Geriatric-palliative care units model for improvement of elderly care

The aim of this research was to indicate the necessity of a new organizational model of health and social care system for the geriatric population in Croatia. Modern geriatrics puts special emphasis on the idea that the care of the elderly should be performed through home care or long-term care institutions, rather than in the acute care hospital departments. The social healthcare of the elderly requires a multidisciplinary approach, as well as teamwork and coordination of institutional and non-institutional departments. Founding of palliative care units is clearly absent from the existing elderly care system. 33% of the total deceased geriatric population within the target area (2000-2002) has passed away in institutions (Dubrovnik General Hospital and nursing homes), what clearly indicates a need for organized palliative care on the stationary level. Nursing homes in Croatia should accept about 4% of the total number of older population (according to the gerontology research). Nevertheless, this research shows that the available capacity of the nursing homes in the Dubrovansko-Neretvanska County is 50% of the projected percentage. The solution might be setting up of palliative-geriatric units in already existing institutions, as shown by the SWOT analysis.     

Comparison of long-term care in an acute care institution and in a long-term care institution

BACKGROUND: Acute care hospitals in Quebec are required to reserve 10% of their beds for patients receiving long-term care while awaiting transfer to a long-term care facility. It is widely believed that this is inefficient because it is more costly to provide long-term care in an acute care hospital than in one dedicated to long-term care. The purpose of this study was to compare the quality and cost of long-term care in an acute care hospital and in a long-term care facility. METHODS: A concurrent cross-sectional study was conducted of 101 patients at the acute care hospital and 102 patients at the long-term care hospital. The 2 groups were closely matched in terms of age, sex, nursing care requirements and major diagnoses. Several indicators were used to assess the quality of care: the number of medical specialist consultations, drugs, biochemical tests and radiographic examinations; the number of adverse events (reportable incidents, nosocomial infections and pressure ulcers); and anthropometric and biochemical indicators of nutritional status. Costs were determined for nursing personnel, drugs and biochemical tests. A longitudinal study was conducted of 45 patients who had been receiving long-term care at the acute care hospital for at least 5 months and were then transferred to the long-term care facility where they remained for at least 6 months. For each patient, the number of adverse events, the number of medical specialist consultations and the changes in activities of daily living status were assessed at the 2 institutions. RESULTS: In the concurrent study, no differences in the number of adverse events were observed; however, patients at the acute care hospital received more drugs (5.9 v. 4.7 for each patient, p < 0.01) and underwent more tests (299 v. 79 laboratory units/year for each patient, p < 0.001) and radiographic examinations (64 v. 46 per 1000 patient-weeks, p < 0.05). At both institutions, 36% of the patients showed anthropometric and biochemical evidence of protein-calorie undernutrition; 28% at the acute care hospital and 27% at the long-term care hospital had low serum iron and low transferrin saturation, compatible with iron deficiency. The longitudinal study showed that there were more consultations (61 v. 37 per 1000 patient-weeks, p < 0.02) and fewer pressure ulcers (18 v. 34 per 1000 patient-weeks, p < 0.05) at the acute care hospital than at the long-term care facility; other measures did not differ. The cost per patient-year was $7580 higher at the acute care hospital, attributable to the higher cost of drugs ($42), the greater use of laboratory tests ($189) and, primarily, the higher cost of nursing ($7349). For patients requiring 3.00 nursing hours/day, the acute care hospital provided more hours than the long-term care facility (3.59 v. 3.03 hours), with a higher percentage of hours from professional nurses rather than auxiliary nurses or nursing aides (62% v. 28%). The nurse staffing pattern at the acute care hospital was characteristic of university-affiliated acute care hospitals. INTERPRETATION: The long-term care provided in the acute care hospital involved a more interventionist medical approach and greater use of professional nurses (at a significantly higher cost) but without any overall difference in the quality of care.     

Seeking early care: the role of prenatal care advocates

This exploratory study investigates the role of social support in the initiation of prenatal care by analyzing data from interviews with 36 pregnant women at a public health facility in Tuscaloosa, Alabama. A systematic sample of U.S.-born women aged 19 to 34 who initiated care in each of the three trimesters was interviewed. After controlling for age and education, three variables were found to be associated with earlier estimated gestational age at the time of a woman's first prenatal visit: self-referral to care, more prenatal care advocates, and fewer children. There was no significant effect on the timing of entry to care associated with ethnicity, marital status, transportation availability, rural vs. urban residence, distance of residence from the clinic, or prior prenatal care at the public health facility. These results suggest that first-time mothers are likely to seek early care and that family and friends play a significant support role in encouraging women to begin care.     

