International Journal of Geriatric Psychiatry, 20(10), October 2005, pp.973-982.
Publisher:
Wiley
Somatic symptoms of depression such as fatigue create a diagnostic dilemma when assessing an older patient with medical comorbidities, since chronic medical illnesses may produce similar symptoms. Alternatively, somatic symptoms attributed to medical illness may actually be caused by depression. These analyses were designed to determine if somatic symptoms in older patients are more strongly associated with chronic physical problems or with depression. Reanalysis of data from an observational study of depression in primary care and a randomized trial of paroxetine and nortriptyline for the treatment of major depression. Patients were evaluated with a structured diagnostic interview and a battery of psychiatric, physical, and psychosocial measures. Two hundred and forty eight primary care and psychiatric patients aged 60 years. Associations among depression, somatization, and chronic physical problems were examined using correlations and regression modeling. The results found that in multiple regression models, psychological symptoms of depression remained significant predictors of somatization after controlling for age, gender, and medical comorbidities.
Somatic symptoms of depression such as fatigue create a diagnostic dilemma when assessing an older patient with medical comorbidities, since chronic medical illnesses may produce similar symptoms. Alternatively, somatic symptoms attributed to medical illness may actually be caused by depression. These analyses were designed to determine if somatic symptoms in older patients are more strongly associated with chronic physical problems or with depression. Reanalysis of data from an observational study of depression in primary care and a randomized trial of paroxetine and nortriptyline for the treatment of major depression. Patients were evaluated with a structured diagnostic interview and a battery of psychiatric, physical, and psychosocial measures. Two hundred and forty eight primary care and psychiatric patients aged 60 years. Associations among depression, somatization, and chronic physical problems were examined using correlations and regression modeling. The results found that in multiple regression models, psychological symptoms of depression remained significant predictors of somatization after controlling for age, gender, and medical comorbidities.
Subject terms:
older people, primary care, depression, health, comorbidity;
Providing appropriate, sustainable care to older people for the coming decades is a challenge that all EU member states are facing, because of demographic changes, cost containment and empowerment. An increasing number of older people have long-term, complex needs which may require support from any combination of primary, residential or acute hospital care, as well as social care and practical support. A key solution to this challenge is integrated care – a well-planned and well-organised set of services and care processes, targeted at the multidimensional needs and problems of an individual client, or at a group of people with similar needs or problems. Members of the integrated care team work closely to offer timely detection, appropriate assessment, treatment and care, so that the older person‘s health and well-being might be significantly enhanced. This resource book for managers provides guidelines for those involved in the development of integrated care services, focusing on the management of integrated care at the client level, the organisation level and the system level, this book will be invaluable to managers and professionals in the health and social care field.
Providing appropriate, sustainable care to older people for the coming decades is a challenge that all EU member states are facing, because of demographic changes, cost containment and empowerment. An increasing number of older people have long-term, complex needs which may require support from any combination of primary, residential or acute hospital care, as well as social care and practical support. A key solution to this challenge is integrated care – a well-planned and well-organised set of services and care processes, targeted at the multidimensional needs and problems of an individual client, or at a group of people with similar needs or problems. Members of the integrated care team work closely to offer timely detection, appropriate assessment, treatment and care, so that the older person‘s health and well-being might be significantly enhanced. This resource book for managers provides guidelines for those involved in the development of integrated care services, focusing on the management of integrated care at the client level, the organisation level and the system level, this book will be invaluable to managers and professionals in the health and social care field.
Extended abstract:
Author:NIES Henk, BERMAN Philip C., eds. Title: Integrating services for older people: a resource book for managers Publisher: European Health Management Association, 2004
Summary
This resource book for managers provides guidelines for those involved in the development of integrated care services, focusing on the management of integrated care at the client level, the organisation level and the system level.
Context
Providing appropriate, sustainable care to older people for the coming decades is a challenge that all EU member states are facing, because of demographic changes, cost containment and empowerment. An increasing number of older people have long-term, complex needs which may require support from any combination of primary, residential or acute hospital care, as well as social care and practical support. A key solution to this challenge is integrated care – a well-planned and well-organised set of services and care processes, targeted at the multidimensional needs and problems of an individual client, or at a group of people with similar needs or problems. Members of the integrated care team work closely to offer timely detection, appropriate assessment, treatment and care, so that the older person‘s health and well-being might be significantly enhanced.
