Geriatric assessment with management for older patients with cancer receiving radiotherapy: a cluster-randomised controlled pilot study.

BACKGROUND: Geriatric assessment and management (GAM) improve outcomes in older patients with cancer treated with surgery or chemotherapy. It is unclear whether GAM may provide better function and quality of life (QoL), or be cost-effective, in a radiotherapy (RT) setting. METHODS: In this Norwegian cluster-randomised controlled pilot study, we assessed the impact of a GAM intervention involving specialist and primary health services. It was initiated in-hospital at the start of RT by assessing somatic and mental health, function, and social situation, followed by individually adapted management plans and systematic follow-up in the municipalities until 8 weeks after the end of RT, managed by municipal nurses as patients' care coordinators. Thirty-two municipal/city districts were 1:1 randomised to intervention or conventional care. Patients with cancer ≥ 65 years, referred for RT, were enrolled irrespective of cancer type, treatment intent, and frailty status, and followed the allocation of their residential district. The primary outcome was physical function measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (QLQ-C30). Secondary outcomes were overall quality of life (QoL), physical performance, use and costs of health services. Analyses followed the intention-to-treat principle. Study registration at ClinicalTrials.gov ID NCT03881137. RESULTS: We included 178 patients, 89 in each group with comparable age (mean 74.1), sex (female 38.2%), and Edmonton Frail Scale scores (mean 3.4 [scale 0-17], scores 0-3 [fit] in 57%). More intervention patients received curative RT (76.4 vs 61.8%), had higher irradiation doses (mean 54.1 vs 45.5 Gy), and longer lasting RT (mean 4.4 vs 3.6 weeks). The primary outcome was completed by 91% (intervention) vs 88% (control) of patients. No significant differences between groups on predefined outcomes were observed. GAM costs represented 3% of health service costs for the intervention group during the study period. CONCLUSIONS: In this heterogeneous cohort of older patients receiving RT, the majority was fit. We found no impact of the intervention on patient-centred outcomes or the cost of health services. Targeting a more homogeneous group of only pre-frail and frail patients is strongly recommended in future studies needed to clarify the role and organisation of GAM in RT settings.

Disease-specific clinical pathways - are they feasible in primary care? A mixed-methods study.

OBJECTIVE: To explore the feasibility of disease-specific clinical pathways when used in primary care. DESIGN: A mixed-method sequential exploratory design was used. First, merging and exploring quality interview data across two cases of collaboration between the specialist care and primary care on the introduction of clinical pathways for four selected chronic diseases. Secondly, using quantitative data covering a population of 214,700 to validate and test hypothesis derived from the qualitative findings. SETTING: Primary care and specialist care collaborating to manage care coordination. RESULTS: Primary-care representatives expressed that their patients often have complex health and social needs that clinical pathways guidelines seldom consider. The representatives experienced that COPD, heart failure, stroke and hip fracture, frequently seen in hospitals, appear in low numbers in primary care. The quantitative study confirmed the extensive complexity among home healthcare nursing patients and demonstrated that, for each of the four selected diagnoses, a homecare nurse on average is responsible for preparing reception of the patient at home after discharge from hospital, less often than every other year. CONCLUSIONS: The feasibility of disease-specific pathways in primary care is limited, both from a clinical and organisational perspective, for patients with complex needs. The low prevalence in primary care of patients with important chronic conditions, needing coordinated care after hospital discharge, constricts transferring tasks from specialist care. Generic clinical pathways are likely to be more feasible and efficient for patients in this setting. Key points Clinical pathways in hospitals apply to single-disease guidelines, while more than 90% of the patients discharged to community health care for follow-up have multimorbidity. Primary care has to manage the health care of the patient holistically, with all his or her complex needs. Patients most frequently admitted to hospitals, i.e. patients with COPD, heart failure, stroke and hip fracture are infrequent in primary care and represent a minority among patients in need of coordinated community health care. In primary care, the low rate of receiving patients discharged from hospitals of major chronic diseases hampers maintenance of required specific skills, thus constricting the transfer of tasks to primary care. Generic clinical pathways are suggested to be more feasible than disease-specific pathways for most patients with complex needs.

Generic care pathway for elderly patients in need of home care services after discharge from hospital: a cluster randomised controlled trial.

