Evaluation of integrated care services in Catalonia: Population-based and service-based real-life deployment protocols

Background: Comprehensive assessment of integrated care deployment constitutes a major challenge to ensure quality, sustainability and transferability of both healthcare policies and services in the transition toward a coordinated service delivery scenario. To this end, the manuscript articulates four different protocols aiming at assessing large-scale implementation of integrated care, which are being developed within the umbrella of the regional project Nextcare (2016-2019), undertaken to foster innovation in technologically-supported services for chronic multimorbid patients in Catalonia (ES) (7.5 M inhabitants). Whereas one of the assessment protocols is designed to evaluate population-based deployment of care coordination at regional level during the period 2011-2017, the other three are service-based protocols addressing: i) Home hospitalization; ii) Prehabilitation for major surgery; and, iii) Community-based interventions for frail elderly chronic patients. All three services have demonstrated efficacy and potential for health value generation. They reflect different implementation maturity levels. While full coverage of the entire urban health district of Barcelona-Esquerra (52

Rehabilitation Profiles of Older Adult Stroke Survivors Admitted to Intermediate Care Units: A Multi-Centre Study

Background: Stroke is a major cause of disability in older adults, but the evidence around post-acute treatment is limited and heterogeneous. We aimed to identify profiles of older adult stroke survivors admitted to intermediate care geriatric rehabilitation units. Methods: We performed a cohort study, enrolling stroke survivors aged 65 years or older, admitted to 9 intermediate care units in Catalonia-Spain. To identify potential profiles, we included age, caregiver presence, comorbidity, pre-stroke and post-stroke disability, cognitive impairment and stroke severity in a cluster analysis. We also proposed a practical decision tree for patient's classification in clinical practice. We analyzed differences between profiles in functional improvement (Barthel index), relative functional gain (Montebello index), length of hospital stay (LOS), rehabilitation efficiency (functional improvement by LOS), and new institutionalization using multivariable regression models (for continuous and dichotomous outcomes). Results: Among 384 patients (79.1±7.9 years, 50.8% women), we identified 3 complexity profiles: a) Lower Complexity with Caregiver (LCC), b) Moderate Complexity without Caregiver (MCN), and c) Higher Complexity with Caregiver (HCC). The decision tree showed high agreement with cluster analysis (96.6%). Using either linear (continuous outcomes) or logistic regression, both LCC and MCN, compared to HCC, showed statistically significant higher chances of functional improvement (OR = 4.68, 95%CI = 2.54-8.63 and OR = 3.0, 95%CI = 1.52-5.87, respectively, for Barthel index improvement ≥20), relative functional gain (OR = 4.41, 95%CI = 1.81-10.75 and OR = 3.45, 95%CI = 1.31-9.04, respectively, for top Vs lower tertiles), and rehabilitation efficiency (OR = 7.88, 95%CI = 3.65-17.03 and OR = 3.87, 95%CI = 1.69-8.89, respectively, for top Vs lower tertiles). In relation to LOS, MCN cluster had lower chance of shorter LOS than LCC (OR = 0.41, 95%CI = 0.23-0.75) and HCC (OR = 0.37, 95%CI = 0.19-0.73), for LOS lower Vs higher tertiles. Conclusion: Our data suggest that post-stroke rehabilitation profiles could be identified using routine assessment tools and showed differential recovery. If confirmed, these findings might help to develop tailored interventions to optimize recovery of older stroke patients

Association between the clusters and outcomes.

<p>Association between the clusters and outcomes.</p

Decision tree for cluster´s allocation.

<p>^a The total of patient classified into this cluster are represent by the first number; if there is a misclassification, a second number is shown, and if missing data exists, the algorithm assigned “half patient” to each cluster; ^b NIHSS: National Institute of Health Stroke Scale; a score of 16 define a severe stroke; ^c Rancho Los Amigos Scale measures cognitive function at admission (1–8, worse-better); at level 6, patient gives context appropriate, goal-directed responses, present recent memory problems; ^d Barthel index of 10 or less indicates severe disability.</p

Clusters´ characteristics: variables not included in the cluster analysis.

<p>Clusters´ characteristics: variables not included in the cluster analysis.</p

Inclusion and Exclusion chart.

<p>Inclusion and Exclusion chart.</p

Rehabilitation Profiles of Older Adult Stroke Survivors Admitted to Intermediate Care Units: A Multi-Centre Study.

BACKGROUND: Stroke is a major cause of disability in older adults, but the evidence around post-acute treatment is limited and heterogeneous. We aimed to identify profiles of older adult stroke survivors admitted to intermediate care geriatric rehabilitation units. METHODS: We performed a cohort study, enrolling stroke survivors aged 65 years or older, admitted to 9 intermediate care units in Catalonia-Spain. To identify potential profiles, we included age, caregiver presence, comorbidity, pre-stroke and post-stroke disability, cognitive impairment and stroke severity in a cluster analysis. We also proposed a practical decision tree for patient's classification in clinical practice. We analyzed differences between profiles in functional improvement (Barthel index), relative functional gain (Montebello index), length of hospital stay (LOS), rehabilitation efficiency (functional improvement by LOS), and new institutionalization using multivariable regression models (for continuous and dichotomous outcomes). RESULTS: Among 384 patients (79.1±7.9 years, 50.8% women), we identified 3 complexity profiles: a) Lower Complexity with Caregiver (LCC), b) Moderate Complexity without Caregiver (MCN), and c) Higher Complexity with Caregiver (HCC). The decision tree showed high agreement with cluster analysis (96.6%). Using either linear (continuous outcomes) or logistic regression, both LCC and MCN, compared to HCC, showed statistically significant higher chances of functional improvement (OR = 4.68, 95%CI = 2.54-8.63 and OR = 3.0, 95%CI = 1.52-5.87, respectively, for Barthel index improvement ≥20), relative functional gain (OR = 4.41, 95%CI = 1.81-10.75 and OR = 3.45, 95%CI = 1.31-9.04, respectively, for top Vs lower tertiles), and rehabilitation efficiency (OR = 7.88, 95%CI = 3.65-17.03 and OR = 3.87, 95%CI = 1.69-8.89, respectively, for top Vs lower tertiles). In relation to LOS, MCN cluster had lower chance of shorter LOS than LCC (OR = 0.41, 95%CI = 0.23-0.75) and HCC (OR = 0.37, 95%CI = 0.19-0.73), for LOS lower Vs higher tertiles. CONCLUSION: Our data suggest that post-stroke rehabilitation profiles could be identified using routine assessment tools and showed differential recovery. If confirmed, these findings might help to develop tailored interventions to optimize recovery of older stroke patients.This study was partially funded by the Generalitat de Catalunya.—Dr. Quinn is supported by a joint Stroke Association/Chief Scientist Office Senior Clinical Lecturer Fellowship. The mathematical analysis was supported by the projects SGR2014-890 (MACDA) of AGAUR (Agència de Gestió d’Ajuts Universitaris i de Recerca) and by MINECO (Ministry of Economy and Competitiveness) project APCO