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A home-based, primary-care model for epilepsy care in India: Basis and design.

ABSTRACT: Objectives:A cluster-randomized trial of home-based care using primary-care resources for people with epilepsy has been set up to optimize epilepsy care in resource-limited communities in low- and middle-income countries. The primary aim is to determine whether treatment adherence to antiepileptic drugs is better with home-based care or with routine clinic-based care. The secondary aims are to compare the effects of the two care pathways on seizure control and quality of life. Methods:The home-based intervention comprises epilepsy medication provision, adherence reinforcement, and epilepsy self-management and stigma management guidance provided by an auxiliary nurse-midwife equivalent. The experimental group will be compared to a routine clinic-based care group using a cluster-randomized design in which the unit of analysis is a cluster of 10 people with epilepsy residing in an area cared for by a single accredited government grass-roots health care worker. The primary outcome is treatment adherence as measured by monthly tablet counts supplemented by two self-completed questionnaires. The secondary outcomes include monthly seizure frequency, time to first seizure (in days) after enrollment, proportion of patients experiencing seizure freedom for the duration of the study, and quality of life measured by the "Personal Impact of Epilepsy Scale," all assessed by an independent study nurse. Results:The screening phase and neurologic evaluations and randomizations have been recently completed and follow-up is underway. Significance:The results of the trial are likely to have substantial bearing on the development of governmental policies and strategies to provide coverage and care for patients with epilepsy in resource-limited countries.

SUBMITTER: Singh G

PROVIDER: S-EPMC6546011 | biostudies-literature | 2019 Jun

REPOSITORIES: biostudies-literature

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A home-based, primary-care model for epilepsy care in India: Basis and design.

Singh Gagandeep G Sharma Suman S Bansal Rajnder K RK Setia Raj K RK Sharma Sarit S Bansal Namita N Chowdhury Anuraag A Goraya Jatinder S JS Chatterjee Susmita S Kaur Sukhpreet S Kaur Manpreet M Kalra Shivani S Sander Josemir W JW

Epilepsia open 20190306 2

<h4>Objectives</h4>A cluster-randomized trial of home-based care using primary-care resources for people with epilepsy has been set up to optimize epilepsy care in resource-limited communities in low- and middle-income countries. The primary aim is to determine whether treatment adherence to antiepileptic drugs is better with home-based care or with routine clinic-based care. The secondary aims are to compare the effects of the two care pathways on seizure control and quality of life.<h4>Methods ...[more]

PMID: 31168493

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Project description:ImportanceVeterans Affairs (VA) Home-Based Primary Care (HBPC) provides comprehensive, interdisciplinary primary care at home to patients with complex, chronic, disabling disease, but little is known about care fragmentation patterns and consequences among these patients.ObjectiveTo examine outpatient care fragmentation patterns and subsequent acute care among HBPC-engaged patients at high risk of hospitalization or death.Design, setting, and participantsThis retrospective cohort study included VA patients aged at least 65 years who were enrolled in the VA and Medicare, whose risk of hospitalization or death was in the top 10%, and who had at least 4 outpatient visits between October 1, 2013, and September 30, 2014. HBPC engagement was defined as having at least 2 HBPC encounters between July 1, 2014, and September 30, 2014. Data were analyzed from March 2020 to March 2022.ExposuresTwo indices of outpatient care fragmentation: practitioner count and the Usual Provider Continuity Index (UPC), based on VA and non-VA health care use from October 1, 2013, to September 30, 2014. All care delivered by HBPC clinicians was analyzed as coming from a single practitioner.Main outcomes and measuresEmergency department (ED) visits and hospitalizations for ambulatory care sensitive conditions (ACSC) from VA records and Medicare claims from October 1, 2014, to September 30, 2015.ResultsAmong 8908 identified HBPC patients, 8606 (96.6%) were male, 1562 (17.5%) were Black, 249 (2.8%) were Hispanic, 6499 (73.0%) were White, 157 (1.8%) were other race or ethnicity, and 441 (5.0%) had unknown race or ethnicity; the mean (SD) age was 80.0 (9.02) years; patients had a mean (SD) of 11.25 (3.87) chronic conditions, and commonly had disabling conditions such as dementia (38.8% [n = 3457]). In adjusted models, a greater number of practitioners was associated with increased odds of an ED visit (adjusted odds ratio [aOR], 1.05 [95% CI, 1.03-1.07]) and hospitalization for an ACSC (aOR, 1.04 [95% CI, 1.02-1.06]), whereas more concentrated care with a higher UPC was associated with reduced odds of these outcomes (highest vs lowest tertile of UPC: aOR for ED visit, 0.77 [95% CI, 0.67-0.88], aOR for ACSC hospitalization, 0.78 [95% CI, 0.68-0.88]).Conclusions and relevanceAmong patients in HBPC, fragmented care was associated with more ED visits and ACSC hospitalizations. These findings suggest that consolidating or coordinating fragmented care may be a target for reducing preventable acute care.