BACKGROUND: Improved discharge arrangements and targeted post-discharge follow-up can reduce the risk of adverse events after hospital discharge for elderly patients. Although more care is to shift from specialist to primary care, there are few studies on post-discharge interventions run by primary care. A generic care pathway, Patient Trajectory for Home-dwelling elders (PaTH) including discharge arrangements and follow-up by primary care, was developed and introduced in Central Norway Region in 2009, applying checklists at defined stages in the patient trajectory. In a previous paper, we found that PaTH had potential of improving follow-up in primary care. The aim of this study was to establish the effect of PaTH-compared to usual care-for elderly in need of home care services after discharge from hospital. METHODS: We did an unblinded, cluster randomised controlled trial with 12 home care clusters. Outcomes were measured at the patient level during a 12-month follow-up period for the individual patient and analysed applying linear and logistic mixed models. Primary outcomes were readmissions within 30 days and functional level assessed by Nottingham extended ADL scale. Secondary outcomes were number and length of inpatient hospital care and nursing home care, days at home, consultations with the general practitioners (GPs), mortality and health related quality of life (SF-36). RESULTS: One-hundred and sixty-three patients were included in the PaTH group (six clusters), and 141 patients received care as usual (six clusters). We found no statistically significant differences between the groups for primary and secondary outcomes except for more consultations with the GPs in PaTH group (p = 0.04). Adherence to the intervention was insufficient as only 36% of the patients in the intervention group were assessed by at least three of the four main checklists in PaTH, but this improved over time. CONCLUSIONS: Lack of adherence to PaTH rendered the study inconclusive regarding the elderly's functional level, number of readmissions after hospital discharge, and health care utilisation except for more consultations with the GPs. A targeted exploration of prerequisites for implementation is recommended in the pre-trial phase of complex intervention studies. TRIAL REGISTRATION: Clinical Trials.gov NCT01107119 , retrospectively registered 2010.04.18.

Implementing a care pathway for elderly patients, a comparative qualitative process evaluation in primary care.

BACKGROUND: In Central Norway a generic care pathway was developed in collaboration between general hospitals and primary care with the intention of implementing it into everyday practice. The care pathway targeted elderly patients who were in need of home care services after discharge from hospital. The aim of the present study was to investigate the implementation process of the care pathway by comparing the experiences of health care professionals and managers in home care services between the participating municipalities. METHODS: This was a qualitative comparative process evaluation using data from individual and focus group interviews. The Normalization Process Theory, which provides a framework for understanding how a new intervention becomes part of normal practice, was applied in our analysis. RESULTS: In all of the municipalities there were expectations that the generic care pathway would improve care coordination and quality of follow-up, but a substantial amount of work was needed to make the regular home care staff understand how to use the care pathway. Other factors of importance for successful implementation were involvement of the executive municipal management, strong managerial focus on creating engagement and commitment among all professional groups, practical facilitation of work processes, and a stable organisation without major competing priorities. At the end of the project period, the pathway was integrated in daily practice in two of the six municipalities. In these municipalities the care pathway was found to have the potential of structuring the provision of home care services and collaboration with the GPs, and serving as a management tool to effect change and improve knowledge and skills. CONCLUSION: The generic care pathway for elderly patients has a potential of improving follow-up in primary care by meeting professional and managerial needs for improved quality of care, as well as more efficient organisation of home care services. However, implementation of this complex intervention in full-time running organisations was demanding and required comprehensive and prolonged efforts in all levels of the organisation. Studies on implementation of such complex interventions should therefore have a long follow-up time to identify whether the intervention becomes integrated into everyday practice.

Care pathways as boundary objects between primary and secondary care: Experiences from Norwegian home care services.

The need for integration of healthcare services and collaboration across organisational boundaries is highlighted as a major challenge within healthcare in many countries. Care pathways are often presented as a solution to this challenge. In this article, we study a project of developing, introducing and using a care pathway across healthcare levels focusing on older home-dwelling patients in need of home care services after hospital discharge. In so doing, we use the concept of boundary object, as described by Star and Griesemer, to explore how care pathways can act as tools for translation between specialist healthcare services and home care services. Based on interviews with participants in the project, we find that response to existing needs, local tailoring, involvement and commitment are all crucial for the care pathway to function as a boundary object in this setting. Furthermore, the care pathway, as we argue, can be used to push boundaries just as much as it can be used as a tool for bridging across them, thus potentially contributing to a more equal relationship between specialist healthcare services and home care services.

Development of a patient-centred care pathway across healthcare providers: a qualitative study.

