Paule Lebel

Adult day care for the frail elderly: outcomes, satisfaction, and cost.

Objectives: To assess outcomes and satisfaction among frail elderly day care clients and their informal caregivers and the impact of adult day care on the cost of health services. Methods:One-hundred eight elderly participants were randomly assigned to the experimental group (immediate admission to an adult day care center) and 104 participants to the control group (3 months on a waiting list). Results:Participants’ and caregivers’ subjective perceptions of the day center’s effects were positive. However, using standard research instruments, there was no evidence of an effect of day center attendance on the client’s anxiety, depression, or functional status; on caregiver burden; or on the cost of health services. Discussion:It is difficult to demonstrate objectively the benefits of programs and interventions that are perceived by clients, caregivers, and staff to have positive effects. In future studies, maintenance of high levels of participation should be incorporated as an explicit program goal.

Selecting process quality indicators for the integrated care of vulnerable older adults affected by cognitive impairment or dementia

BackgroundThis study aimed at evaluating face and content validity, feasibility and reliability of process quality indicators developed previously in the United States or other countries. The indicators can be used to evaluate care and services for vulnerable older adults affected by cognitive impairment or dementia within an integrated service system in Quebec, Canada.MethodsA total of 33 clinical experts from three major urban centres in Quebec formed a panel representing two medical specialties (family medicine, geriatrics) and seven health or social services specialties (nursing, occupational therapy, psychology, neuropsychology, pharmacy, nutrition, social work), from primary or secondary levels of care, including long-term care. A modified version of the RAND®/University of California at Los Angeles (UCLA) appropriateness method, a two-round Delphi panel, was used to assess face and content validity of process quality indicators. The appropriateness of indicators was evaluated according to a) agreement of the panel with three criteria, defined as a median rating of 7–9 on a nine-point rating scale, and b) agreement among panellists, judged by the statistical measure of the interpercentile range adjusted for symmetry. Feasibility of quality assessment and reliability of appropriate indicators were then evaluated within a pilot study on 29 patients affected by cognitive impairment or dementia. For measurable indicators the inter-observer reliability was calculated with the Kappa statistic.ResultsInitially, 82 indicators for care of vulnerable older adults with cognitive impairment or dementia were submitted to the panellists. Of those, 72 (88%) were accepted after two rounds. Among 29 patients for whom medical files of the preceding two years were evaluated, 63 (88%) of these indicators were considered applicable at least once, for at least one patient. Only 22 indicators were considered applicable at least once for ten or more out of 29 patients. Four indicators could be measured with the help of a validated questionnaire on patient satisfaction. Inter-observer reliability was moderate (Kappa = 0.57).ConclusionA multidisciplinary panel of experts judged a large majority of the initial indicators valid for use in integrated care systems for vulnerable older adults in Quebec, Canada. Most of these indicators can be measured using patient files or patient or caregiver interviews and reliability of assessment from patient-files is moderate.

Interprofessional learning in the trenches: fostering collective capability.

The greatest resource for improving interprofessional learning and practice is the knowledge, wisdom, and energy of professionals who adapt to challenging situations in their everyday work. We call collective capability the ability of a group of professionals to balance two interdependent levels of organization of practice: what professionals know and what they do collectively over time. Organizing what professionals know links the relational value – caring for patients – to the knowledge value of practice. Organizing what professionals do includes human and organizational factors that facilitate collective work and learning: technical skills for care delivery, institutional support, and a complex mix of emotional, ethical and moral factors involved in social decision-making. Performance gaps can result from a lack of an integrated knowledge framework or from a disembodied knowledge that is not anchored in practice. Opportunities for continuous learning can be seized by documenting the source of the performance gap, and providing the relevant resources to establish the balance between the organization of knowledge and the organization of work.

Caregiver satisfaction with support services: influence of different types of services.

