Sarah Hm Robben

Effects of hospital-wide interventions to improve care for frail older inpatients: a systematic review.

Background Although it is widely recognised that frail older persons need adaptation of healthcare services, it is unclear how hospital care in general can best be tailored to their frailty. Objective To systematically review the evidence for hospital-wide interventions for older patients. Methods PubMed, Cochrane CENTRAL, Cinahl and reference lists of included articles (1980–2009) were searched. Papers describing (1) randomised controlled trials, controlled clinical trials, controlled before–after studies or interrupted time series, (2) patients ≥65 years admitted to hospital, (3) hospital-wide organisational interventions, and (4) patient-related outcomes, quality of care, patient safety, resource use or costs were included. Two reviewers extracted data and assessed risk of bias independently, according to Cochrane Effective Practice and Organization of Care Review Group guidelines. Results The authors included 20 articles out of 1175. The mean age of the study populations ranged from 74.2 to 85.8 years. Interventions included multidisciplinary (consultative) teams, nursing care models, structural changes in physical environment and/or changes in site of service delivery. Small or no effects were found on patient-related outcomes such as functional performance, length of stay, discharge destination, resource use and costs compared with usual care. Methodological quality evaluation showed data incompleteness and contamination as main sources of bias. Conclusions No single best hospital-wide intervention could be identified using strict methodological criteria. However, several interventions had positive results, and may be used in hospital practice. Since strict methodological designs are not optimal for evaluating highly complex interventions and settings, the authors recommend studying hospital-wide interventions for older persons using adapted quality and research criteria.

Implementation of an innovative web-based conference table for community-dwelling frail older people, their informal caregivers and professionals: a process evaluation

BackgroundDue to fragmentation of care, continuity of care is often limited in the care provided to frail older people. Further, frail older people are not always enabled to become involved in their own care. Therefore, we developed the Health and Welfare Information Portal (ZWIP), a shared Electronic Health Record combined with a communication tool for community-dwelling frail older people and primary care professionals. This article describes the process evaluation of its implementation, and aims to establish (1) the outcomes of the implementation process, (2) which implementation strategies and barriers and facilitators contributed to these outcomes, and (3) how its future implementation could be improved.MethodsMixed methods study, consisting of (1) a survey among professionals (n = 118) and monitoring the use of the ZWIP by frail older people and professionals, followed by (2) semi-structured interviews with purposively selected professionals (n = 12).Results290 frail older people and 169 professionals participated in the ZWIP. At the end of the implementation period, 55% of frail older people and informal caregivers, and 84% of professionals had logged on to their ZWIP at least once. For professionals, the exposure to the implementation strategies was generally as planned, they considered the interprofessional educational program and the helpdesk very important strategies. However, frail older people’s exposure to the implementation strategies was less than intended. Facilitators for the ZWIP were the perceived need to enhance interprofessional collaboration and the ZWIP application being user-friendly. Barriers included the low computer-literacy of frail older people, a preference for personal communication and limited use of the ZWIP by other professionals and frail older people. Interviewees recommended using the ZWIP for other target populations as well and adding further strategies that may help frail older people to feel more comfortable with computers and the ZWIP.ConclusionsThis study describes the implementation process of an innovative e-health intervention for community-dwelling frail older people, informal caregivers and primary care professionals. As e-health is an important medium for overcoming fragmentation of healthcare and facilitating patient involvement, but its adoption in everyday practice remains a challenge, the positive results of this implementation are promising.

Evaluation of an eHealth Intervention in Chronic Care for Frail Older People: Why Adherence is the First Target

