Goal attainment scaling with older people in general practice: A feasibility study.

Background: The impact of health problems on daily life and consequent treatment goals differ from person to person, particularly for older people with multiple health problems. Personalized care in general practice can help address these health problems, but evaluation of its effects remains difficult. In rehabilitation, a common approach to the evaluation of personalized care is Goal Attainment Scaling. This feasibility study assesses whether goal attainment scaling can also be applied to the evaluation of personal care for community-dwelling older people in general practice. Methods: General practices were invited to participate in this longitudinal, observational feasibility study. Practice nurses and general practitioners received training in care plans and goal attainment scaling. They were each asked to create care plans and goal attainment scales for patients (aged ≥75 years) and to carry out evaluations at three and six months. Professionals and patients both completed a short questionnaire to evaluate their experiences regarding the (dis)advantages of goal attainment scaling. Results: Professionals (n=10) and patients (n=23) were able to set goals and scales (n=57) for problems across five health domains (somatic, functional, social, psychological and communicative), but experienced difficulties formulating goals and corresponding goal attainment scaling levels. Reported benefits of goal attainment scaling were 1) important problems were addressed, 2) patients were involved and motivated to attain goals, and 3) evaluation was straightforward once a scale was created. Disadvantages were 1) difficult for older people, 2) time-consuming and complex for clinical practice. Conclusions: Goal attainment scaling shows potential benefit for clinical practice and general practice research in terms of the setting and evaluation of goals for community-dwelling older persons. Further research is needed to develop more standardized and less time-consuming goal attainment scaling methods.

Perceived doctor-patient relationship and satisfaction with general practitioner care in older persons in residential homes.

OBJECTIVE: Understanding patient satisfaction from the perspective of older adults is important to improve quality of their care. Since patient and care variables which can be influenced are of specific interest, this study examines the relation between patient satisfaction and the perceived doctor-patient relationship in older persons and their general practitioners (GPs). DESIGN: Cross-sectional survey. SUBJECTS AND SETTING: Older persons (n = 653, median age 87 years; 69.4% female) living in 41 residential homes. MAIN OUTCOME MEASURES: Patient satisfaction (report mark) and perceived doctor-patient relationship (Leiden Perioperative care Patient Satisfaction questionnaire); relationships were examined by comparing medians and use of regression models. RESULTS: The median satisfaction score was 8 (interquartile range 7.5-9; range 0-10) and doctor-patient relationship 65 (interquartile range 63-65; range 13-65). Higher satisfaction scores were related to higher scores on doctor-patient relationship (Jonckheere Terpstra test, p for trend <.001) independent of gender, age, duration of stay in the residential home, functional and clinical characteristics. Adjusted for these characteristics, per additional point for doctor-patient relationship, satisfaction increased with 0.103 points (ß = 0.103, 95% CI 0.092-0.114; p < .001). In those with a 'low' doctor-patient relationship rating, the percentage awarding 'sufficient or good' to their GP for 'understanding about the personal situation' was 12%, 'receiving attention as an individual' 22%, treating the patient kindly 78%, and being polite 94%. CONCLUSION: In older persons, perceived doctor-patient relationship and patient satisfaction are related, irrespective of patient characteristics. GPs may improve patient satisfaction by focusing more on the affective aspects of the doctor-patient relationship. Key Points Examination of the perceived doctor-patient relationship as a variable might better accommodate patients' expectations and improve satisfaction with the provided primary care.

A Structured Process Description of a Pragmatic Implementation Project: Improving Integrated Care for Older Persons in Residential Care Homes.

Evaluation of the implementation of integrated care can differ from trial-based research due to complexity. Therefore, we examined whether a theory-based method for process description of implementation can contribute to improvement of evidence-based care. MOVIT, a Dutch project aimed at implementing integrated care for older vulnerable persons in residential care homes, was used as a case study. The project activities were defined according to implementation taxonomy and mapped in a matrix of theoretical levels and domains. Project activities mainly targeted professionals (both individual and group). A few activities targeted the organizational level, whereas none targeted the policy level, or the patient, or the "social, political, and legal" domains. However, the resulting changes in care delivery arrangement had consequences for professionals, patients, organizations, and the social, political, and legal domains. A structured process description of a pragmatic implementation project can help assess the fidelity and quality of the implementation, and identify relevant contextual factors for immediate adaptation and future research. The description showed that, in the MOVIT project, there was a discrepancy between the levels and domains targeted by the implementation activities and those influenced by the resulting changes in delivery arrangement. This could have influenced, in particular, the adoption and sustainability of the project.

Satisfaction in Older Persons and General Practitioners during the Implementation of Integrated Care.