OBJECTIVES This article examines factors influencing satisfaction with support services of caregivers of frail older adults and determines what types of support services are associated with greater satisfaction, controlling for frail individual and caregiver characteristics. METHODS The study includes 291 frail older adults-caregiver dyads from Montreal in which caregivers receive support services. The Client Satisfaction Questionnaire-8 is used to measure caregiver satisfaction with these services. RESULTS Caregivers receiving information, advice, or emotional support, and those caring for seniors receiving integrated care are more likely to be highly satisfied. Other factors increasing satisfaction are fewer number of health problems of frail individuals, caregiver being the spouse of the frail person, as well as greater caregiver perceived health, autonomy in instrumental activities of daily living, and available social support. DISCUSSION The results support the importance of integrated care for frail seniors and informational services for their caregivers.

A discharge summary adapted to the frail elderly to ensure transfer of relevant information from the hospital to community settings: a model

BackgroundElderly patients admitted to Geriatric Assessment Units (GAU) typically have complex health problems that require multi-professional care. Considering the scope of human and technological resources solicited during hospitalization, as well as the many risks and discomforts incurred by the patient, it is important to ensure the communication of pertinent information for quality follow-up care in the community setting. Conventional discharge summaries do not adequately incorporate the elements specific to an aging clientele.ObjectiveTo develop a discharge summary adapted to the frail elderly patient (D-SAFE) in order to communicate relevant information from hospital to community services.MethodsThe items to be included in the D-SAFE have been determined by means of a modified Delphi method through consultation with clinical experts from GAUs (11 physicians and 5 pharmacists) and the community (10 physicians and 5 pharmacists). The consensus analysis and the level of agreement among the experts were reached using a modified version of the RAND®/University of California at Los Angeles appropriateness method.ResultsA consensus was reached after two rounds of consultation for all the items evaluated, where none was judged «inappropriate». Among the items proposed, four were judged to be « uncertain » and were eliminated from the final D-SAFE, which was divided into two sections: the medical discharge summary (22 main items) and the discharge prescription (14 main items).ConclusionsThe D-SAFE was developed as a more comprehensive tool specifically designed for GAU inpatients. Additional research to validate its acceptability and practical impact on the continuity of care is needed before it can be recommended for use on a broader scale.

Informational role self-efficacy: a validation in interprofessional collaboration contexts involving healthcare service and project teams

BackgroundHealthcare professionals perform knowledge-intensive work in very specialized disciplines. Across the professional divide, collaboration becomes increasingly difficult. For effective teamwork and collaboration to occur, it is considered necessary for individuals to believe in their ability to draw on their expertise and provide what others need to perform their job well. To date, however, no instruments exist to measure such a construct.MethodsA two-study design is used to test the psychometric properties, factor structure and incremental validity of a five-item questionnaire measuring informational role self-efficacy.ResultsBased on parallel analysis and exploratory factor analysis, Study 1 shows a robust and reliable one-dimensional construct. Study 2 cross-validates this factor structure using confirmatory factor analysis. Study 2 also shows that informational role self-efficacy predicts proactive teamwork behaviors over and above goal similarity, interdependence, coordination and intra-team trust.ConclusionsThe instrument can be used in research to assess an individual’s capability beliefs in communicating his/her informational characteristics that are pertinent to the task performance of others. The construct is also shown to have value in team-building exercises.

Multi-Level Efficacy Evidence of a Combined Interprofessional Collaboration and Project Management Training Program for Healthcare Project Teams

Project work is essential for the improvement of healthcare organizations; yet, project management and collaboration in the project context are not taught to healthcare professionals. Three half-day training workshops integrating project management and collaboration were designed and delivered to 14 interprofessional healthcare project teams. Multivariate measures were taken over the course of 36 weeks. Individual, team, and project-level results showed high satisfaction and perceptions of utility; improved self-efficacy for project-specific task work and teamwork; increased goal clarity and coordination; and a significant impact on the functional performance of projects. This study provides initial benchmark measures regarding the pertinence of project management and interprofessional collaboration training for healthcare project teams.

Short-term geriatric assessment units: 30 years later.

