Simone R. de Bruin

Comprehensive care programs for patients with multiple chronic conditions: A systematic literature review

OBJECTIVE To provide insight into the characteristics of comprehensive care programs for patients with multiple chronic conditions and their impact on patients, informal caregivers, and professional caregivers. METHODS Systematic literature search in multiple electronic databases for English language papers published between January 1995 and January 2011, supplemented by reference tracking and a manual search on the internet. Wagners chronic care model (CCM) was used to define comprehensive care. After inclusion, the methodological quality of each study was assessed. A best-evidence synthesis was applied to draw conclusions. RESULTS Forty-two publications were selected describing thirty-three studies evaluating twenty-eight comprehensive care programs for multimorbid patients. Programs varied in the target patient groups, implementation settings, number of included interventions, and number of CCM components to which these interventions related. Moderate evidence was found for a beneficial effect of comprehensive care on inpatient healthcare utilization and healthcare costs, health behavior of patients, perceived quality of care, and satisfaction of patients and caregivers. Insufficient evidence was found for a beneficial effect of comprehensive care on health-related quality of life in terms of mental functioning, medication use, and outpatient healthcare utilization and healthcare costs. No evidence was found for a beneficial effect of comprehensive care on cognitive functioning, depressive symptoms, functional status, mortality, quality of life in terms of physical functioning, and caregiver burden. CONCLUSION Because of the heterogeneity of comprehensive care programs, it is as yet too early to draw firm conclusions regarding their effectiveness. More rigorous evaluation studies are necessary to determine what constitutes best care for the increasing number of people with multiple chronic conditions.

Impact of disease management programs on healthcare expenditures for patients with diabetes, depression, heart failure or chronic obstructive pulmonary disease: A systematic review of the literature

OBJECTIVE Evaluating the impact of disease management programs on healthcare expenditures for patients with diabetes, depression, heart failure or COPD. METHODS Systematic Pubmed search for studies reporting the impact of disease management programs on healthcare expenditures. Included were studies that contained two or more components of Wagners chronic care model and were published between January 2007 and December 2009. RESULTS Thirty-one papers were selected, describing disease management programs for patients with diabetes (n=14), depression (n=4), heart failure (n=8), and COPD (n=5). Twenty-one studies reported incremental healthcare costs per patient per year, of which 13 showed cost-savings. Incremental costs ranged between -

Pay-for-performance in disease management: a systematic review of the literature

16,996 and

Effectiveness of comprehensive care programs for patients with multiple chronic conditions or frailty: A systematic literature review.

3305 per patient per year. Substantial variation was found between studies in terms of study design, number and combination of components of disease management programs, interventions within components, and characteristics of economic evaluations. CONCLUSION Although it is widely believed that disease management programs reduce healthcare expenditures, the present study shows that evidence for this claim is still inconclusive. Nevertheless disease management programs are increasingly implemented in healthcare systems worldwide. To support well-considered decision-making in this field, well-designed economic evaluations should be stimulated.

The concept of green care farms for older people with dementia An integrative framework

BackgroundPay-for-performance (P4P) is increasingly implemented in the healthcare system to encourage improvements in healthcare quality. P4P is a payment model that rewards healthcare providers for meeting pre-established targets for delivery of healthcare services by financial incentives. Based on their performance, healthcare providers receive either additional or reduced payment. Currently, little is known about P4P schemes intending to improve delivery of chronic care through disease management. The objectives of this paper are therefore to provide an overview of P4P schemes used to stimulate delivery of chronic care through disease management and to provide insight into their effects on healthcare quality and costs.MethodsA systematic PubMed search was performed for English language papers published between 2000 and 2010 describing P4P schemes related to the implementation of disease management. Wagners chronic care model was used to make disease management operational.ResultsEight P4P schemes were identified, introduced in the USA (n = 6), Germany (n = 1), and Australia (n = 1). Five P4P schemes were part of a larger scheme of interventions to improve quality of care, whereas three P4P schemes were solely implemented. Most financial incentives were rewards, selective, and granted on the basis of absolute performance. More variation was found in incented entities and the basis for providing incentives. Information about motivation, certainty, size, frequency, and duration of the financial incentives was generally limited. Five studies were identified that evaluated the effects of P4P on healthcare quality. Most studies showed positive effects of P4P on healthcare quality. No studies were found that evaluated the effects of P4P on healthcare costs.ConclusionThe number of P4P schemes to encourage disease management is limited. Hardly any information is available about the effects of such schemes on healthcare quality and costs.

Initiatives on early detection and intervention to proactively identify health and social problems in older people: experiences from the Netherlands

OBJECTIVE To describe comprehensive care programs targeting multimorbid and/or frail patients and to estimate their effectiveness regarding improvement of patient and caregiver related outcomes, healthcare utilization and costs. METHODS Systematic search in six electronic databases for scientific papers published between January 2011 and March 2014, supplemented by reference tracking. Wagners Chronic Care Model (CCM) was used to operationalize comprehensive care. The quality of the included studies was assessed, and a best-evidence synthesis was applied. RESULTS Nineteen publications were included describing effects of eighteen comprehensive care programs for multimorbid or frail patients, of which only one was implemented in a European country. Programs varied in target groups, settings, interventions and number of CCM components addressed. Providing comprehensive care might result in more patient satisfaction, less depressive symptoms, a better health-related quality of life or functioning of multimorbid or frail patients, but the evidence is insufficient. There is no evidence that comprehensive care reduces the number of primary care or GP visits or healthcare costs. Regarding the use of inpatient care, the evidence was insufficient. No evidence was found for a beneficial effect of comprehensive care on caregiver-related outcomes. CONCLUSION Despite the fact that over the years several (good-quality) studies have been performed to estimate the value of comprehensive care for multimorbid and/or frail patients, evidence for their effectiveness remains insufficient. More good-quality studies and/or studies allowing meta-analysis are needed to determine which specific target groups at what moment will benefit from comprehensive care. Moreover, evaluation studies could improve by using more appropriate outcome measures, e.g. measures that relate to patient-defined (personal) goals of care.

