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Most patients with hip fractures are characterised by older age (>70 years), frailty, and functional deterioration, and their long-term outcomes are poor with increased costs. We compared the effectiveness and cost-effectiveness of giving these patients comprehensive geriatric care in a dedicated geriatric ward versus the usual orthopaedic care. We did a prospective, single-centre, randomised, parallel-group, controlled trial. Between April 18, 2008, and Dec 30, 2010, we randomly assigned home-dwelling patients with hip-fractures aged 70 years or older who were able to walk 10 m before their fracture, to either comprehensive geriatric care or orthopaedic care in the emergency department, to achieve the required sample of 400 patients. Randomisation was achieved via a web-based, computer-generated, block method with unknown block sizes. The primary outcome, analysed by intention to treat, was mobility measured with the Short Physical Performance Battery (SPPB) 4 months after surgery for the fracture. The type of treatment was not concealed from the patients or staff delivering the care, and assessors were only partly masked to the treatment during follow-up. This trial is registered with ClinicalTrials.gov, number NCT00667914. We assessed 1077 patients for eligibility, and excluded 680, mainly for not meeting the inclusion criteria such as living in a nursing home or being aged less than 70 years. Of the remaining patients, we randomly assigned 198 to comprehensive geriatric care and 199 to orthopaedic care. At 4 months, 174 patients remained in the comprehensive geriatric care group and 170 in the orthopaedic care group; the main reason for dropout was death. Mean SPPB scores at 4 months were 5·12 (SE 0·20) for comprehensive geriatric care and 4·38 (SE 0·20) for orthopaedic care (between-group difference 0·74, 95% CI 0·18–1·30, p=0·010). Immediate admission of patients aged 70 years or more with a hip fracture to comprehensive geriatric care in a dedicated ward improved mobility at 4 months, compared with the usual orthopaedic care. The results suggest that the treatment of older patients with hip fractures should be organised as orthogeriatric care. Norwegian Research Council, Central Norway Regional Health Authority, St Olav Hospital Trust and Fund for Research and Innovation, Liaison Committee between Central Norway Regional Health Authority and the Norwegian University of Science and Technology, the Department of Neuroscience at the Norwegian University of Science and Technology, Foundation for Scientific and Industrial Research at the Norwegian Institute of Technology (SINTEF), and the Municipality of Trondheim.

Background Comprehensive care is important for ensuring patients receive coordinated delivery of healthcare that aligns with their needs and preferences. While comprehensive care programs are recognised as beneficial, optimal implementation strategies in the real world remain unclear. This study utilises existing implementation theory to investigate barriers and enablers to implementing the Australian National Safety and Quality Health Service Standard 5 - Comprehensive Care Standard in acute care hospitals. The aim is to develop implementation enhancement strategies for work with comprehensive care standards in acute care. Methods Free text data from 256 survey participants, who were care professionals working in acute care hospitals across Australia, were coded using the Consolidated Framework for Implementation Research (CFIR) using deductive content analysis. Codes were then converted to barrier and enabler statements and themes using inductive theme analysis approach. Subsequently, CFIR barriers and enablers were mapped to the Expert Recommendations for Implementing Change (ERIC) using the CFIR-ERIC Matching Tool, facilitating the development of implementation enhancement strategies. Results Twelve ( n  = 12) CFIR barriers and 10 enablers were identified, with 14 barrier statements condensed into 12 themes and 11 enabler statements streamlined into 10 themes. Common themes of barriers include impact of COVID-19 pandemic; heavy workload; staff shortage, lack of skilled staff and high staff turnover; poorly integrated documentation system; staff lacking availability, capability, and motivation; lack of resources; lack of education and training; culture of nursing dependency; competing priorities; absence of tailored straties; insufficient planning and adjustment; and lack of multidisciplinary collaboration. Common themes of enablers include leadership from CCS committees and working groups; integrated documentation systems; established communication channels; access to education, training and information; available resources; culture of patient-centeredness; consumer representation on committees and working groups; engaging consumers in implementation and in care planning and delivery; implementing changes incrementally with a well-defined plan; and regularly collecting and discussing feedback. Following the mapping of CFIR enablers and barriers to the ERIC tool, 15 enhancement strategies were identified. Conclusion This study identified barriers, enablers, and recommended strategies associated with implementing a national standard for comprehensive care in Australian acute care hospitals. Understanding and addressing these challenges and strategies is not only crucial for the Australian healthcare landscape but also holds significance for the broader international community that is striving to advance comprehensive care.