Contents
The editors' foreword gives the background, discusses definitions and terminology and implementing the concept, and explains how the book developed, that it users should mainly be managers of care-providing organisations and managers and officials responsible for commissioning long-term care for older people, how to use it, topics covered, the geographical spread of content, and how to get involved. Chapter 1 discusses the concepts and background of integrated care. Chapter 2 considers integrated organisational structures. Chapter 3 is on involvement, empowerment and advocacy. Needs assessment is covered by Chapter 4. Chapter 5 covers care pathways. Case management is the theme of Chapter 6. Chapter 7 is about integrated teams. The workforce is discussed in Chapter 8 and cultural change in Chapter 9. Leadership is the theme of Chapter 10. Chapter 11 considers strategic planning. Information management is discussed in Chapter 12, and quality management in Chapter 13. Almost all chapters have sections on definitions, implementation, objectives and intended outcomes, models and approaches, the implementation process, staff, monitoring and evaluation, staff, barriers, supports, references and further reading, and sometimes a conclusion. Some also give web links. Much information is given in figures and tables.
352 references
Subject terms:
hospitals, intermediate care, older people, primary care, residential care;
Health and Social Care in the Community, 13(1), January 2005, pp.21-29.
Publisher:
Wiley
The prevention of disability in later life is a major challenge facing industrialised societies. Primary care practitioners are well positioned to maintain and promote health in older people, but the British experience of population-wide preventive interventions has been disappointing. Health risk appraisal (HRA), an emergent information technology-based approach from the USA, has potential for fulfilling some of the objectives of the National Service Framework for Older People. Information technology and expert systems allow older people's perspectives on health and health risk behaviours to be collated, analysed and converted into tailored health promotion advice without adding to the workload of primary care practitioners. This paper describes a preliminary study of the portability of HRA to British settings. Cultural adaptation and feasibility testing of a comprehensive health risk assessment questionnaire was carried out in a single group practice with 12,500 patients, in which 58% of the registered population aged 65 and over participated. Eight of 10 respondents at all ages found the questionnaire easy or very easy to understand and complete, although more than one-third had or would have liked assistance. More than half felt the length of the questionnaire was about right, and 1 in 10 disliked some questions. Of those who completed the questionnaire and received tailored, written health promotion advice, 39% provided feedback with comments that can be used for increasing the acceptability of tailored advice. These findings have informed a wider exploratory study in general practice.
The prevention of disability in later life is a major challenge facing industrialised societies. Primary care practitioners are well positioned to maintain and promote health in older people, but the British experience of population-wide preventive interventions has been disappointing. Health risk appraisal (HRA), an emergent information technology-based approach from the USA, has potential for fulfilling some of the objectives of the National Service Framework for Older People. Information technology and expert systems allow older people's perspectives on health and health risk behaviours to be collated, analysed and converted into tailored health promotion advice without adding to the workload of primary care practitioners. This paper describes a preliminary study of the portability of HRA to British settings. Cultural adaptation and feasibility testing of a comprehensive health risk assessment questionnaire was carried out in a single group practice with 12,500 patients, in which 58% of the registered population aged 65 and over participated. Eight of 10 respondents at all ages found the questionnaire easy or very easy to understand and complete, although more than one-third had or would have liked assistance. More than half felt the length of the questionnaire was about right, and 1 in 10 disliked some questions. Of those who completed the questionnaire and received tailored, written health promotion advice, 39% provided feedback with comments that can be used for increasing the acceptability of tailored advice. These findings have informed a wider exploratory study in general practice.
Subject terms:
older people, prevention, primary care, risk, health needs;
Health and Social Care in the Community, 11(2), March 2003, pp.85-94.
