Undertaking a Collaborative Rapid Realist Review to Investigate What Works in the Successful Implementation of a Frail Older Person's Pathway (original) (raw)
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HRB Open Research, 2018
Background: Frailty is the age-accelerated decline across multiple organ systems which leads to vulnerability to poor resolution of homeostasis after a stressor event. This loss of reserve means that a minor illness can result in a disproportionate loss of functional ability. Improving acute care for frail older patients is now a national priority and an important aspect of the National Programme for Older People in Ireland. Evidence suggests that an interdisciplinary approach incorporating rapid comprehensive geriatric assessment and early intervention by an interdisciplinary team can reduces susceptibility to hospitalisation related functional decline. The aim of the Systematic Approach to Improving Care for Frail Older Patients (SAFE) is to develop and explore the process of implementing a model of excellence in the delivery of patient-centred integrated care within the context of frail older people’s acute admissions. Methods: The SAFE study will employ a mixed methodology appro...
BMC Health Services Research, 2019
Background Although not an inevitable part of ageing, frailty is an increasingly common condition in older people. Frail older patients are particularly vulnerable to the adverse effects of hospitalisation, including deconditioning, immobility and loss of independence (Chong et al, J Am Med Dir Assoc 18:638.e7–638.e11, 2017). The ‘Systematic Approach to improving care for Frail older patients’ (SAFE) study co-designed, with public and patient representatives, quality improvement initiatives aimed at enhancing the delivery of care to frail older patients within an acute hospital setting. This paper describes quality improvement initiatives which resulted from a co-design process aiming to improve service delivery in the acute setting for frail older people. These improvement initiatives were aligned to five priority areas identified by patients and public representatives. Methods The co-design work was supported by four pillars of effective and meaningful public and patient represent...
Journal of Medical Internet Research
Background: There is a call for bold and innovative action to transform the current care systems to meet the needs of an increasing population of frail multimorbid elderly. International health organizations propose complex transformations toward digitally supported (1) Person-centered, (2) Integrated, and (3) Proactive care (Digi-PIP care). However, uncertainty regarding both the design and effects of such care transformations remain. Previous reviews have found favorable but unstable impacts of each key element, but the maturity and synergies of the combination of elements are unexplored. Objective: This study aimed to describe how the literature on whole system complex transformations directed at frail multimorbid elderly reflects (1) operationalization of intervention, (2) maturity, (3) evaluation methodology, and (4) effect on outcomes. Methods: We performed a systematic health service and electronic health literature review of care transformations targeting frail multimorbid elderly. Papers including (1) Person-centered, integrated, and proactive (PIP) care; (2) at least 1 digital support element; and (3) an effect evaluation of patient health and/ or cost outcomes were eligible. We used a previously published ideal for the quality of care to structure descriptions of each intervention. In a secondary deductive-inductive analysis, we collated the descriptions to create an outline of the generic elements of a Digi-PIP care model. The authors then reviewed each intervention regarding the presence of critical elements, study design quality, and intervention effects. Results: Out of 927 potentially eligible papers, 10 papers fulfilled the inclusion criteria. All interventions idealized Person-centered care, but only one intervention made what mattered to the person visible in the care plan. Care coordinators responsible for a whole-person care plan, shared electronically in some instances, was the primary integrated care strategy. Digitally supported risk stratification and management were the main proactive strategies. No intervention included workflow optimization, monitoring of care delivery, or patient-reported outcomes. All interventions had gaps in the chain of care that threatened desired outcomes. After evaluation of study quality, 4 studies remained. They included outcome analyses on patient satisfaction, quality of life, function, disease process quality, health care utilization, mortality, and staff burnout. Only 2 of 24 analyses showed significant effects. Conclusions: Despite a strong common-sense belief that the Digi-PIP ingredients are key to sustainable care in the face of the silver tsunami, research has failed to produce evidence for this. We found that interventions reflect a reductionist paradigm, which forces care workers into standardized narrowly focused interventions for complex problems. There is a paucity of studies that meet complex needs with digitally supported flexible and adaptive teamwork. We predict that consistent results from care
Aging Clinical and Experimental Research
