La qualité des services d’aide à domicile dispensés aux personnes âgées dépendantes : les perspectives des différents acteurs

Le nombre des personnes âgées nécessitant de l’aide pour accomplir les activités essentielles de la vie quotidienne ne cesse d’augmenter. Leur maintien à domicile devient de plus en plus un défi sociétal majeur et nécessite la dispensation de services d’aide de qualité. L’organisation de ces services est souvent confrontée à plusieurs difficultés telles que les problèmes de financement, l’augmentation importante des demandes, la fragmentation du système de santé et le manque de personnel compétent. Cette situation ne facilite pas l’amélioration de la qualité d’aide qui, par ailleurs, reste difficile à définir et à mesurer. En France les travaux de recherche et d’évaluation concernant la qualité d’aide à domicile sont peu développés. D’après différents auteurs, les études existantes, y compris celles réalisées dans d’autres contextes, sont confrontées aux problèmes méthodologiques et conceptuels. Ces auteurs constatent le manque de précision des concepts utilisés dans ces travaux, le recours aux méthodes et aux outils de recherche et d’évaluation peu appropriés à l’étude des services concernés, ainsi que le défaut d’implication des acteurs intéressés. C’est pourquoi il est opportun de poursuivre la recherche dans ce domaine afin de disposer de connaissances scientifiques permettant de mieux comprendre en quoi consiste la qualité d’aide pour mieux la définir et l’apprécier. C’est dans ce but que nous avons réalisé une étude qualitative des perspectives des acteurs de l’aide à domicile, personnes âgées, intervenants et gestionnaires, visant à comprendre la conception de la qualité d’aide, à décrire ses attributs et à identifier les facteurs facilitant ou limitant la dispensation d’un service d’aide de qualité. La pertinence de cette étude relève à la fois de la prise en compte des perspectives de tous les acteurs concernés, mais aussi de la considération de leurs expériences, y compris celles des personnes âgées considérées comme acteurs et non pas uniquement comme bénéficiaires. Les résultats de l’étude montrent que la qualité d’aide est multidimensionnelle. Elle comprend sept dimensions, la justesse, la relation interpersonnelle, l’attitude, les qualités personnelles et la compétence des intervenants, la qualité organisationnelle et les valeurs éthiques qui constituent trois champs de la qualité d’aide : relationnel, procédural et transversal. En plus de l’information descriptive très détaillée concernant les attributs de la qualité d’aide, trois principaux résultats synthétiques de cette étude sont à souligner : l’ensemble des répondants s’accorde sur l’importance de certaines dimensions de la qualité d’aide à savoir la relation interpersonnelle, la justesse des réponses et les qualités personnelles; ensuite, la relation socioaffective entre les intervenants et les personnes âgées est considérée avant toute autre mission instrumentale affirmant que le besoin principal de la personne âgée est celui de garder le lien social; enfin, plusieurs attributs de la qualité sont interdépendants et forment un système de relations nécessitant l’implication de chaque acteur. Ainsi, un service d’aide de qualité s’inscrit dans une approche globale et personnalisée afin de répondre à la fois aux besoins fonctionnels et aux besoins socioaffectifs des personnes aidées. Il requiert des compétences individuelles et collectives. De ce fait, la qualité d’aide devient le produit d’un processus organisationnel et clinique visant à répondre aux besoins de la personne âgée dans une approche personnalisée lui permettant d’être en relation, d’avoir une aide fonctionnelle spécifique à ses incapacités et prenant en compte ses capacités restantes. Cette étude contribue au développement des connaissances pour l’amélioration de la qualité des services d’aide, en apportant les éléments de compréhension relatifs à la conception et à la définition de la qualité d’aide, basés sur les perceptives des acteurs directement concernés, et en identifiant les facteurs perçus par ces acteurs comme des obstacles à la qualité. En outre, les résultats de l’étude précisent les attributs et les dimensions de la qualité des services d’aide, cela permet de rendre la notion de la qualité d’aide moins abstraite, donc de déterminer les prémisses d’un cadre conceptuel propre à la qualité d’aide à domicile et de faciliter l’élaboration des indicateurs de la qualité d’aide et la mise en place de la démarche qualité pour les services d’aide à domicile.The number of elderly in needs of personal assistance services in Activities of daily living and Instrumental activities of daily living keeps on increasing. The home- and community-based support for that population is becoming a major societal challenge and requires delivering quality home support services. The organization of these services is often faced with financial problems, increasing service demands, health care system fragmentation and lack of health care professionals qualified in home care services for the elderly. Such situation does not facilitate quality service improvement; moreover, definition and measurement of quality remain difficult. Indeed, in France, research and evaluation of personal assistance services’ quality are underdeveloped. According to different authors, most of the existing studies, including those conducted in other contexts, have faced methodological and conceptual problems. These authors note in particular the lack of clarification of the concepts used in these studies, the use of research methods and evaluation tools which are less appropriate according to the nature of the concerned services, as well as not considering the stakeholders’ perspectives. For those reasons, they recommend further research in this field in order to produce scientific knowledge that will allow a better understanding of the quality of personal assistance services, its definition and measurement. To address this concern, we conducted a qualitative study based on stakeholder’s perspectives, of both the elderly person and the service providers (formal carers and organization managers). This research was aimed at understanding the quality of home care services from a stakeholder’s perspective, to describe its attributes and to identify the factors facilitating or hindering the provision of a quality support service. Taking into account the point of view of all these actors, considering the elderly person as the key actor and not only as the beneficiary of services, as well as emphasizing the real experience of the concerned actors, are among the elements making the relevancy of this thesis. The results of the study show that the quality of personal assistance services is multidimensional. It consists of seven dimensions categorized into three fields. The relationship field composed of interpersonal relationship, attitude of providers, personal qualities, the procedural field composed of appropriateness and relevance of services, and the transversal field composed of competence and ethical values. In addition, three main findings of this study must be emphasized. Firstly, all participants agreed on the importance of essential dimensions of the quality of personal assistance services, namely interpersonal relationship, appropriateness and relevance of services according to the elderly needs, and personal qualities. Secondarily, socio-affective support was firmly asserted more than instrumental support, in acknowledgment of the necessity of meeting the main need of older persons to maintain social contact. Lastly, several quality attributes are interrelated and form a system of relations requiring the involvement of each actor. Thus, quality personal assistance service falls under a comprehensive and personalized approach in order to meet both the functional and socio-affective needs for the elderly person. It requires individual and collective competences. A such, the quality of personal assistance becomes the result of an organizational and clinical process, aimed at addressing the needs of the elderly person in a personalized approach enabling him to be in relationship and maintain social links, to have a functional assistance specific to his disabilities all while considering his remaining capacities. This study contributes to both the development of knowledge and the improvement of home personal assistance practices. The attributes and dimensions of quality identified constitute the premises of a specific conceptual framework of the quality of home care services. In addition, they may contribute to the development of relevant indicators of quality and the implementation of quality assurance for home care services