Publisher:
Wiley
Although it is perceived wisdom that joint working must be beneficial there is little evidence to support this. Evaluates 2 integrated co-located health and social care teams established in a rural county to meet the needs of older people and their carers. Identifies that patients from 'integrated teams' may self-refer more and are assessed more quickly, maybe indicating the 'one-stop shop' approach is having an impact on service delivery. Findings also suggest that in integrated teams the initial stages of the process of seeking help and being assessed for a service may have improved through better communication, understanding and exchange of information among professional groups. However, the degree of 'integration' seen within these teams does not appear sufficiently well developed to have had an impact on clinical outcomes for patients/users. It appears unlikely from available evidence that measures such as co-location go far enough to produce changes in outcomes for older people. If the Department of Health wishes to see benefits in process progress to benefits to users more major structural changes will be required. The process of changing organisational structures can be enhanced where there is evidence that changes will produce better outcomes. At present this evidence does not exist, although this study suggests that benefits might be forthcoming if greater integration can be achieved. Nevertheless, until social services and NHS trusts develop more efficient and compatible information systems it will be impossible to evaluate what impact any further steps towards integration might have on older people without significant external resources.
Although it is perceived wisdom that joint working must be beneficial there is little evidence to support this. Evaluates 2 integrated co-located health and social care teams established in a rural county to meet the needs of older people and their carers. Identifies that patients from 'integrated teams' may self-refer more and are assessed more quickly, maybe indicating the 'one-stop shop' approach is having an impact on service delivery. Findings also suggest that in integrated teams the initial stages of the process of seeking help and being assessed for a service may have improved through better communication, understanding and exchange of information among professional groups. However, the degree of 'integration' seen within these teams does not appear sufficiently well developed to have had an impact on clinical outcomes for patients/users. It appears unlikely from available evidence that measures such as co-location go far enough to produce changes in outcomes for older people. If the Department of Health wishes to see benefits in process progress to benefits to users more major structural changes will be required. The process of changing organisational structures can be enhanced where there is evidence that changes will produce better outcomes. At present this evidence does not exist, although this study suggests that benefits might be forthcoming if greater integration can be achieved. Nevertheless, until social services and NHS trusts develop more efficient and compatible information systems it will be impossible to evaluate what impact any further steps towards integration might have on older people without significant external resources.
Subject terms:
older people, primary care, social care, social care provision, health care;
Health and Social Care in the Community, 11(2), March 2003, pp.138-145.
Publisher:
Wiley
The UK Government has highlighted the need to develop appropriate information and support services for informal carers. Previous research has found that managing medication is one aspect of the role that presents its own problems; however, these have not been subject to detailed examination. The objective of this paper is to report the number and type of problems experienced by informal carers when managing medication for older care recipients and relate these to measures of coping and health. This was a cross-sectional survey undertaken in one district in each of 4 randomly selected health authority areas in England. Structured interviews, comprising closed and open questions, with 184 informal carers and 93 associated older care recipients were conducted in participants' own homes. Data were gathered on the number and type of medication-related problems experienced in relation to the informal caring role, and the impact of these from carers' perspectives in terms of coping and health. Problems with at least one medication-related activity were reported by 67% of carers. Problems were associated with all types of medication-related activities and experienced by carers providing different levels of care for older people. Four themes were identified from carers' accounts which illustrated a diversity of practical problems and anxieties: maintaining continuous supplies of medication in the home, assisting with administration, making clinical judgments and communicating with care recipients and health professionals. Carers reporting greater numbers of medication-related problems were more likely to experience higher levels of carer strain and poorer mental health status. The findings provide insights to inform the development of primary care services to support informal carers in the management of medication for older people.
