Ronald Uittenbroek

Embrace, a model for integrated elderly care : study protocol of a randomized controlled trial on the effectiveness regarding patient outcomes, service use, costs, and quality of care

BackgroundOngoing growth in health care expenditures and changing patterns in the demand for health care challenge societies worldwide. The Chronic Care Model (CCM), combined with classification for care needs based on Kaiser Permanente (KP) Triangle, may offer a suitable framework for change. The aim of the present study is to investigate the effectiveness of Embrace, a population-based model for integrated elderly care, regarding patient outcomes, service use, costs, and quality of care.Methods/DesignThe CCM and the KP Triangle were translated to the Dutch setting and adapted to the full elderly population living in the community. A randomized controlled trial with balanced allocation was designed to test the effectiveness of Embrace. Eligible elderly persons are 75 years and older and enrolled with one of the participating general practitioner practices. Based on scores on the INTERMED-Elderly Self-Assessment and Groningen Frailty Indicator, participants will be stratified into one of three strata: (A) robust; (B) frail; and (C) complex care needs. Next, participants will be randomized per stratum to Embrace or care as usual. Embrace encompasses an Elderly Care Team per general practitioner practice, an Electronic Elderly Record System, decision support instruments, and a self-management support and prevention program – combined with care and support intensity levels increasing from stratum A to stratum C. Primary outcome variables are patient outcomes, service use, costs, and quality of care. Data will be collected at baseline, twelve months after starting date, and during the intervention period.DiscussionThis study could provide evidence for the effectiveness of Embrace.Trial registrationThe Netherlands National Trial Register NTR3039

Integrated Care for Older Adults Improves Perceived Quality of Care: Results of a Randomized Controlled Trial of Embrace

BackgroundAll community-living older adults might benefit from integrated care, but evidence is lacking on the effectiveness of such services for perceived quality of care.ObjectiveTo examine the impact of Embrace, a community-based integrated primary care service, on perceived quality of care.DesignStratified randomized controlled trial.ParticipantsIntegrated care and support according to the “Embrace” model was provided by 15 general practitioners in the Netherlands. Based on self-reported levels of case complexity and frailty, a total of 1456 community-living older adults were stratified into non-disease-specific risk profiles (“Robust,” “Frail,” and “Complex care needs”), and randomized to Embrace or control groups.InterventionEmbrace provides integrated, person-centered primary care and support to all older adults living in the community, with intensity of care dependent on risk profile.MeasurementsPrimary outcome was quality of care as reported by older adults on the Patient Assessment of Integrated Elderly Care (PAIEC). Effects were assessed using mixed model techniques for the total sample and per risk profile. Professionals’ perceived level of implementation of integrated care was evaluated within the Embrace condition using the Assessment of Integrated Elderly Care.Key resultsOlder adults in the Embrace group reported a higher level of perceived quality of care than those in the control group (B = 0.33, 95 % CI = 0.15-0.51, ES d = 0.19). The advantages of Embrace were most evident in the “Frail” and “Complex care needs” risk profiles. We found no significant advantages for the “Robust” risk profile. Participating professionals reported a significant increase in the perceived level of implementation of integrated care (ES r = 0.71).ConclusionsThis study shows that providing a population-based integrated care service to community-living older adults improved the quality of care as perceived by older adults and participating professionals.

The Geriatric ICF Core Set reflecting health-related problems in community-living older adults aged 75 years and older without dementia: development and validation

Abstract Purpose: The aim of the present study was to develop a valid Geriatric ICF Core Set reflecting relevant health-related problems of community-living older adults without dementia. Methods: A Delphi study was performed in order to reach consensus (≥70% agreement) on second-level categories from the International Classification of Functioning, Disability and Health (ICF). The Delphi panel comprised 41 older adults, medical and non-medical experts. Content validity of the set was tested in a cross-sectional study including 267 older adults identified as frail or having complex care needs. Results: Consensus was reached for 30 ICF categories in the Delphi study (fourteen Body functions, ten Activities and Participation and six Environmental Factors categories). Content validity of the set was high: the prevalence of all the problems was >10%, except for d530 Toileting. The most frequently reported problems were b710 Mobility of joint functions (70%), b152 Emotional functions (65%) and b455 Exercise tolerance functions (62%). No categories had missing values. Conclusion: The final Geriatric ICF Core Set is a comprehensive and valid set of 29 ICF categories, reflecting the most relevant health-related problems among community-living older adults without dementia. This Core Set may contribute to optimal care provision and support of the older population. Implications for Rehabilitation The Geriatric ICF Core Set may provide a practical tool for gaining an understanding of the relevant health-related problems of community-living older adults without dementia. The Geriatric ICF Core Set may be used in primary care practice as an assessment tool in order to tailor care and support to the needs of older adults. The Geriatric ICF Core Set may be suitable for use in multidisciplinary teams in integrated care settings, since it is based on a broad range of problems in functioning. Professionals should pay special attention to health problems related to mobility and emotional functioning since these are the most prevalent problems in community-living older adults.