Background Older people suffering from frailty often receive fragmented chronic care from multiple professionals. According to the literature, there is an urgent need for coordination of care. Objective The objective of this study was to investigate the effectiveness of an online health community (OHC) intervention for older people with frailty aimed at facilitating multidisciplinary communication. Methods The design was a controlled before-after study with 12 months follow-up in 11 family practices in the eastern part of the Netherlands. Participants consisted of frail older people living in the community requiring multidisciplinary (long-term) care. The intervention used was the health and welfare portal (ZWIP): an OHC for frail elderly patients, their informal caregivers and professionals. ZWIP contains a secure messaging system supplemented by a shared electronic health record. Primary outcomes were scores on the Instrumental Activities of Daily Living scale (IADL), mental health, and social activity limitations. Results There were 290 patients in the intervention group and 392 in the control group. Of these, 76/290 (26.2%) in the intervention group actively used ZWIP. After 12 months follow-up, we observed no significant improvement on primary patient outcomes. ADL improved in the intervention group with a standardized score of 0.21 (P=.27); IADL improved with 0.50 points, P=.64. Conclusions Only a small percentage of frail elderly people in the study intensively used ZWIP, our newly developed and innovative eHealth tool. The use of this OHC did not significantly improve patient outcomes. This was most likely due to the limited use of the OHC, and a relatively short follow-up time. Increasing actual use of eHealth intervention seems a precondition for large-scale evaluation, and earlier adoption before frailty develops may improve later use and effectiveness of ZWIP.

Preferences for receiving information among frail older adults and their informal caregivers: a qualitative study

BACKGROUND Patient involvement in clinical decision making is increasingly advocated. Although older patients may be more reluctant to become involved, most do appreciate being informed. However, knowledge about their experiences with and preferences for receiving information is limited, and even less is known about these topics for frail older people. OBJECTIVE To explore the experiences of frail older people and informal caregivers with receiving information from health care professionals as well as their preferences for receiving information. METHODS We conducted semi-structured interviews with frail older people (n = 11, 65-90 years) and informal caregivers (n = 11, 55-87 years). Interviews were transcribed verbatim and analysed using a grounded theory approach. RESULTS Frail older people and informal caregivers varied in their information needs and discussed both positive and negative experiences with receiving information. They preferred receiving verbal information from their physician during the consultation; yet would appreciate receiving brief, clearly written information leaflets in addition. They employed several strategies to enhance the information provided, i.e. advocacy, preparing for a consultation and searching their own information. Contextual factors for receiving information, such as having enough time and having a good relationship with professionals involved, were considered of great importance. CONCLUSIONS Participants described a wide range of experiences with and preferences for receiving information. However, even if the information provided would meet all their preferences, this would be of limited significance if not provided within the context of an ongoing trusting relationship with a professional, such as a GP or practice nurse, who genuinely cared for them.

Care-related goals of community-dwelling frail older adults.

ACKNOWLEDGMENTS The authors would like to thank the Brazilian Society of Geriatrics Gerontology, São Paulo, and all students from the disciplines of geriatrics and gerontology who actively took part in this project and contributed daily and voluntarily for the expansion and strengthening of geriatrics and gerontology in Brazil: Adriana I Un Huang, Aghata Teixeira Silva, Aline Vial Cobello, Ana Beatrice Torres Carvalho, Ana Carolina Araújo Oliveira, Ana Cristina da Silva Fernandes, Ana Paula de Oliveira Marques, Ana Paula de Souza Oliveira, Anne Grazielle Lima Bindá, Bárbara Araújo Oliveira, Blenda Sousa Carli Rodrigues, Bruna Danielle de Menezes, Carolina Burgarelli Testa, Caroline Monteiro Conceição, Cristiane Andrade da Costa, Christyanne Maria Rodrigues Barreto de Assis, Daniela Teles da Silva, Danielle Figueredo da Silva, Danielle Florêncio dos Santos, Darlene Mara dos Santos Tavares, Debora Lee Vianna Paulo, Denise Cristina de Oliveira Ferreira, Diego Adão F. Silva, Edna Corrêa Moreira, Elder Lanzani Freitas, Erika Kiyomi Yuyama, Fábia Helena Muniz, Fernanda Gasparini, Fernanda Santucci, Giovanna Arcaro de Lima, Gustavo Ferrão, Hugo Moura de Albuquerque Melo, João Augusto Hidalgo Barros Abomorad, Karen Christine Albuquerque Moreira, Karoline Bento Ribeiro, Leila Fortes, Lilian César Salgado Boaventura, Liliane Ramos Costa, Li Men Zhao, Lorena Rodrigues Netto, Lucas Certain, Lucı́lia Rocha Lopes, Maria de Fátima Nunes Marucci, Maria Lucia Buziqui Piruzeli, Maria Monique Silva Oliveira, Mariana Leme Gomes, Mariani Mendes Madisson, Marisa Accioly Rodrigues da Costa Domingues, Marcos Alexandre Frota, Marta Nagai Coelho, Mayra Jacuviske Venegas, Maysa Seabra Cendoroglo, Mirella Carla de Melo Mendonça, Natália Sanchez Oliveira, Natalia Waldmann Okai, Natasha Casteli Bonfim, Nayara Paula Fernandes Martins, Nelisa Sandrini Alves Maciel, Paula Caroline O. Souza, Paulo André de Lacerda Alves, Raphael Valadão Dadalto, Raquel Aparecida Casarotto, Rebeca Matos Velez de Andrade Lima, Renata Borges Facury, Renato Lı́rio Morelato, Ricardo Ramiris Silva Gasperazzo, Silmara Rondon, Simone da Silva Henriques, Tiffany Moukbel Chaim, Valdeci de Oliveira Santos Rigolin, Vanessa Bezerra de Lima, Wagner Vicente de Morais Silva, Wilson Jacob Filho. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors contributed equally to the data collection, analyses, and conclusion of this study. Sponsor’s Role: This study had no sponsor support.

