In most OECD member countries, the number of subspecialists has increased at a much higher rate than the number of generalists. This trend has led to fragmented care and needs to be reversed. To meet the needs of aging populations, more family physicians and geriatricians, in particular, will be needed.
Medical school curricula and training programs should be altered to support this shift. It is important that providers treating a patient with complex needs are able to share important data about that patient; this ensures clinicians have the information they need, when they need it. Also critical is good and timely provider communication, including the prompt relay of information to the primary care physician following hospitalization and specialist visits and the sharing of care plans with after-hours and emergency services. For the patient with multiple health conditions, treatment that adheres to evidence-based guidelines for each individual condition can lead to an unacceptable burden of treatment, adverse interactions between treatments, and risks from polypharmacy.
Patients with complex conditions need to be part of an open discussion of the benefits and risks of individual treatments. Such a process allows them to bring their own needs, preferences, and hopes into the treatment conversation.
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Elderly people and those with complex needs often receive care from family members and friends. They are usually unpaid and often provide support around-the-clock. Health services need to take steps to identify and support these informal caregivers. Support might include respite care to provide relief for caregivers and assistance to help them look after their own health. Current funding mechanisms and payment incentives often exacerbate the problems of fragmented care.
For example, fee-for-service encourages the overprovision of specialist services; capitation- and salary-based payments may lead to undertreatment; and quality incentives tend to prioritize only those aspects of care that are most easily measured. Payments systems for complex patients need to be redesigned so that they reduce barriers to collaboration, adequately compensate for the complexity of cases treated, and incentivize hospitals to work with community providers.
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Constrained social service spending may also lead directly to inefficient use of health care resources — for example, when patients are unable to be discharged from the hospital because of a lack of support available in the community. Care for patients with complex needs therefore requires close cooperation between the two sectors. Failure to integrate physical and mental health care also causes problems for patients with complex needs.
Care for mental health must be integrated with physical health care, with multidisciplinary teams ensuring that physical and mental health problems are addressed together in a timely fashion.
Implementing these recommendations will challenge notions of professional autonomy, established beliefs, and engrained ways of working. Clinical leadership is key to delivering successful change, and the clinicians leading change need support from local managers to ensure that local administrative systems and budgetary arrangements do not stifle change.
Clinicians may also benefit from formal leadership training and opportunities to meet with peers on a regular basis. Different solutions will suit different environments. Policymakers and health care managers should provide opportunities for sharing experiences and learning from success as well as failure. It is important to understand that successful projects tend to develop iteratively over time — and sometimes over a long period.
Mount Sinai Hospital developed a comprehensive, integrated approach to improve care for hospitalized older adults and older adults at high risk of hospitalization, particularly because of functional, cognitive, social, or other problems.
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To improve the delivery and quality of care, patient and system outcomes in all older patients, and those older patients at especially high risk of poor outcomes. All patients age 65 and older admitted with an acute medical condition. High-risk patients are identified in emergency department ED based on having any three or more of: 1 recent decline in functional abilities; 2 recent change in cognition or behavior; 3 geriatric syndrome e.
Complementary community-based programs also identify and support high-risk patients. Program enrolled approximately 10, patients between and ISAR screening for all older ED patients, with additional support from geriatric emergency management nurses. All older patients have access to hospitalwide consultation liaison services in geriatrics, psychiatry, and palliative medicine and to volunteer-based Hospital Elder Life Program HELP.
All professionals are educated in geriatric care. ACE strategy integrates these interventions to create seamless, interprofessional, technology-enabled integrated team-based delivery model spanning the care continuum. Geriatricized order sets and care protocols to support safer evidence-based care; tracking systems to monitor flow of ACE patients throughout Mount Sinai Hospital in real time and support timely transfer to ACE unit; secure e-mail notification and flagging systems to allow primary care, home care, emergency, and inpatient care providers to communicate effectively; and risk identification tools ACE Tracker to support early identification of high-risk patients.
Usual funding through global block payments for hospitals and other community-based agencies. Physicians paid fee-for-service; other professionals are salaried. Hospital budget structures create incentives to reduce admissions and length of stay. No model-specific incentives. Ongoing quarterly performance tracking system, using balanced scorecard and regional benchmarking to identify areas for improvement.