The UK Government has highlighted the need to develop appropriate information and support services for informal carers. Previous research has found that managing medication is one aspect of the role that presents its own problems; however, these have not been subject to detailed examination. The objective of this paper is to report the number and type of problems experienced by informal carers when managing medication for older care recipients and relate these to measures of coping and health. This was a cross-sectional survey undertaken in one district in each of 4 randomly selected health authority areas in England. Structured interviews, comprising closed and open questions, with 184 informal carers and 93 associated older care recipients were conducted in participants' own homes. Data were gathered on the number and type of medication-related problems experienced in relation to the informal caring role, and the impact of these from carers' perspectives in terms of coping and health. Problems with at least one medication-related activity were reported by 67% of carers. Problems were associated with all types of medication-related activities and experienced by carers providing different levels of care for older people. Four themes were identified from carers' accounts which illustrated a diversity of practical problems and anxieties: maintaining continuous supplies of medication in the home, assisting with administration, making clinical judgments and communicating with care recipients and health professionals. Carers reporting greater numbers of medication-related problems were more likely to experience higher levels of carer strain and poorer mental health status. The findings provide insights to inform the development of primary care services to support informal carers in the management of medication for older people.
Subject terms:
informal care, medication, older people, primary care, carers;
British Journal of General Practice, 52(481), August 2002, pp.646-651.
Publisher:
Royal College of General Practitioners
Health assessments for older people have become an increasing priority with the NSF for Older People. In response to low level of activity in primary care around health assessment for older people, Camden and Islington Health Authority initiated a project in 1996-97 to develop innovative primary care for older people. This article reports on the study which was conducted in four general practices. Results found all four practices identified problems needing attention in the older population, developed different projects focused on particular needs among older people, and tested them in practice. Patient and public involvement were central to the design and implementation process in only one practice. Innovations were sustained in only one practice, but some were adopted by primary care group and others extended to a wider group of practices by the health authority.
Health assessments for older people have become an increasing priority with the NSF for Older People. In response to low level of activity in primary care around health assessment for older people, Camden and Islington Health Authority initiated a project in 1996-97 to develop innovative primary care for older people. This article reports on the study which was conducted in four general practices. Results found all four practices identified problems needing attention in the older population, developed different projects focused on particular needs among older people, and tested them in practice. Patient and public involvement were central to the design and implementation process in only one practice. Innovations were sustained in only one practice, but some were adopted by primary care group and others extended to a wider group of practices by the health authority.
Subject terms:
older people, primary care, assessment, general practitioners, health needs;
GALVEZ-HERNANDEZ Pablo, PAZ Luis Gonzalez-de, MUNTANER Carles
Journal article citation:
BMJ Open, 12(2), 2022, Online only
Publisher:
BMJ Publishing Group
Objectives: Primary care is well positioned to identify and address loneliness and social isolation in older adults, given its gatekeeper function in many healthcare systems. This study aimed to identify and characterise loneliness and social isolation interventions and detect factors influencing implementation in primary care. Design: Scoping review using the five-step Arksey and O’Malley Framework. Data sources: MEDLINE, CINAHL, EMBASE, COCHRANE databases and grey literature were searched from inception to June 2021. Eligibility criteria: Empirical studies in English and Spanish focusing on interventions addressing social isolation and loneliness in older adults involving primary care services or professionals. Data extraction and synthesis: The researchers extracted data on loneliness and social isolation identification strategies and the professionals involved, networks and characteristics of the interventions and barriers to and facilitators of implementation. This study conducted a thematic content analysis to integrate the information extracted. Results:32 documents were included in the review. Only seven articles (22%) reported primary care professionals screening of older adults’ loneliness or social isolation, mainly through questionnaires. Several interventions showed networks between primary care, health and non-healthcare sectors, with a dominance of referral pathways (n=17). Two-thirds of reports did not provide clear theoretical frameworks, and one-third described lengths under 6 months. Workload, lack of interest and ageing-related barriers affected implementation outcomes. In contrast, well-defined pathways, collaborative designs, long-lasting and accessible interventions acted as facilitators. Conclusions: There is an apparent lack of consistency in strategies to identify lonely and socially isolated older adults. This might lead to conflicts between intervention content and participant needs. This study also identified a predominance of schemes linking primary care and non-healthcare sectors. However, although professionals and participants reported the need for long-lasting interventions to create meaningful social networks, durable interventions were scarce. Sustainability should be a core outcome when implementing loneliness and social isolation interventions in primary care.
