Rural Elder Care Coordination on Cape Cod: A Community-Based Approach to Closing the Gaps

One quarter of the population of Cape Cod is over age 65, and in the eight outermost towns on the peninsula of Cape Cod, known as the Lower and Outer Cape, the challenges of caring for an older population are compounded by the effects of rural isolation. As many residents have chosen to “age in place” with little family or social support, medical and behavioral health needs often go unaddressed due to the lack of access to needed healthcare and supporting services that plagues underserved rural areas. Outer Cape Health Services (OCHS), a federally-qualified community health center and the primary medical and behavioral health provider in the area, has established a home visit program to reach isolated patients who may otherwise be denied access to these services. This program is lead by the Care Coordination team, which collaborates with local Councils on Aging, the Visiting Nurses Association, EMS, and other community resources to identify and engage these complex, high-acuity patients and provide wrap-around services. However, gaps remain in communication among agencies regarding existing and potential cases. Additionally, little data exist on the health challenges faced by this underserved population, and how care coordination can better address medical and psychosocial needs. To address these gaps, a cross-departmental team at OCHS has begun a community-based research project with the goal of developing a network of consumers, providers and agencies to develop research questions and collaborate on interventions. The team is in the process of identifying key stakeholders and developing community-building strategies

AI-Based Chest CT Analysis for Rapid COVID-19 Diagnosis and Prognosis: A Practical Tool to Flag High-Risk Patients and Lower Healthcare Costs

peer reviewedEarly diagnosis of COVID-19 is required to provide the best treatment to our patients, to prevent the epidemic from spreading in the community, and to reduce costs associated with the aggravation of the disease. We developed a decision tree model to evaluate the impact of using an artificial intelligence-based chest computed tomography (CT) analysis software (icolung, icometrix) to analyze CT scans for the detection and prognosis of COVID-19 cases. The model compared routine practice where patients receiving a chest CT scan were not screened for COVID-19, with a scenario where icolung was introduced to enable COVID-19 diagnosis. The primary outcome was to evaluate the impact of icolung on the transmission of COVID-19 infection, and the secondary outcome was the in-hospital length of stay. Using EUR 20000 as a willingness-to-pay threshold, icolung is cost-effective in reducing the risk of transmission, with a low prevalence of COVID-19 infections. Concerning the hospitalization cost, icolung is cost-effective at a higher value of COVID-19 prevalence and risk of hospitalization. This model provides a framework for the evaluation of AI-based tools for the early detection of COVID-19 cases. It allows for making decisions regarding their implementation in routine practice, considering both costs and effects

Are the benefits of advance care planning for care home residents, as demonstrated by research studies, seen when implemented in a large-scale clinical service offering advance care planning for care home residents as part of Comprehensive Geriatric Assessment (CGA)?

Introduction Care home residents have a short life expectancy and are more likely to have emergency admissions than people of the same age living in the community. Although such admissions may resolve crises, maintain and restore functional and relieve physical and mental distress, there is evidence that hospital admission may be burdensome or detrimental to the health of older people with severe frailty. Furthermore, admission may not reflect their wishes, or those of their families. Advance care planning is a means by which care home residents can express their health care preferences, not only regarding admission to hospital, but also their choices in relation to other aspects of their care. I conducted a systematic review which found that some research studies showed that advance care planning for care home residents was associated with reduced hospital admissions and increased proportions dying in the care home. The evidence appeared stronger for advance care planning educational interventions than interventions delivered by specialist teams, but there was much less evidence as to whether these findings could be replicated in routine practice. Aims The research questions this thesis asked was whether Advance Care Plans (ACPs): • could be implemented in unselected care homes • were acceptable to care home residents • were associated with reduced hospital admissions • were associated with more residents dying in their preferred place of care. Methods To test this research question, a service was implemented and evaluated in Lincoln, UK. The intervention involved a multidisciplinary team trained in comprehensive geriatric assessment and the use of ACPs and led by me. The effect of this service on hospital admissions was evaluated using a step wedge randomised control designed study, under clinical governance, using routine hospital and mortality data. The extent to which the intervention was delivered was evaluated using routine service records. A trustworthiness framework was used justify the credibility, dependability, confirmability, transferability and authenticity of the use of field notes, multidisciplinary team meeting and diary records, and reports from residents’ electronic primary care records obtained during the implementation and delivery of the service and the results of the quantitative study to formulate retrospectively a synthesis using soft systems methodology and a widely used framework for understanding service implementation, the Consolidated Framework for Implementation Research. Results I found that: • Advance care planning could be implemented in 68% of care homes • ACPs were acceptable to almost 80% of residents, similar levels to research trials • the intervention did not lead to a reduction in hospital admissions, but rather a trend towards increased admissions • Possession of an ACP was associated with a greater chance of dying in the care home which, for most residents, was their preferred place of care • Residents were more likely to opt for active medical treatment while their function remained good, whereas residents with greater frailty were more likely to emphasise preference for palliative care The synthesis illustrated that, in implementation of the project, multiple interfaces needed to be considered, including individual residents, their families, care homes and general practices, local health and social care organisations, and the wider context of a whole system experiencing increasing financial constraint and organisational change. Discussion This service successfully delivered ACPs alongside a comprehensive geriatric assessment, although not all care home managers co-operated. Most residents in whom ACPs were put in place opted for their preferred place of death to be the care home, and having an ACP increased the likelihood of doing so. However, hospital admissions were not reduced. Although advance care planning is not a new concept to palliative care in the UK, most NHS staff, and the Lincolnshire population, were unfamiliar with the concept. Thus, implementation of a relatively novel concept for residents of care homes in Lincoln presented challenges. Importantly, care home residents were able to have their choices formalised and communicated to stakeholders, including primary care and out of hours services. The failure to demonstrate a reduction in admissions was likely to reflect several factors, including residents’ choice for active intervention, and lack of community services to support implementation of ACPs. However, in a climate of economic austerity, no reduction in admissions has implications for future funding and sustainability of advance care planning. The importance of proactive use of implementation science models for future implementation is proposed

