Haalbaarheid van een poliklinisch geriatrisch Revalidatieprogramma – lessen uit een pilotproject

Doel Beschrijven van de haalbaarheid van een poliklinisch geriatrisch behandelprogramma, als pilotproject ontwikkeld in Vivium Naarderheem. Methoden De uitkomsten werden onderzocht in een pretest-posttest design met één groep. Haalbaarheid werd onderzocht door mondelinge afname van een patiënttevredenheidsvragenlijst en door gestructureerde interviews met behandelaars en management. Het effect werd onderzocht door bij start (T0) en bij ontslag (T1) van het behandelprogramma schriftelijke vragenlijsten af te nemen: bij de patiënten over het participatieniveau en de gezondheidsgerelateerde kwaliteit van leven en bij hun mantelzorgers over de ervaren belasting. Resultaten Er werden 18 patiënten geïncludeerd. Vijftien daarvan revalideerden na een CVA. Behandelaars en managers vonden het programma uitvoerbaar, op voorwaarde dat het vervoer van de patiënten, de roosterplanning en de financiering goed geregeld zijn. Het behandelprogramma werd door de patiënten met een gemiddeld rapportcijfer van 8,1 gewaardeerd. Er zijn geen statistisch significante verschillen gevonden in het participatieniveau van de patiënten en in de zorgbelasting van de mantelzorgers bij de start en het einde van de poliklinische behandeling. De algemene gezondheidsbeleving, gemeten met de RAND-36, was na poliklinische revalidatie achteruit gegaan. Conclusie Uit deze pilotstudie blijkt dat vijftien van de achttien patiënten die gebruik maken van de polikliniek, revalideert vanwege CVA. Poliklinische geriatrische revalidatie is een door de bevraagde patiënten gewaardeerde aanvulling op de klinische revalidatieperiode, en de uitvoering ervan lijkt haalbaar. Een verbetering van de gezondheidstoestand of van het participatieniveau kon niet worden aangetoond

Association of Vulnerability Screening on Hospital Admission with Discharge to Rehabilitation-Oriented Care after Acute Hospital Stay

Background The short Dutch Safety Management Screening (DSMS) is applied at hospital admission of all patients aged >70 years to assess vulnerability. Screening of four geriatric domains aims to prevent adverse outcomes and may support targeted discharge planning for post-acute care. We explored whether the DSMS criteria for acutely admitted patients were associated with rehabilitation-oriented care needs. Methods This retrospective cohort study included community-dwelling patients aged ≥70 years acutely admitted to a tertiary hospital. We recorded patient demographics, morbidity, functional status, malnutrition, fall risk, and delirium and used descriptive analysis to calculate the risks by comparing the discharge destination groups. Results Among 491 hospital discharges, 349 patients (71.1%) returned home, 60 (12.2%) were referred for geriatric rehabilitation, and 82 (16.7%) to other inpatient post-acute care. Non-home referrals increased with age from 21% (70–80 years) to 61% (>90 years). A surgical diagnosis (odds ratio [OR]=4.92; 95% confidence interval [CI], 2.03–11.95), functional decline represented by Katz-activities of daily living positive screening (OR=3.79; 95% CI, 1.76–8.14), and positive fall risk (OR=2.87; 95% CI, 1.31–6.30) were associated with non-home discharge. The Charlson Comorbidity Index did not differ significantly between the groups. Conclusion Admission diagnosis and vulnerability screening outcomes were associated with discharge to rehabilitation-oriented care in patients >70 years of age. The usual care data from DSMS vulnerability screening can raise awareness of discharge complexity and provide opportunities to support timely and personalized transitional care

Value-based healthcare in ischemic stroke care: Case-mix adjustment models for clinical and patient-reported outcomes

Background: Patient-Reported Outcome Measures (PROMs) have been proposed for benchmarking health care quality across hospitals, which requires extensive case-mix adjustment. The current study's aim was to develop and compare case-mix models for mortality, a functional outcome, and a patient-reported outcome measure (PROM) in ischemic stroke care. Methods: Data from ischemic stroke patients, admitted to four stroke centers in the Netherlands between 2014 and 2016 with available outcome information (N = 1022), was analyzed. Case-mix adjustment models were developed for mortality, modified Rankin Scale (mRS) scores and EQ-5D index scores with respectively binary logistic, proportional odds and linear regression models with stepwise backward selection. Predictive ability of these models was determined with R-squared (R2) and area-under-The-receiver-operating-characteristic-curve (AUC) statistics. Results: Age, NIHSS score on admission, and heart failure were the only common predictors across all three case-mix adjustment models. Specific predictors for the EQ-5D index score were sex (β = 0.041), socio-economic status (β =-0.019) and nationality (β =-0.074). R2-values for the regression models for mortality (5 predictors), mRS score (9 predictors) and EQ-5D utility score (12 predictors), were respectively R2 = 0.44, R2 = 0.42 and R2 = 0.37. Conclusions: The set of case-mix adjustment variables for the EQ-5D at three months differed considerably from the set for clinical outcomes in stroke care. The case-mix adjustment variables that were specific to this PROM were sex, socio-economic status and nationality. These variables should be considered in future attempts to risk-Adjust for PROMs during benchmarking of hospitals

Geriatrische revalidatiezorg: samen werken aan herstel!