Integrated care programs for patients with psychological comorbidity: A systematic review and meta-analysis.

In the Netherlands community-dwelling older people with dementia can attend regular day care services (RDCS). Since approximately 2000, farms (so-called ‘green care farms’) also offer day care. The present study introduces the concept of green care farms for older people with dementia. We further provide an integrative framework for the expected health benefits of day care at green care farms (GCF) for older people with dementia. We present an overview of evidence for dementia related interventions that correspond with the current developments in health care (i.e. environmental, activity-based and psychosocial interventions), and that are relevant for day care. We subsequently focus on the differences between day care at GCF and RDCS with regard to these interventions, and describe the integrative framework for the expected health benefits of GCF for older people with dementia. We conclude that at GCF interventions are naturally integrated in the environment. They are present simultaneously and continuously, which is more difficult to realize in RDCS. We hypothesize that GCF have more health benefits for older people with dementia than RDCS.

Comparing day care at green care farms and at regular day care facilities with regard to their effects on functional performance of community-dwelling older people with dementia

BackgroundOver the last years, several initiatives on early detection and intervention have been put in place to proactively identify health and social problems in (frail) older people. An overview of the initiatives currently available in the Netherlands is lacking, and it is unknown whether they meet the preferences and needs of older people. Therefore, the objectives of this study were threefold: 1. To identify initiatives on early detection and intervention for older people in the Netherlands and compare their characteristics; 2. To explore the experiences of professionals with these initiatives; and 3. To explore to what extent existing initiatives meet the preferences and needs of older people.MethodsWe performed a qualitative descriptive study in which we conducted semi-structured interviews with seventeen experts in preventive elderly care and three group interviews with volunteer elderly advisors. Data were analysed using the framework analysis method.ResultsWe identified eight categories of initiatives based on the setting (e.g. general practitioner practice, hospital, municipality) in which they were offered. Initiatives differed in their aims and target groups. The utilization of peers to identify problems and risks, as was done by some initiatives, was seen as a strength. Difficulties were experienced with identifying the target group that would benefit from proactive delivery of care and support most, and with addressing prevalent issues among older people (e.g. psychosocial issues, self-reliance issues).ConclusionAlthough there is a broad array of initiatives available, there is a discrepancy between supply and demand. Current initiatives insufficiently address needs of (frail) older people. More insight is needed in “what should be done by whom, for which target group and at what moment”, in order to improve current practice in preventive elderly care.

Green Care Farms: An Innovative Type of Adult Day Service to Stimulate Social Participation of People With Dementia

OBJECTIVE Presently, little is known about the characteristics and impact of integrated care programs for patients with psychological comorbidity. The aim was to provide an overview of these integrated care programs and their effectiveness. METHODS Systematic literature review including papers published between 1995 and 2014. An integrated care program had to consist of interventions related to at least two out of the six components of the Chronic Care Model. Programs had to address patients with psychological comorbidity, which is a psychological disease next to a somatic chronic disease. A meta-analysis was performed on depression treatment response and a best evidence synthesis was performed on other outcomes. RESULTS Ten programs were identified, which mostly addressed comorbid depression and consisted of interventions related to three to five components of the Chronic Care Model. Meta-analysis showed significantly higher odds for depression treatment response for patients receiving integrated care (OR: 2.49, 95%CI [1.66-3.75]). Best evidence synthesis suggested moderate evidence for cost-effectiveness and for a beneficial effect on patient satisfaction and emotional well-being. Insufficient evidence was found for a beneficial effect on health-related quality of life, medication adherence, Hb1Ac levels and mortality. CONCLUSION There are few studies evaluating integrated care programs for patients with psychological comorbidity. Although these studies suggest that integrated care programs could positively affect several patient outcomes and could be cost-effective, additional studies are recommended to further assess the value of integrated care for this patient group. This is especially important since the number of people with psychological comorbidity is rising.

Improving early detection initiatives: a qualitative study exploring perspectives of older people and professionals.

Day care at green care farms (GCFs) is a new care modality for community-dwelling older people with dementia. In view of the more physical and normal daily life activities available at GCFs than at RDCFs, we investigated whether functional decline differed between subjects from both day care settings. In this observational cohort study, primary caregivers of 47 subjects from GCFs and 41 subjects from RDCFs rated the subjects’ functional performance three times during one year. They also provided information on the subjects’ diseases and medication use. Generally, no significant change over time in functional performance, the number of diseases and the number of medications was observed, and no differences in these rates of change were found between subjects from both day care settings. This study suggests that GCFs are not more effective in maintaining functional performance or slowing down its decline in community-dwelling older people with dementia than RDCFs.