Miquel Àngel Mas

A Critical Review of Early Supported Discharge for Stroke Patients: From Evidence to Implementation into Practice

After an acute stroke, a multidimensional approach based on multidisciplinary work and rehabilitation is required in order to promote functional independence and social reinsertion and to maintain medical stability. These activities are usually developed in the hospital setting as a continuum of the acute phase, but hospitalization is resource consuming and resources are limited. Early Support Discharge strategies base postacute care and rehabilitation at home after an early discharge planning and represent possible alternatives to conventional hospitalization. Recent evidence suggests that Early Supported Discharge might be superior to hospitalization from both the clinical-functional and the economic viewpoints. Moreover, home-based rehabilitation might potentiate important determinants of effectiveness, such as patients motivation and goal-directed rehabilitation. However, hitherto produced evidence and recommendations show a number of limitations related to the organization models, the inclusion/exclusion criteria, and the questionable applicability of results to any healthcare setting worldwide. In this article, we critically review different methodological and organizational aspects of the available studies. For example in the definition of the target population, based mainly on residual disability and medical stability, we suggest that other relevant aspects, such as premorbid functional status, cognitive function, and previous institutionalization, should be better defined. Focusing on the outcomes, we suggest that, besides strong outcomes such as global functioning, surrogate outcomes, such as physical function, could help to refine the specific interventions. Finally, considering that the majority of studies were conducted in northern Europe, further studies are needed to test the implementation of Early Supported Discharge in different regions.

Hospital-at-home integrated care programme for older patients with orthopaedic conditions: Early community reintegration maximising physical function

OBJECTIVE Older citizens with orthopaedic conditions need specialised care for the facilitation of early community reintegration and restitution of physical function. We introduced a new community care programme as an alternative to usual hospital rehabilitation for orthopaedic patients. STUDY DESIGN This was an observational study of a cohort of older orthopaedic patients attending a hospital-at-home integrated care programme (HHU), compared with a contemporary cohort of users of a geriatric rehabilitation unit (GRU) in the urban area of Badalona, Catalonia, Spain. MAIN OUTCOMES MEASURES Functional gain at discharge was measured using the Barthel Index (BI). Other outcomes were: length of intervention (days), rehabilitation efficiency and discharge destination. RESULTS Over the 2 years of the study we assessed 270 patients (69 at HHU; 201 at GRU). We found no significant differences in baseline characteristics between HHU and GRU groups-mean (IQR) or % age 83 (79-87) vs. 84 (79-88), cognitive impairment 27.5% vs. 24.9%, functional decline 40 (31-48) vs. 43 (32-58). Overall, we found no statistically significant differences between HHU and GRU groups on functional gain: 35 (22-45) vs. 32 (18-46), and discharge home 85.5% vs. 86.1%. Length of intervention was shorter in the HHU group, 43 (32-56) vs. 57 (44-81); p<0.01, for hip fracture patients. In a multivariate analysis, the adjusted mean difference in rehabilitation efficiency between HHU and GRU groups in the hip fracture subgroup was 0.27 (0.09 to 0.46); p=0.004. CONCLUSIONS This hospital-at-home service obtained similar clinical results to the usual hospital-based rehabilitation care, and for hip fracture patients attending that service, rehabilitation efficiency was better.

Direct Admission to Intermediate Care for Older Adults With Reactivated Chronic Diseases: Avoiding Both Conventional Hospitalization and Emergency Department Use?

