Quality standard for Person-centred and Integrated Care for Older adults

Background: Current healthcare systems are challenged to cope with changing demands of the growing population of older adults, while maintaining quality of care at lower costs. Between 2008 and 2016, the Dutch National Care for the Elderly Program was organized by the ‘Netherlands Organization for Health Research and Development’ ZonMw and financially supported by the Dutch ministry of Health. Aim of the program was to contribute to a solution to these challenges. One of the projects was Embrace1, a person-centered and integrated care service for community-living older adults. Aims of this service are to improve quality of care by reducing the fragmentation in health services, to improve patient outcomes, and to increase sustainability of the healthcare system. Embrace combines two globally recognized models, the Chronic Care Model and a population health management model. Both models were translated to the Dutch situation and specified for older adults. Embrace has been implemented in the Netherlands since 2012. Short- and long-term evaluations, using mixed methods, showed positive results regarding patient outcomes, quality of care, and costs. Before final closing of the national programme, the program committee, with support from the Dutch Care institute and the Dutch ministry of Health, decided to develop a ‘Quality standard Person-centred and Integrated Care for older adults’ based on the characteristics and positive results of Embrace. Aim of this quality standard is to support the transformation in the Dutch health system towards person-centred and integrated care by reaching consensus on values and standards of care for older adults, creating clarity for older adults and professionals, and providing tools for administrative accountability. This network discussion is part of the preparation phase before the actual development of the quality standard. Aim of this phase is to explore the support, scope, and potential bottlenecks for the new standard with future owners of this standard. These owners may include older adults’ representatives, professional organizations and funders for care and welfare. Aims and Objectives: Aim of this network discussion is to use the available expertise among participants of this conference to further explore the support, scope, and potential bottlenecks for the new standard. We have the intention to invite Dutch participants and share the results of the explorations until then, and ask for feedback. Format: The meeting is planned at the end of the six months preparation phase starting January 2018. The preliminary results will be shared with participants, and their reflections and advises will be collected and discussed. Target audience: Dutch experts on person-centred and integrated care. Take away: Results will be included in the final report for the committee of the Dutch National Care for the Elderly Program

Integrated Care for Older Adults Improves Perceived Quality of Care:Results of a Randomized Controlled Trial of Embrace

BACKGROUND: All community-living older adults might benefit from integrated care, but evidence is lacking on the effectiveness of such services for perceived quality of care. To examine the impact of Embrace, a community-based integrated primary care service, on perceived quality of care. Stratified randomized controlled trial. Integrated care and support according to the "Embrace" model was provided by 15 general practitioners in the Netherlands. Based on self-reported levels of case complexity and frailty, a total of 1456 community-living older adults were stratified into non-disease-specific risk profiles ("Robust," "Frail," and "Complex care needs"), and randomized to Embrace or control groups. Embrace provides integrated, person-centered primary care and support to all older adults living in the community, with intensity of care dependent on risk profile. Primary outcome was quality of care as reported by older adults on the Patient Assessment of Integrated Elderly Care (PAIEC). Effects were assessed using mixed model techniques for the total sample and per risk profile. Professionals' perceived level of implementation of integrated care was evaluated within the Embrace condition using the Assessment of Integrated Elderly Care. Older adults in the Embrace group reported a higher level of perceived quality of care than those in the control group (B = 0.33, 95 % CI = 0.15-0.51, ES d = 0.19). The advantages of Embrace were most evident in the "Frail" and "Complex care needs" risk profiles. We found no significant advantages for the "Robust" risk profile. Participating professionals reported a significant increase in the perceived level of implementation of integrated care (ES r = 0.71). This study shows that providing a population-based integrated care service to community-living older adults improved the quality of care as perceived by older adults and participating professionals

Improving self-management of health through an eHealth application:an action-based study among older adults living in the community