Filling the Gaps in a Fragmented Health Care System: Development of the Health and Welfare Information Portal (ZWIP)

Background Current health care systems are not optimally designed to meet the needs of our aging populations. First, the fragmentation of care often results in discontinuity of care that can undermine the quality of care provided. Second, patient involvement in care decisions is not sufficiently facilitated. Objective To describe the development and the content of a program aimed at: (1) facilitating self-management and shared decision making by frail older people and informal caregivers, and (2) reducing fragmentation of care by improving collaboration among professionals involved in the care of frail older people through a combined multidisciplinary electronic health record (EHR) and personal health record (PHR). Methods We used intervention mapping to systematically develop our program in six consecutive steps. Throughout this development, the target populations (ie, professionals, frail older people, and informal caregivers) were involved extensively through their participation in semi-structured interviews and working groups. Results We developed the Health and Welfare Information Portal (ZWIP), a personal, Internet-based conference table for multidisciplinary communication and information exchange for frail older people, their informal caregivers, and professionals. Further, we selected and developed methods for implementation of the program, which included an interdisciplinary educational course for professionals involved in the care of frail older people, and planned the evaluation of the program. Conclusions This paper describes the successful development and the content of the ZWIP as well as the strategies developed for its implementation. Throughout the development, representatives of future users were involved extensively. Future studies will establish the effects of the ZWIP on self-management and shared decision making by frail older people as well as on collaboration among the professionals involved.

Which Frail Older Patients Use Online Health Communities and Why? A Mixed Methods Process Evaluation of Use of the Health and Welfare Portal

Background Frail older people often receive fragmented care from multiple providers. According to the literature, there is an urgent need for coordination of care. Online and eHealth tools are increasingly used to improve coordination. However, there are significant barriers to their implementation in frail older people. Objective Our aim was to (1) evaluate differences in use of a personal online health community (POHC) for frail older people in relation to personal characteristics, and (2) explore barriers and facilitators for use as experienced by older people and their informal caregivers, using the case of the Health and Welfare Information Portal (ZWIP). Methods This is a mixed methods study. For the quantitative analysis, we used POHC usage information (2 years follow-up) and baseline characteristics of frail older people. For the qualitative analysis, we used semistructured interviews with older people and their informal caregivers. Participants were recruited from 11 family practices in the east of the Netherlands and frail older people over 70 years. The ZWIP intervention is a personal online health community for frail older people, their informal caregivers, and their providers. ZWIP was developed at the Geriatrics Department of Radboud University Medical Center. We collected data on POHC use for 2 years as well as relevant patient characteristics. Interview topics were description of use, reasons for use and non-use, and user profiles. Results Of 622 frail patients in the intervention group, 290 were connected to ZWIP; 79 used ZWIP regularly (at least monthly). Main predictors for use were having an informal caregiver, having problems with activities of daily living, and having a large number of providers. Family practice level predictors were being located in a village, and whether the family practitioners had previously used electronic consultation and cared for a large percentage of frail older people. From 23 interviews, main reasons for use were perceiving ZWIP to be a good, quick, and easy way of communicating with providers and the presence of active health problems. Important reasons for non-use were lack of computer skills and preferring traditional means of consultation. Conclusions Only 27.2% (79/290) of frail older enrolled in the POHC intervention used the POHC frequently. For implementation of personal online health communities, older people with active health problems and a sizable number of health care providers should be targeted, and the informal caregiver, if present, should be involved in the implementation process. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 11165483; http://www.controlled-trials.com/isrctn/pf/11165483 (Archived by WebCite at http://www.webcitation.org/6U3fZovoU).

