To show the extent to which social and health care services are integrated across European home care systems.
Introduction and theory
Home care incorporates several types of services. It is part of both the social system and health care system. Different disciplines/providers from different organisational settings, which may be financed differently, provide care at the clients' home. Furthermore, client's access to care may be organised in various ways. A European wide study (EURHOMAP) is used to look at these aspects in several countries.
A systematic literature review and consultations with experts across Europe resulted in a set of consensus-based indicators. Major topics are: provision, financing and regulation. Data were collected in 31 countries in 2008–2009. To enhance comparability, a panel of key informants in each country answered a set of questions related to four vignettes about people in need of home care.
Results and conclusion
Results will be presented for some countries which form a contrast in the extent of service delivery and integration in home care. The delivery, needs assessment, financing and policy and regulation of each will be discussed. There are several levels at which integration can occur: regulation, financing, access and service delivery. Whether and at which level integration occurs varies from country to country.
home care; integrated care; Europe
Health and social services provided at home are becoming increasingly important. Hence, there is a need for information on home care in Europe. The objective of this literature review was to respond to this need by systematically describing what has been reported on home care in Europe in the scientific literature over the past decade.
A systematic literature search was performed for papers on home care published in English, using the following data bases: Cinahl, the Cochrane Library, Embase, Medline, PsycINFO, Sociological Abstracts, Social Services Abstracts, and Social Care Online. Studies were only included if they complied with the definition of home care, were published between January 1998 and October 2009, and dealt with at least one of the 31 specified countries. Clinical interventions, instrument developments, local projects and reviews were excluded. The data extracted included: the characteristics of the study and aspects of home care 'policy & regulation', 'financing', 'organisation & service delivery', and 'clients & informal carers'.
Seventy-four out of 5,133 potentially relevant studies met the inclusion criteria, providing information on 18 countries. Many focused on the characteristics of home care recipients and on the organisation of home care. Geographical inequalities, market forces, quality and integration of services were also among the issues frequently discussed.
Home care systems appeared to differ both between and within countries. The papers included, however, provided only a limited picture of home care. Many studies only focused on one aspect of the home care system and international comparative studies were rare. Furthermore, little information emerged on home care financing and on home care in general in Eastern Europe. This review clearly shows the need for more scientific publications on home care, especially studies comparing countries. A comprehensive and more complete insight into the state of home care in Europe requires the gathering of information using a uniform framework and methodology.
home care; European Union; care systems; international comparison
Long-term care (LTC) in the form of care provided in nursing homes, homes for the aged and home care is considered an appropriate answer to the growing needs of the aging populations of the industrialized world. However, the provision of and expenditures on LTC vary considerably between these industrialized countries. Although one would expect LTC to be subject to many internationally comparative studies, including all European countries, this is not the case. A paper presented by Damiani et al. in BMC Health Services Research contains an internationally comparative model regarding the development of LTC in Europe (2003 to 2007). They achieve an intriguing compromise between depth and width in the sparsely populated domain of internationally comparative research on LTC by characterizing countries' LTC and interpreting the large north/south differences found. Their results also show that 'cash for care' schemes form a substantial alternative to traditional LTC provision. An additional time series analysis showed that many countries seem to be engaged in reorganizing the LTC sector. This study widens knowledge in a neglected area of health services research and should serve as a source of inspiration for further studies.
Please see related article: http://www.biomedcentral.com/1472-6963/11/316 
The aim of this study is to use an advanced telerehabilitation system in the context of an IHC service to find out: in which specific situations telerehabilitation enriches the home treatment; if it is feasible to use the telerehabilitation gear in patients home; tendencies concerning the effect of training in relation to improvement in arm function.
The increasing number of survivors following acute events such as stroke are enlightening new needs to guarantee appropriate care and quality of life support at home. A potential application of telerehabilitation is to deliver home services. The World Health Organisation (WHO) Europe Regional Office considers as a critical issue in Western-countries the fragmented delivery of health and social services. Research on this topic has been called at the last European Community Call Health-2007-3.1.6: Continuity of Clinical Care.
A Danish HTA shows that EHSD improved the ADL function and reduces both the time of stay in hospital and the risk of hard endpoint. Empowerment of the EHSD model is encouraged by means of an already tested telerehabilitation approach, in order to improve functional patients outcomes with a resulting better allocation of resources and saving costs. Within an already running Early Home Support Discharge (EHSD) project model for persons with stroke we implement a telerehabilitation approach.
