Article

The Dutch Move Beyond the Concept of Nursing Home Physician Specialists

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... [1][2][3] In the Netherlands, nursing home physician specialists are called elderly care physicians (ECPs) and are employed by the nursing home organisation. [4][5][6] This is a unique specialty that may contribute to the quality of healthcare. 5 7 8 However, there is a high workload for ECPs in the Netherlands and there are many vacancies. ...
... The mechanism of substituting for ECPs largely autonomously was not present in three cases (1,5,6). In two cases the professional was an RN and in one an NP. ...
... The first reason that applied to two NP cases and two PA cases is that ECPs are enabled to focus on more complex medical activities for which they are trained, such as treating residents with complex healthcare problems and providing high-quality geriatric treatment for older people in primary care. 6 The second reason is that NPs, PAs and RNs have a different way of working, such as focusing on resident centredness (seen in two RN cases), supporting the care team (seen in three NP cases and two RN cases), and performing additional tasks compared with ECPs (seen in all NP, PA and RN cases). The manner in which each type of professional contributes to perceived quality of healthcare corresponds to their education and competences. ...
Article
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Objectives This study aimed to gain insight into how substitution of elderly care physicians (ECPs) by nurse practitioners (NPs), physician assistants (PAs) or registered nurses (RNs) in nursing homes is modelled in different contexts and what model in what context contributes to perceived quality of healthcare. Second, this study aimed to provide insight into elements that contribute to an optimal model of substitution of ECPs by NPs, PAs or RNs. Design A multiple-case study was conducted that draws on realist evaluation principles. Setting Seven nursing homes in the Netherlands Participants The primary participants were NPs (n=3), PAs (n=2) and RNs (n=2), working in seven different nursing homes and secondary participants were included; ECPs (n=15), medical doctors (MDs) (n=2), managing directors/managers/supervisors (n=11), nursing team members (n=33) and residents/relatives (n=78). Data collection Data collection consisted of: (1) observations of the NP/PA/RN and an ECP/MD, (2) interviews with all participants, (3) questionnaires filled out by the NP/PA/RN, ECPs/MDs and managing directors/managers and (4) collecting internal policy documents. Results An optimal model of substitution of ECPs seems to be one in which the professional substitutes for the ECP largely autonomously, well-balanced collaboration occurs between the ECP and the substitute, and quality of healthcare is maintained. This model was seen in two NP cases and one PA case. Elements that enabled NPs and PAs to work according to this optimal model were among others: collaborating with the ECP based on trust; being proactive, decisive and communicative and being empowered by organisational leaders to work as an independent professional. Conclusions Collaboration based on trust between the ECP and the NP or PA is a key element of successful substitution of ECPs. NPs, PAs and RNs in nursing homes may all be valuable in their own unique way, matching their profession, education and competences.
... Les milieux d'hébergement et de soins de longue durée au sein de plusieurs pays de l'OCDE se ressemblent notamment par la présence 24 heures sur 24, 7 jours par semaine de personnel infirmier [AIHW, 2020;Kwak et al., 2019;Koopmans et al., 2017;Connolly et al., 2015]. À certains endroits, comme aux États-Unis [Baker et al., 2021], aux Pays-Bas et en Nouvelle-Zélande [Connolly et al., 2015], il existe différents types de milieux d'hébergement et de soins de longue durée, lesquels sont dédiés à des clientèles distinctes. ...
... Dans le modèle avec une dotation fermée, les médecins sont généralement salariés [Agotnes et al., 2019]. Ce modèle est notamment documenté au Canada [Agotnes et al., 2019], aux États-Unis, dans quelques pays européens (Allemagne, Norvège et Pays-Bas) Bell et al., 2017;Fosse et al., 2017;Koopmans et al., 2017] et en Australie [Haines et al., 2020;Reed, 2015]. ...
... La British Geriatrics Society [BGS, 2021] souligne qu'au Royaume-Uni, aucun programme de formation en soins de première ligne, en médecine gériatrique, en psychiatrie gériatrique, en médecine interne ou en réadaptation ne couvre totalement l'éventail des compétences requises de la part d'un médecin qui travaille en care homes. En fait, les Pays-Bas semblent être le seul pays européen qui offre une formation médicale dédiée à la pratique en nursing homes Koopmans et al., 2017]. Dans ...