[Reducing fragmentation in the care of frail older people: the successful development and implementation of the Health and Welfare Information Portal].

Our fragmented health care systems are insufficiently equipped to provide frail older people with high quality of care. Therefore, we developed the Health and Welfare Information Portal (ZWIP), an e-health intervention which aims (1) to facilitate self-management by frail older people and informal caregivers and (2) to improve collaboration among professionals. The ZWIP is a personal conference table, accessible through a secure internet connection, for multidisciplinary communication and information exchange for frail older people, their informal caregivers and professionals. After development, the ZWIP was implemented in seven general practices, and this process was evaluated by means of a mixed-methods study. Eventually, 290 frail older people and 169 professionals participated in the ZWIP. Most professionals were positive about its implementation. Facilitators for the implementation were the experienced need for improvement of interprofessional collaboration and the user-friendliness of the ZWIP. Barriers were the low computer-literacy of frail older people, start-up problems, preferring personal contact, and limited use of the ZWIP by other professionals. In sum, this article describes the successful development and implementation of the ZWIP, an e-health intervention which can reduce fragmentation in the care of frail older people.Reducing fragmentation in the care of frail older people: the successful development and implementation of the Health and Welfare Information PortalOur fragmented health care systems are insufficiently equipped to provide frail older people with high quality of care. Therefore, we developed the Health and Welfare Information Portal (ZWIP), an e-health intervention which aims (1) to facilitate self-management by frail older people and informal caregivers and (2) to improve collaboration among professionals. The ZWIP is a personal conference table, accessible through a secure internet connection, for multidisciplinary communication and information exchange for frail older people, their informal caregivers and professionals. After development, the ZWIP was implemented in seven general practices, and this process was evaluated by means of a mixed-methods study. Eventually, 290 frail older people and 169 professionals participated in the ZWIP. Most professionals were positive about its implementation. Facilitators for the implementation were the experienced need for improvement of interprofessional collaboration and the user-friendliness of the ZWIP. Barriers were the low computer-literacy of frail older people, start-up problems, preferring personal contact, and limited use of the ZWIP by other professionals. In sum, this article describes the successful development and implementation of the ZWIP, an e-health intervention which can reduce fragmentation in the care of frail older people.SamenvattingOns gefragmenteerde zorgstelsel is onvoldoende in staat om goede zorg te bieden aan kwetsbare ouderen. Daarom ontwikkelden we het Zorg en WelzijnsInfoPortaal (ZWIP), een e-health interventie die beoogt om (1) zelfmanagement door kwetsbare ouderen en mantelzorgers te ondersteunen en (2) de samenwerking tussen hulpverleners te verbeteren. Dit ZWIP kan gezien worden als een persoonlijke, via internet toegankelijke overlegtafel voor multidisciplinaire communicatie en informatie-uitwisseling voor kwetsbare ouderen, hun mantelzorgers en hulpverleners. Het ZWIP werd geïmplementeerd in zeven verschillende huisartsenpraktijken en dit proces werd geëvalueerd met een mixed-methods onderzoek. In totaal namen 290 kwetsbare ouderen en 169 hulpverleners deel aan het ZWIP. De meeste hulpverleners waren positief over de implementatie. Bevorderende factoren voor de implementatie waren de ervaren noodzaak tot verbetering van de samenwerking tussen hulpverleners en het gebruiksgemak van het ZWIP. Belemmerende factoren waren beperkte computervaardigheden van kwetsbare ouderen, opstartproblemen, een voorkeur voor persoonlijk contact, en beperkt gebruik van het ZWIP door andere hulpverleners. Concluderend beschrijft dit artikel de succesvolle ontwikkeling en implementatie van het ZWIP, een interventie die de fragmentatie in de zorg kan verminderen. Dit wordt nog eens ondersteund door het feit dat een zorgverzekeraar het ZWIP als een declareerbare inspanning heeft erkend.

