Development of integrated care pathways: toward a care management system to meet the needs of frail and disabled community-dwelling older people

Dubuc, Nicole; Bonin, Lucie; Tourigny, André; Mathieu, Luc; Couturier, Yves; Tousignant, Michel; Corbin, Cinthia; Delli-Colli, Nathalie; Raı̂che, Michel

doi:10.5334/ijic.976

Cited by 42 publications

(38 citation statements)

References 68 publications

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“…18 However, no care pathways or evidence bases currently exist for frail older persons, which makes it challenging for case managers to make decisions, especially case managers with less experience with older frail populations. 27 Cognitive impairment is often referred to as a challenge for geriatric rehabilitation. 28 According to the participants, cognitive decline tends to affect decisions related to allocation only if the impairment is severe and only if a client does not have caregivers who can assist with his or her exercises.…”

Section: Discussionmentioning

confidence: 99%

“…The challenges of providing home care in rural areas of Canada have been discussed in the literature, [25][26][27] and a few of the participants from more rural regions spoke to this issue. In addition, this study did not include any interviews with stakeholders from the northern health regions (North West LHIN and North East LHIN), whose size and larger proportion of remote and rural clients magnify these issues.…”

Section: Discussionmentioning

confidence: 99%

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Allocation of Rehabilitation Services for Older Adults in the Ontario Home Care System

Armstrong¹,

Sims‐Gould

Stolee

2016

Physiotherapy Canada

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Background: Physiotherapy and occupational therapy services can play a critical role in maintaining or improving the physical functioning, quality of life, and overall independence of older home care clients. Despite their importance, however, there is limited understanding of the factors that influence how rehabilitation services are allocated to older home care clients. The aim of this pilot study was to develop a preliminary understanding of the factors that influence decisions to allocate rehabilitation therapy services to older clients in the Ontario home care system, as perceived by three stakeholder groups. Methods: Semi-structured interviews were conducted with 10 key informants from three stakeholder groups: case managers, service providers, and health system policymakers. Results: Drivers of the allocation of occupational therapy and physiotherapy for older adults included functional needs and postoperative care. Participants identified challenges in providing home care rehabilitation to older adults, including impaired cognition and limited capacity in the home care system. Conclusions: Considering the changing demands for home care services, knowledge of current practices across the home care system can inform efforts to optimize rehabilitation services for the growing number of older adults. Further research is needed to advance the understanding of, and optimize rehabilitation service allocation to, older frail clients with multiple morbidities. Developing novel decision-support mechanisms and standardized clinical care pathways for older client populations may be beneficial.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Allocation of Rehabilitation Services for Older Adults in the Ontario Home Care System

Armstrong¹,

Sims‐Gould

Stolee

2016

Physiotherapy Canada

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“…Questa consapevolezza è presente fin dai primi lavori [7] sull'integrated care, ma è chiaro che la difficoltà è l'equilibrata propensione del medico al mantenimento o alla fuoriuscita del singolo paziente nel/dal PDTA. Per superare la soggettività, vi sono proposte canadesi [29] di adattamento personalizzato su base clinico-diagnostica dello standard, da proporre al paziente per una collaborazione e per definire il processo tagliato su misura. È uno strumento molto impegnativo non ancora pienamente valutato.…”

Section: Percorsi Diagnostico-terapeutici Assistenziali (Pdta)unclassified

PDTA e Medicina di Laboratorio

Cappelletti

2017

Riv Ital Med Lab

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Riassunto I Percorsi Diagnostico-Terapeutici Assistenziali (PDTA) sono definiti come interventi complessi che descrivono i processi delle decisioni cliniche e dell'organizzazione di cura di un ben definito gruppo di pazienti, in un definito periodo di tempo. Costituiscono i pilastri per la realizzazione della "centralità del paziente" sulla base delle evidenze scientifiche. I PDTA possono essere definiti come la contestualizzazione di una o più linee guida, relative a una patologia o problematica clinica, nella specifica realtà organizzativa di un'Azienda sanitaria. I PDTA sono ampiamente utilizzati ed esistono evidenze, seppur narrative, della loro efficacia. I principali problemi sono la personalizzazione e l'innovazione. La Medicina di Laboratorio deve fare la sua parte nella costruzione dei PDTA, partecipando ai gruppi multidisciplinari e multiprofessionali, con attenzione ai test pivot, al loro uso e alla loro interpretazione; alla qualità delle linee guida scelte; al dettaglio dei protocolli operativi che sostanziano il percorso; agli aspetti "interni" che determinano (performance analitica) o aumentano (total testing process) la qualità della risposta; alla verifica continua dell'appropriatezza e adeguatezza dei marcatori utilizzati e all'audit dell'effectiveness del PDTA. Si tratta di uno degli aspetti più alti di "lavoro all'interfaccia", nelle aree di pre-pre e post-post testing process, ove l'affidabilità analitica e il suo rapporto con la realtà clinica e i suoi esiti sono immediatamente percepibili. Centralità del paziente e PDTA La "centralità del paziente" [1] è divenuta un tema cruciale della Medicina occidentale, anche per la presa d'atto delle iniquità, frammentazioni, sovrapposizioni e discontinuità che caratterizzano molto spesso l'erogazione dei servizi sanitari (effetto silo) e delle loro conseguenze sugli esiti Parole chiave Medicina di Laboratorio

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“…in France [36], Switzerland [37] and Brazil [38], namely). The profiles constitute a central part of integrated care pathways [39] to plan services for older people. Therefore, extensive knowledge of transitions and associated factors are important.…”

Section: Source Of the Data And Measuresmentioning

confidence: 99%

Covariates of Disability-Profile Transitions in Older People Living at Home

Raı̂che

Hébert

Dubois

et al. 2014

JBM

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The objective of this study was to explore the relationship of sociodemographic, clinical, and health-services use-related variables with transitions between disability-based profiles. In a longitudinal study of 1386 people aged 75 and over living in the community at baseline, disabilities were assessed annually for up to four years with the Functional Autonomy Measurement System (SMAF), which generates 14 Iso-SMAF profiles. These profiles are grouped into 4 disability states, which are predominant alterations in instrumental activities of daily living (IADLs), mobility, mental functions as well as severe and mixed disabilities. Continuous-time, multi-state Markov modeling was used to identify the factors associated with transitions made by older people between these states and to institutionalization and death. Greater age and receiving help for ADL were associated with four transitions, while altered cognitive functions and hospitalization were associated with three, all involving more decline or less recovery. From mild IADL profiles, men have a higher risk of transitioning to intermediate predominantly mental profiles, while women are at higher risk of transitioning to intermediate predominantly mobility profiles. Unmet needs are associated with deterioration, from mild IADL to intermediate predominantly mobility profiles. These results help understanding the complex progression of disabilities in older people.

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Development of integrated care pathways: toward a care management system to meet the needs of frail and disabled community-dwelling older people

Cited by 42 publications

References 68 publications

Allocation of Rehabilitation Services for Older Adults in the Ontario Home Care System

Allocation of Rehabilitation Services for Older Adults in the Ontario Home Care System

PDTA e Medicina di Laboratorio

Covariates of Disability-Profile Transitions in Older People Living at Home

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