For those admitted to hospital, there was 28 percent decrease in mean length of stay; Average direct cost of care per patient reduced by 23 percent, and general inpatient medical beds reduced by Personal communication with Samir K. Sinha, S. Oakes, S. Chaudhry et al. Malone, E. Capezuti, R. Palmer, eds. Sinha, J. Bennett, T. After a stroke, patients may need prolonged rehabilitation, traditionally provided in inpatient settings.
To improve continuity of care by supporting transition from inpatient to home-based stroke rehabilitation and improve cost efficiency by shortening length of hospital stays. Patients are assessed for rehabilitation needs before discharge to set initial objectives and ensure continuity of care. Upon hospital discharge, patients are visited at home within 24 hours by the therapy team and receive needed daily physiotherapy, occupational therapy, and speech therapy for up to six weeks.
Other social services are provided as usual. Each patient receives an individual care plan, which is reviewed at a weekly team meeting. There is variation across England in the composition and leadership of rehabilitation teams, as well as their operational policies and the way in which they interact with referring hospitals during discharge planning. All teams involve stroke specialists, including doctors, nurses, physiotherapists, and occupational and speech therapists.
Many teams also include or provide access to psychologists and social workers. No specific system. ESD can also be financed from savings from reduced length of hospital stays. Professionals are salaried employees of NHS providers; there are no financial incentives for providers. Several randomized controlled trials were published internationally, as well as metaanalysis and a cost-effectiveness model. Evaluation of the first implementation of ESD in England showed improved patient satisfaction, reduced length of hospital stays, and resulted in small cost savings. It did not find significant differences in health outcomes.
Metaanalysis of 14 randomized controlled trials from Australia, Canada, Denmark, Norway, Sweden, Thailand, the United Kingdom, and the United States found a reduction in long-term dependency and admission to institutional care, as well as reducing the length of hospital stay. Meta-analysis also found improvements in extended activities of daily living scores and patient satisfaction.
No significant effects were found in mortality, hospital readmissions, or caregiver-reported health status, mood, or satisfaction. Of the trials that evaluated costs, six found ESD services to show cost savings compared with the control group; one found cost increases. Chouliara, R. Fisher, M.
Kerr et al. Beech, A. Rudd, K. Tilling et al. Fearon and P.
Rudd, C. Wolfe, K. Saka, V. Serra, Y. Samyshkin et al.
Stroke is the third-highest cause of death and most common cause of adult disability in high-income countries. Well-organized care by specialized stroke units can reduce mortality and disability. Poor-quality stroke care led the London Primary Care Trusts to form a joint committee, supported by a panel of expert clinicians, other health professionals, and lay members, to develop evidence-based and centralized stroke services.
To improve health outcomes by providing a uniform and high-quality standard of care for all stroke patients in London. Eight specialized hyper-acute stroke units HASUs and 24 stroke units with colocated transient ischemic attack assessment services provide centralized care. HASUs provide faster response times when a stroke is suspected and continuous access to specialist care throughout the first 72 hours. Specialized nurses and medical teams assess and treat patients from the time of hospital admission.
HASUs are accessible to the entire London population by ambulance within 30 minutes. Stroke units provide ongoing inpatient care as necessary after 72 hours. All units are staffed by doctors, nurses, physiotherapists, and occupational, speech, and language therapists; most also have psychologists. The model requires regular multidisciplinary team meetings and goal setting. A service manager oversees the unit. Nurses and doctors are trained in a simulation unit.
Paramedics also receive training. Units are expected to engage in regular and continued professional development. Hospitals operate their own information technology systems. All units participate in the Sentinel Stroke National Audit Program, the data source for quality of care for stroke treatment in England. An estimated 9 million British pounds in capital investments were made to develop stroke units and an additional 23 million British pounds per year were needed to support the model.
Effects on health outcomes in London were evaluated, using the rest of England as a control group. Effects on process measures and costs were evaluated in pre—post intervention comparisons. Bray, S. Ayis, J. Campbell et al. Hunter, C. Davie, A. Rudd et al. Morris, R. Hunter, A. Ramsay et al. Wardlaw, V. Murray, E. Berge et al. In nine pilot regions across France in —14; seven additional regions in in order to ensure full deployment on the French territory and provide PAERPA coverage to a total of , persons.