Het ZWIP, een digitale overlegtafel voor ouderen en hulpverleners

SamenvattingRobben SH, Perry M, Huisjes M, Van Nieuwenhuijzen L, Schers HJ, Van Weel C, Rikkert MG, Van Achterberg T, Heinen MM, Melis RJ. Het ZWIP, een digitale overlegtafel voor ouderen en hulpverleners. Huisarts Wet 2014;57(2):58-62.Achtergrond Ons huidige zorgstelsel is onvoldoende in staat om adequate zorg te bieden aan het toenemende aantal kwetsbare ouderen. Het geeft weinig ruimte voor zelfmanagement door ouderen en mantelzorgers, en de zorg is vaak gefragmenteerd over verschillende hulpverleners. Om zelfmanagement en samenwerking te verbeteren, is in de omgeving van Nijmegen het Zorg en WelzijnsInfoPortaal (ZWIP) van start gegaan, een persoonlijke, via internet toegankelijke overlegtafel voor kwetsbare ouderen, mantelzorgers en hulpverleners.Methode Na de implementatie van het ZWIP evalueerden wij het gebruik van het portal gedurende het eerste jaar in zeven huisartsenpraktijken in Gelderland en Noord-Brabant. Als aanvulling op de kwantitatieve gegevens uit de implementatie legden wij alle deelnemende hulpverleners een vragenlijst voor en n amen wij een aantal van hen een semigestructureerd interview af.Resultaten In de onderzochte praktijken hebben uiteindelijk 290 kwetsbare ouderen en 169 hulpverleners het ZWIP gebruikt in het eerste jaar na implementatie. Het succes van de implementatie varieerde per praktijk, maar over het algemeen waren de hulpverleners positief, vooral over het scholingsprogramma en de helpdesk. Factoren die deelname bevorderden, waren het gebruiksgemak en de wens van hulpverleners om de onderlinge samenwerking te verbeteren. Factoren die deelname belemmerden, waren de beperkte computervaardigheden van de ouderen en een gedeelde voorkeur voor persoonlijk contact.Conclusie Per saldo kan de implementatie van het ZWIP een succes genoemd worden. De hulpverleners gaven aan dat het systeem ook voor andere groepen patiënten waardevol kan zijn. In hoeverre ouderen en hulpverleners het ZWIP ook daadwerkelijk actief gebruiken, wordt nog onderzocht, maar de verwachting is dat het ZWIP belangrijk kan bijdragen aan het verminderen van de fragmentatie in de zorg.

Filling the Gaps in a Fragmented Health Care System

Background Current health care systems are not optimally designed to meet the needs of our aging populations. First, the fragmentation of care often results in discontinuity of care that can undermine the quality of care provided. Second, patient involvement in care decisions is not sufficiently facilitated. Objective To describe the development and the content of a program aimed at: (1) facilitating self-management and shared decision making by frail older people and informal caregivers, and (2) reducing fragmentation of care by improving collaboration among professionals involved in the care of frail older people through a combined multidisciplinary electronic health record (EHR) and personal health record (PHR). Methods We used intervention mapping to systematically develop our program in six consecutive steps. Throughout this development, the target populations (ie, professionals, frail older people, and informal caregivers) were involved extensively through their participation in semi-structured interviews and working groups. Results We developed the Health and Welfare Information Portal (ZWIP), a personal, Internet-based conference table for multidisciplinary communication and information exchange for frail older people, their informal caregivers, and professionals. Further, we selected and developed methods for implementation of the program, which included an interdisciplinary educational course for professionals involved in the care of frail older people, and planned the evaluation of the program. Conclusions This paper describes the successful development and the content of the ZWIP as well as the strategies developed for its implementation. Throughout the development, representatives of future users were involved extensively. Future studies will establish the effects of the ZWIP on self-management and shared decision making by frail older people as well as on collaboration among the professionals involved.