The EHSD model provide an enrolment at 10 days from the stroke event for persons meeting the following criteria: 250, De Renzi test>62, Albert test=36, Mini Mental State Examination (MMSE)>24.
Mental illness, dementia, severe language disturbances, pregnancy, former acquired brain injury and transfer to another unit were considered as exclusion criteria.
In the EHSD program eight home-therapy sessions were provided during the in-charge time (hospital stay included), with at minimum two sessions provided after the hospital discharge. We implement the tele-treatment (based on the remote control of an already tested virtual reality device for motor treatment) in the month after hospital discharge, at minimum one hour/three times/week.
Primary outcomes: overall mortality, hospital readmission rate, costs, EQoL, interview addressing acceptability, usability and feasibility.
Secondary outcomes: F-M UE, Reaching Performance Scale, MMSE, Ashworth and FIM.
Conclusion and discussion
We expect that an enriched EHSD model can be accepted by patients and caregivers improving functions and saving costs.
homecare; stroke; telerehabilitation
In this paper, integrated care in an inter-organisational cooperative setting of in-home elderly care is studied. The aim is to explore how home care workers coordinate their daily work, identify coordination issues in situ and discuss possible actions for supporting seamless and integrated elderly care at home.
The empirical findings are drawn from an ethnographic workplace study of the cooperation and coordination taking place between home care workers in a Swedish county. Data were collected through observational studies, interviews and group discussions.
The paper identifies a need to support two core issues. Firstly, it must be made clear how the care interventions that are currently defined as ‘self-treatment’ by the home health care should be divided. Secondly, the distributed and asynchronous coordination between all care workers involved, regardless of organisational belonging must be better supported.
Integrated care needs to be developed between organisations as well as within each organisation. As a matter of fact, integrated care needs to be built up beyond organisational boundaries. Organisational boundaries affect the planning of the division of care interventions, but not the coordination during the home care process. During the home care process, the main challenge is the coordination difficulties that arise from the fact that workers are distributed in time and/or space, regardless of organisational belonging. A core subject for future practice and research is to develop IT tools that reach beyond formal organisational boundaries and processes while remaining adaptable in view of future structure changes.
integrated care; cooperative work; coordination; home care; home health care; home help service
Over the past decade, policy makers in developed countries have begun to pay increasing attention to reform of the long-term care system for the frail elderly and younger people with disabilities. A continuum of strategies have generated interest, including integrated systems of care with agency/professionally managed service packages on the one end, and programs offering cash benefits along with the flexibility to decide how to best use these funds to meet individual needs and preferences, on the other. The latter approach, known as “consumer-directed care,” is found in various forms and degrees in Europe and North America. Primarily organised around the provision of home and community care, consumer-directed services are aimed at empowering clients and family carers, giving them major control over the what, who and when of needed care. Consumer-directed care appears to be the antithesis of integrated care. However, it actually holds important lessons and implications for the latter. This policy paper explores the rationale and models of consumer-directed services at home, reviews developments, designs and outcomes of programs in the Austria, Germany, the Netherlands, and the US. It also discusses how this experience could be helpful in shaping better and more responsive integrated models of care for vulnerable long term care populations.
consumer-directed care; home and community services; long term care; integrated care
Municipal home care workers provide high-quality services to an increasing proportion of elderly people living in private homes. The work environments and working conditions of these workers vary to a great extent, implying rapid priority-making among both employers and employees to ensure that the work can be performed in a safe way.
This study aims to examine home care workers’ perceptions of health, risks, working conditions, and risk management within their organization.
The study was based on cross-sectional data collected from home care service staff in a municipality in the north of Sweden. Nursing assistants and care aides (n = 133) replied to a self-administered questionnaire. Descriptive statistics and between-group differences were analysed.
Home care work was perceived to require high levels of professional skill and ingenuity, a good psychosocial work situation, but required a high physical workload. The general health, the capacity and self-efficacy of the staff in relation to work were good. Difficulty in performing risk assessments and following safety regulations due to lack of time, equipment, and information were identified.
There is a need to increase participation in risk assessments among the staff, improve management support, structures, and cooperation with other divisions of the social services and the medical care organizations.
Health; Risk management; Home care work
Evidence demonstrates that measures are needed to optimise therapy and improve administration of medicines in care homes for older people. The aim of this study is to determine the clinical and cost effectiveness of a novel model of multi-professional medication review.