Voluntary participation 3.0 1.0 3.2 1.1 .072 Positive anticipation 3.3 0.9 3.5 0.9 .124 Activation 3.3 1.0 3.5 0.9 .159 Profession 3.4 0.9 3.5 0.9 .359 Active participation 3.4 0.9 3.5 0.9 .181 Computer usage 3.2 0.9 3.5 1.0 .009 Total 22.6 5.1 23.9 5.4 .024 Job satisfaction Satisfaction 3.5 0.9 3.7 0.9 .039 Pride 3.5 0.9 3.8 0.8 .019 Growth 3.5 0.9 3.7 0.9 .036 Professional 3.6 1.0 3.7 0.9 .197 Total 14.0 3.3 14.8 3.3 .028 Total 60.3 11.1 63.8 11.7 .004 Letters to the Editor / JAMDA 14 (2013) 443e449 444

Protocol for regional implementation of community-based collaborative management of complex chronic patients

Supported by CONNECARE (H2020-PHC-2015, Grant no. 689802), PITES (FIS-PI15/00576), SELFIE (H2020, Grant no. 634288), and NEXTCARE (RIS3CAT), Generalitat de Catalunya (2014SGR661), and CERCA Programme / Generalitat de Catalunya

Does the presence of pressure ulcers entail “high risk of negative outcomes” in geriatric rehabilitation? Results from a retrospective cohort study

AIM A retrospective cohort study was performed in order to evaluate the prevalence of pressure ulcers (PrUs) in older patients admitted to a geriatric rehabilitation unit of a postacute care hospital and to investigate the impact of the presence of PrUs on clinical outcomes of the rehabilitation process. METHODS We studied 668 post-acute patients consecutively attended, from January 2010 to December 2011. The effect of having PrUs at admission was evaluated based on its impact on outcomes: final destination, functional status, mortality and length of stay in the rehabilitation unit. RESULTS PrUs prevalence at admission was 16%. Patients with PrUs were older, more disabled and had more complex conditions, including malnutrition and cognitive impairment. In the bivariate analysis, we found patients with PrUs at admission had worst final outcome (%): discharge home (69.2 vs.82.5), discharge long term care setting (14 vs.6.4), discharge acute care (8.4 vs.6.2) and death (8.4 vs.4.8); p < 0.001, and worst Barthel Index score at discharge 57 (SD 34.1) vs.83 (SD 33.6); p < 0.001, with longer length of stay in the unit 61 (SD 42.3) vs.53 (SD 37.1); p 0.004. In the multivariate analysis, PrUs presence was found as one of the variables with significant association to no return to home. Finally, a negative association between PrUs at admission and functional gain at discharge of the postacute unit was identified. CONCLUSIONS PrUs were prevalent and had negative impact on clinical outcomes of our geriatric unit, as discharge destination, functional gain and Length of Stay, in vulnerable patients.

Hospital-at-home Integrated Care Programme for the management of disabling health crises in older patients: comparison with bed-based Intermediate Care

Objective to analyse the clinical impact of a home-based Intermediate Care model in the Catalan health system, comparing it with usual bed-based care. Design quasi-experimental longitudinal study. Setting hospital Municipal de Badalona and El Carme Intermediate Care Hospital, Badalona, Catalonia, Spain. Participants we included older patients with medical and orthopaedic disabling health crises in need of Comprehensive Geriatric Assessment (CGA) and rehabilitation. Methods a CGA-based hospital-at-home Integrated Care Programme (acute care and rehabilitation) was compared with a propensity score matched cohort of contemporary patients attended by usual inpatient hospital care (acute care plus intermediate care hospitalisation), for the management of medical and orthopaedics processes. Main outcomes measures were: (a) Health crisis resolution (referral to primary care at the end of the intervention); (b) functional resolution: relative functional gain (functional gain/functional loss) ≥ 0.35; and (c) favourable crisis resolution (health + functional) = a + b. We compared between-groups outcomes using uni/multivariable logistic regression models. Results clinical characteristics were similar between home-based and bed-based groups. Acute stay was shorter in home group: 6.1 (5.3-6.9) versus 11.2 (10.5-11.9) days, P < 0.001. The home-based scheme showed better results on functional resolution 79.1% (versus 75.2%), OR 1.62 (1.09-2.41) and on favourable crisis resolution 73.8% (versus 69.6%), OR 1.54 (1.06-2.22), with shorter length of intervention, with a reduction of -5.72 (-9.75 and -1.69) days. Conclusions in our study, the extended CGA-based hospital-at-home programme was associated with shorter stay and favourable clinical outcomes. Future studies might test this intervention to the whole Catalan integrated care system.

