Sebastià Santaeugènia

Rehabilitation profiles of older adult stroke survivors admitted to intermediate care units: A multi-centre study

Background Stroke is a major cause of disability in older adults, but the evidence around post-acute treatment is limited and heterogeneous. We aimed to identify profiles of older adult stroke survivors admitted to intermediate care geriatric rehabilitation units. Methods We performed a cohort study, enrolling stroke survivors aged 65 years or older, admitted to 9 intermediate care units in Catalonia-Spain. To identify potential profiles, we included age, caregiver presence, comorbidity, pre-stroke and post-stroke disability, cognitive impairment and stroke severity in a cluster analysis. We also proposed a practical decision tree for patient’s classification in clinical practice. We analyzed differences between profiles in functional improvement (Barthel index), relative functional gain (Montebello index), length of hospital stay (LOS), rehabilitation efficiency (functional improvement by LOS), and new institutionalization using multivariable regression models (for continuous and dichotomous outcomes). Results Among 384 patients (79.1±7.9 years, 50.8% women), we identified 3 complexity profiles: a) Lower Complexity with Caregiver (LCC), b) Moderate Complexity without Caregiver (MCN), and c) Higher Complexity with Caregiver (HCC). The decision tree showed high agreement with cluster analysis (96.6%). Using either linear (continuous outcomes) or logistic regression, both LCC and MCN, compared to HCC, showed statistically significant higher chances of functional improvement (OR = 4.68, 95%CI = 2.54–8.63 and OR = 3.0, 95%CI = 1.52–5.87, respectively, for Barthel index improvement ≥20), relative functional gain (OR = 4.41, 95%CI = 1.81–10.75 and OR = 3.45, 95%CI = 1.31–9.04, respectively, for top Vs lower tertiles), and rehabilitation efficiency (OR = 7.88, 95%CI = 3.65–17.03 and OR = 3.87, 95%CI = 1.69–8.89, respectively, for top Vs lower tertiles). In relation to LOS, MCN cluster had lower chance of shorter LOS than LCC (OR = 0.41, 95%CI = 0.23–0.75) and HCC (OR = 0.37, 95%CI = 0.19–0.73), for LOS lower Vs higher tertiles. Conclusion Our data suggest that post-stroke rehabilitation profiles could be identified using routine assessment tools and showed differential recovery. If confirmed, these findings might help to develop tailored interventions to optimize recovery of older stroke patients.

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

Nuevo modelo de atención integrada orientada a ancianos ingresados en Unidades de Atención Intermedia en Cataluña: protocolo de un estudio cuasiexperimental

OBJECTIVE To evaluate the clinical effectiveness of an intermediate care model based on a system of care focused on integrated care pathways compared to the traditional model of geriatric care (usual care) in Catalonia. PATIENTS AND METHODS The design is a quasi-experimental pre-post non-randomised study with non-synchronous control group. The intervention consists of the development and implementation of integrated care pathways and the creation of specialised interdisciplinary teams in each of the processes. The two groups will be compared for demographic, clinical variables on admission and discharge, geriatric syndromes, and use of resources. DISCUSSION This quasi-experimental study, aims to assess the clinical impact of the transformation of a traditional model of geriatric care to an intermediate care model in an integrated healthcare organisation. It is believed that the results of this study may be useful for future randomised controlled studies.

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.

The “Results Centre” of the Catalan healthcare system: A tool for integrated care

Introduction: Improving the quality and transparency of the healthcare government has an impact on the health of the population through policies, management of organizations, and clinical practice. Moreover, the comparison between healthcare centres or territories on a population basis, and the transparent and open feedback of results to policy makers, managers, professionals and citizens contributes directly to improve results. Description of policy context and objective: The Results Centre of the Catalan healthcare system measures and disseminates the results achieved by the different healthcare centres in order to facilitate a co-responsible decision making process, to improve the quality of healthcare provided to the population of Catalonia. It favours the benchmarking between defined geographical local areas and healthcare centres and share best practices in a transparent way. As a result of the development of a chronic care and an integrated health and social care strategy in Catalonia, there is an increasing need to introduce a population based shared outcome framework with objectives and indicators which could act as drivers for integration with an increasing “triple aim” orientation Targeted population: For citizens, the Results Center promotes a wider and better understanding of the field of health, and allows them to interact with the healthcare system and participate in decisions that affect their health. For healthcare centres, it allows them to compare the results achieved, identify and share best practices, and look for opportunities for improvement and cooperation between institutions. For the health administration, the Results Centre respond to the demand for transparency in health policy decisions, as well as for accountability in the use of resources. Highlights: Since 2012, an annual report has been produced for hospitals, primary care, long-term care, mental healthcare, public health activities, and territory with population based indicators. For each topic, around 60 quality indicators are measured, identifying the provider and the territory. Some of the indicators are especially relevant for integrated care such as prevalence of people with complex healthcare needs or in advanced chronic disease condition, rate of avoidable emergency admissions related to a range of selected chronic conditions, readmission rates related to selected chronic conditions, and others. The experiences of centres with better results, and the opinion of experts are incorporated, and a version for citizens is published. The “territory report” offers a picture of population-based health, and a tool to monitor changes due to integrated care policies. All detailed results are available in tables, together with technical definitions (http://observatorisalut.gencat.cat), and in open data format. Comments on transferability: This project is possible due to the high level of development of health information systems in Catalonia, and to the maturity and compromise of the healthcare sector. The Chronic care Program and Integrated Health and Social care Plan is working in partnership with the Results Centre to continuously improve the project, incorporating new indicators significant for the evaluation of integrated care (i.e. “high needs, high cost”-) and spread this vision of integrated care with a population based orientation. Conclusions: Engaging healthcare professionals is essential to move towards better clinical practice by identifying and sharing best practices. These reports are used among managers and clinical and other professional leaders as a tool for benchmarking, and among commissioners to facilitate better understanding of the territorial performance. This is a pioneering initiative in Spain, and is aligned with the most advanced countries in terms of policies of transparency and accountability.

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.