Technical Report
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Le ministère de la Santé et des Services sociaux (MSSS) souhaite que soient explorés les modalités de prestation médicale et les modèles de prise en charge pluridisciplinaire en CHSLD qui ont cours au sein d’autres pays. Les objectifs de ce rapport sont donc de documenter, au Canada et dans d’autres pays membres de l’Organisation de coopération et de développement économiques (OCDE) : i) l’offre de soins et services médicaux et les modalités de prestation médicale, ii) la composition des équipes de soins et services médicaux ainsi que les rôles et responsabilités de ses membres (médecin, infirmier, infirmier praticien spécialisé et pharmacien) et iii) l’implication des médecins au regard de la gestion. L’Institut national d’excellence en santé et en services sociaux (INESSS) a réalisé un état des connaissances à partir de la littérature scientifique, de sites Web d’organisations, de sociétés savantes et d’organismes gouvernementaux. En tout, 58 études primaires, 9 revues, 9 opinions d’experts publiées dans un journal scientifique, 7 sites Web ou rapports gouvernementaux et 23 sites Web ou rapports d’organisations ont été analysés. Les résultats présentés dans le cadre de cet état des connaissances fournissent des avenues de réflexion pertinentes en matière d’organisation des soins et services médicaux dans ces milieux d’hébergement. Les différents modèles de dotation existants à travers les pays de l’OCDE, la variabilité du niveau d’engagement (et des modalités de celui-ci) des médecins dans la gestion des milieux d’hébergement, tout comme la présence de plusieurs formes de chevauchement des compétences, permettent d’alimenter les réflexions sur l’organisation des soins et services et le partage des responsabilités entre les divers membres de l’équipe de soins.
... While Van der Roest et al. (2020) analysed the views of care staff, family and residents without cognitive problems, our study analyzed the views of practitioners. Dutch nursing homes employ multidisciplinary teams consisting of the care staff, and practitioners such as a psychologist, and an elderly care physician (Koopmans, Pellegrom, & van der Geer, 2017). The aims were to gain understanding, from the perspective of the practitioners, (1) whether challenging behavior in residents changed because of the COVID-19 quarantine measures, (2) whether the practitioners' involvement in the treatment of challenging behavior and their work load and satisfaction changed, and (3) what lessons can be learned from these experiences and the strategies that nursing home staff used to minimize potentially negative effects of the measures. ...
... An online survey was distributed among nursing home psychologists in the Netherlands. They were asked to complete the survey and to forward the link to their fellow elderly care physicians (Koopmans et al., 2017) and nurse practitioners. The psychologists were approached through the networks of LinkedIn, the Netherlands Institute for Psychologists, Amsterdam University Medical Center (Department of Medicine for Older People), and the Psychogeriatric Service, a network on expertise in elderly care (www.pgdexpertise.nl). ...
Article
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Objectives From the perspective of the nursing home (NH) practitioners, to gain understanding of (1) whether challenging behavior in NH residents changed during the COVID-19 measures, (2) whether the practitioners’ involvement in the treatment of challenging behavior changed, (3) what can be learned from the experience of NH staff. Methods A mixed methods study with a survey in 323 NH practitioners (psychologists, elderly care physicians, nurse practitioners) in the Netherlands, and in-depth interviews in 16 NH practitioners. Nonparametric analyses were used to compare estimated proportions of residents with increased and with decreased challenging behavior. Content analyses were conducted for open-ended questions and in-depth interviews. Results Participants reported changes in challenging behavior with slightly higher proportions for increased (Q1/Mdn/Q3: 12.5%, 21.7%, 30.8%) than for decreased (8.7%, 14.8%, 27.8%, Z = –2.35, p = .019) challenging behavior. Half of the participants reported that their work load increased and work satisfaction worsened during the measures. Different strategies were described to respond to the effects of COVID-19 measures, such as video calls, providing special areas for residents to meet their loved ones, adjusting activities, and reducing the exposure to negative news. Conclusions Because COVID-19 measures resulted in both increased and decreased challenging behavior in NH residents, it is important to monitor for their potential long lasting effects. Increased work load and worsened work satisfaction of the NH staff, together with the changes in type of challenging behavior, indicate that the harmful effects of the anti-pandemic measures should be taken seriously.