BackgroundThe increasing number of hospitalized elderly persons has greatly challenged decision makers to reorganize services so as to meet the needs of this clientele. Established progressively over the last 30 years, the short-term Geriatric Assessment Unit (GAU) is a specialized care program, now implemented in all the general hospital centres in Quebec. Within the scope of a broader reflection upon the appropriate care delivery for elderly patients in our demographic context, there is a need to revisit the role of GAU within the hospital and the continuum of care. The objective of this project is to describe the range of activities offered by Quebec GAU and the resources available to them.MethodsIn 2004, 64 managers of 71 GAU answered a mail questionnaire which included 119 items covering their units operation and resources in 2002-2003. The clinical and administrative characteristics of the clientele admitted during this period were obtained from the provincial database Med-Echo. The results were presented according to the geographical location of GAU, their size, their university academic affiliation, the composition of their medical staff, and their clinical care profile.ResultsOverall, GAU programs admitted 9% of all patients aged 65 years and older in the surveyed year. GAU patients presented one or more geriatric syndromes, including dementia. Based on their clientele, three distinct clinical care profiles of GAU were identified. Only 19% of GAU were focused on geriatric assessment and acute care management; 23% mainly offered rehabilitation care, and the others offered a mix of both types. Thus, there was a significant heterogeneity in GAUs operation.ConclusionsThe GAU is at the cutting edge of geriatric services in hospital centres. Given the scarcity of these resources, it would be appropriate to better target the clientele that may benefit from them. Standardizing and promoting GAUs primary role in acute care must be reinforced. In order to meet the needs of the frail elderly not admitted in GAU, alternative care models centered on prevention of functional decline must be applied throughout all hospital wards.

Determinants of Adult Day Center Attendance Among Older Adults With Functional Limitations

Objective: To examine factors related to regularity of adult day center (ADC) attendance among seniors with functional limitations. Methods: Using data collected as part of a larger study, we identified the proportion of scheduled days attended among 101 ADC users in Montréal and identified determinants of this attendance. Results: More regular attendance was associated with previous profession of ADC participant or spouse in a sector other than health care, receiving formal help for activities of daily living or instrumental activities of daily living on days of expected ADC participation, participating for the whole day rather than half a day, lower participation in prevention and health-promotion activities, and lower caregiver burden among persons with cognitive impairments and higher caregiver burden among persons without cognitive impairments. Discussion: To enhance ADC intervention effects, levels of participation should be maximized. Study findings suggest ways to promote more regular attendance.

Quality-of-Care Processes in Geriatric Assessment Units: Principles, Practice, and Outcomes

OBJECTIVES To assess quality-of-care processes and to examine whether care processes are associated with short-term postdischarge outcomes in older vulnerable hospitalized patients. DESIGN Retrospective study. SETTING Forty-nine Geriatric Assessment Units. PARTICIPANTS Patients aged 65 and older who were admitted to a Geriatric Assessment Unit for a fall with trauma. MEASUREMENTS Three care processes (comprehensiveness, informational continuity, patient-centered care) assessed through chart audit; three-month postdischarge outcomes (emergency department visit, hospital readmission, and death) obtained from national databases. RESULTS A total of 934 hospitalization records were included. Mean comprehensiveness and informational continuity scores were 55% ± 12% and 42% ± 16%, respectively. Items related to geriatric global assessment (eg, functional autonomy) were particularly overlooked. Patient-centered care was poorly provided, with only 24% of hospitalization records showing evidence of advance care directives and at least one patient/family meeting with the physician to discuss clinical evolution. For the three care processes, a large variability among Geriatric Assessment Units was observed. Better comprehensiveness of care was associated with lowered short-term mortality (OR = 0.73, 95% CI = 0.55-0.96, P = .023), whereas higher scores on informational continuity was associated with fewer emergency department visits (OR = 0.91, 95% CI = 0.82-1.00, P = .046), hospital readmissions (OR = 0.84, 95% CI = 0.74-0.94, P = .003), and mortality (OR = 0.72, 95% CI = 0.59-0.88, P = .002). Patient-centered care was not associated with any of the postdischarge outcomes. CONCLUSION A large gap between geriatric care principles and practice in Geriatric Assessment Units has been observed. Our results show that improvement in care processes may be translated to decreased short-term health services use and mortality.