Understanding implementation of comprehensive geriatric care programs: a multiple perspective approach is preferred.
BACKGROUND
The Prevention and Reactivation Care Program (PReCaP) provides a novel approach targeting hospital-related functional decline among elderly patients. Despite the high expectations, the PReCaP was not effective in preventing functional decline (ADL and iADL) among older patients. Although elderly PReCaP patients demonstrated slightly better cognitive functioning (Mini Mental State Examination; 0.4 [95% confidence interval (CI) 0.2-0.6]), lower depression (Geriatric Depression Scale 15; -0.9 [95% -1.1 to -0.6]), and higher perceived health (Short-form 20; 5.6 [95% CI 2.8-8.4]) 1 year after admission than control patients, the clinical relevance was limited. Therefore, this study aims to identify factors impacting on the effectiveness of the implementation of the PReCaPand geriatric care 'as usual'.


METHODS
We conducted semi-structured interviews with 34 professionals working with elderly patients in three hospitals, selected for their comparable patient case mix and different levels of geriatric care. Five non-participatory observations were undertaken during multidisciplinary meetings. Patient files (n = 42), hospital protocols, and care plans were screened for elements of geriatric care. Clinical process data were analysed for PReCaP components.


RESULTS
The establishment of a geriatric unit and employment of geriatricians demonstrates commitment to geriatric care in hospital A. Although admission processes are comparable, early identification of frail elderly patients only takes place in hosptial A. Furthermore, nursing care in the hospital A geriatric unit excels with regard to maximizing patient independency, an important predictor for hospital-related functional decline. Transfer nurses play a key role in arranging post-discharge geriatric follow-up care. Geriatric consultations are performed by geriatricians, geriatric nurses, and PReCaP case managers in hospital A. Yet hospital B consultative psychiatric nurses provide similar consultation services. The combination of standardized procedures, formalized communication channels, and advanced computerization contributes significantly to geriatric care in hospital B. Nevertheless, a small size hospital (hospital C) provides informal opportunities for information sharing and decision making, which are essential in geriatric care, given its multidisciplinary nature.


CONCLUSIONS
Geriatric care for patients with multimorbidity requires a multidisciplinary approach in a geriatric unit. Geriatric care, which integrates medical and reactivation treatment, by means of early screening of risk factors for functional decline, promotion of physical activity, and adequate discharge planning, potentially reduces the incidence of functional decline in elderly patients. Yet low treatment fidelity played a major role in the ineffective implementation of the PReCaP. Treatment fidelity issues are caused by various factors, including the complexity of projects, limited attention for implementation, and inadequate interdisciplinary communication. © 2016 The Authors The International Journal of Health Planning and Management Published by John Wiley & Sons Ltd.
Erasmus University Rotterdam, Rotterdam, Netherlands.
Annemarie
A
de Vos
Erasmus University Rotterdam, Rotterdam, Netherlands.
Jane-Murray
JM
Cramm
Erasmus University Rotterdam, Rotterdam, Netherlands.
Jeroen D H
JDH
van Wijngaarden
Stichting Wetenschap Balans, Rotterdam, Netherlands.
Ton J E M
TJEM
Bakker
Department of Public Health, Erasmus MC, Rotterdam, Netherlands.
Johan P
JP
Mackenbach
Erasmus University Rotterdam, Rotterdam, Netherlands.
Anna P
AP
Nieboer
D000203:Activities of Daily Living; D000368:Aged; D000369:Aged, 80 and over; D060825:Cognitive Dysfunction / Q000517:prevention & control; D003863:Depression / Q000517:prevention & control; D006299:Health Services for the Aged / Q000458:organization & administration*; D006304:Health Status; D006760:Hospitalization; D006801:Humans; D007407:Interviews as Topic; D016730:Program Development
early screening; geriatric care; geriatric consultation service; geriatric unit
J Am Geriatr Soc. 2003 Apr;51(4):451-8
12657063
Pragmat Obs Res. 2010 Aug 21;1:1-6
27774002
Health Policy. 2006 Dec;79(2-3):203-13
16472886
J Am Geriatr Soc. 2002 May;50(5):792-8
12028163
BMJ. 2009 Jan 22;338:b50
19164393
BMC Geriatr. 2014 Jan 10;14:3
24410889
J Am Geriatr Soc. 2000 Nov;48(11):1381-8
11083312
J Am Geriatr Soc. 2000 Dec;48(12):1572-81
11129745
Cochrane Database Syst Rev. 2011 Jul 06;(7):CD006211
21735403
Clin Rehabil. 2007 Jan;21(1):3-16
17213236
Ann Intern Med. 1989 Jan 1;110(1):79-84
2642284
BMC Geriatr. 2012 Mar 16;12:7
22423638
J Am Geriatr Soc. 2000 Dec;48(12):1697-706
11129764
Arch Intern Med. 1996 Mar 25;156(6):645-52
8629876
Am J Occup Ther. 1991 Mar;45(3):214-22
2031523
Int J Nurs Stud. 2013 Sep;50(9):1184-96
23384696
J Gerontol A Biol Sci Med Sci. 2003 Jan;58(1):37-45
12560409
J Am Geriatr Soc. 2010 Jan;58(1):83-92
20002509
Br Med Bull. 2005 Jan 31;71:45-59
15684245
Clin Interv Aging. 2015 Mar 30;10:649-61
25878492
J Am Geriatr Soc. 2006 Oct;54(10):1492-9
17038065
Lancet. 2008 Mar 1;371(9614):725-35
18313501
Ann Intern Med. 1993 Feb 1;118(3):219-23
8417639
JAMA. 1999 Feb 17;281(7):613-20
10029122
BMC Geriatr. 2013 Apr 12;13:31
23586895
Int J Integr Care. 2013 Nov 28;13:e047
24363635
Int J Health Plann Manage. 2017 Oct;32(4):608-636
27682420
Int J Integr Care. 2000 Nov 01;1:e08
16902699
J Am Geriatr Soc. 1990 Dec;38(12):1296-303
2123911
JAMA. 1998 Apr 15;279(15):1187-93
9555758
Acad Emerg Med. 2004 Dec;11(12):1341-5
15576526
BMC Geriatr. 2013 Oct 10;13:107
24112948
JAMA Intern Med. 2016 Mar;176(3):302-9
26882111
Ind Psychiatry J. 2010 Jan;19(1):60-5
21694795
J Am Geriatr Soc. 2004 Sep;52(9):1417-23
15341540
J Clin Nurs. 2010 May;19(9-10):1219-25
20345834
Cochrane Database Syst Rev. 2003;(4):CD000340
14583918
Am J Geriatr Psychiatry. 2011 Jun;19(6):507-20
20808147
BMC Health Serv Res. 2013 Jan 26;13:29
23351355
BMC Geriatr. 2011 Aug 03;11:36
21812988