Project description:BackgroundThe Veterans Health Administration (VA) implemented the comprehensive life-sustaining treatment (LST) Decisions Initiative to provide training and standardize documentation of goals of care and LST preferences for seriously ill Veterans to improve end-of-life (EOL) outcomes. LST documentation is expected for all Home-Based Primary Care (HBPC) Veterans because they are at high risk of hospitalization and mortality.MethodsA retrospective, cross-sectional analysis compared associations between Bereaved Family Survey (BFS) EOL care ratings and LST documentation. Participants were Veterans who died August 1, 2018 through September 30, 2019 in one of 55 VA HBPC programs. Regression modeling generated odds for key BFS outcomes. LST template completion rate was plotted by month to understand the interaction between time, LST completion rate, and EOL care family ratings.ResultsLST preferences were documented for 39% of HBPC Veterans. Family members rated overall EOL care as excellent for 53% of Veterans but significant divergence in BFS ratings occurred during the last 7 months of the study with 60% of family members of LST completers rating care as excellent compared with 48% for Veterans lacking LST documentation (p = 0.003). The adjusted odds of rating overall care in the final month of life as excellent was higher among those with a completed LST template (1.64 95% CI 1.19, 2.26).ConclusionsHigher rates of LST documentation were associated with more favorable ratings of EOL but not in initial months following implementation of the comprehensive initiative; however, LST documentation rates were lower than expected among HBPC Veterans. Following an initial period of implementation of a comprehensive national initiative to promote Veteran choice about care during serious illness, documented LST preferences were associated with better family ratings of EOL care. HBPC clinicians may improve the bereaved family experience by using LSDTI tools and training to elicit and document preferences.

Project description:BackgroundThe ageing population with multiple conditions and complex health needs has forced healthcare systems to rethink the optimal way of delivering services. Instead of trying to manage numerous diseases in a siloed approach, the emphasis should be on people-centred practice, in which healthcare services are tailored to people's needs and provided in partnership with them.ObjectiveThe aim was to develop an interprofessional people-centred care model (PCCM), including the contribution of a clinically trained pharmacist for home-living multimorbid older people in primary care.MethodsParticipatory action research method, including the active involvement of healthcare professionals, was utilised to develop the PCCM in a public health centre in Finland. The data comprised interview transcripts, workshop materials, field notes, surveys, and memos and were analysed using inductive content analysis.ResultsThe PCCM was developed in iterative phases, including planning, acting, observing, and reflecting. The PCCM comprised: 1) A self-management evaluation questionnaire sent before a home visit; 2) A person-centred patient interview at home with a named nurse and a pharmacist; 3) A nurse-led health review and a pharmacist-led clinical medication review; 4) An interprofessional (a GP, a pharmacist and a named nurse) case conference meeting; 5) A care plan, including health and medication plans; and 6) Health support and empowerment interventions. The PCCM shifted working practices in the health centre from parallel and consultative practice towards interprofessional people-centred practice and more holistic care. The patient's active involvement in their own care was encouraged. Healthcare professionals appreciated the advantages of the new skill-mix, including the clinically trained pharmacist. Building trust among healthcare professionals and between the professionals and the patients was essential.ConclusionThe successfully developed PCCM improved holistic and more people-centred care in primary care. Healthcare professionals appreciated the advantages of the skill mix and found that trust was essential for implementing the PCCM.

Dataset Information

A home-based, primary-care model for epilepsy care in India: Basis and design.

Publications

A home-based, primary-care model for epilepsy care in India: Basis and design.

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