A cluster randomised controlled trial design, involving thirty care homes. In line with current practice in medication reviews, recruitment and consent will be sought from general practitioners and care homes, rather than individual residents. Care homes will be segmented according to size and resident mix and allocated to the intervention arm (15 homes) or control arm (15 homes) sequentially using minimisation. Intervention homes will receive a multi-professional medication review at baseline and at 6 months, with follow-up at 12 months. Control homes will receive usual care (support they currently receive from the National Health Service), with data collection at baseline and 12 months. The novelty of the intervention is a review of medications by a multi-disciplinary team. Primary outcome measures are number of falls and potentially inappropriate prescribing. Secondary outcome measures include medication costs, health care resource use, hospitalisations and mortality.
The null hypothesis proposes no difference in primary outcomes between intervention and control patients. The primary outcome variable (number of falls) will be analysed using a linear mixed model, with the intervention specified as a fixed effect and care homes included as a random effect. Analyses will be at the level of the care home. The economic evaluation will estimate the cost-effectiveness of the intervention compared to usual care from a National Health Service and personal social services perspective.
The study is not measuring the impact of the intervention on professional working relationships, the medicines culture in care homes or the generic health-related quality of life of residents.
This study will establish the effectiveness of a new model of multi-professional clinical medication reviews in care homes, using novel approaches to recruitment and consent. It is the first study to undertake an examination of direct patient outcomes, together with an economic analysis.
Elderly chronic patients are an increasing population using more and more national health services all around Europe. One way to better manage this social and economic challenge is to improve home care through the introduction of information and communication technologies (ICTs).
The K4Care European research project has developed a web-based multi-agent platform providing the medical and management e-services required in a home care system. Due to the comorbidity of the typical patients of this application, the tool allows medical practitioners to define fully personalised care treatments (Individual Intervention Plans). Each of them involves the execution of diverse actions from different actors of the system. Every actor deals with an intelligent agent of the K4Care platform. Agents coordinate their activities autonomously in order to efficiently execute these personalised plans under the supervision of practitioners. Moreover, all the behaviour of the system is guided dynamically by the organisational and medical knowledge represented in the form of ontologies and formal intervention plans.
The prototype developed in the K4Care project can be taken as a proof-of-concept of the viability of improving home care assistance in the near future by using a combination of artificial intelligence methodologies, medical knowledge and ICTs.
home care e-services; elderly; disabled; ontologies; medical knowledge; information and communication technologies
Almost all societies carry responsibility towards patients who require continuous medical care at home. In many health systems the general practitioner cooperates with community based services of home care and coordinates all medical and non medical activities. In Austria the general practitioner together and in cooperation with relatives of the patient and professional organisations usually takes on this task by visiting his patients.
This study was carried out to identify diseases that need home care and to describe the functional profile of home care patients in eastern Austria.
Cross sectional observational study with 17 GP practices participating during 2 study periods in 1997 and in 2004 in eastern Austria. Each GP identified patients requiring home care and assessed their underlying diseases and functional status by filling in a questionnaire personally after an encounter. Patients in nursing homes were excluded. Statistical tests used were t-tests, contingency tables, nonparametric Wilcoxon signed rank sum test and Fisher-combination test.
Patients with degenerative diseases of the central nervous system (65%) caused by Alzheimer's disease and cerebrovascular occlusive disease and patients with degenerative diseases of the skeletal system (53%) were the largest groups among the 198 (1997) and 261 (2004) home care cases of the 11 (1997) and 13 (2004) practices. Malignant diseases in a terminal state constituted only 5% of the cases. More than two thirds of all cases were female with an average age of 80 years. Slightly more than 70% of the patients were at least partially mobile.
Home care and home visits for patients with degenerative diseases of the central nervous and skeletal system are important elements of GP's work. Further research should therefore focus on effective methods of training and rehabilitation to better the mental and physical status of patients living in their private homes.
