Effectiveness of a Care Delivery Model for High-Need Older Adults in Communities

Chen, Kuei‐Min; Hsu, Hui‐Fen; Yang, Li‐Yen; Chang, Chiang-Ching; Chen, Yuming; Chang, Wei-Yun

doi:10.1177/1049731520982355

Cited by 3 publications

(2 citation statements)

References 40 publications

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“…Health and well‐being are promoted when primary care teams partner with patients and for some, provide care coordination that can mitigate risks and promote reaching health goals (Pinto et al., 2016). Disparities in receiving this level of coordinated healthcare persist across the United States (Chen et al., 2021; Flores & Lin, 2013), with 28% of patients unsure how to follow up with their care team after hospital discharge (Osborn et al., 2014). The COVID‐19 pandemic worsened barriers to care for many people (Azar et al., 2020), and this worsening has persisted with the pandemic.…”

Section: Introductionmentioning

confidence: 99%

Improving patient well‐being in the United States through care coordination interventions informed by social determinants of health

Singer

Porta

2022

Health Social Care Comm

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Health and well‐being are promoted when primary care teams partner with patients and provide care coordination to mitigate risks and promote optimal health. Identification of patients for care coordination is typically based on claim‐driven risk assessments. Evidence shows that social determinants of health (SDOH) drive risk for adverse health outcomes but are omitted from existing risk tools. Missed opportunities for care coordination contribute to increased healthcare costs, poorer health outcomes and reduced patient well‐being. To address the gap of risk‐informed care coordination that includes SDOH, the aim of this project was to implement process improvement of a system's care coordination program through refined patient selection and customised engagement in intensive care coordination. A non‐randomised care coordination quality improvement project was conducted at a community health centre in 2020. Inclusion criteria (i.e. presence of risk attribution score, SDOH questionnaire completed) resulted in 540 patients being offered care coordination services; Patients having at least one month of care coordination were included in the analysis (N = 216). Analysis included the 216 patients that chose participation and the 324 patients that maintained usual care. Descriptive statistics were generated to distinguish patient demographics, frequency of care coordination contact, and specific SDOH insecurities for both the study and comparison groups. Paired t‐tests were incorporated to evaluate statistical significance of the intervention group. Impact on well‐being, SDOH barriers, appointment adherence and health outcomes were assessed in both conditions. Intervention condition patients reported improvement in well‐being [feeling anxious (t = 4.051; p < 0.000)] and reduced SDOH barriers [food access (t = 4.662; p < 0.000); housing (t = 2.203; p = 0.008)] that were significantly different from the usual care condition in the expected directions. Care coordination based on factors including SDOH risks shows promise in improving patient well‐being. Future research should refine this approach for comprehensive risk assessment to intervene and support patient health and well‐being.

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Section: Introductionmentioning

confidence: 99%

Improving patient well‐being in the United States through care coordination interventions informed by social determinants of health

Singer

Porta

2022

Health Social Care Comm

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“…However, publishing articles in journals of a different discipline is not unusual for scholars. For example, social work scholars often publish articles in the American Journal of Orthopsychiatry (Al-Krenawi et al, 2007; Benbenishty et al, 2018), Journal of Behavioral Medicine (Ai et al, 2009; Ai et al, 2011; Levy et al, 2010), and Journal of Nursing Care Quality (Galambos et al, 2021), whereas scholars of nursing (Chen et al, 2020; Julion et al, 2021), law (Braun, 2021) and education (Chacón-Cuberos et al, 2021) publish articles in Research Social Work Practice . Therefore, merely focusing on papers published in discipline-restricted journals (Ho, 2013; Holden et al, 2005; Holden et al, 2009; Holosko et al, 2017; Lacasse et al, 2011; Martínez et al, 2014) or non-discipline-restricted journals (Klein & Bloom, 1992; Lacasse et al, 2011) can only paint half the picture of the major research activities and the dynamic nature of social work.…”

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Co-Word Analysis of First-Authored Publications Written by Top Cited Scholars of Social Work

Song

Sun

Duan

2023

Research on Social Work Practice

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Purpose: Bibliometric analysis has been widely adopted to measure individual productivity and discipline development. This study aims to advance the application of this method in the social work discipline. Method: Using the knowledge mapping technique in CiteSpace 5.8.R3, this study performed a co-word analysis of 1,007 first-authored articles published from 2000 to 2022 by 60 scholars who are listed among the top 2% most-cited scholars on social work and are holding doctoral degrees in the same field. Results: The cluster analysis identified seven main research hotspots and burst detection results revealed four groups of research frontiers, including spiritual and cultural needs, children's wellbeing, social work practices and development, and social work research, with bullying and peer victimization, particularly among African-American adolescents and youth in Chicago's southside, continuing to attract much research interest. Discussion: This study examines how individual works contribute to the conceptual structure and scientific evolution of social work.

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Navigating Community-Based Aged Care Services From the Consumer Perspective: A Scoping Review

Xie

Hamilton²,

Peisah

et al. 2023

The Gerontologist

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Background and Objectives The shift to consumer-directed aged care means that older adults need to play a more active role in navigating the complex aged care system for adequate health and social services. Challenges in the navigation process result in unmet needs and difficulty accessing available resources. This scoping review investigates how aged care navigation is conceptualized in literature and interrogates research on the experiences of older adults navigating community-based aged care services with or without support from their informal carers. Research Design and Methods This review follows the Joanna Briggs Institute methodological guidelines. PubMed, Scopus, and ProQuest were searched for relevant literature published from 2008 to 2021, supplemented by grey literature and manual reference list searching. Data were extracted using a predefined data-extraction table and synthesized with an inductive thematic analysis. Results The current conceptualization of aged care navigation focuses on the support provided to older adults, rather than actions taken by older adults themselves. Thematic analysis from the included studies (n = 26) revealed shared themes (lack of knowledge, social networks as information providers, complex care systems) among older adults and informal carers; unique challenges faced by older adults (difficulties with technology, waiting game), and informal carers (structural burden) in aged care navigation. Discussion and Implications Findings suggest the need to comprehensively assess individual circumstances including social networks and access to informal carers as predictors of successful navigation. Changes that reduce the complexity of the aged care system and improve coordination will relieve the structural burden experienced by consumers.

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Effectiveness of a Care Delivery Model for High-Need Older Adults in Communities

Cited by 3 publications

References 40 publications

Improving patient well‐being in the United States through care coordination interventions informed by social determinants of health

Improving patient well‐being in the United States through care coordination interventions informed by social determinants of health

Co-Word Analysis of First-Authored Publications Written by Top Cited Scholars of Social Work

Navigating Community-Based Aged Care Services From the Consumer Perspective: A Scoping Review

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