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Integrated and Person-Centered Care for Community-Living Older Adults: A Cost-Effectiveness Study.

ABSTRACT: OBJECTIVES:To assess the cost-effectiveness of Embrace, an integrated primary care service for older adults. DATA SOURCES:Care and support claims from health care insurers, long-term care administration, and municipalities for enrolled older adults between 2011 and 2013. STUDY DESIGN:A total of 1,456 older adults, listed with 15 general practitioners practices in the Netherlands, were stratified into risk profiles ("Robust," "Frail," and "Complex care needs") and randomized to Embrace or care-as-usual groups. Incremental costs were calculated per quality-adjusted life year, per day able to age in place, and per percentage point risk profile improvement. PRINCIPAL FINDINGS:Total average costs were higher for Embrace compared to care-as-usual. Differences in health-associated outcomes were small and not statistically significant. Probabilities that Embrace is cost-effective were below 80 percent, except for "risk profile improvements" within risk profile "Complex care needs." Complete case analysis resulted in smaller differences in total average costs across conditions and differences in health-associated outcomes remained small. CONCLUSIONS:According to current standards, Embrace is not considered cost effective after 12 months. However, it could be considered worthwhile in terms of "risk profile improvements" for older adults with "Complex care needs," if society is willing to invest substantially.

SUBMITTER: Uittenbroek RJ

PROVIDER: S-EPMC6153174 | biostudies-literature | 2018 Oct

REPOSITORIES: biostudies-literature

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Integrated and Person-Centered Care for Community-Living Older Adults: A Cost-Effectiveness Study.

Uittenbroek Ronald J RJ van Asselt Antoinette D I ADI Spoorenberg Sophie L W SLW Kremer Hubertus P H HPH Wynia Klaske K Reijneveld Sijmen A SA

Health services research 20180324 5

<h4>Objectives</h4>To assess the cost-effectiveness of Embrace, an integrated primary care service for older adults.<h4>Data sources</h4>Care and support claims from health care insurers, long-term care administration, and municipalities for enrolled older adults between 2011 and 2013.<h4>Study design</h4>A total of 1,456 older adults, listed with 15 general practitioners practices in the Netherlands, were stratified into risk profiles ("Robust," "Frail," and "Complex care needs") and randomized ...[more]

PMID: 29573398

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Project description:BACKGROUND:Many health and social needs can be assessed and met in community settings, where lower-cost, person-centered, preventative and proactive services predominate. This study reports on the development and implementation of a person-centered care model integrating dental, social, and health services for low-income older adults at a community dental clinic co-located within a senior wellness center. METHODS:A digital comprehensive geriatric assessment (CGA) and referral system linking medical, dental, and psychosocial needs by real-time CGA-derived metrics for 996 older adults (age???60) was implemented in 2016-2018 as part of a continuous quality improvement project. This study aims to describe: 1) the development and content of a new CGA; 2) CGA implementation, workflows, triage, referrals; 3) correlations between CGA domains, and adjusted regression models, assessing associations with self-reported recent hospitalizations, emergency department (ED) visits, and clinically-assessed dental urgency. RESULTS:The multidisciplinary team from the senior wellness and dental centers planned and implemented a CGA that included standard medical history along with validated instruments for functional status, mental health and social determinants, and added oral health. Care navigators employed the CGA with 996 older adults, and made 1139 referrals (dental?=?797, care coordination?=?163, social work?=?90, mental health?=?32). CGA dimensions correlated between oral health, medical status, depressive symptoms, isolation, and reduced quality of life (QoL). Pain, medical symptoms, isolation and depressive symptoms were associated with poorer self-reported health, while general health was most strongly correlated with lower depressive symptoms, and higher functional status and QoL. Isolation was the strongest correlate of lower QoL. Adjusted odds ratios identified social and medical factors associated with recent hospitalization and ED visits. General and oral health were associated with dental urgency. Dental urgency was most strongly associated with general health (AOR?=?1.78,95%CI [1.31, 2.43]), dental symptoms (AOR?=?2.39,95%CI [1.78, 3.20]), dental pain (AOR?=?2.06,95%CI [1.55-2.74]), and difficulty chewing (AOR?=?2.80, 95%CI [2.09-3.76]). Dental symptoms were associated with recent ED visits (AOR?=?1.61, 95%CI [1.12-2.30]) or hospitalizations (AOR?=?1.47, 95%CI [1.04-2.10]). CONCLUSION:Community-based inter-professional care is feasible with CGAs that include medical, dental, and social factors. A person-centered care model requires coordination supported by new workflows. Real-time metrics-based triage process provided efficient means for client review and a robust process to surface needs in complex cases.