BACKGROUND: Recent changes in the North American health care system and certain demographic factors have led to increases in home care services. Little information is available to identify the strategies that could facilitate this transformation in medical practice and ensure that such changes respond adequately to patients' needs. As a first step, the authors attempted to identify the major factors influencing physicians' home care practices in the Quebec City area. METHODS: A self-administered questionnaire was sent by mail to all 696 general practitioners working in the Quebec City area. The questionnaire was intended to gather information on physicians' personal and professional characteristics, as well as their home care practice (practice volume, characteristics of both clients and home visits, and methods of patient assessment and follow-up). RESULTS: A total of 487 physicians (70.0%) responded to the questionnaire, 283 (58.1%) of whom reported making home visits. Of these, 119 (42.0%) made fewer than 5 home visits per week, and 88 (31.1%) dedicated 3 hours or less each week to this activity. Physicians in private practice made more home visits than their counterparts in family medicine units and CLSCs (centres locaux des services communautaires [community centres for social and health services]) (mean 11.5 v. 5.8 visits per week), although the 2 groups reported spending about the same amount of time on this type of work (mean 5.6 v. 5.0 hours per week). The proportion of visits to patients in residential facilities or other private residences was greater for private practitioners than for physicians from family medicine units and CLSCs (29.7% v. 18.9% of visits), as were the proportions of visits made at the patient's request (28.0% v. 14.2% of visits) and resulting from an acute condition (21.4% v. 16.0% of visits). The proportion of physicians making home visits at the request of a CLSC was greater for those in family medicine units and CLSCs than for those in private practice (44.0% v. 11.3% of physicians), as was the proportion of physicians making home visits at the request of a colleague (18.0% v. 4.5%) or at the request of hospitals (30.0% v. 6.8%). Physicians in family medicine units and CLSCs did more follow-ups at a frequency of less than once per month than private practitioners (50.9% v. 37.1% of patients), and they treated a greater proportion of patients with cognitive disorders (17.2% v. 12.6% of patients) and palliative care needs (13.7% v. 8.6% of patients). Private practitioners made less use of CLSC resources to assess home patients or follow them. Male private practitioners made more home visits than their female counterparts (mean 12.8 v. 8.3 per week), although they spent an almost equal amount of time on this activity (mean 5.7 v. 5.2 hours per week). INTERPRETATION: These results suggest that practice patterns for home care vary according to the physician's practice setting and sex. Because of foreseeable increases in the numbers of patients needing home care, further research is required to evaluate how physicians' practices can be adapted to patients' needs in this area.
Health services across Europe provide health care for migrant patients every day. However, little systematic research has explored the views and experiences of health care professionals in different European countries. The aim of this study was to assess the difficulties professionals experience in their service when providing such care and what they consider constitutes good practice to overcome these problems or limit their negative impact on the quality of care.
Structured interviews with open questions and case vignettes were conducted with health care professionals working in areas with high proportion of migrant populations in 16 countries. In each country, professionals in nine primary care practices, three accident and emergency hospital departments, and three community mental health services (total sample = 240) were interviewed about their views and experiences in providing care for migrant patients, i.e. from first generation immigrant populations. Answers were analysed using thematic content analysis.
Eight types of problems and seven components of good practice were identified representing all statements in the interviews. The eight problems were: language barriers, difficulties in arranging care for migrants without health care coverage, social deprivation and traumatic experiences, lack of familiarity with the health care system, cultural differences, different understandings of illness and treatment, negative attitudes among staff and patients, and lack of access to medical history. The components of good practice to overcome these problems or limit their impact were: organisational flexibility with sufficient time and resources, good interpreting services, working with families and social services, cultural awareness of staff, educational programmes and information material for migrants, positive and stable relationships with staff, and clear guidelines on the care entitlements of different migrant groups. Problems and good care components were similar across the three types of services.
Health care professionals in different services experience similar difficulties when providing care to migrants. They also have relatively consistent views on what constitutes good practice. The degree to which these components already are part of routine practice varies. Implementing good practice requires sufficient resources and organisational flexibility, positive attitudes, training for staff and the provision of information.
Aims of the present study are the following: 1. to describe the rationale and methodology of the Services and Health for Elderly in Long TERm care (SHELTER) study, a project funded by the European Union, aimed at implementing the interRAI instrument for Long Term Care Facilities (interRAI LTCF) as a tool to assess and gather uniform information about nursing home (NH) residents across different health systems in European countries; 2. to present the results about the test-retest and inter-rater reliability of the interRAI LTCF instrument translated into the languages of participating countries; 3 to illustrate the characteristics of NH residents at study entry.
A 12 months prospective cohort study was conducted in 57 NH in 7 EU countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands) and 1 non EU country (Israel). Weighted kappa coefficients were used to evaluate the reliability of interRAI LTCF items.