Introduction: Older adults living at home benefit from self-management support to stay healthy for as long as possible. An eHealth application could be a solution to meet older adults’ individual supportive needs. The aim of this study was to identify quality criteria for eHealth applications targeting personalized access to self-management support of health from a community-living older adult’s perspective. The study is conducted as part of the EU-supported CONNECARE research and the NFU program eHealth.Methods: We designed an action-based study using focus groups, individual interviews, and questionnaires among robust, community-living older adults participating in Embrace, a person-centred and integrated service in the Netherlands. The study was designed in three phases. The results of each phase led to an improved version of the quality criteria underlying the eHealth application, which was used as input for the next phase of development. In the first phase, twelve older adults participated in two focus groups that gathered twice. The majority was male n=8 and participants were between the age of 76 and 85. Participants were asked about their needs concerning physical activity, nutrition, and social activity in their daily lives, and the support of a potential eHealth application. Based on a first list of quality criteria resulting from these focus groups, a self-management application prototype was developed. In the second phase, seven participants male: n=6 tested the prototype and individual interviews were conducted, resulting in a second version of the quality criteria. Focus group discussions were audio-recorded and interviews were video-recorded. All data were transcribed verbatim and then analyzed and coded into key issues and themes. Results of the first two phases are now used to further develop and improve the self-management application. The third phase concerns evaluation research in which robust older adults living at home n=40, 75 years and older will use the application in their daily lives. Evaluation will involve quantitative and qualitative measures, resulting in a final list of quality criteria.Results: A list of quality criteria for eHealth applications has been established based on the first two phases of the study. Quality criteria concern accessibility, functionalities, navigation, readability, trust and privacy.Discussions: Study results provide insight into quality criteria needed to design, build and implement an eHealth application targeting personalized access to self-management support of health from the older adults’ perspective.Conclusions: An eHealth application targeting older adults’ self-management should be easy to use, personalized, and beneficial for the person using it.Lessons learned: For a successful eHealth application it is essential to actively involve potential end users at all stages of the developmental process. Traditional research methods have to be adapted to successfully study the quality of an eHealth application.Limitations: Participants were all relatively healthy older adults with at least an interest in ICT early adopters, frail older adults were excluded.Suggestions for future research: Viewpoints of care providers and more vulnerable older adults, for example people with complex care needs, low health literacy, or different ethnicity should be addressed

Results of a cross-sectional study on health-related problems of community-living older adults using the GeriatrICS, an ICF-based assessment tool

Introduction: Ideally, older adults should receive person-centred care and support that meets their individual needs and wishes, taking all relevant health-related aspects into account. A first step towards that goal is to gain insight into their health-related problems. For that purpose, a person-centred ICF Core Set for community-living older adults, the GeriatrICS, was developed. The objectives of this study were to assess the prevalence and severity of health-related problems in community-living older adults, and to assess the differences between subgroups of older adults: those with complex care needs, frail and robust older adults. Methods: A cross-sectional study was conducted among older adults receiving person-centred and integrated care and support from Embrace, a person-centred and integrated service. Older adults with complex care needs n=163 and frail older adults n=104 were interviewed by case managers, who assessed the older adults using the GeriatrICS. Robust older adults n=274 received a questionnaire version of the GeriatrICS. All older adults had to rate the items on a scale ranging from 0 no problem to 10 complete problem. We examined data per item in terms of prevalence of problems and severity. Differences in prevalence between subgroups was tested using Chi-square tests and differences in severity were tested using Mann-Whitney U tests. Results: Mean age of participants n=541 was 80.7 years SD 4.4, 56% was female, and 51% had a lower educational level.Preliminary analyses showed that, overall, the most prevalent and severe problems were related to the clusters Mobility, Mental Functions and Physical Health. For example, prevalence of Mobility-related problems: Complex care needs 52.0%, Frail 55.6% and Robust 43.6%, and severity: Complex care needs 1.9, Frail 2.4 and Robust 1.0. Although prevalence was comparable among frail older adults and those with complex care needs, results showed a trend in higher severity scores for frail participants. Robust older adults also showed health-related problems e.g. Physical Health: prevalence 33.8%, severity 0.8, but less frequent and less severe compared to participants with complex care needs 45.7%, 1.5 and frail participants 47.1%, 1.8. Discussions and conclusions: We assessed health-related problems due to ageing using the GeriatrICS in a community-sample of older adults. Frail older adults and those with complex care needs showed the highest prevalence of problems, but frail participants experienced them as more severe. Besides, robust older adults already showed health-related problems, indicating the need for prevention. Lessons learned: Prevention of health-related problems in older adults is necessary and should also be targeted at robust older adults.Results suggest that using the GeriatrICS could be a good starting point for the development of person-centred, proactive and preventive care and support programs. Limitations: We may have to deal with common method bias, due to the difference in assessment methods interview by a case manager versus a questionnaire version. However, in both situations, the assessment was self-reported because the older adults had to indicate the severity of their problems. Suggestions for future research: Future studies should examine the concurrent validity of both assessment methods using the GeriatrICS