... Types of wards on which they can be accommodated include somatic wards (ie, for persons with mainly physical issues), psychogeriatric wards (ie, for persons with cognitive disorders, mainly dementia), rehabilitation wards, and palliative care wards. 15,16 A unique feature of medical care in Dutch NHs is that it is provided by elderly care physicians. Elderly care medicine is a separate medical discipline in the Netherlands. ...
... Elderly care physicians are employed by and have their principal site of practice in the NH, although they increasingly also support general practitioners (GPs) in care for older persons with frailty living at home. 16 Intravenous (IV) administration of antibiotics is rare in Dutch NHs. During evenings and nights, weekends, and holidays, medical care is provided by out-of-hours service (elderly care) physicians cross-covering for each other. ...
Article
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Antibiotics are among the most widely prescribed drugs in long-term care facilities, which highlights the importance of antibiotic stewardship (ABS) in this setting. In this article, we describe the experiences with ABS in nursing homes (NHs) from the perspective of 4 European countries: the Netherlands, Norway, Poland, and Sweden. In these countries, a large variety of initiatives to develop and implement ABS in NHs have been introduced in recent years. Among these initiatives are national antibiotic prescribing surveillance systems, NH-specific prescribing guidelines, and national networks of healthcare institutions that exchange information and develop ABS policy. Several initiatives evolved as a result of political prioritization of antibiotic resistance, translated into national action plans. Experiences of the 4 countries with the presented initiatives may inspire other countries that aim to develop or improve ABS in the long-term care setting.
... 15 Sixteen physicians in training to be an elderly care physician (ECP), working in 16 nursing homes, collected data on patients under their responsibility. 16,17 Eligible participants were selected when diabetes mellitus had been diagnosed. All eligible participants, their proxy, and the educational nursing homes received adequate oral and written information about the study and were given reasonable time to opt-out. ...
... An ECP is "a medical practitioner who has specialized as a primary care expert in geriatric medicine". 16,17 Per TSTI session, an ECP filled out the index and exchanged thoughts with the researcher. The ECP was asked to verbally express all thoughts while filling out the w-FCI. ...
Article
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Purpose: To investigate the reliability of a weighted version of the Functional Comorbidity Index (w-FCI) compared with that of the original Functional Comorbidity Index (FCI) and to test its usability. Patients and methods: Sixteen physicians collected data from 102 residents who lived in 16 different nursing homes in the Netherlands. A multicenter, prospective observational study was carried out in combination with a qualitative part using the three-step test interview, in which participants completed the w-FCI while thinking aloud and being observed, and were then interviewed afterward. To analyze inter-rater reliability, a subset of 41 residents participated. The qualitative part of the study was completed by eleven elderly care physicians and one advanced nurse practitioner. Measurements: The w-FCI was composed of the original FCI supplemented with a severity rating per comorbidity, ranging from 0 (disease absent) to 3 (severe impact on daily function). The w-FCI was filled out at baseline by 16 physicians and again 2 months later to establish intra-rater reliability (intraclass correlations; ICCs). For inter-rater reliability, four pairs of raters completed the w-FCI independently from each other. Results: The ICCs were 0.90 (FCI) and 0.94 (w-FCI) for intra-rater reliability, and 0.61 (FCI) and 0.55 (w-FCI) for inter-rater reliability. Regarding usability of the w-FCI, five meaningful themes emerged from the qualitative data: 1) sources of information; 2) deciding on the presence or absence of disease; 3) severity of comorbidities; 4) usefulness; and 5) content. Conclusion: The intra-rater reliability of the FCI and the w-FCI was excellent, whereas the inter-rater reliability was moderate for both indices. Based on the present results, a modified w-FCI is proposed that is acceptable and feasible for use in older patients and requires further investigation to study its (predictive) validity.