Mean age of 4156 residents entering the study was 83.4 ± 9.4 years, 73% were female. ADL disability and cognitive impairment was observed in 81.3% and 68.0% of residents, respectively. Clinical complexity of residents was confirmed by a high prevalence of behavioral symptoms (27.5% of residents), falls (18.6%), pressure ulcers (10.4%), pain (36.0%) and urinary incontinence (73.5%). Overall, 197 of the 198 the items tested met or exceeded standard cut-offs for acceptable test-retest and inter-rater reliability after translation into the target languages.
The interRAI LTCF appears to be a reliable instrument. It enables the creation of databases that can be used to govern the provision of long-term care across different health systems in Europe, to answer relevant research and policy questions and to compare characteristics of NH residents across countries, languages and cultures.
Few studies have examined empowerment interventions as they actually unfold in home care in the context of chronic health problems. This study aims to document the empowerment process as it plays out in interventions with adults receiving home care services.
The qualitative design chosen is a fourth generation evaluation combined with case studies. A home care team of a health and social services center situated in the Eastern Townships (Québec, Canada) will be involved at every step in the study. A sample will be formed of 15 health care professionals and 30 of their home care clients and caregiver. Semi-structured interviews, observations of home care interventions and socio-demographic questionnaires will be used to collect the data. Nine instruments used by the team in prior studies will be adapted and reviewed. A personal log will document the observers' perspectives in order to foster objectivity and the focus on the intervention. The in-depth qualitative analysis of the data will illustrate profiles of enabling interventions and individual empowerment.
The ongoing process to transform the health care and social services network creates a growing need to examine intervention practices of health care professionals working with clients receiving home care services. This study will provide the opportunity to examine how the intervention process plays out in real-life situations and how health care professionals, clients and caregivers experience it. The intervention process and individual empowerment examined in this study will enhance the growing body of knowledge about empowerment.
People suffering from mild dementia may get lost during a walk, which can be dangerous for them and may add to the anxiety felt by their informal caregivers. TalkMeHome is a new service that allows these people to get home safely in such situations using their mobile phone. With an emergency button they can call a remote care professional who will guide the lost person home. To accomplish this, the professional caregiver is able to follow the person’s GPS-location on a map and in Google Streetview. This paper reports on the gathering of user requirements, the technical design of the TalkMeHome service, and small scale experiments to assess the effectiveness and user experience of the service.
Aims and objectives
The goal of the evaluation of the TalkMeHome service was to assess the effectiveness of this novel service and to investigate how persons with mild dementia and care professionals experience the service. The final aim is to make the TalkMeHome service structurally available for the target group.
User requirements were collected through desk research, expert interviews with care professionals, and pre-experiments by researchers in which conventional trackers were used combined with an additional mobile phone to simulate the anticipated implementation as close as possible. In the small scale experiments four participants with mild dementia were included using inclusion criteria based on the target group. Each participant was accompanied outdoor by two researchers, one observing the participant, the other ensuring the participant’s safety regarding traffic. The actual test began by pushing the alarm button, simulating being ‘lost’. This established a connection with the care professional who then started guiding the participant back home. Data were collected by observation, interviews with the participants, and questionnaires and interviews with the care professionals.
As for effectiveness, all four participants were guided home satisfactorily, technical imperfections set aside. Only a few easily corrected mistakes were noticed. The evaluations further showed that guiding people with dementia home is possible even under suboptimal conditions (unreliable information of the person with dementia, missing location updates or an incomplete map). Regarding the experiences of the users, both persons with dementia and care professionals, we conclude that the contact between both was easy but guiding somebody home is a demanding task for a care professional.
dementia; navigation; remote assistance; independent living
The palliative services and programs have been developed with different intensity and modalities in all countries. Several studies have reported that a geographic variation in the availability and provision of palliative care services between and within countries exists, and that a number of vulnerable groups are excluded from these services. This survey estimates the distribution of places of care for Italian cancer patients during the last three months of their lives, the proportion receiving palliative care support at home and in hospital, and the factors associated with the referral to palliative care services.
This is a mortality follow-back survey of 2,000 cancer deaths identified with a 2-stage probability sample, representative of the whole country. Information on patients' experience was gathered from the non-professional caregiver through an interview, using an adapted version of the VOICES questionnaire. A section of the interview concerned the places of care and the palliative care services provided to patients. Multivariate logistic regression analyses were conducted to identify the determinants of palliative care service use.
