professionals who work with this profile of patients was also taken into account. A qualitative study was conducted using semi-structured interviews with open-ended questions. Separate topic guides were developed for patients, careers and health professionals. We included 12 patients, 11 caregivers and 16 health professionals in Spain. The results showed multiple unmet needs of patients and families/caregivers, including feelings of uncertainty, a sense of fear, low awareness and knowledge about palliative care in non-malignant settings, and a desire to improve physical, psychosocial and financial status. A consistent lack of specialized psychosocial care for both patients and caregivers was expressed and professionals highlighted the need for holistic needs assessment and effective and early referral pathways to palliative care. There is a lack of institutional support for multimorbid older patients in need of palliative care and important barriers need to be addressed by health systems to face the significant increase in these patients.

Palliative Care Needs and Integration of Palliative Care Support in COPD: A Qualitative Study.

BACKGROUND: The provision of palliative care for severe COPD remains low, resulting in unmet needs in patients and carers. RESEARCH QUESTIONS: What are the palliative care needs of patients living with severe COPD and their caregivers? What views of accessing and providing palliative care and factors influence these experiences. To what extent have palliative care and COPD services been integrated? STUDY DESIGN AND METHODS: A multicentre qualitative study was undertaken in COPD services and specialist palliative care in the United Kingdom involving patients with severe COPD, their carers, and health professionals. Data were collected using semistructured interviews and were analyzed using framework analysis. Themes were integrated using the constant comparison process, enabling systematic data synthesis. RESULTS: Four themes were generated from interviews with 20 patients, six carers, and 25 health professionals: management of exacerbations, palliative care needs, access to palliative care and pathways, and integration of palliative care support. Uncertainty and fear were common in patients and carers, with identified needs for reassurance, rapid medical access, home care, and finance advice. Timely palliative care was perceived as important by health professionals. Palliative care was integrated into COPD services, although models of working varied across regions. Reliable screening tools and needs assessment, embedded psychological care, and enhanced training in palliative care and communication skills were perceived to be important by health professionals for timely palliative care referrals and optimized management. INTERPRETATION: Palliative care increasingly is being implemented for nonmalignant diseases including COPD throughout the United Kingdom, although models of working vary. A theoretical model was developed to illustrate the concept and pathway of the integration of palliative care support. A standardized screening and needs assessment tool is required to improve timely palliative care and to address the significant needs of this population.

Impact of a primary-based telemonitoring programme in HRQOL, satisfaction and usefulness in a sample of older adults with chronic diseases in Valencia (Spain).

BACKGROUND: Chronic patients are frequent users of healthcare services and are prone to hospital admissions. In Valencia (Spain) the Valcronic programme aims to manage chronic patients through different levels of telemonitoring and telecare. This paper examines the impact of the Valcronic programme on self-perceived HRQOL in a one-year period and on perceptions of satisfaction and usefulness in a sample of older adults with chronic diseases. METHODS: The sample (n=74) was randomly selected from Valcronic users and was stratified considering different variables. HRQOL was assessed using the EQ-5D questionnaire at two points in time: before the beginning of the Valcronic programme and after a one-year follow-up. Satisfaction and usefulness were evaluated one year after users' inclusion. RESULTS: The whole sample experienced improvement, although not significant, of its HRQOL; patients over 75 showed impairment. Patients with at least one problem in the EQ-5D dimensions decreased after one year (82.43% vs. 74.32%). Users' perceptions of satisfaction and usefulness were highly positive. CONCLUSIONS: Our sample benefited from the Valcronic programme, experiencing an improvement in their HRQOL, a decreased use of health resources or high satisfaction levels. IMPLICATIONS: Further adjustments are needed to address a comprehensive response to the needs of the global population of reference.

Application of screening tools to detect risk of hospital readmission in elderly patients in Valencian Healthcare System (VHS) (Spain).

The Sustainable Social and Healthcare Model (SSHM) is aimed to establish new care pathways in primary care systems contributing to the decrease of health services use and costs and improve the integration and efficiency of social and health care for elderly people with long-term care (LTC) needs. One of these strategies is the segmentation of population in risk groups through standardized tools. This paper is a retrospective study aimed to determine the viability of the implementation of the screening tools Probability of Repeated Admission - Pra - and The Community Assessment Risk Screen - CARS - to detect patients at risk of hospital readmission in a sample of 500 elderly people (65+) from the VHS in Spain. Patients were recruited from three Health Departments. Data from selected tools and predictive variables were collected through the healthcare database from the VHS. The most important results indicate that both instruments predict with high efficacy the proportion of patients not readmitted (negative predictive value between 91% and 92%). Moreover, the tools performed with a moderate efficiency being the Pra less sensitive (54%) and more specific (81%) than CARS (with a sensitivity and specificity of 64%). Results from this study suggest that the application of instruments as Pra and CARS are of interest to the Valencian Health Administration as they can be a good strategy to improve the management of elderly patients at risk with comorbidities and guiding clinical decision.