Effects of a population-based, person-centred and integrated care service on health, wellbeing and self-management of community-living older adults:A randomised controlled trial on Embrace

<div><p>Objective</p><p>To evaluate the effects of the population-based, person-centred and integrated care service ‘Embrace’ at twelve months on three domains comprising health, wellbeing and self-management among community-living older people.</p><p>Methods</p><p>Embrace supports older adults to age in place. A multidisciplinary team provides care and support, with intensity depending on the older adults’ risk profile. A randomised controlled trial was conducted in fifteen general practices in the Netherlands. Older adults (≥75 years) were included and stratified into three risk profiles: Robust, Frail and Complex care needs, and randomised to Embrace or care as usual (CAU). Outcomes were recorded in three domains. The EuroQol-5D-3L and visual analogue scale, INTERMED for the Elderly Self-Assessment, Groningen Frailty Indicator and Katz-15 were used for the domain ‘Health.’ The Groningen Well-being Indicator and two quality of life questions measured ‘Wellbeing.’ The Self-Management Ability Scale and Partners in Health scale for older adults (PIH-OA) were used for ‘Self-management.’ Primary and secondary outcome measurements differed per risk profile. Data were analysed with multilevel mixed-model techniques using intention-to-treat and complete case analyses, for the whole sample and per risk profile.</p><p>Results</p><p>1456 eligible older adults participated (49%) and were randomized to Embrace (n(T0) = 747, n(T1) = 570, mean age 80.6 years (SD 4.5), 54.2% female) and CAU (n(T0) = 709, n(T1) = 561, mean age 80.8 years (SD 4.7), 55.6% female). Embrace participants showed a greater–but clinically irrelevant–improvement in self-management (PIH-OA Knowledge subscale effect size [ES] = 0.14), and a greater–but clinically relevant–deterioration in health (ADL ES = 0.10; physical ADL ES = 0.13) compared to CAU. No differences in change in wellbeing were observed. This picture was also found in the risk profiles. Complete case analyses showed comparable results.</p><p>Conclusions</p><p>This study found no clear benefits to receiving person-centred and integrated care for twelve months for the domains of health, wellbeing and self-management in community-living older adults.</p></div

Compromised intestinal integrity in older adults during daily activities:a pilot study

Abstract Background Malnutrition is a common and significant problem in older adults. Insight into factors underlying malnutrition is needed to develop strategies that can improve the nutritional status. Compromised intestinal integrity caused by gut wall hypoperfusion due to atherosclerosis of the mesenteric arteries in the aging gastrointestinal tract may adversely affect nutrient uptake. The presence of compromised intestinal integrity in older adults is not known. The aim of this study is to provide a proof-of-concept that intestinal integrity is compromised in older adults during daily activities. Methods Adults aged ≥75 years living independently without previous gastrointestinal disease or abdominal surgery were asked to complete a standardized walking test and to consume a standardized meal directly afterwards to challenge the mesenteric blood flow. Intestinal fatty acid-binding protein (I-FABP) was measured as a plasma marker of intestinal integrity, in blood samples collected before (baseline) and after the walking test, directly after the meal, and every 15 min thereafter to 75 min postprandially. Results Thirty-four participants (median age 81 years; 56% female) were included. Of the participants, 18% were malnourished (PG-SGA score ≥ 4), and 32% were at risk of malnutrition (PG-SGA score, 2 or 3). An I-FABP increase of ≥50% from baseline was considered a meaningful loss of intestinal integrity and was observed in 12 participants (35%; 8 females; median age 80 years). No significant differences were observed in either baseline characteristics, walking test scores, or calorie/macronutrient intake between the groups with and without a ≥ 50% I-FABP peak. Conclusion This study is first to indicate that intestinal integrity is compromised during daily activities in a considerable part of older adults living independently