Valid interviews were obtained for 67% of the identified caregivers (n = 1,271). Most Italian cancer patients were cared for at home (91%) or in hospital (63%), but with substantial differences within the country. Only 14% of Italian cancer patients cared for at home against 20% of those admitted to hospital, received palliative care support. The principal determinants identified for receiving these service were: an extended interval between diagnosis and death (P = 0.01) and the caregiver's high educational level (P = 0.01) for patients at home; the low patient's age (P < 0.01) and the caregiver's high educational level (P = 0.01) for patients in hospital.
In Italy palliative care services are not equally available across the country. Moreover, access to the palliative care services is strongly associated with socio demographic characteristics of the patients and their caregivers. Italian Policy-makers need to equalise palliative care provision and access across the country to meet the needs of all cancer patients.
Over the last three decades significant efforts have been made in many European countries to move away from a mental health system dominated by institutional care towards one whereby the main emphasis is on providing care and support within the community. Although the time of starting the reforms, their pace, the political context, and the exact objectives varies substantially across Europe, practically all countries have been undergoing such major reforms aimed at establishing services in the community to replace institutional based care. Each country makes its own decisions about the necessary mental health services taking into account a range of factors including population needs, level of resources, flexibility and coordination of organizational structures, as well as local culture. These factors become an integral element of a national mental health policy and action plan, closely linked with national public health strategies.
Greece has been modernizing an outdated mental health system, which was based on institutional care, over the last 20 years, by developing community-based mental health care. This article describes the methodology used for the evaluation of the Psychargos programme of the mental health reforms in Greece. Various forms of community-based mental health services have been developed including supported living facilities, community mental health centres and employment opportunities.
Evaluation; Mental health reforms; Community mental health services; Greece
The harmonization of European health systems brings with it a need for tools to allow the standardized collection of information about medical care. A common coding system and standards for the description of services are needed to allow local data to be incorporated into evidence-informed policy, and to permit equity and mobility to be assessed. The aim of this project has been to design such a classification and a related tool for the coding of services for Long Term Care (DESDE-LTC), based on the European Service Mapping Schedule (ESMS).
The development of DESDE-LTC followed an iterative process using nominal groups in 6 European countries. 54 researchers and stakeholders in health and social services contributed to this process. In order to classify services, we use the minimal organization unit or “Basic Stable Input of Care” (BSIC), coded by its principal function or “Main Type of Care” (MTC). The evaluation of the tool included an analysis of feasibility, consistency, ontology, inter-rater reliability, Boolean Factor Analysis, and a preliminary impact analysis (screening, scoping and appraisal).
DESDE-LTC includes an alpha-numerical coding system, a glossary and an assessment instrument for mapping and counting LTC. It shows high feasibility, consistency, inter-rater reliability and face, content and construct validity. DESDE-LTC is ontologically consistent. It is regarded by experts as useful and relevant for evidence-informed decision making.
DESDE-LTC contributes to establishing a common terminology, taxonomy and coding of LTC services in a European context, and a standard procedure for data collection and international comparison.
Health service research; Health system research; Healthcare terminology; Healthcare taxonom; Healthcare instrument
The incidence of cognitive impairment in older age is increasing, as is the number of cognitively impaired older adults living in their own homes. Due to lack of social care resources for these adults and their desires to remain in their own homes and live as independently as possible, research shows that the current standard care provisions are inadequate. Promising opportunities exist in using home assistive technology services to foster healthy aging and to realize the unmet needs of these groups of citizens in a user-centered manner. ISISEMD project has designed, implemented, verified, and assessed an assistive technology platform of personalized home care (telecare) for the elderly with cognitive impairments and their caregivers by offering intelligent home support services. Regions from four European countries have carried out long-term pilot-controlled study in real-life conditions. This paper presents the outcomes from intermediate evaluations pertaining to user satisfaction with the system, acceptance of the technology and the services, and quality of life outcomes as a result of utilizing the services.
Older people living in care homes in England have complex health needs due to a range of medical conditions, mental health needs and frailty. Despite an increasing policy expectation that professionals should operate in an integrated way across organisational boundaries, there is a lack of understanding between care homes and the National Health Service (NHS) about how the two sectors should work together, meaning that residents can experience a poor "fit" between their needs, and services they can access. This paper describes a survey to establish the current extent of integrated working that exists between care homes and primary and community health and social services.
