Integrated Care with GP Participation for Older Persons in the Ambulatory Care Hub: a Prospective Cohort Study of Clinical and Process Outcomes.
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 入组人数
- 303
- 试验地点
- 1
- 主要终点
- Incidence of functional decline
研究概览
简要总结
Comprehensive Geriatric Assessment (CGA) demonstrates positive outcomes amoung community-dwelling older people living with frailty. However, there is currently no evidence of benefit for CGA with General Practitioner (GP) participation within the Irish Primary Care setting. This study aims to explore the clinical and process outcomes of older adults living with frailty who are screened by and referred to one of the three Ambulatory Care Hub's in the primary care setting in the Mid-West of Ireland by their GP, where they undergo a CGA .
详细描述
The growth of ageing population poses significant difficulties in the delivery of healthcare to older adults. As people age, they experience a decline in their intrinsic capacities which leads to an increasing prevalence of multi-morbidity which ultimately leads to older adults at increased risk of requiring emergency care and increased multidisciplinary health needs.
With functional decline and deterioration in an older persons' ability to self-care being a common consequence of hospitalisation, older people are placed at higher risk of requiring increased care needs after discharge from acute care and transfer between care settings proves a challenge for the provision of seamless quality care.
The World Health Organisation recommends health and social care professionals intervening at an early stage of this ageing process in order to prevent or delay the process of becoming frail through delivering effective interventions that are targeted at functional decline. Internationally, there is recognition for health and social care systems to reorient towards longitudinal, preventive, coordinated and integrated care models, reflecting the growth in multi-morbidity and the needs of older people's complex health and social care requirements. The World Health Organisation acknowledges this shift in healthcare delivery and launched the 'WHO Guidelines on Integrated Care for Older People' programme where it highlighted the need to develop and implement comprehensive community-based approaches at the primary healthcare level in the context of a needs assessment and integrated care plan.
CGA is an interdisciplinary diagnostic process which includes an assessment and holistic management plan that is based on the individual needs of the older person. As many older adults' first point of contact with the health service is through primary care, General Practitioners (GPs) play a crucial role in the coordination of the older person's care.
Frailty screening by the GP and comprehensive geriatric assessment within the primary care setting has demonstrated significant positive health outcomes in community-dwelling older people, demonstrating reduced rates of hospitalisation, reduced hospital re-admissions, reduced GP visits and an increase in social activities.
研究设计
- 研究类型
- Observational
- 观察模型
- Cohort
- 时间视角
- Prospective
入排标准
- 年龄范围
- 75 Years 至 —（Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Referred to the ACH by their GP
- •Score between 4 and 6 on the Rockwood Clinical Frailty Scale
- •Reside within CHO 3 and the catchment area of the relevant ACH hub
- •Have been assessed in-person by the referrer
- •Has not had MDT input within the last three months
- •And any one of the following criteria:
- •Fall within the last month unrelated to acute cardiac or neurological cause & no previous falls assessment
- •Increased dependency or increased carer burden in the last month
- •A deterioration in swallow in the last month including symptoms of recurrent chest infections
- •Weight loss
- •Coughing when eating/drinking
- •Self-modifying diet secondary to difficulties or experienced an adverse drug reaction within the last month excluding allergic reaction.
排除标准
- •Patients will be excluded if they:
- •Present with an acute neurological or cardiovascular event
- •Are more appropriate to an alternative care pathway or service e.g. primary care or geriatric medicine clinic
- •Present with injuries, unless the injury has already been appropriately managed,
- •Are experiencing an acute medical illness requiring treatment in an acute hospital setting
- •If care is being provided by other health care professionals at the time of referral and it is apparent that they are working to meet goals aligned with the current service
- •They require investigation or treatment not available in the relevant ICPOP hub (unless these investigations are already being arranged elsewhere)
- •They have had MDT input in the last three months
- •Have confirmed or suspected Covid-19 infection
- •Or other exclusions at the discretion of the integrated care team based on clinical expertise and available resource.
结局指标
主要结局
Incidence of functional decline
时间窗: 6-months
The number of participants who experience functional decline or do not as measured by the Barthel Index (BI). Functional decline is defined as a net decrease in the number of activities of daily living performed independently as measured by the self-reported BI. The sum of all of the 10 subscales of the BI ranges from 0-20 points where a higher score indicates increased independence.
次要结局
- Primary healthcare use (within and outside of ACH healthcare utilisation)(6-months)
- Secondary healthcare use(6-months)
- Quality of integrated care from the perspective of participants(30-days)
- Nursing home admission(6-months)
- Health related quality of life (HRQOL)(6-months)
- Mortality(6-months)