... The work of GP and EM is quite comparable in The Netherlands. The track consists of an alternating three years of practice and research [3][4][5]. There are similar initiatives in the UK as well [6]. ...
... However, these authors conclude, knowledge brokering is context-specific and, because they included studies on brokers in diverse healthcare related settings, their results remain rather general. Although a number of initiatives in GP and EM aimed at improving academic capacity and quality of clinical practice are currently underway across Europe [3][4][5]11,12], there is no data available on CSs brokering activities and the perceived barriers and facilitators in these specific fields. Such data would give valuable insights into how to support CSs and how to prepare trainees for a role as a CS and enhance their future impact on their profession. ...
Article
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Background: Clinician-scientists (CSs) are physicians who work in daily care and have an academic role in research or education. They may act as knowledge brokers and help to connect research and clinical practice. There is no data available on CSs’ brokering activities and the perceived barriers and facilitators to optimising their role in general practice (GP) and elderly care medicine (EM). Aim: To identify the brokering activities of CSs in these fields and the barriers and facilitators they come across whilst sharing knowledge and connecting people in research and frontline health care. Design and setting: Qualitative interview study among 17 Dutch senior CSs. Method: Interview data were audio recorded, transcribed verbatim and thematic interpretative analysis was used to identify themes. Results: CSs facilitate collaboration between researchers and practitioners. They exchange knowledge on both sides, make use of extensive networks and constantly and actively involve care in research and research in care. CSs come across barriers as well as facilitators that influence their brokering activities. Some barriers and facilitators are at the individual level, other are related more to the job context and workplace. Conclusions: This study reveals barriers to overcome and facilitators to develop related to the brokering role of CSs. To make the best use of CSs, brokering activities and the added value of CSs should be recognised and supported. Awareness of what CSs need to function effectively in demanding work settings could be important for the future impact of the role on the fields of GP and EM.
... A reduced number of responsible GPs might improve the collaboration and coordination of care leading to a reduction of transfers from NHs [27]. In the Netherlands for example, 'elderly care physicians' with a 3-year training program are employed in NHs to care for all residents on-site [12,55,56]. They have the potential to monitor health changes more closely which can prevent deteriorations of health status. ...
... However, it is still not part of regular health care. In other countries, nurse practitioners or specialist nurses, as established in the USA for example [12,35,55,56] perform in the first-line assessment of residents which is correlated with fewer hospital transfers [59][60][61][62]. In Germany, these professional groups are not established due to the legal right to choose the GP freely and nursing staffs' limited rights in medical care. ...
Article
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Background Emergency department visits and hospital admissions are common among nursing home residents (NHRs) and seem to be higher in Germany than in other countries. Yet, research on characteristics of transfers and involved persons in the transfer decision is scarce. Aims The aim of this study was to analyze the characteristics of hospital transfers from nursing homes (NHs) focused on contacts to physicians, family members and legal guardians prior to a transfer. Methods We conducted a multi-center study in 14 NHs in the regions Bremen and Lower Saxony (Northwestern Germany) between March 2018 and July 2019. Hospital transfers were documented for 12 months by nursing staff using a standardized questionnaire. Data were derived from care records and perspectives of nursing staff and were analyzed descriptively. Results Among 802 included NHRs, n = 535 unplanned hospital transfers occurred of which 63.1% resulted in an admission. Main reasons were deterioration of health status (e.g. fever, infections, dyspnea and exsiccosis) (35.1%) and falls/accidents/injuries (33.5%). Within 48 h prior to transfer, contact to at least one general practitioner (GP)/specialist/out-of-hour-care physician was 46.2% and varied between the NHs (range: 32.3–83.3%). GPs were involved in only 34.8% of transfer decisions. Relatives and legal guardians were more often informed about transfer (62.3% and 66.8%) than involved in the decision (21.8% and 15.1%). Discussion Contacts to physicians and involvement of the GP were low prior to unplanned transfers. The ranges between the NHs may be explained by organizational differences. Conclusion Improvements in communication between nursing staff, physicians and others are required to reduce potentially avoidable transfers.