French residents age 75 or older are 9 percent of the population but accrue 22 percent of health expenditures. Those age 75 or older who: live in long-term care facilities; are admitted to hospital via emergency departments; are frail; take certain prescription drugs; or have one or more chronic condition. Eligibility for a personal care plan is assessed by a primary care physician or care coordinator. Across regions, 6 percent to 14 percent of elders were enrolled. Some features, including eligibility criteria, vary by region. Integrated health and social services are provided through mobile geriatric teams; respite facilities for informal caregivers; telemedicine; a fast-track application for welfare benefits; and temporary stays in long-term care facilities to facilitate transitions from hospital to home.
Nurse coordinators coordinate the work. A secure e-mail system facilitates communication and web-based systems provide information to patients and professionals. Although special legislation permits data sharing among members of care teams, medical records are not yet widely shared. National funding for information systems, coordination units, financial incentives, and additional services. Regional Health Authorities fund pilot projects through social security and have autonomy in funding local variations.
Providers are paid as usual. Qualitative and health economic evaluations are under way at the national level. Bourgueil, J. Combes, N. Le Guen et al. Patients with multiple chronic conditions multimorbidity require proactive, coordinated care management to effectively manage their numerous health conditions.
CC—MAP aims to improve the quality of care and reduce preventable hospital admissions for adult Clalit members with multiple morbidities who are at risk for deteriorating health status and incurring high costs. Adults with multiple morbidities, defined as three or more chronic diseases, and who are at risk for deteriorating health status, as defined by a validated risk prediction score in primary care clinics that serve the largest percent of multimorbid patients.
The intervention is overseen by CC—MAP nurses, who work with primary care physicians to provide comprehensive care management for to of the highest-risk patients in each targeted clinic. Nurses and primary care physicians receive tailored training and have access to a set of supportive practice tools developed for the intervention. Patients are encouraged to involve their informal caregivers.
Formal social care services, which are separately financed and delivered by social welfare services, are not fully integrated. CC—MAP nurses help patients access social services.
Clalit operates an integrated information system that centralizes all administrative, electronic health, and demographic data. This platform allows for algorithmic identification of high-risk patients, sharing of information among providers across primary, specialty, and inpatient services , streamlining care processes, and monitoring outcomes and processes, such as medication adherence and use of preventive services. Primary care physicians continue to receive their usual salaried payment.
There are no financial incentives for professionals, and participation is voluntary by informed consent. Preliminary results comparing month follow-up of patients in the intervention versus control patients indicated a 40 percent reduction in hospital days average of Additionally, quality of chronic care, quality of life, and the performance of daily activities such as shopping and medication management were significantly higher in patients enrolled in the intervention compared to controls.
Balicer, M. Reducing readmissions is a focus of health care systems worldwide to improve quality of care and efficiency. Evidence points to the importance of in-hospital interventions that address patient needs early to prevent unplanned hospital readmissions. Develop and implement an ongoing strategy to prevent day hospital readmissions among high-risk elderly patients insured by Clalit Health Services.
All Clalit members, ages 65 and older, admitted to hospitals. A prediction algorithm the Preadmission Readmission Detection Model or PREADM uses electronic medical record and administrative data to derive a risk score and identify high-risk patients. COC nurses provide in-hospital coordination, discharge planning, and coordination with primary care clinic nurses for post-discharge follow-up and monitoring.
Electronic messaging between nursing staff in hospital wards and general practices is used to facilitate joint discharge planning. Primary care clinics are responsible for post-discharge follow-up and monitoring, performed by nurses at the clinics according to structured outreach protocols. The PREADM score is used in all primary care clinics to prioritize outreach efforts to high-risk patients within 72 hours of discharge.
Clalit operates an integrated information system that centralizes all electronic health and demographic patient data. This platform allows for identification of high-risk patients, sharing of information among providers, and periodic collection of patient data for monitoring. Additional systems include a platform for automated electronic messaging between hospitals and primary clinics and a post-discharge assessment tool that notifies primary clinics of admissions and discharges and facilitates discharge and post-discharge activities.
Financed by Clalit Health Services. Providers are paid as usual; COC nurses are salaried Clalit employees. COC nurses represent the main additional investment; the program employs 14 full-time nurses across 27 hospitals. Case Management and the Documentation of Avoidable Days. Avoidable Days cannot be reduced or eliminated without accurate causal documentation. The purpose of this study was to determine whether a system upgrade with a change in documentation layout for AD tracking increased case manager compliance with AD documentation.
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