Revalidatie in samenwerking met verschillende discipline

The Influence of Activity-Based Funding on Treatment Intensity and Length of Stay of Geriatric Rehabilitation Patients

Aim Little is known about the impact of activity-based funding (ABF) to increase treatment intensity and decrease length of stay (LOS) of inpatient geriatric patients. In January 2014, ABF was implemented in The Netherlands with the aim to increase treatment intensity and shorten LOS in geriatric rehabilitation (GR). Objectives To describe the influence of ABF on treatment intensity and LOS of inpatient GR patients before and after ABF was implemented. Design Population-based, retrospective cohort study. Setting Thirty nursing homes providing inpatient GR across The Netherlands. Data Collection Digital medical records of patients who had received inpatient GR in Dutch nursing homes across The Netherlands were studied between January 1, 2013 and March 14, 2016. We calculated the mean treatment intensity in hours per week and median LOS in days in 3 cohorts according to the year of admittance. In addition, a historical representative cohort of GR patients who were admitted in 2007 was studied that represented the situation before the ABF reform was announced (eg, funding with a fixed price per day). In 2013, the funding with a fixed price per day was still in use but with compulsory ABF registration. In 2014 and 2015, the ABF was fully implemented. Statistical differences in treatment intensity and LOS were calculated between patients admitted in 2007 and 2013, 2013 and 2014, and 2013 and 2015. Statistical significance was set at a P value of <.02 (Bonferroni correction P =.05/3). Discharge destinations of patients discharged from March 1, 2015 to January 1, 2016 could be obtained and compared with 2007. Results The treatment intensity and LOS of 16,823 GR patients could be obtained and compared with the historical cohort from 2007 (n = 2950). Patients who were admitted in the year 2013 received higher treatment intensities and had the same median LOS compared with 2007. After the implementation of ABF in January 2014, the mean treatment intensity increased significantly by 37% (3.8 hours/week in 2013, 4.7 hours/week in 2014, and 5.2 hours/week in 2015). This trend was significant across all rehabilitation diagnoses. After the implementation of ABF, the median LOS decreased significantly by 7 days (46 days in 2013, 42 days in 2014, and 39 days in 2015), which was consistent in all rehabilitation categories except for patients with a total joint replacement or amputation. Conclusions Patients who received inpatient GR after introduction of ABF received higher treatment intensities and had a shorter LOS compared with the year before implementation

Parkinson rehabilitation in nursing homes: a qualitative exploration of the experiences of patients and caregivers

Purpose: Worldwide, an increasing number of people are diagnosed with atypical Parkinsonism or idiopathic Parkinson’s disease (PD). Periods of acute functional decline, triggered by acute disease, are common. Rehabilitation is often necessary to restore functioning. Skilled nursing facilities (SNFs) in the Netherlands have developed evidence-based geriatric rehabilitation for Parkinson (GR-P) programs. However, data on the experiences and needs of patients and their caregivers are lacking. This study aims to address these, in order to propose recommendations for improvement. Methods: We performed a qualitative study, using semi-structured interviews in two Dutch SNFs offering GR-P. Nine patients with PD and six informal caregivers were included. We subjected verbatim transcripts of 15 interviews to qualitative analysis. Results: Data saturation was reached after 15 interviews. Three overarching themes emerged: (1) autonomy, (2) sharing information and (3) contact with others. Loss of autonomy was linked to the underlying disease and the rehabilitation environment itself. Patients and caregivers felt overwhelmed by events before and during rehabilitation, expressing a need to receive information and discuss prior experiences. They considered communication between hospitals and SNFs to be poor. Patients did not always appreciate contact with peers. Both patients and caregivers appreciated empathic healthcare personnel with a firm knowledge on PD. Conclusions: Autonomy, sharing information and contact with others are central themes for patients and caregivers during GR-P in SNFs. We recommend actively exploring these three central themes with every patient and caregiver entering a GR-P program and offering staff continuing education on PD, in order to improve care

Effectiveness and characteristics of physical fitness training on aerobic fitness in vulnerable older adults: an umbrella review of systematic reviews