BACKGROUND: Integrated care for older persons with complex care needs is widely advocated. Particularly professionals and policy makers have positive expectations. Care outcome results are ambiguous. Receiver and provider satisfaction is relevant but still poorly understood. METHODS: During implementation of integrated care in residential homes (The MOVIT project), we compared general satisfaction and satisfaction with specific aspects of General Practitioner (GP) care in older persons and GPs before (cohort I) and after at least 12 months of implementation (cohort II). RESULTS: The general satisfaction score for GP care given by older persons does not change (Cohort I (n = 762) mean score 8.0 (IQR:7.0-9.0) vs. Cohort II (n = 505) mean score 8.0 (IQR:7.0-8.0);P = 0.01). Expressions of general satisfaction in GPs do not show consistent change (Cohort I (n = 87) vs Cohort II (n = 66), percentage satisfied about; role as GP, 56% vs 67%;P = 0.194, ability to provide personal care, 60% vs 67%;P = 0.038, quality of care, 54% vs 62%;P = 0.316). Satisfaction in older persons about some specific aspects of care do show change; GP-patient relationship, points 61.6 vs 63.3;P = 0.001, willingness to talk about mistakes, score 3.47 vs 3.73;P = 0.001, information received about drugs, score 2.79 vs 2.46;P = 0.002. GPs also report changes in specific aspects: percentage satisfied about multidisciplinary meetings; occurrence, 21% vs 53%;P = <0.001, GP presence, 12% vs 41%;P = <0.001, and participation, 29% vs.51%;P = 0.046. CONCLUSION: General satisfaction about care received and provided shows no consistent change in older persons and GPs during the implementation of integrated care. Specific changes in satisfaction are found. These show an emphasis on inter-personal aspects in older persons and organizational aspects in GPs.

[A treatment plan as method and compass]. / Het zorgplan als methode en kompas.

For elderly people with complex care needs, working with a treatment plan is a method for offering personalized, proactive, integrated care. The treatment plan works as a 'compass' because it indicates the key points to focus on in the care for the elderly person. It can take personal wishes and preferences into account, improve the person's ability to cope independently and involve family and caregivers in the process. The treatment plan provides an overview of the most important problems in all domains and of the professional caregivers involved. In this article we describe the potential opportunities and action points within working with treatment plans. Opportunities include shared decision making, paying attention to functioning and independent coping, and stimulation of care in the community. Action points include organization of care, registration, education and privacy. Drawing up a treatment plan is not an end in itself, but a working method, which takes into account the diversity of the elderly population and the complexity of care giving.

[Do not screen all elderly for cognitive impairment]. / Screen niet alle ouderen op cognitieve stoornissen.

Early and routine screening of older people for cognitive impairment is widely advocated as it is thought to support proactive interventions and improve treatment results. However, scientific evidence to support this strategy is lacking. The recent systematic review of screening instruments and interventions discussed in this commentary shows that the widely implemented Mini-mental state examination questionnaire (MMSE) is indeed adequate to confirm the diagnosis of dementia, and to a lesser extent also mild cognitive impairment. However, no pharmacological interventions have shown any convincing evidence of a positive effect in the groups selected by screening. Pharmacological treatment is often discontinued because of its side effects. No convincing evidence could be found to support the effect of any other caregiver-oriented intervention either. This commentary concludes that the MMSE can be used for diagnosing dementia in primary care, but should not be used for screening otherwise healthy older patients.

Assessment of appropriateness of screening community-dwelling older people to prevent functional decline.

OBJECTIVES: To identify appropriate screening conditions, stratified according to age and vulnerability, to prevent functional decline in older people. DESIGN: A RAND/University of California at Los Angeles appropriateness method. SETTING: The Netherlands. PARTICIPANTS: A multidisciplinary panel of 11 experts. MEASUREMENTS: The panelists assessed the appropriateness of screening for 29 conditions mentioned in guidelines from four countries, stratified according to age (60-74, 75-84, ≥85) and health status (general, vital, and vulnerable) and received a literature overview for each condition, including the guidelines and up-to-date literature. After an individual rating round, panelists discussed disagreements and performed a second individual rating. The median of the second ratings defined the appropriateness of screening. RESULTS: The panel rated screening to be appropriate in three of the 29 conditions, indicating that screening was expected to prevent functional decline. Screening for insufficient physical activity was considered appropriate for all three age and health groups. Screening for cardiovascular risk factors and smoking was considered appropriate for the general and vital population aged 60 to 74. Of the 261 ratings, 63 (24%) were classified as uncertain, of which 42 (67%) concerned the vulnerable population. The panelists considered conditions inappropriate mainly because of lack of an adequate screening tool or lack of evidence of effective interventions for positive screened persons. CONCLUSION: The expert panel considered screening older people to prevent functional decline appropriate for insufficient physical activity and smoking and cardiovascular risk in specific groups. For other conditions, sufficient evidence does not support screening. Based on their experience, panelists expected benefit from developing tests and interventions, especially for vulnerable older people.

[Working together responsibly in primary care--from ideal to reality]. / Verantwoordelijk samenwerken in de eerstelijn: Van ideaalbeeld naar werkelijkheid.

In January 2010, the Royal Dutch Medical Association (KNMG) will publish the guideline 'Sharing responsibilities when cooperating in cure and care'. However, in practice the situation is a long way off from the ideal outlined in the guideline. The ideal situation for a patient in need of complex care would be to have coordination and case management in the hands of one person, but in practice, several care providers are involved. The physician has the final medical responsibility and should maintain an overview. The care coordinator is the person who ensures the other care providers keep to the arrangements made. The case manager is the one who has frequent contact with the patient and relatives. This requires sound working agreements and adequate, timely exchange of information between care providers themselves and between care providers and the patient. Working with care plans contributes to this exchange of information and should become routine.