Background Interprofessional collaborative practice (ICP) is currently recommended for the delivery of high-quality integrated care for older people. Frailty prevention and management are key elements to be tackled on a multi-professional level. Aim This study aims to develop a consensus-based European multi-professional capability framework for frailty prevention and management. Methods Using a modified Delphi technique, a consensus-based framework of knowledge, skills and attitudes for all professions involved in the care pathway of older people was developed within two consultation rounds. The template for the process was derived from competency frameworks collected in a comprehensive approach from EU-funded projects of the European Commission (EC) supported best practice models for health workforce development. Results The agreed framework consists of 25 items structured in 4 domains of capabilities. Content covers the understanding about frailty, skills for screening and assessment as well as management procedures for every profession involved. The majority of items focused on interprofessional collaboration, communication and person-centred care planning. Discussion This framework facilitates clarification of professionals' roles and standardizes procedures for cross-sectional care processes. Despite a lack of evidence for educational interventions, health workforce development remains an important aspect of quality assurance in health care systems. Conclusions The multi-professional capability framework for frailty prevention and management incorporated interprofessional collaborative practice, consistent with current recommendations by the World Health Organization, Science Advice for Policy by European Academies and the European Commission.
PloS one, 2017
Frailty is a common condition in older age and is a public health concern which requires integrated care and involves different stakeholders. This meta-synthesis focuses on experiences, understanding, and attitudes towards screening, care, intervention and prevention for frailty across frail and healthy older persons, caregivers, health and social care practitioners. Studies published since 2001 were identified through search of electronic databases; 81 eligible papers were identified and read in full, and 45 papers were finally included and synthesized. The synthesis was conducted with a meta-ethnographic approach. We identified four key themes: Uncertainty about malleability of frailty; Strategies to prevent or to respond to frailty; Capacity to care and person and family-centred service provision; Power and choice. A bottom-up approach which emphasises and works in synchrony with frail older people's and their families' values, goals, resources and optimisation strategies...
Frailty inclusive care in acute and community-based settings: a systematic review protocol
Systematic Reviews, 2021
Background: Frailty is a known risk factor for an array of adverse outcomes including more frequent and prolonged health services use and high health care costs. Aging of the population has implications for care provision across the care continuum, particularly for people living with frailty. Despite known risks associated with frailty, there has been limited research on care pathways that address the needs of persons living with frailty. Our study aims to review and examine, in a rigorous way, the quality of evidence for multi-component interventions and care pathways focused on frailty. Methods: A comprehensive electronic search strategy will be used to identify studies that evaluate multicomponent interventions or care pathways for persons living with frailty. The search strategy will include terms for frailty, multi-component interventions, effectiveness, and cost effectiveness applied to the following databases: MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews. An adapted search for Google Scholar and gray literature databases will also be used. References of included studies will be hand-searched for additional citations of frailty-inclusive care. Known experts and corresponding authors of identified articles will be contacted by email to identify further eligible studies. Risk of bias will be assessed using the Effective Public Health Practice Project Quality Assessment tool. Data will be extracted from eligible studies and it is anticipated that narrative analysis will be used. If studies with sufficient homogeneity are found, then pooled effects will be reported using meta-analysis. Discussion: This review will appraise the evidence currently available on multi-component frailty interventions. Results will inform on clinical pathway development for people living with frailty across the care continuum and will guide future research to address gaps in the literature and areas in need of further development. Systematic review registration: PROSPERO CRD42020166733
International Journal of Health Governance, 2021
PurposeDifferent pathways of frailty care to prevent or delay progression of frailty and enable people to live well with frailty are emerging in primary and community care in the UK. The purpose of the study is to understand effective frailty care pathways and their components to inform future service development and pathway evaluation in primary- and community-care services.Design/methodology/approachA rapid evidence review was conducted: 11 research publications met the inclusion criteria and were analysed using narrative thematic synthesis.FindingsThere is strong evidence that resistance-based exercise, self-management support, community geriatric services and hospital at home (HAH) improve patient health and function. In general, evaluation and comparison of frailty care pathways, components and pathway operations is challenging due to weaknesses, inconsistencies and differences in evaluation, but it is essential to include consideration of process, determinant and implementatio...