BACKGROUND:Women Veterans are a significant minority of users of the VA healthcare system, limiting provider and staff experience meeting their needs in environments historically designed for men. The VA is nonetheless committed to ensuring that women Veterans have access to comprehensive care in environments sensitive to their needs. OBJECTIVES:We sought to determine what aspects of care need to be tailored to the needs of women Veterans in order for the VA to deliver gender-sensitive comprehensive care. RESEARCH DESIGN:Modified Delphi expert panel process. SUBJECTS:Eleven clinicians and social scientists with expertise in women’s health, primary care, and mental health. MEASURES:Importance of tailoring over 100 discrete aspects of care derived from the Institute of Medicine’s definition of comprehensive care and literature-based domains of sex-sensitive care on a 5-point scale. RESULTS:Panelists rated over half of the aspects of care as very-to-extremely important (median score 4+) to tailor to the needs of women Veterans. The panel arrived at 14 priority recommendations that broadly encompassed the importance of (1) the design/delivery of services sensitive to trauma histories, (2) adapting to women’s preferences and information needs, and (3) sex awareness and cultural transformation in every facet of VA operations. CONCLUSIONS:We used expert panel methods to arrive at consensus on top priority recommendations for improving delivery of sex-sensitive comprehensive care in VA settings. Accomplishment of their breadth will require national, regional, and local strategic action and multilevel stakeholder engagement, and will support VA’s national efforts at improving customer service for all Veterans.

BackgroundA large and increasing proportion of health care costs are spent caring for a small segment of medically and socially complex patients. To date, it has been difficult to identify which patients are best served by intensive care management.ObjectiveTo characterize factors that best identify which complex patients are most suited for intensive care management.DesignWe conducted a mixed-methods study involving 35 care managers (CMs; 10 licensed social workers and 25 registered nurses) working in intensive care management programs within Kaiser Permanente Northern California (KPNC) outpatient medical centers. We asked CMs to review a randomly selected list of up to 50 patients referred to them in the prior year and to categorize each patient as either (1) “good candidates” for care management, (2) “not needing” intensive care management, or (3) “needing more” than traditional care management could provide. We then conducted semi-structured interviews to understand how CMs separated patients into these three groups.ResultsCMs assigned 1178 patients into the 3 referral categories. Less than two thirds (62%, n = 736) of referred patients were considered good candidates, with 18% (n = 216) categorized as not needing care management and 19% (n = 226) as needing more. Compared to the other two categories, good candidates were older (76.2 years vs. 73.2 for not needing and 69.8 for needing more, p < 0.001), prescribed more medications (p = 0.02) and had more prior year outpatient visits (p = 0.04), while the number of prior year hospital and emergency room admissions were greater than not needing but less than needing more (p < 0.001). A logistic regression model using available electronic record data predicted good candidate designation with a c statistic of 0.75. Several qualitative themes emerged that helped define appropriateness for referral, including availability of social support, patient motivation, non-medical transitions, recent trajectory of medical condition, and psychiatric or substance use issues.ConclusionMany apparently complex patients are not good candidates for intensive care management. Current electronic medical records do not capture several of the most salient characteristics that determine appropriateness for care management. Our findings suggest that systematic collection of social support, patient motivation, and recent non-medically related life change information may help identify which complex patients are most likely to benefit from care management.

Background Comprehensive care (CC) is becoming a widely acknowledged standard for modern healthcare as it has the potential to improve health service delivery impacting both patient-centred care and clinical outcomes. In 2019, the Australian Commission on Safety and Quality in Health Care mandated the implementation of the Comprehensive Care Standard (CCS). However, little is known about the implementation and impacts of the CCS in acute care hospitals. Our study aimed to explore care professionals’ self-reported knowledge, experiences, and perceptions about the implementation and impacts of the CCS in Australian acute care hospitals. Methods An online survey using a cross-sectional design that included Australian doctors, nurses, and allied health professionals in acute care hospitals was distributed through our research team and organisation, healthcare organisations, and clinical networks using various methods, including websites, newsletters, emails, and social media platforms. The survey items covered self-reported knowledge of the CCS and confidence in performing CC, experiences in consumer involvement and CC plans, and perceptions of organisational support and impacts of CCS on patient care and health outcomes. Quantitative data were analysed using Rstudio, and qualitative data were analysed thematically using Nvivo. Results 864 responses were received and 649 were deemed valid responses. On average, care professionals self-reported a moderate level of knowledge of the CCS (median = 3/5) and a high level of confidence in performing CC (median = 4/5), but they self-reported receiving only a moderate level of organisational support (median = 3/5). Only 4% (n = 17) of respondents believed that all patients in their unit had CCS-compliant care plans, which was attributed to lack of knowledge, motivation, teamwork, and resources, documentation issues, system and process limitations, and environment-specific challenges. Most participants believed the CCS introduction improved many aspects of patient care and health outcomes, but also raised healthcare costs. Conclusion Care professionals are confident in performing CC but need more organisational support. Further education and training, resources, multidisciplinary collaboration, and systems and processes that support CC are needed to improve the implementation of the CCS. Perceived increased costs may hinder the sustainability of the CCS. Future research is needed to examine the cost-effectiveness of the implementation of the CCS.