Patients’ Experiences of Seclusion during Admission in Psychiatric Settings in KwaZulu-Natal: A Qualitative Study

Background In South Africa, seclusion is one of the practices used in the management of disruptive behaviors in psychiatric settings. Despite its continued use, seclusion is always subject to controversial debates, and patients who undergo it express a range of negative experiences. Objective To explore the experiences of patients regarding seclusion during their admission in a psychiatric hospital. Methods A qualitative descriptive design was used. In-depth interviews were conducted with ten patients attending a community psychiatric clinic in KwaZulu-Natal. Interviews were analyzed using content analysis. Results Two themes emerged from the findings: controversial views of seclusion and negative experiences of seclusion. Seclusion was considered more as a punishment measure which was often used abusively, than a therapeutic intervention. Participants expressed loneliness, humiliation, and powerlessness following their seclusion experience. Limited patient-staff interaction and communication worsened patients’ negativity towards seclusion. Conclusion Findings from this study underscore the need to review practices, policies and procedures regarding the use of seclusion. Seclusion should be only used when the need is absolute and as the last treatment option. Open communication between the care providers and the patients should be emphasized during the time of seclusion. Rwanda J Med Health Sci 2020;3(3):342-36

Diagnostic study, design and implementation of an integrated model of care in France: a bottom-up process with continuous leadership

<strong>Background: </strong>Sustaining integrated care is difficult, in large part because of problems encountered securing the participation of health care and social service professionals and, in particular, general practitioners (GPs). <p><br /><strong>Purpose: </strong>To present an innovative bottom-up and pragmatic strategy used to implement a new integrated care model in France for community-dwelling elderly people with complex needs.</p><p><br /><strong>Results: </strong>In the first step, a diagnostic study was conducted with face-to-face interviews to gather data on current practices from a sample of health and social stakeholders working with elderly people. In the second step, an integrated care model called Coordination Personnes Agées (COPA) was designed by the same major stakeholders in order to define its detailed characteristics based on the local context. In the third step, the model was implemented in two phases: adoption and maintenance. This strategy was carried out by a continuous and flexible leadership throughout the process, initially with a mixed leadership (clinician and researcher) followed by a double one (clinician and managers of services) in the implementation phase.</p><p><br /><strong>Conclusion: </strong>The implementation of this bottom-up and pragmatic strategy relied on establishing a collaborative dynamic among health and social stakeholders. This enhanced their involvement throughout the implementation phase, particularly among the GPs, and allowed them to support the change practices and services arrangements</p

Assessing the implementation and effectiveness of early integrated palliative care in long-term care facilities in France: an interventional mixed-methods study protocol