Are the benefits of advance care planning for care home residents, as demonstrated by research studies, seen when implemented in a large-scale clinical service offering advance care planning for care home residents as part of Comprehensive Geriatric Assessment (CGA)?

Introduction Care home residents have a short life expectancy and are more likely to have emergency admissions than people of the same age living in the community. Although such admissions may resolve crises, maintain and restore functional and relieve physical and mental distress, there is evidence that hospital admission may be burdensome or detrimental to the health of older people with severe frailty. Furthermore, admission may not reflect their wishes, or those of their families. Advance care planning is a means by which care home residents can express their health care preferences, not only regarding admission to hospital, but also their choices in relation to other aspects of their care. I conducted a systematic review which found that some research studies showed that advance care planning for care home residents was associated with reduced hospital admissions and increased proportions dying in the care home. The evidence appeared stronger for advance care planning educational interventions than interventions delivered by specialist teams, but there was much less evidence as to whether these findings could be replicated in routine practice. Aims The research questions this thesis asked was whether Advance Care Plans (ACPs): • could be implemented in unselected care homes • were acceptable to care home residents • were associated with reduced hospital admissions • were associated with more residents dying in their preferred place of care. Methods To test this research question, a service was implemented and evaluated in Lincoln, UK. The intervention involved a multidisciplinary team trained in comprehensive geriatric assessment and the use of ACPs and led by me. The effect of this service on hospital admissions was evaluated using a step wedge randomised control designed study, under clinical governance, using routine hospital and mortality data. The extent to which the intervention was delivered was evaluated using routine service records. A trustworthiness framework was used justify the credibility, dependability, confirmability, transferability and authenticity of the use of field notes, multidisciplinary team meeting and diary records, and reports from residents’ electronic primary care records obtained during the implementation and delivery of the service and the results of the quantitative study to formulate retrospectively a synthesis using soft systems methodology and a widely used framework for understanding service implementation, the Consolidated Framework for Implementation Research. Results I found that: • Advance care planning could be implemented in 68% of care homes • ACPs were acceptable to almost 80% of residents, similar levels to research trials • the intervention did not lead to a reduction in hospital admissions, but rather a trend towards increased admissions • Possession of an ACP was associated with a greater chance of dying in the care home which, for most residents, was their preferred place of care • Residents were more likely to opt for active medical treatment while their function remained good, whereas residents with greater frailty were more likely to emphasise preference for palliative care The synthesis illustrated that, in implementation of the project, multiple interfaces needed to be considered, including individual residents, their families, care homes and general practices, local health and social care organisations, and the wider context of a whole system experiencing increasing financial constraint and organisational change. Discussion This service successfully delivered ACPs alongside a comprehensive geriatric assessment, although not all care home managers co-operated. Most residents in whom ACPs were put in place opted for their preferred place of death to be the care home, and having an ACP increased the likelihood of doing so. However, hospital admissions were not reduced. Although advance care planning is not a new concept to palliative care in the UK, most NHS staff, and the Lincolnshire population, were unfamiliar with the concept. Thus, implementation of a relatively novel concept for residents of care homes in Lincoln presented challenges. Importantly, care home residents were able to have their choices formalised and communicated to stakeholders, including primary care and out of hours services. The failure to demonstrate a reduction in admissions was likely to reflect several factors, including residents’ choice for active intervention, and lack of community services to support implementation of ACPs. However, in a climate of economic austerity, no reduction in admissions has implications for future funding and sustainability of advance care planning. The importance of proactive use of implementation science models for future implementation is proposed