Use of Dementia Assessment Sheet for Community-based Integrated Care System 8-items (DASC-8) for the screening of frailty and components of comprehensive geriatric assessment

Comprehensive geriatric assessment (CGA)—a key tool for geriatric medicine—is commonly used to assess older people’s health status and frailty. However, performing CGA in outpatient clinics is difficult because the assessment of cognition, activities of daily living (ADLs), depression, quality of life (QoL), nutrition, medications and social conditions is time consuming and requires the cooperation of medical staff. Frailty—an aspect of geriatric medicine that indicates the weakness of the body—is a critical measure of older adults’ physical function.

The Dementia Assessment Sheet for Community-based Integrated Care System 8-items (DASC-8) is a validated and simple ...

Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study

Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home.

This protocol outlines the plan for the development, implementation, and ...

Indicators of an Integrated Home Care Model Shaped by the Needs of Patients Discharged from the Emergency Department

Developing community care models aims to satisfy the needs of patients’ in-home care comprehensively. This is crucial to decrease adverse events and prevent rehospitalization.

The growing burden of chronic diseases, patients experiencing fragmented care, and increasing demand for coordination across providers in the health and social sector correlates with the need for the integration of care. The starting point in developing an integrated care strategy should be identifying and assessing population needs.

Models of integrated care may enhance patient satisfaction, increase the perceived quality of care, and enable access to services. The term ‘new models of care’ refers to a ...

Enhanced Integrated Behavioral Health Model Improves Depressive Symptoms in a Low-Income, Uninsured, Primarily Hispanic Population Served by a Free and Charitable Clinic

Residents living in US-Mexico border communities have some of the worst health outcomes nationally. Rates of chronic disease such as obesity, diabetes, and related mortality in the Rio Grande Valley exceed those in most other regions of Texas and the nation. Poverty is pervasive, placing residents at high risk for poor health; they are more likely to be exposed to environmental hazards and have higher rates of chronic physical and mental health concerns.

At its foundation, integrated behavioral health care aims to address multiple health concerns, and related social determinants, by bringing behavioral health and primary care services together. No ...

Finding the Person in Electronic Health Records. A Mixed-methods Analysis of Person-centered Content and Language

The co-creation and sharing of documentation of person-centered care is important, but challenging in clinical practice. Online access to health records is considered essential to increase patient participation and empowerment in person-centered care provision.

The aims of this study were (1) to identify the extent of person-centered content in medical inpatient records and discharge letters; (2) to describe the characteristics of the language and rhetoric used in discharge letters.

Established norms for documentation in healthcare are a barrier to person-centered documentation. Patients’ needs and preferences about documentation should be explored to increase understanding of how person-centered documentation can be achieved ...

Screening Isn’t Enough: A Call to Integrate Behavioral Health Providers in Women’s Health and Perinatal Care Settings

This paper aims to enhance the current understanding of integrated mental health services in the United States and how they can be better incorporated in perinatal and women’s health specialty care from the perspective of a behavioral health provider. 

Patient Privacy and Integrated Care: The Multidisciplinary Health Care Team

This article explores legislative provisions in relation to patient privacy in the context of integrated health and social care and the development of multidisciplinary health care teams that include practitioners from private sector and government agencies in the health, education, child protection, family welfare, disability, aged-care, housing, local government and criminal justice sectors. 

The reimagination of sustainable integrated care in Ontario, Canada

To encourage clinical and financial efficiency, the Canadian province of Ontario initiated an integrated care program – Integrated Funding Models (IFMs) that required collaboration and coordination across acute and post-acute care sectors. This research shows how program implementers went beyond policy-makers’ original designs, to make integrated care sustainable for chronic diseases.

“It’s Difficult, There’s No Formula”: Qualitative Study of Stroke Related Communication Between Primary and Secondary Healthcare Professionals

The proportion of people living with stroke is growing. In England, National Institute for Health and Care Excellence (NICE) Guidelines for stroke recommend that a person with suspected or confirmed stroke event is admitted to a specialist stroke unit, in order to receive required treatment promptly. Stroke rehabilitation follows, which involves providing stroke survivors with support and treatment from a multidisciplinary rehabilitation team. Stroke survivors’ transition from acute settings to rehabilitation can take place either in hospital, at home or the community.

One model of care is Early Supported Discharge (ESD), which offers community-based health and social care as an ...

Re-organising primary health care to respond to the Coronavirus epidemic in Cape Town, South Africa

Cape Town is currently one of the hotspots for COVID-19 on the African continent. The Metropolitan Health Services have re-organised their primary health care (PHC) services to tackle the epidemic with a community-orientated primary care perspective. Two key goals have guided the re-organisation, the need to maintain social distancing and reduce risk to people using the services and the need to prepare for an influx of people with COVID-19. Facilities were re-organised to have ‘screening and streaming’ at the entrance and patients were separated into hot and cold streams.