(Edited publisher abstract)
Objectives: Primary care is well positioned to identify and address loneliness and social isolation in older adults, given its gatekeeper function in many healthcare systems. This study aimed to identify and characterise loneliness and social isolation interventions and detect factors influencing implementation in primary care. Design: Scoping review using the five-step Arksey and O’Malley Framework. Data sources: MEDLINE, CINAHL, EMBASE, COCHRANE databases and grey literature were searched from inception to June 2021. Eligibility criteria: Empirical studies in English and Spanish focusing on interventions addressing social isolation and loneliness in older adults involving primary care services or professionals. Data extraction and synthesis: The researchers extracted data on loneliness and social isolation identification strategies and the professionals involved, networks and characteristics of the interventions and barriers to and facilitators of implementation. This study conducted a thematic content analysis to integrate the information extracted. Results:32 documents were included in the review. Only seven articles (22%) reported primary care professionals screening of older adults’ loneliness or social isolation, mainly through questionnaires. Several interventions showed networks between primary care, health and non-healthcare sectors, with a dominance of referral pathways (n=17). Two-thirds of reports did not provide clear theoretical frameworks, and one-third described lengths under 6 months. Workload, lack of interest and ageing-related barriers affected implementation outcomes. In contrast, well-defined pathways, collaborative designs, long-lasting and accessible interventions acted as facilitators. Conclusions: There is an apparent lack of consistency in strategies to identify lonely and socially isolated older adults. This might lead to conflicts between intervention content and participant needs. This study also identified a predominance of schemes linking primary care and non-healthcare sectors. However, although professionals and participants reported the need for long-lasting interventions to create meaningful social networks, durable interventions were scarce. Sustainability should be a core outcome when implementing loneliness and social isolation interventions in primary care.
(Edited publisher abstract)
Subject terms:
literature reviews, social isolation, loneliness, intervention, primary care, older people, screening;
Background: Quality improvement collaboratives (QICs) bring together multidisciplinary teams in a structured process to improve care quality. How QICs can be used to support healthcare improvement in care homes is not fully understood. Methods: A realist evaluation to develop and test a programme theory of how QICs work to improve healthcare in care homes. A multiple case study design considered implementation across 4 sites and 29 care homes. Observations, interviews and focus groups captured contexts and mechanisms operating within QICs. Data analysis classified emerging themes using context-mechanism-outcome configurations to explain how NHS and care home staff work together to design and implement improvement. Results: QICs will be able to implement and iterate improvements in care homes where they have a broad and easily understandable remit; recruit staff with established partnership working between the NHS and care homes; use strategies to build relationships and minimise hierarchy; protect and pay for staff time; enable staff to implement improvements aligned with existing work; help members develop plans in manageable chunks through QI coaching; encourage QIC members to recruit multidisciplinary support through existing networks; facilitate meetings in care homes and use shared learning events to build multidisciplinary interventions stepwise. Teams did not use measurement for change, citing difficulties integrating this into pre-existing and QI-related workload. Conclusions: These findings outline what needs to be in place for health and social care staff to work together to effect change. Further research needs to consider ways to work alongside staff to incorporate measurement for change into QI.
(Edited publisher abstract)
Background: Quality improvement collaboratives (QICs) bring together multidisciplinary teams in a structured process to improve care quality. How QICs can be used to support healthcare improvement in care homes is not fully understood. Methods: A realist evaluation to develop and test a programme theory of how QICs work to improve healthcare in care homes. A multiple case study design considered implementation across 4 sites and 29 care homes. Observations, interviews and focus groups captured contexts and mechanisms operating within QICs. Data analysis classified emerging themes using context-mechanism-outcome configurations to explain how NHS and care home staff work together to design and implement improvement. Results: QICs will be able to implement and iterate improvements in care homes where they have a broad and easily understandable remit; recruit staff with established partnership working between the NHS and care homes; use strategies to build relationships and minimise hierarchy; protect and pay for staff time; enable staff to implement improvements aligned with existing work; help members develop plans in manageable chunks through QI coaching; encourage QIC members to recruit multidisciplinary support through existing networks; facilitate meetings in care homes and use shared learning events to build multidisciplinary interventions stepwise. Teams did not use measurement for change, citing difficulties integrating this into pre-existing and QI-related workload. Conclusions: These findings outline what needs to be in place for health and social care staff to work together to effect change. Further research needs to consider ways to work alongside staff to incorporate measurement for change into QI.