BACKGROUND: Different models for care pathways involving both specialist and primary care have been developed to ensure adequate follow-up after discharge. These care pathways have mainly been developed and run by specialist care and have been disease-based. In this study, primary care providers took the initiative to develop a model for integrated care pathways across care levels for older patients in need of home care services after discharge. Initially, the objective was to develop pathways for patients diagnosed with heart failure, COPD and stroke. The aim of this paper is to investigate the process and the experiences of the participants in this developmental work. The participants were drawn from three hospitals, six municipalities and patient organizations in Central Norway. METHODS: This qualitative study used focus group interviews, written material and observations. Representatives from the hospitals, municipalities and patient organizations taking part in the development process were chosen as informants. RESULTS: The development process was very challenging because of the differing perspectives on care and different organizational structures in specialist care and primary care. In this study, the disease perspective, being dominant in specialist care, was not found to be suitable for use in primary health care because of the need to cover a broader perspective including the patient's functioning, social situation and his or her preferences. Furthermore, managing several different disease-based care pathways was found to be unsuitable in home care services, as well as unsuitable for a population characterized by a substantial degree of comorbidity. The outcome of the development process was a consensus that outlined a single, common patient-centred care pathway for transition from hospital to follow-up in primary care. The pathway was suitable for most common diseases and included functional and social aspects as well as disease follow-up, thus merging the differing perspectives. The disease-based care pathways were kept for use within the hospitals. CONCLUSIONS: Disease-based care pathways for older patients were found to be neither feasible nor sustainable in primary care. A common patient-centred care pathway that could meet the needs of multi- morbid patients was recommended.

Unwanted incidents during transition of geriatric patients from hospital to home: a prospective observational study.

BACKGROUND: Geriatric patients recently discharged from hospital experience increased chance of unplanned readmissions and admission to nursing homes. Several studies have shown that medication-related discrepancies are common. Few studies report unwanted incidents by other factors than medications. In 2002 an ambulatory team (AT) was established within the Department of Geriatrics, St. Olavs University Hospital HF, Trondheim, Norway. The AT monitored the transition of the patients from hospital to home and four weeks after discharge in order to reveal unwanted incidents.The aim of the present study was to describe unwanted incidents registered by the AT among patients discharged from a geriatric evaluation and management unit (GEMU) by character, frequency and stage in the transitional process. Only unwanted incidents with a severity making contact with the primary health care (PHC) necessary were registered. METHODS: A prospective observational study with patients treated in the GEMU and followed by the AT was performed. Current practice included comprehensive geriatric assessment and management including discharge planning in the GEMU and collaboration with the primary health care on appointments on assistance to be provided after discharge from hospital. Unwanted incidents severe enough to induce contact with the primary health care were registered during the transitional phase and after discharge. RESULTS: 118 patients (65% female), with mean age 83.2 +/- 6.4 years participated. Median Barthel Index at discharge was 18 (interquartile range 16-19) and median Mini Mental Status Examination 24 (interquartile range 21-26). A total of 146 unwanted incidents were registered in 70 (59%) of the patients. Most frequent were unwanted incidents related to drug prescription regime (32%), exchange of information in and between the GEMU and the primary health care (25%) and service or help provided from the PHC (17%). CONCLUSIONS: Despite a seemingly well-organised system for transition of patients from the GEMU to their homes, one or more unwanted incidents occurred in most patients during discharge or four weeks post discharge. The study has revealed areas of importance for improving transitional care of geriatric patients.

[Specialised short-term wards in nursing homes--the Trondheim model]. / Spesialiserte korttidsplasser i sykehjem--Trondheims-modellen.

BACKGROUND: The health sector faces major challenges as a consequence of the elderly constituting a growing proportion of the population. Doctors at all levels will need to acquire the skills needed for dealing with patients with multiple and complex conditions, and hospitals will need to be dynamic in dealing with patients with acute and curable diseases as well as with the elderly and chronically ill. There is a considerable professional gap between community care services and services offered by the general hospitals. MATERIAL AND METHODS: In the City of Trondheim, Norway, the community care and hospital services have analysed the challenges they share and what they can do to make the "chain of care" better for those patients that are the most in need of coordinated efforts. One initiative is two short-term units specialising in treatment and care at an intermediary level between ordinary nursing homes and hospitals. RESULTS: In 2003, 275 patients were admitted to the intermediary care department in Søbstad nursing home, and at Havstein nursing home 79 patients were admitted to its palliative care department. The operating costs in these nursing homes are higher than in traditional units, but far lower than in hospitals. We suggest that these specialised units represent a good solution, professionally as well as financially.