Background The primary health care system is acknowledged as the essential entry point to health services. In Iran, primary health care has historically been a key focus for policymakers. However, the accreditation of these services has only recently gained attention as a significant consideration. This study aims to qualitatively examine the prerequisites necessary for the effective implementation of accreditation programs within the primary health care system. Methods This qualitative study was conducted using semi-structured interviews with a diverse group of participants, including specialists from the Iran Ministry of Health, managers of comprehensive health centers in Kerman, physicians, and representatives from the Deputy of Health at Tehran, Kerman, and Mashhad Universities of Medical Sciences. Purposive sampling was utilized through a snowball approach. Content analysis and MAXQDA12 software were used for data analyzing. Results The results showed that various factors are prerequisites for the accreditation program. These requirements were subthemes of the three major concepts introduced by Avedis Donabedian, i.e., structure, process, and outcome. Structural challenges encompassed programs, culture, accreditation platforms, evaluation teams, and motivation. Process challenges included program comprehensiveness, financial resource sustainability, implementation leveling, knowledge translation, implementation protocols, comprehensive training, accreditation standards, and system design. On the basis of the Donabedian model, the results section includes the outcome and expected output. With respect to the challenges of the accreditation program, most of the issues raised by the participants were related to the fundamental and structural defects of the country’s healthcare system. Conclusion The challenges faced in the accreditation program are largely rooted in the fundamental and structural defects of the country’s healthcare system. The prerequisites for effective accreditation are not limited to the process itself; rather, they are heavily influenced by broader systemic issues related to the program, culture, resources, and overall design of the healthcare infrastructure. Addressing these underlying structural problems is crucial for the successful implementation and sustainability of the accreditation program. In any case, without considering major challenges, the implementation of the accreditation program could face serious problems.

Self-medication, a help-seeking behavior to control individual symptoms, can be promoted to prevent the overuse of medical care and improve self-management among older adults. However, evidence regarding the association between self-medication and quality of life (QOL) is lacking. The purpose of this study is to investigate the association between QOL and the usage of self-medication among rural older adults. This cross-sectional study included participants older than 65 years in rural Japanese communities. Data were collected using a questionnaire regarding self-medication trends, the EQ-5D-5L to assess QOL, and a demographics questionnaire. Participants were divided into exposure and control groups based on their tendencies toward self-medication usage. Differences in the demographics between groups were adjusted using propensity score matching. Results: The health status in the exposure group was statistically significantly better than that in the control group in the dimensions of movement, self-care, and usual activities. Conversely, the pain/discomfort and anxiety/depression dimensions were not statistically significantly different. The quality of self-medication behaviors for mild symptoms can be improved with practical knowledge of and access to home remedies and over-the-counter drugs. Educational interventions and system development for better self-medication for mild symptoms and medical care for critical symptoms in rural contexts can be effective in improving QOL among rural older adults.

Purpose Hemophilia Treatment Centers (HTCs) provide integrated and comprehensive services to individuals affected with rare bleeding disorders, such as hemophilia and Von Willebrand disease. Through the 340 Drug Pricing Program, HTCs may use pharmacy income to support clinical staff and patient services. The objective of this study was to describe the impact of the 340B program funding on services and support provided by HTCs to persons affected by rare bleeding disorders. Description Federally designated comprehensive HTCs with established 340B programs were invited to participate in a mailed survey in 2014. Participants were requested to report on 340B program-funded staff and services in the calendar year 2013. Assessment The 31 of 37 HTCs responding served over 10,000 individuals, or one-third of the national HTC patient population. The majority of responding HTCs reported that 340B program income supported over 90% of staff such as nurses, social workers, and physical therapists. Conclusion The results from this survey of 31 centers with established programs demonstrates the HTCs’ reliance on 340B program support for vital comprehensive services, that are otherwise non-reimbursable, and highlights the importance of the 340B program in sustaining the high quality of care and in increasing access for a geographically dispersed, medically vulnerable population.

Increasing prevalence of dementia is a major challenge for the German healthcare system. The study DelpHi-MV (“Dementia: life- and person-centered help in Mecklenburg-Western Pomerania”) aims to implement and evaluate an innovative subsidiary support system for persons with dementia (PwDs) living at home and their caregivers. DelpHi-MV is a GP-based cluster randomized controlled intervention trial. DelpHi-Intervention aims to provide “optimum care” by integrating multi-professional and multimodal strategies to individualize and optimize treatment of dementia within the framework of the established healthcare and social service system. The intervention is conducted by Dementia Care Managers (DCMs) – nurses with dementia-specific training – at the people's homes. Based on German guidelines for evidence-based diagnoses and treatment of dementia, a comprehensive set of 95 intervention modules – the “DelpHi-Standard” – was defined. Each module consists of predefined trigger condition(s), a subsequent intervention task, as well as at least one criterion for its completion. The intervention begins with a comprehensive assessment of the care situation, needs, and resources. The DCM develops and implements an intervention plan tailored to the individual conditions in close cooperation with the GP. We expect statistically significant differences between control and intervention group in primary outcomes (quality of life, behavioral and psychological symptoms of dementia, pharmacotherapy, caregiver burden). Results can provide evidence for the effectiveness and efficacy of dementia care management according to the “Delphi-Standard” – prerequisites for implementing this concept into routine healthcare.