(Edited publisher abstract)
Subject terms:
care homes, nursing homes, older people, quality improvement, primary care, multidisciplinary teams;
Purpose: The scaling up of promising, innovative integration projects presents challenges to social and health care systems. Evidence that a new service provides (cost) effective care in a (pilot) locality can often leave us some way from understanding how the innovation worked and what was crucial about the context to achieve the goals evidenced when applied to other localities. Even unpacking the “black box” of the innovation can still leave gaps in understanding with regard to scaling it up. Theory-led approaches are increasingly proposed as a means of helping to address this knowledge gap in understanding implementation. Our particular interest here is exploring the potential use of theory to help with understanding scaling up integration models across sites. The theory under consideration is Normalisation Process Theory (NPT). Design/methodology/approach: The article draws on a natural experiment providing a range of data from two sites working to scale up a well-thought-of, innovative integrated, primary care-based dementia service to other primary care sites. This provided an opportunity to use NPT as a means of framing understanding to explore what the theory adds to considering issues contributing to the success or failure of such a scaling up project. Findings: NPT offers a framework to potentially develop greater consistency in understanding the roll out of models of integrated care. The knowledge gained here and through further application of NPT could be applied to inform evaluation and planning of scaling-up programmes in the future. Research limitations/implications: The research was limited in the data collected from the case study; nevertheless, in the context of an exploration of the use of the theory, the observations provided a practical context in which to begin to examine the usefulness of NPT prior to embarking on its use in more expensive, larger-scale studies. Practical implications: NPT provides a promising framework to better understand the detail of integrated service models from the point of view of what may contribute to their successful scaling up. Social implications: NPT potentially provides a helpful framework to understand and manage efforts to have new integrated service models more widely adopted in practice and to help ensure that models which are effective in the small scale develop effectively when scaled up. Originality/value: This paper examines the use of NPT as a theory to guide understanding of scaling up promising innovative integration service models.
(Edited publisher abstract)
Purpose: The scaling up of promising, innovative integration projects presents challenges to social and health care systems. Evidence that a new service provides (cost) effective care in a (pilot) locality can often leave us some way from understanding how the innovation worked and what was crucial about the context to achieve the goals evidenced when applied to other localities. Even unpacking the “black box” of the innovation can still leave gaps in understanding with regard to scaling it up. Theory-led approaches are increasingly proposed as a means of helping to address this knowledge gap in understanding implementation. Our particular interest here is exploring the potential use of theory to help with understanding scaling up integration models across sites. The theory under consideration is Normalisation Process Theory (NPT). Design/methodology/approach: The article draws on a natural experiment providing a range of data from two sites working to scale up a well-thought-of, innovative integrated, primary care-based dementia service to other primary care sites. This provided an opportunity to use NPT as a means of framing understanding to explore what the theory adds to considering issues contributing to the success or failure of such a scaling up project. Findings: NPT offers a framework to potentially develop greater consistency in understanding the roll out of models of integrated care. The knowledge gained here and through further application of NPT could be applied to inform evaluation and planning of scaling-up programmes in the future. Research limitations/implications: The research was limited in the data collected from the case study; nevertheless, in the context of an exploration of the use of the theory, the observations provided a practical context in which to begin to examine the usefulness of NPT prior to embarking on its use in more expensive, larger-scale studies. Practical implications: NPT provides a promising framework to better understand the detail of integrated service models from the point of view of what may contribute to their successful scaling up. Social implications: NPT potentially provides a helpful framework to understand and manage efforts to have new integrated service models more widely adopted in practice and to help ensure that models which are effective in the small scale develop effectively when scaled up. Originality/value: This paper examines the use of NPT as a theory to guide understanding of scaling up promising innovative integration service models.
(Edited publisher abstract)
Subject terms:
older people, integrated care, case studies, innovation, intervention, dementia, primary care;