Development and psychometric evaluation of a measure to evaluate the quality of integrated care: the Patient Assessment of Integrated Elderly Care

Novel population‐based integrated care services are being developed to adequately serve the growing number of elderly people. Suitable, reliable and valid measurement instruments are needed to evaluate the quality of care delivered.

Effects of a population-based, person-centred and integrated care service on health, wellbeing and self-management of community-living older adults: A randomised controlled trial on Embrace

Objective To evaluate the effects of the population-based, person-centred and integrated care service ‘Embrace’ at twelve months on three domains comprising health, wellbeing and self-management among community-living older people. Methods Embrace supports older adults to age in place. A multidisciplinary team provides care and support, with intensity depending on the older adults’ risk profile. A randomised controlled trial was conducted in fifteen general practices in the Netherlands. Older adults (≥75 years) were included and stratified into three risk profiles: Robust, Frail and Complex care needs, and randomised to Embrace or care as usual (CAU). Outcomes were recorded in three domains. The EuroQol-5D-3L and visual analogue scale, INTERMED for the Elderly Self-Assessment, Groningen Frailty Indicator and Katz-15 were used for the domain ‘Health.’ The Groningen Well-being Indicator and two quality of life questions measured ‘Wellbeing.’ The Self-Management Ability Scale and Partners in Health scale for older adults (PIH-OA) were used for ‘Self-management.’ Primary and secondary outcome measurements differed per risk profile. Data were analysed with multilevel mixed-model techniques using intention-to-treat and complete case analyses, for the whole sample and per risk profile. Results 1456 eligible older adults participated (49%) and were randomized to Embrace (n(T0) = 747, n(T1) = 570, mean age 80.6 years (SD 4.5), 54.2% female) and CAU (n(T0) = 709, n(T1) = 561, mean age 80.8 years (SD 4.7), 55.6% female). Embrace participants showed a greater–but clinically irrelevant–improvement in self-management (PIH-OA Knowledge subscale effect size [ES] = 0.14), and a greater–but clinically relevant–deterioration in health (ADL ES = 0.10; physical ADL ES = 0.13) compared to CAU. No differences in change in wellbeing were observed. This picture was also found in the risk profiles. Complete case analyses showed comparable results. Conclusions This study found no clear benefits to receiving person-centred and integrated care for twelve months for the domains of health, wellbeing and self-management in community-living older adults.

The Partners in Health scale for older adults: design and examination of its psychometric properties in a Dutch population of older adults

Self‐management is an important asset in helping older adults remain independent and in control for as long as possible. There is no reliable and valid measurement instrument to evaluate self‐management behaviour of older adults.

[Embrace, a model for integrated elderly care].

UNLABELLED Ongoing growth in health care expenditures and changing patterns in the demand for health care challenge societies worldwide. The Chronic Care Model (CCM), combined with classification for care needs based on Kaiser Permanente (KP) Triangle, may offer a suitable framework for change. The aim of the present study is to investigate the effectiveness of Embrace, a population-based model for integrated elderly care, regarding patient outcomes, service use, costs, and quality of care. METHODS The CCM and the KP Triangle were translated to the Dutch setting and adapted to the full elderly population living in the community. A randomized controlled trial with balanced allocation was designed to test the effectiveness of Embrace. Eligible elderly persons are 75 years and older and enrolled with one of the participating general practitioner practices. Based on scores on the INTERMED-Elderly Self-Assessment and Groningen Frailty Indicator, participants will be stratified into one of three strata: (A) robust; (B) frail; and (C) complex care needs. Next, participants will be randomized per stratum to Embrace or care as usual. Embrace encompasses an Elderly Care Team per general practitioner practice, an Electronic Elderly Record System, decision support instruments, and a self-management support and prevention program - combined with care and support intensity levels increasing from stratum A to stratum C. Primary outcome variables are patient outcomes, service use, costs, and quality of care. Data will be collected at baseline, twelve months after starting date, and during the intervention period. DISCUSSION This study could provide evidence for the effectiveness of Embrace.