Geriatric frailty applied to fibromyalgia patients

women with FM have less impact of the disease on the physical and social dimensions as compared with younger patients [3]. FM patients appear to age significantly earlier and faster than the general population. Some studies suggest that a shorter telomere length may be linked to chronic FM pain [4], and there is a growing evidence for an acceleration of age-related changes in the gray matter substance of the brain [5]. This concept is congruent with the huge number of similarities between FM and geriatric patients’ symptoms. For example, functional disability can be threatening in FM patient’s health because FM can be extremely debilitating and interfere with basic daily activities. Both types of patients need a multimodal approach having in mind also the social and economical aspects of the disease. They need care from many different caregivers at different care levels and with different competences, such as internal medicine, geriatrics, rehabilitation, nursing and social care services. This care should be integrated in order to reduce fragmentation and to improve its continuity and coordination [6]. As a matter of fact, FM patients could be the paradigm of frailty patients. Frailty is a common geriatric syndrome that embodies an increased risk of catastrophic declines in health and function among older adults and facing older adults, their families and society in general [7]. The occurrence of frailty increases with advancing age and is more prevalent in older women than in men. While there are numerous definitions and theoretical models of frailty, all agree that frailty is associated with increasing vulnerability and a reduced reserve to deal with stressors, because of a decline in physiologic reserve. This systemic decline affects the normal complex adaptive behavior that is essential to health and eventually results in frailty typically manifesting as a syndrome of a constellation of weakness,

Re: Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities.

To the Editor: In an article published in the American Journal of PhysicalMedicine andRehabilitation, Wang et al. reported results of negative impact of pressure ulcers (PUs) on outcomes in patients admitted to rehabilitation facilities in the United States. The authors would like to support this article on the basis of the results of a recently presented local study in Europe. In some European countries, inpatient rehabilitation of older patients with complex conditions is based on intermediate care hospitalization. The authors of this article have data from a retrospective study performed during the period from January 2010 to December 2011 in several geriatric rehabilitation units of El Carme Intermediate Care Hospital in Badalona, north of Barcelona urban area, Catalonia (Spain). Rehabilitation intervention was provided by a multidisciplinary care team (medical, nursing, physiotherapy, occupational therapy, social work) and was based on Comprehensive Geriatric Assessment. A total of 668 patients were included (mean age, 83 yrs; Charlson Comorbidity Index, 2; referred from acute care unit, 87%; main diagnostic group orthopedic, 46%; medical, 30%; stroke, 18%; and surgical, 6%).The sample of older patients in this study had a high prevalence of geriatric syndromes at admission, including immobility (32%), cognitive impairment (24%), mood disorder (22%), and malnutrition (17%). It conditioned higher prevalence of PUs at admission (16%) and longer length of stay than did the sample of the Wang et al. Age (82.1 T 9.9 vs. 80.1 T 9.6 yrs), Barthel Index at admission (32.9 T 25.3 vs. 44.3 T 25), and number of geriatric conditions (5.4 T 1.7 vs. 4.2 T 1.8) were significantly found as characteristics related with PU at admission. Negative impact of PU presence at admission to the rehabilitation unit (compared with PU free) was measured using Barthel Index at discharge (53.1 T 34.1 vs. 68.6 T 33.6; P G 0.001), length of stay in days (70.4 T 42 vs. 59.2 T 37.1; P G 0.001), and percentage of discharge destination (community, 69.2% vs. 82.5%; long-term care unit, 14% vs. 6.4%; acute care unit, 8.4% vs. 6.2%; death, 8.4% vs. 4,8%, P G 0.001). In our experience, from a geriatric rehabilitation facility in Europe, we support the following information in the study of Wang et al.: the results of negative effect of PUs among functional outcomes, length of stay in the facility, and odds of being discharged to the community.