Long-term advantages of person-centred and integrated care:results of a longitudinal study on Embrace

Introduction: Embrace1 is a population-based, person-centred, and integrated care service for community-living older adults that combines the Chronic Care Model with risk profiles based on a population health management model. A multidisciplinary Elderly Care Team organizes and evaluates care and support, with intensity depending on an older adult’s risk profile. Embrace has been implemented since 2012 and showed positive outcomes after 12 months regarding patient outcomes, quality of care, and costs. Aim of this study was to assess the long-term outcomes, overall and by risk profile. Methods: We performed a longitudinal study on patient outcomes, quality of care, and costs, with evaluation of change after 12, 24, and 36 months compared to baseline. Results: In total, 1308 older adults participated in the study mean age 80.7 years SD 4.6, 55% female, 57% low educational level. The risk profile distribution changed after 12 and 24 months, with an increase in frail participants Robust 66% vs 39% after 24 months, Frail 17% vs 41%, Complex care needs 18% vs 20%. Overall, general health EQ-VAS remained stable across measurement moments. Quality of life ‘compared to the year before’ SF-36 was stable after 12 months, and decreased after 24 months p=0.026, ES=0.12 and 36 months p0.001, ES=0.61. Discussion and conclusion: Overall, long-term outcomes of Embrace for the older adults are beneficial, particularly for older adults with complex care needs. It seems that Embrace has halted the declining trends in general health and well-being associated with ageing, as well as the related costs increase. Lessons learned: Implementation of Embrace among frail older adults can be improved. Limitations: The lack of a control group. Suggestions for future research: Further research should focus on preventive en proactive support programs for older adults

Experiences of Community-Living Older Adults Receiving Integrated Care Based on the Chronic Care Model:A Qualitative Study

Integrated care models aim to solve the problem of fragmented and poorly coordinated care in current healthcare systems. These models aim to be patient-centered by providing continuous and coordinated care and by considering the needs and preferences of patients. The objective of this study was to evaluate the opinions and experiences of community-living older adults with regard to integrated care and support, along with the extent to which it meets their health and social needs.Semi-structured interviews were conducted with 23 older adults receiving integrated care and support through "Embrace," an integrated care model for community-living older adults that is based on the Chronic Care Model and a population health management model. Embrace is currently fully operational in the northern region of the Netherlands. Data analysis was based on the grounded theory approach.Responses of participants concerned two focus areas: 1) Experiences with aging, with the themes "Struggling with health," "Increasing dependency," "Decreasing social interaction," "Loss of control," and "Fears;" and 2) Experiences with Embrace, with the themes "Relationship with the case manager," "Interactions," and "Feeling in control, safe, and secure". The prospect of becoming dependent and losing control was a key concept in the lives of the older adults interviewed. Embrace reinforced the participants' ability to stay in control, even if they were dependent on others. Furthermore, participants felt safe and secure, in contrast to the fears of increasing dependency within the standard care system.The results indicate that integrated care and support provided through Embrace met the health and social needs of older adults, who were coping with the consequences of aging

The association between health literacy and self-management abilities in adults aged 75 and older, and its moderators

Low health literacy is an important predictor of poor health outcomes and well-being among older adults. A reason may be that low health literacy decreases older adults' self-management abilities. We therefore assessed the association between health literacy and self-management abilities among adults aged 75 and older, and the impact of demographic factors, socioeconomic factors, and health status on this association. We used data of 1052 older adults, gathered for a previously conducted randomized controlled trial on Embrace, an integrated elderly care model. These data pertained to health literacy, self-management abilities, demographic background, socioeconomic situation, and health status. Health literacy was measured by the validated three-item Brief Health Literacy Screening instrument. Self-management abilities were measured by the validated Self-Management Ability Scale (SMAS-30). After adjustment for confounders, self-management abilities were poorer in older adults with low health literacy (beta = .34, p <.001). This was more pronounced in medium- to high-educated older adults than in low-educated older adults. Sex, age, living situation, income, presence of chronic illness, and mental health status did not moderate the association between health literacy and self-management abilities. Low health literacy is associated with poor self-management abilities in a wide range of older adults. Early recognition of low health literacy among adults of 75 years and older and interventions to improve health literacy might be very beneficial for older adults