Oral care training in the basic education of care professionals

doi:10.1111/j.1741‐2358.2009.00304.x
Oral care training in the basic education of care professionals Objective: To investigate the quantity and quality of oral care training in the basic education of future long‐term care (LTC) professionals in Norway. Background: The level of oral hygiene has often proved inadequate in LTC facilities. It has been maintained that this could be due to insufficient knowledge of oral care among care professionals. Materials and methods: A self‐administered questionnaire was sent to all 270 schools in Norway which offered basic education of LTC personnel in 2004/05. Information on theoretical and practical oral care training, scope of oral care in teaching material and curriculum, educational background of the teaching staff and schools opinion regarding adequacy of their training programme was collected. Results: Of the 203 respondents (75% response rate), 188 (participants) included oral care in their educational programme. Approximately two‐thirds of the participating schools provided 3 h or more of oral care training and many of the important themes were presented in the textbooks that were recommended. Moreover, the practical exercises performed in practice placement supplemented the knowledge. Conclusion: The results could not confirm that LTC professional’s basic education concerning oral care was inadequate. There may therefore be other explanations for the poor oral hygiene in many LTC facilities.     

Characteristics of primary care practices associated with high quality of care

Background:

No primary practice care model has been shown to be superior in achieving high-quality primary care. We aimed to identify the organizational characteristics of primary care practices that provide high-quality primary care.

Methods:

We performed a cross-sectional observational study involving a stratified random sample of 37 primary care practices from 3 regions of Quebec. We recruited 1457 patients who had 1 of 2 chronic care conditions or 1 of 6 episodic care conditions. The main outcome was the overall technical quality score. We measured organizational characteristics by use of a validated questionnaire and the Team Climate Inventory. Statistical analyses were based on multilevel regression modelling.

Results:

The following characteristics were strongly associated with overall technical quality of care score: physician remuneration method (27.0; 95% confidence interval [CI] 19.0–35.0), extent of sharing of administrative resources (7.6; 95% CI 0.8–14.4), presence of allied health professionals (15.3; 95% CI 5.4–25.2) and/or specialist physicians (19.6; 95% CI 8.3–30.9), the presence of mechanisms for maintaining or evaluating competence (7.7; 95% CI 3.0–12.4) and average organizational access to the practice (4.9; 95% CI 2.6–7.2). The number of physicians (1.2; 95% CI 0.6–1.8) and the average Team Climate Inventory score (1.3; 95% CI 0.1–2.5) were modestly associated with high-quality care.

Interpretation:

We identified a common set of organizational characteristics associated with high-quality primary care. Many of these characteristics are amenable to change through practice-level organizational changes.A health care system is only as strong as its primary care sector,¹ which provides “entry into the system for all new needs and problems, provides person-focused (not disease-oriented) care over time, provides care for all but very uncommon or unusual conditions …”² Patient enrolment, team-based care, information technology, and funding and remuneration schemes that foster comprehensiveness and collaboration are key characteristics of effective primary care systems.³ None can be singled out as the most determining, but how they are clustered defines a limited set of organizational models that have been associated with a variety of outcomes.⁴ Canadian provinces have implemented different primary care models with different scopes of changes.⁵ Research has not yet identified a “winning” model. For example, in Ontario, community health centres deliver better chronic illness care⁶ but have less accessibility than fee-for-service enrolment models,⁷ and no model provided more comprehensive preventive care.⁸ Walk-in clinics achieved better quality scores than did family medicine clinics for treatment of a set of acute problems.⁹ How the work is organized may be as important, if not more important, than what the model is called.These observations suggest that the challenges associated with providing high-quality services differ depending on the nature of care considered.^9–11 Even if chronic illness is a major challenge, the quality of care must not be improved at the expense of accessibility, preventive or good episodic care, which are all essential components of primary care.In this study, we report the results of the quantitative component of a multimethod observational study conducted in Quebec to determine which organizational characteristics of primary care practices are associated with high-quality care. We sought to find a quality measure of care that would encompass the comprehensive nature of primary care (episodic, chronic and preventive care), and we explored how the contribution of organizational characteristics varied based on the type of care provided.