Abstract Background Majority of residents in long-term care facilities (LTCF) have limited and delayed access to palliative care even though many suffer from incurable chronic illnesses that will likely require the provision of palliative care. We present the study protocol of “PADI-Palli”, an intervention aims to advance early integrated palliative care into standard care delivered in LTCF. This study will assess the effectiveness of early integrated palliative care on palliative care accessibility for older persons in LTCF, and identify the key factors for the successful implementation of early integrated palliative care and its sustainability in the LTCF context. Methods This multicentre interventional study utilises a pragmatic research design with a convergent parallel mixed-methods approach. The qualitative study will use a case study design and the quantitative study will use a stepped wedge cluster randomised trial. In total, 21 participating LTCF from three French regions will be randomly allocated to one of seven clusters. The clusters will cross over from the usual care to the active intervention condition over the course of the study. The primary outcome relates to the accurate identification of palliative care needs and early access to palliative care for LTCF residents. Secondary outcomes are quality of care, quality of life for residents and their families, and quality of life at work for professionals. Measurements will be performed before and after the intervention. Implementation and evaluation of PADI-Palli intervention is grounded in the Consolidated Framework for Implementation Research. Discussion Existing evidence demonstrates that early integrated palliative care in cancer care leads to a significant improvement in patient outcomes and processes of care. Little is known, however, about early integrated palliative care in the context of LTCF for older persons. This study has the potential to fill this gap in the literature by providing evidence on the effectiveness of early integrated palliative care for older persons in LTCF. Moreover, this study will provide a better understanding of the relevant contextual elements that facilitate or hinder early integrated palliative care implementation and transferability. If proven effective, this intervention can be scaled to other care settings in which older persons require palliative care. Trial registration ClinicalTrials.gov ID: NCT04708002; National registration: ID-RCB number: 2020-A01832-37

Impacts on health outcomes and on resource utilisation of home-based parenteral chemotherapy administration: a systematic review protocol

International audienceINTRODUCTION:Despite the demonstrated feasibility and policies to enable more to receive chemotherapy at home, in a few countries, parenteral chemotherapy administration at home remains currently marginal. Of note, findings of different studies on health outcomes and resources utilisation vary, leading to conflicting results. This protocol outlines a systematic review that seeks to synthesise and critically appraise the current state of evidence on the comparison between home setting and hospital setting for parenteral chemotherapy administration within the same high standards of clinical care.METHODS AND ANALYSIS:This protocol has been prepared following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols approach. Electronic searches will be conducted on bibliographic databases selected from the earliest available data through 15 November 2017 published in French and English languages. Additional potential papers in the selected studies and grey literature will be also included in the review. The review will include all types of studies exploring patients receiving anticancer drugs for injection at home compared with patients receiving the drugs in a hospital setting, and will assess at least one of the following criteria: patients' health outcomes, patients' or caregivers' satisfaction, resource utilisation with cost savings, and incentives and/or barriers of each admission setting according to patients' and relatives' points of view. Two reviewers will independently screen studies and extract relevant data from the included studies. Methodological quality of studies will be assessed using the 'Quality Assessment Tool for Quantitative Studies' developed by the Effective Public Health Practice Project tool, in addition to the Consolidated Health Economic Evaluation Reporting Standards statement for economic studies.ETHICS AND DISSEMINATION:As the review is focused on the analysis of secondary data, it does not require ethics approval. The results of the study will be disseminated through articles in peer-reviewed journals and trade publications, as well as presentations at relevant conferences.PROSPERO REGISTRATION NUMBER:CRD42017068164

Implementation of a Standardized Comprehensive Assessment Tool in France: A Case Using the InterRAI Instruments

Background: The improvement of quality of care requires a standardized and comprehensive assessment tool but implementation is challenging. Purpose: We have reported on the development of the interRAI instruments in France from the onset to the mandatory use at the national level. We also have identified in the literature and in practices, incentives and barriers for the implementation of this integrated clinical information system in long term care. Results: Three periods in the interRAI instruments development were identified over the last twenty years. The first one was a research approach about improving quality of long term care. The second one was an experimental clinical use into an integrated care model with case management. The third one was a call for tenders issued by a French national agency, and the choice to use the interRAI-HC (Home Care) for all case managers. The main incentives and barriers that were identified include the national context, the target population, the providers involved and the impact on their practice, the interRAI instrument characteristics, training and leadership. Conclusion: This historical overview of the development of interRAI instruments in France gives health care organizations pertinent information to guide the implementation of a standardized and comprehensive assessment tool

: Safety culture in nursing homes

International audienceThe objective was to translate into French the American questionnaire "Nursing Home Survey on Patient Safety Culture" and to test the feasibility of its use in a sample of nursing homes. The questionnaire was translated by a multidisciplinary group of six experts and tested on a sample of people working in nursing homes. The questionnaire was then administered in five nursing homes. A first version of the French NHSPSC is proposed in this article. Despite similarities between items and ceiling effect for one item, the choices made were conservative to allow international comparisons. The administration of the questionnaire in five nursing homes confirmed the feasibility of the approach, with a participation of more than 50 per cent. This work made a French version of the NHSPSC available and confirmed that it is a feasible method for evaluating safety culture in nursing homes