SamenOud, een model voor geïntegreerde ouderenzorg: studieprotocol van een gerandomiseerde studie naar de effectiviteit betreffende patiëntuitkomsten, kwaliteit van zorg, zorggebruik en kosten

UNLABELLED Ongoing growth in health care expenditures and changing patterns in the demand for health care challenge societies worldwide. The Chronic Care Model (CCM), combined with classification for care needs based on Kaiser Permanente (KP) Triangle, may offer a suitable framework for change. The aim of the present study is to investigate the effectiveness of Embrace, a population-based model for integrated elderly care, regarding patient outcomes, service use, costs, and quality of care. METHODS The CCM and the KP Triangle were translated to the Dutch setting and adapted to the full elderly population living in the community. A randomized controlled trial with balanced allocation was designed to test the effectiveness of Embrace. Eligible elderly persons are 75 years and older and enrolled with one of the participating general practitioner practices. Based on scores on the INTERMED-Elderly Self-Assessment and Groningen Frailty Indicator, participants will be stratified into one of three strata: (A) robust; (B) frail; and (C) complex care needs. Next, participants will be randomized per stratum to Embrace or care as usual. Embrace encompasses an Elderly Care Team per general practitioner practice, an Electronic Elderly Record System, decision support instruments, and a self-management support and prevention program - combined with care and support intensity levels increasing from stratum A to stratum C. Primary outcome variables are patient outcomes, service use, costs, and quality of care. Data will be collected at baseline, twelve months after starting date, and during the intervention period. DISCUSSION This study could provide evidence for the effectiveness of Embrace.

SamenOud, een model voor geïntegreerde ouderenzorg

UNLABELLED Ongoing growth in health care expenditures and changing patterns in the demand for health care challenge societies worldwide. The Chronic Care Model (CCM), combined with classification for care needs based on Kaiser Permanente (KP) Triangle, may offer a suitable framework for change. The aim of the present study is to investigate the effectiveness of Embrace, a population-based model for integrated elderly care, regarding patient outcomes, service use, costs, and quality of care. METHODS The CCM and the KP Triangle were translated to the Dutch setting and adapted to the full elderly population living in the community. A randomized controlled trial with balanced allocation was designed to test the effectiveness of Embrace. Eligible elderly persons are 75 years and older and enrolled with one of the participating general practitioner practices. Based on scores on the INTERMED-Elderly Self-Assessment and Groningen Frailty Indicator, participants will be stratified into one of three strata: (A) robust; (B) frail; and (C) complex care needs. Next, participants will be randomized per stratum to Embrace or care as usual. Embrace encompasses an Elderly Care Team per general practitioner practice, an Electronic Elderly Record System, decision support instruments, and a self-management support and prevention program - combined with care and support intensity levels increasing from stratum A to stratum C. Primary outcome variables are patient outcomes, service use, costs, and quality of care. Data will be collected at baseline, twelve months after starting date, and during the intervention period. DISCUSSION This study could provide evidence for the effectiveness of Embrace.

Effects on well-being, quality of care and costs of the combined Chronic Care Model and a population health management model: Embrace

Background Embrace is a new care model for elderly people living in the community, which combines the Kaiser Permanente (KP) triangle with the Chronic Care Model (CCM). The KP triangle is a population health management model that divides patients with chronic conditions into three distinct groups based on their degree of need. Embrace encompasses an Elderly Care Team per General practitioner (GP), an Electronic Elderly Record System, decision support instruments, and a self-management support and prevention program. Its intensity of care and support varies per profile: Robust, Frail and Complex needs. Methods We assessed the effectiveness of Embrace concerning well-being and complexity of care needs of the elderly, quality of care, service use and costs with a Randomized Controlled Trial among elderly people (aged 75 years and older) living in the community. The intervention occurred from January 2012 to April 2013. Embrace was delivered by Elderly Care teams led by a GP and further consisted of an elderly care physician, a district nurse, and a social worker (both district nurse and social worker acting as case managers). Results In total1476 elderly people registered in 15 GP practices in the province of Groningen were included in the study and were stratified to the three Embrace profiles: 59% to the Robust profile, 16% to the Frail profile and 25% to the Complex needs profile. Next patients were randomized to the control group (n = 719) that received care-as-usual, or to the intervention group (n = 757) that received Embrace care and support. The results after one year of intervention will be presented. We expect improved well-being and decreased care needs for the elderly people, improved quality of care and decreased – or at leased stable – overall levels of service use and costs. Conclusions We succeeded to develop and to realize a promising new care model that includes all CCM key-elements in combination with a population health management model (KP-triangle). Effectiveness of this model was examined with a strong design. The follow-up period may be too short to demonstrate cost effectiveness because of the so-called ‘investment effect’. Therefore, the intervention period is prolonged in order to measure the real long-term effectiveness of Embrace.