A self-completion, online questionnaire was designed by the research team. Items on the different dimensions of integration (funding, administrative, organisational, service delivery, clinical care) were included. The survey was sent to a random sample of residential care homes with more than 25 beds (n = 621) in England in 2009. Responses were analysed using quantitative and qualitative methods.
The survey achieved an overall response rate of 15.8%. Most care homes (78.7%) worked with more than one general practice. Respondents indicated that a mean of 14.1 professionals/ services (other than GPs) had visited the care homes in the last six months (SD 5.11, median 14); a mean of .39 (SD.163) professionals/services per bed. The most frequent services visiting were district nursing, chiropody and community psychiatric nurses. Many (60%) managers considered that they worked with the NHS in an integrated way, including sharing documents, engaging in integrated care planning and joint learning and training. However, some care home managers cited working practices dictated by NHS methods of service delivery and priorities for care, rather than those of the care home or residents, a lack of willingness by NHS professionals to share information, and low levels of respect for the experience and knowledge of care home staff.
Care homes are a hub for a wide range of NHS activity, but this is ad hoc with no recognised way to support working together. Integration between care homes and local health services is only really evident at the level of individual working relationships and reflects patterns of collaborative working rather than integration. More integrated working between care homes and primary health services has the potential to improve quality of care in a cost- effective manner, but strategic decisions to create more formal arrangements are required to bring this about. Commissioners of services for older people need to capitalise on good working relationships and address idiosyncratic patterns of provision to care homes.The low response rate is indicative of the difficulty of undertaking research in care homes.
To examine how case managers in a state-funded home care program allocate home care services in response to information about a client's Medicare home health care status, with particular attention to the influence of work environment.
Data Sources/Study Setting
Primary data collected on 355 case managers and 26 agency directors employed in June 1999 by 26 of the 27 regional agencies administering the Massachusetts Home Care Program for low-income elders.
Data were collected in a cross-sectional survey study design. A case manager survey included measures of work environment, demographics, and factorial survey vignette clients (N=2,054), for which case managers assessed service eligibility levels. An agency director survey included measures of management practices.
Data Collection/Extraction Methods
Hierarchical linear models estimated the effects of work environment on the relationship between client receipt of Medicare home health care and care plan levels while controlling for case-mix differences in agencies' clients.
Case managers did not supplement extant Medicare home health services, but did allocate more generous service plans to clients who have had Medicare home health care services recently terminated. This finding persisted when controlling for case mix and did not vary by work environment. Work environment affected overall care plan levels.
Study findings indicate systematic patterns of frontline resource allocation shaping the relationships among community-based long-term care payment sources. Further, results illustrate how nonuniform implementation of upper-level initiatives may be partially attributed to work environment characteristics.
Home health care; case management; work environment
Health services in Europe face the challenge of delivering care to a heterogeneous group of irregular migrants (IM). There is little empirical evidence on how health professionals cope with this challenge. This study explores the experiences of health professionals providing care to IM in three types of health care service across 16 European countries.
Semi-structured interviews were conducted with health professionals in 144 primary care services, 48 mental health services, and 48 Accident & Emergency departments (total n = 240). Although legal health care entitlement for IM varies across countries, health professionals reported facing similar issues when caring for IM. These issues include access problems, limited communication, and associated legal complications. Differences in the experiences with IM across the three types of services were also explored. Respondents from Accident & Emergency departments reported less of a difference between the care for IM patients and patients in a regular situation than did respondents from primary care and mental health services. Primary care services and mental health services were more concerned with language barriers than Accident & Emergency departments. Notifying the authorities was an uncommon practice, even in countries where health professionals are required to do this.
The needs of IM patients and the values of the staff appear to be as important as the national legal framework, with staff in different European countries adopting a similar pragmatic approach to delivering health care to IM. While legislation might help to improve health care for IM, more appropriate organisation and local flexibility are equally important, especially for improving access and care pathways.
Irregular migrants; Europe; Qualitative method; Health services; Accessibility
For the first time in India, a Pain and Palliative Care policy to guide the community-based home care initiatives was declared by the Government of Kerala state. In Kerala, majority of the panchayats (local self-governments) are now conducting home-based palliative care as part of primary health care. National focus domain areas in palliative care research are structure and process, the physical aspects, and also the social aspects of care.
The study was conducted to assess the patient's status and the services provided by palliative home care.