Project description:Background:The article reports on the cost-effectiveness of the proactive, integrated primary care program Finding and Follow-up of Frail older persons (FFF) compared with usual primary care for community-dwelling frail older persons in the Netherlands. Methods:This study had a matched quasi-experimental design (pretest and posttest). The economic evaluation was performed from a healthcare perspective with a time horizon of 12 months. The target population consisted of community-dwelling frail older persons aged ??75 years in the FFF intervention group (11 general practitioner (GP) practices) and in the control group receiving usual care (4 GP practices). The effectiveness measures for the cost-effectiveness and cost-utility analyses were subjective well-being (Social Production Function Instrument for the Level of well-being short; SPF-ILs) and QALYs (EuroQol; EQ-5D-3L), respectively. Costs were assessed using resource use questionnaires. Differences in mean effectiveness between groups were assessed using univariate, multilevel and propensity score matched analyses, with and without imputation of missing values. Differences in costs were assessed using Mann-Whitney U-tests and independent samples t-tests. Bootstrapping was performed, and predicted incremental cost-effectiveness ratios (ICERs) and incremental cost-utility ratios (ICURs) were depicted on cost-effectiveness planes. Results:The various analyses showed slightly different results with respect to differences in estimated costs and effects. Multilevel analyses showed a small but significant difference between the groups for well-being, in favor of the control group. No significant differences between groups in terms of QALYs were found. Imputed data showed that mean total costs were significantly higher in the intervention group at follow-up. Conclusion:Proactive, integrated care for community-dwelling frail older persons as provided in the FFF program is most likely not a cost-effective initiative, compared with usual primary care in the Netherlands, in terms of well-being and QALYs over a 12-month period.

Project description: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.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.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.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.

Project description:Care transitions from the hospital to home are critical to the sustainability of our health care system. Ineffective care transitions can be caused by high incidences of post-discharge adverse events, by poor communication with patients, and/or by inadequate information transfer between providers from the hospital to home. Any one of these can lead to fragmented care, high readmission rates, increased visits to the emergency department, and ultimately poor patient outcomes. Despite the ongoing improvement efforts of health care organizations, the efficacy of person- and family-centered care transition interventions on the quality of care and on the patient experience are not known. The aim of this systematic review is to critically analyze the body of evidence regarding the effectiveness of person- and family-centered care transition interventions on the quality of care, and the experience of patients.We will conduct a systematic review using the Cochrane Handbook's guidelines and will adhere to a standardized reporting format: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive search strategy will be conducted in the following databases: MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and the Cochrane Consumers and Communication Group. Following a two-step screening process, data including the full reference, objectives, target population, description of the intervention and control intervention, outcome measures, design, length of post-intervention follow-up period, and the study results will be extracted, synthesized, and reported. Risk of bias and quality of the studies will also be assessed.This systematic review will summarize and present the evidence base for person- and family-centered care transition interventions. This review will also inform further research and will lay the groundwork for more empirical studies on person- and family-centered care transitions. Specifically, the results of this systematic review may inform the development of measures to monitor safe and effective person- and family-centered transitions from the hospital to home. These results may also be important for policy makers, decision-makers, clinicians, and patients/families who are involved in navigating the health care system.PROSPERO CRD42017067990.

Dataset Information

Integrated and Person-Centered Care for Community-Living Older Adults: A Cost-Effectiveness Study.

Publications

Integrated and Person-Centered Care for Community-Living Older Adults: A Cost-Effectiveness Study.

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