Harvey Penelope, Storer Meg, Berlowitz David John, Jackson Bruce, Hutchinson Anastasia, Lim Wen Kwang
Department of Medicine and Aged Care, Northern Health & Department of Medicine, The University of Melbourne, Melbourne, Australia.
BMC Geriatr. 2014 Apr 16;14:48. doi: 10.1186/1471-2318-14-48.
Geriatric evaluation and management has become standard care for community dwelling older adults following an acute admission to hospital. It is unclear whether this approach is beneficial for the frailest older adults living in permanent residential care. This study was undertaken to evaluate (1) the feasibility and consumer satisfaction with a geriatrician-led supported discharge service for older adults living in residential care facilities (RCF) and (2) its impact on the uptake of Advanced Care Planning (ACP) and acute health care service utilisation.
In 2002-4 a randomised controlled trial was conducted in Melbourne, Australia comparing the geriatrician-led outreach service to usual care for RCF residents. Patients were recruited during their acute hospital stay and followed up at the RCF for six months. The intervention group received a post-discharge home visit within 96 hours, at which a comprehensive geriatric assessment was performed and a care plan developed. Participants and their families were also offered further meetings to discuss ACPs and document Advanced Directives (AD). Additional reviews were made available for assessment and management of intercurrent illness within the RCF. Consumer satisfaction was surveyed using a postal questionnaire.
The study included 116 participants (57 intervention and 59 controls) with comparable baseline characteristics. The service was well received by consumers demonstrated by higher satisfaction with care in the intervention group compared to controls (95% versus 58%, p = 0.006).AD were completed by 67% of participants/proxy decision makers in the intervention group compared to 13% of RCF residents prior to service commencement. At six months there was a significant reduction in outpatient visits (intervention 21 (37%) versus controls 45 (76%), (p < 0.001), but no difference in readmissions rates (39% intervention versus 34% control, p = 0.6). There was a trend towards reduced hospital bed-day utilisation (intervention 271 versus controls 372 days).
It is feasible to provide a supported discharge service that includes geriatrician assessment and care planning within a RCF. By expanding the service there is the potential for acute health care cost savings by decreasing the demand for outpatient consultation and further reducing acute care bed-days.
老年评估与管理已成为社区居住的老年人急性入院后常规护理的一部分。目前尚不清楚这种方法对居住在永久性养老院的最虚弱老年人是否有益。本研究旨在评估：（1）由老年病医生主导的针对居住在养老院（RCF）的老年人的支持性出院服务的可行性及消费者满意度；（2）该服务对预先护理计划（ACP）的采用情况及急性医疗服务利用的影响。
2002年至2004年，在澳大利亚墨尔本进行了一项随机对照试验，将由老年病医生主导的外展服务与RCF居民的常规护理进行比较。患者在急性住院期间被招募，并在RCF进行为期六个月的随访。干预组在出院后96小时内接受一次家访，在此期间进行全面的老年评估并制定护理计划。还为参与者及其家人提供进一步的会议，以讨论ACP并记录预先指示（AD）。此外，还提供额外的评估，用于RCF内并发疾病的评估和管理。通过邮寄问卷对消费者满意度进行调查。
该研究纳入了116名参与者（57名干预组和59名对照组），他们具有可比的基线特征。消费者对该服务评价良好，干预组对护理的满意度高于对照组（95%对58%，p = 0.006）。干预组中67%的参与者/代理决策者完成了AD，而在服务开始前，RCF居民中这一比例为13%。六个月时，门诊就诊次数显著减少（干预组21次（37%）对对照组45次（76%），（p < 0.001），但再入院率无差异（干预组39%对对照组34%，p = 0.6）。住院天数的利用有减少的趋势（干预组271天对对照组372天）。
在RCF内提供包括老年病医生评估和护理计划的支持性出院服务是可行的。通过扩大该服务，有可能通过减少门诊咨询需求和进一步减少急性护理住院天数来节省急性医疗费用。