Settings and Design:
The descriptive study was conducted at Mavoor panchayat—Kozhikode district of Kerala, India by collecting information from the case records, nurses diary notes of all enrolled patients.
Materials and Methods:
Collecting information from the case records, nurses diary notes of all enrolled patients.
The data were entered using Microsoft excel for Windows XP and analyzed using SPSS 16.0 (Statistical Package for Social Sciences; SPSS Inc., Chicago, IL, USA).
Totally, 104 patients were enrolled. Diagnosis wise major category was degenerative diseases. There were 27% persons suffering from cerebrovascular accidents, 15.3% with malignancies, 8.7% with coronary artery disease, 5.8% with complications of diabetes, and 8.7% were with fracture of bones. The major complaints were weakness (41.3%), tiredness (31.7%), and pain (27%). Twenty-five percent persons complained of urinary incontinence, 12.5% complained of ulcer, 10.6% of edema, and 9.6% of mental/emotional agony. The activity of daily living status was as follows. Twenty-five percent subjects were completely bed ridden. 5.8% were feeding through Ryles tube, 16.3% had urinary incontinence, 9.6% were having no bowel control.
The service could address most of the medical, psychosocial, and supportive needs of the patients and reduce their pain and symptoms. The interface between institutional-based care and home care needs more exploration and prospective studies.
Activity of daily living; Community nurse; Home-based palliative care; Primary care; Quality of life
Previous qualitative research proved that relatives of elderly terminally ill Turkish and Moroccan immigrants experience several barriers to the use of Dutch professional home care. The aim of this study was to explore how general practitioners and home care nurses perceive the home care for terminally ill Turkish and Moroccan migrants and their families in the Netherlands.
Questionnaires were sent to home care organizations and GPs working in areas where most of these migrants are living. 93 nurses and 78 GPs provided information about their experiences and opinions regarding home care for this group of patients. The data were analyzed by descriptive statistics.
GPs refer relatively few patients from these migrant groups to home care. They often find it difficult to assess the needs of these patients and their families. In 40% of the GPs' cases in which terminally ill Turkish and Moroccan migrants were not referred to home care, the GP regretted this afterwards: the patients had not received sufficient qualified care, and their informal carers had often become overburdened.
In addition, home care nurses often express dissatisfaction with the home care given to terminally ill Turkish or Moroccan patients, because of communication problems, the patients' lack of knowledge of the disease, or difficulties in making suitable appointments with the patient or with the family.
Nurses and GPs cite chiefly similar factors influencing access to and use of home care as family members did in a previous study. However, according to GPs and nurses, the main barrier to the use of home care concerns communication problems, while relatives cited the preference for family care as the main reason for abstaining from the use of home care.
Avoidance of admission through provision of hospital care at home is a scheme whereby health care professionals provide active treatment in the patient's home for a condition that would otherwise require inpatient treatment in an acute care hospital. We sought to compare the effectiveness of this method of caring for patients with that type of in-hospital care.
We searched the MEDLINE, EMBASE, CINAHL and EconLit databases and the Cochrane Effective Practice and Organisation of Care Group register from the earliest date in each database until January 2008. We included randomized controlled trials that evaluated a service providing an alternative to admission to an acute care hospital. We excluded trials in which the program did not offer a substitute for inpatient care. We performed meta-analyses for trials for which the study populations had similar characteristics and for which common outcomes had been measured.
We included 10 randomized trials (with a total of 1327 patients) in our systematic review. Seven of these trials (with a total of 969 patients) were deemed eligible for meta-analysis of individual patient data, but we were able to obtain data for only 5 of these trials (with a total of 844 patients [87%]). There was no significant difference in mortality at 3 months for patients who received hospital care at home (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.54–1.09, p = 0.15). However, at 6 months, mortality was significantly lower for these patients (adjusted HR 0.62, 95% CI 0.45–0.87, p = 0.005). Admissions to hospital were greater, but not significantly so, for patients receiving hospital care at home (adjusted HR 1.49, 95% CI 0.96–2.33, p = 0.08). Patients receiving hospital care at home reported greater satisfaction than those receiving inpatient care. These programs were less expensive than admission to an acute care hospital ward when the analysis was restricted to treatment actually received and when the costs of informal care were excluded.
For selected patients, avoiding admission through provision of hospital care at home yielded similar outcomes to inpatient care, at a similar or lower cost.