Research Involvement and Engagement
Background During care transitions, the older (75+) patient’s agenda can easily be missed. To counteract this, involving patients in shared clinical decision making has proven to be of great value. Likewise, involving patients and other stakeholders as researchers is gaining ground. Patient and public involvement (PPI) in research entails many benefits, for example, by bringing further insight from those with lived experiences of being ill. There are various challenges associated with involving some older patients, for example frailty, cognitive impairment and other chronic illnesses. To the best of our knowledge, there are only a few examples of initiatives involving older patients beyond research participation. The feasibility of involving frail older patients during an ongoing care transition from hospital to primary health care remains unknown. To investigate the feasibility of including older frail patients, their relatives and health care professionals (HCPs) as co-researchers...
Healthcare Quarterly, 2016
The transition from hospital to home is a vulnerable period for patients with complex conditions, who are often frail, at risk for adverse events and unable to navigate a system of poorly coordinated care in the post-discharge period. Care transition interventions are seen as effective care coordinating mechanisms for reducing avoidable adverse events associated with the transition of the patient from the hospital to the home. A study was undertaken to evaluate the effectiveness of a care transition intervention involving a hand-off between a hospital-based care transitions nurse and a communitybased rapid response nurse. Two focus groups were held, one involving rapid response nurses and the other involving care transition nurses. Individual interviews were conducted with the managers (n = 2) and executives (n = 2) to identify the factors that facilitated or were barriers to its implementation. Using thematic content analysis, it was found that the effectiveness of transitional coordination efforts was thwarted by ineffective communication, which affected the quality of the underlying relationships between the two teams. Other barriers to achieving the desired outcomes included the following: issues of role clarity, role awareness and acceptance, the adequacy and reinforcement of coordinating mechanisms, the effectiveness of the information exchange protocols and the absence of shared measures of accountability. Clinical integration initiatives have fewer human resource and financial implementation barriers compared with organizational integration efforts but are complex undertakings requiring clear alignment between organizations, shared accountability measures, effective communication processes and relationships of trust and respect between interprofessional teams.
BMC Geriatrics, 2023
Background The Enhanced Health for Care homes (EHCH) framework is an innovative response to provide more proactive, preventative approaches to care for residents living in care homes. It involves co-producing a shared vision with primary care. As part of EHCH a UK clinical commissioning group supported GP's in two localities to implement their preferred delivery approach involving a new Frailty Nurse-led (FN-led) model in care homes alongside an existing General Practitioner-led (GP-led) model. This paper focuses on implementation of the new FN-led model. Methods A qualitative study design was adopted. Forty-eight qualitative semi-structured interviews were undertaken across six care home sites in a Northern locality: three implementing the FN-led and three engaged in an existing GP-led model. Participants included residents, family members, care home managers, care staff, and health professionals working within the EHCH framework. Results Two overarching themes were generated from data analysis: Unanticipated implementation issues and Unintended consequences. Unsuccessful attempts to recruit Frailty Nurses (FN) with enhanced clinical skills working at the desired level (UK NHS Band 7) led to an unanticipated evolution in the implementation process of the FN-led model towards 'training posts'. This prompted misaligned role expectations subsequently provoking unexpected temporary outcomes regarding role-based trust. The existing, well understood nature of the GP-led model may have further exacerbated these unintended consequences. Conclusion Within the broader remit of embedding EHCH frameworks, the implementation of new FN roles needed to evolve due to unforeseen recruitment issues. Wider contextual factors are not in the control of those developing new initiatives and cannot always be foreseen, highlighting how wider factors can force evolution of planned implementation processes with unintended consequences. However, the unintended consequences in this study highlight the need for careful consideration of information dissemination (content and timing) to key stakeholders, and the influence of existing ways of working.