Objectives To present an overview of effectiveness and training characteristics of physical training on aerobic fitness, compared with alternative or no training, in adults aged over 65 years with various health statuses, providing a basis for guidelines for aerobic training of vulnerable older adults that can be used in geriatric rehabilitation. Design An umbrella review of systematic reviews that included both randomised controlled trials and other types of trials. Data sources MEDLINE, Embase, CINAHL and the Cochrane Library were searched on 9 September 2019. Eligibility criteria for selecting studies We included systematic reviews reporting on physical training interventions that are expected to improve aerobic fitness, presenting results for adults aged 65 years and older, describing at least one of the FITT-characteristics: Frequency, Intensity, Time or Type of exercise, and measuring aerobic fitness at least before and after the intervention. Data extraction and synthesis Two independent reviewers extracted the data and assessed the risk of bias. A narrative synthesis was performed. Results We included 51 papers on 49 reviews. Positive effect of training on aerobic fitness was reported by 33 reviews, 11 reviews remained inconclusive and 5 reviews reported no effect. Training characteristics varied largely. Frequency: 1-35 sessions/week, Intensity: light-vigorous, Time: <10-120 min/session and Types of exercise: many. The methodological quality was most often low. Subgroup analyses revealed positive effects for all health conditions except for trauma patients. Exercise characteristics from current existing guidelines are widely applicable. For vulnerable older adults, lower intensities and lower frequencies were beneficial. Some health conditions require specific adjustments. Information on adverse events was often lacking, but their occurrence seemed rare. Conclusion Physical fitness training can be effective for vulnerable older adults. Exercise characteristics from current existing guidelines are widely applicable, although lower frequencies and intensities are also beneficial. For some conditions, adjustments are advised. PROSPERO registration number CRD42020140575

Changes in geriatric rehabilitation: a national programme to improve quality of care. The Synergy and Innovation in Geriatric Rehabilitation study

<p><strong>Objective: </strong>To describe changes in the health service delivery process experienced by professionals, patients and informal caregivers during implementation of a national programme to improve quality of care of geriatric rehabilitation by improving integration of health service delivery processes.</p><p><br /><strong>Study setting: </strong>Sixteen skilled nursing facilities.</p><p><br /><strong>Study design: </strong>Prospective study, comparing three consecutive cohorts.</p><p><br /><strong>Data collection: </strong>Professionals (elderly care physicians, physiotherapists and nursing staff) rated four domains of health service delivery at admission and at discharge of 1075 patients. In addition, these patients [median age 79 (Interquartile range 71–85) years, 63% females] and their informal caregivers rated their experiences on these domains 4 weeks after discharge.</p><p><br /><strong>Principal findings: </strong>During the three consecutive cohorts, professionals reported improvement on the domain team cooperation, including assessment for intensive treatment and information transfer among professionals. Fewer improvements were reported within the domains alignment with patients’ needs, care coordination and care quality. Between the cohorts, according to patients (<span class="italic">n</span> = 521) and informal caregivers (<span class="italic">n</span> = 319) there were no changes in the four domains of health service delivery.</p><p><br /><strong>Conclusion: </strong>This national programme resulted in small improvements in team cooperation as reported by the professionals. No effects were found on patients’ and informal caregivers’ perceptions of health service delivery.</p

Successful Geriatric Rehabilitation: Effects on Patients' Outcome of a National Program to Improve Quality of Care, the SINGER Study

Objective To determine whether the implementation of a national program to improve quality of care in geriatric rehabilitation (GR) in the Netherlands improves successful GR in terms of independence in activities of daily living (ADL), discharge destination, and length of stay. Design Prospective longitudinal study, comparing 2 consecutive cohorts: at the start of implementation (n = 386) and at 1 year after implementation (n = 357) of this program. Setting/Participants Included were 16 skilled nursing facilities, 743 patients (median age 80 years, interquartile range 72–85; 64.5% females) indicated for GR and their health care professionals (elderly care physicians, physiotherapists, and nursing staff). Intervention National program to stimulate self-organizing capacity to develop integrated care to improve GR service delivery in 4 domains: alignment with patients’ (care) needs, care coordination, team cooperation, and quality of care. Measurements Data on patients’ characteristics, functional outcomes at admission and discharge, length of stay, and discharge destination were collected via an online questionnaire sent to health care professionals. The primary outcome measure was successful rehabilitation defined as independence in ADL (Barthel Index ≥15), discharge home, and a short length of stay (lowest 25% per diagnostic group). Generalized estimating equation analysis was used to adjust for age, gender, and clustering effects in the total population and for the 2 largest diagnostic subgroups, traumatic injuries and stroke. Results In the total population, at 1 year postimplementation there was 12% more ADL independence [odds ratio (OR) 1.59, 95% confidence interval (CI) 1.00–2.54]. Although successful rehabilitation (independence in ADL, discharge home, short length of stay) was similar in the 2 cohorts, patients with traumatic injuries were more successful 1 year postimplementation (OR 1.61, 95% CI 1.01–2.54). In stroke patients, successful rehabilitation was similar between the cohorts, but with more independence in ADL in the follow-up cohort (OR 1.99, 95% CI 1.09–3.63). Conclusions This study shows that 1-year after the implementation of the Dutch national program to improve quality of care there was more independence in ADL at discharge, but the combined outcome of successful GR (independence in ADL, discharge home, short length of stay) was only significantly improved in patients with traumatic injuries