What is the evidence for the effectiveness of managing the hospital/community interface for older people? A critical appraisal of the literature
Ali W, Rasmussen P
Record ID 32004000806
This review was conducted to: - provide evidence for the effectiveness of services managing the hospital/community interface and - provide the evidence base for the Ministry of Health's work to assess the options for intermediate-level care to bridge the gap between the hospital and home-based care.
Overall, 201 articles were identified. 39 papers met the inclusion criteria for appraisal and 25 studies were used as reference material. Those papers appraised have their results presented separately according to the type of services that manage the hospital/community interface they assess. Additional material was also included as this provided useful information about services provided in a number of systematic reviews. The following conclusions are based on the current evidence available from this reports critical appraisal and review of the published literature on the topic.
In general, the evidence is a mixture of benefit, deficit and uncertainty, due to the complexity and variability of the interventions and methodological problems with the evaluations. Evidence supports intervention programmes that provide services to reduce and prevent falls. The literature provided evidence that discharge planning arrangements showed some beneficial effects on subsequent readmission to hospital. Hospital-at-home schemes as an alternative to acute hospital care are an increasingly popular way of delivering health care and the literature shows that outcomes for selected patients seems to be as good as standard hospital care, although studies have used many different outcome measures. Most of the published data on the care needs of older emergency patients are descriptive with minimal evaluation of the effect of the interventions on patient outcomes. Also, the current disease-oriented and episodic models of emergency care did not provide enough evidence to adequately respond to the complex care needs of older patients experiencing multiple and often interrelated medical, functional, and social problems. The mixed results with the ED-based studies suggest that more appropriate care of older ED patients can achieve better outcomes therefore, costs can be more or less depending on the nature of the services. Published data around nurse-led units (NLUs) concern hospital-based NLUs, with none on community-based NLUs. No judgements about effectiveness of nurse-led inpatient care for post-acute patients could be made. Various casemanagement models including a post acute care program (PAC), a short-term case management by an advanced practice nurse, an integrated community care program, case managers for patients discharge from hospital, and integrated home care program guided by a case manager generally showed benefits to patients in the outcomes assessed.
The majority of the studies included were set overseas with some conducted among Veterans Affairs, thus differences in health care delivery may limit how applicable these results are in New Zealand. Their generalisability to the New Zealand population and context needs to be considered. There is a need for future research that focuses on service models that are comparable and applicable to New Zealand's older population.
The general consensus from the analyses of service descriptions from published evidence-based service guidelines and protocols supports a continuum of care model which requires a high degree of collaborative, multidisciplinary and interdisciplinary care. Many recommendations were made for research into service development and care models focusing more on prevention and screening, and for comprehensive geriatric services across different care settings and also rehabilitation care. Funding for these services and monitoring and quality improvement systems are needed.
English language abstract:
An English language summary is available
- Delivery of Health Care, Integrated
- Interinstitutional Relations
- Intermediate Care Facilities
- Health Services for the Aged
New Zealand Health Technology Assessment
Department of Public Health and General Practice, Christchurch School of Medicine and Health Sciences, University of Otago, P.O. Box 4345, Christchurch, New Zealand. Tel: +64 3 364 1145; Fax: +64 3 364 1152;
New Zealand Health Technology Assessment (NZHTA)