... Therefore, physicians employed at LTC facilities are not necessarily geriatricians. The unique example is a specialization of "elderly care physician" in the Netherlands [10]. The Special Interest Group in Long-Term Care of the European Geriatric Medicine Society (SIG-LTC of EUGMS) advocates for implementing a minimum standard of care in the nursing homes, which includes an obligatory training in LTC for physicians, which might improve the quality of care for residents and their protection from infections like SARS-CoV-2 [11]. ...
... Between March and November 2020, a retrospective, 2-center cohort study was conducted in 2 Dutch long-term care organizations with a total of 2500 eligible patients, including patients under the care of an older adult care physician or general practitioner, who were living in hospice settings, somatic departments, and dementia special care units within a nursing home. 9 Patients who were admitted to a unit for geriatric rehabilitation or a hospice-unit were not eligible due to short-stay, chance of loss to follow-up, or short life expectancy. As the medical records of patients under the care of a general practitioner were not accessible, these patients were not included. ...
Article
Objective To assess short- and long-term mortality and risk factors in nursing home patients with COVID-19 infection. Design Retrospective two-center cohort study. Setting and participants Dutch nursing home patients with clinically suspected COVID-19 infection confirmed by RT–PCR testing. Methods Data were gathered between March 2020 and November 2020 using electronic medical records, including demographic characteristics, comorbidities, medical management and symptoms on the first day of suspected COVID-19 infection. Mortality at thirty days and six months was assessed using multivariate logistic regression models and Kaplan–Meier analysis. At six months, a subgroup analysis was performed to estimate the mortality risk between COVID-negative patients and patients who survived COVID-19. Risk factors for mortality were assessed through multivariate logistic regression models. Results A total of 321 patients with suspected COVID-19 infection were included, of whom 134 tested positive. Sixty-two patients in the positive group died at thirty days, with a short-term mortality rate of 2.9 (95% CI 1.7–5.3). Risk factors were fatigue (OR 2.6, 95% CI 1.3–6.2) and deoxygenation (OR 2.9, 95% CI 1.3–7.6). At six months, the mortality risk was 2.1 (95% CI 1.3–3.7). Risk factors for six-month mortality were shortness of breath (OR 2.7, 95% CI 1.3–7.0), deoxygenation (OR 2.5, 95% CI 1.1–6.5) and medical management (OR 4.5, 95% CI 1.7–25.8). However, among patients who survived COVID-19 infection, the long-term mortality risk was not sustained (OR 1.0, 95% CI 0.4–2.7). Conclusions and Implications Overall, COVID-19 infection increases short- and long-term mortality risk among nursing home patients. However, this study shows that surviving COVID-19 infection does not lead to increased mortality in the long term within this population. Therefore advanced care planning should focus on quality of life among nursing home patients after COVID-19 infection.
... Life in these smallscale living facilities is meant to closely resemble normal life outside the nursing home. An elderly care physician is usually responsible for the medical treatment of the residents and is employed by the nursing home [29]. Nursing staff comprises different levels of nursing and education levels, the European Qualification Framework (EQF) provide a framework to describe involved nurses [30]. ...
Article
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Background: Several efforts have been made to change management of neuropsychiatric symptoms (NPS) in nursing homes, however only few were successful. Numerous barriers to change in healthcare were identified, yet only one conceptual model is known to study their interrelationships. Unfortunately, this model does not discuss specific barriers encountered in nursing home practice. The aim of this study is to explore perceived barriers to change in the management of NPS in nursing homes and to construct a conceptual framework providing insight into the relative importance and interrelationships of these barriers when improving quality of care. Methods: Four focus groups were conducted in different dementia special care units of one Dutch nursing home. Participants were either nursing staff, treatment staff or relatives of residents. Qualitative thematic analysis was conducted according to the five phases defined by Braun & Clarke. Finally, a conceptual framework showing the interrelations of barrier-themes was constructed using text fragments of the focus groups. Results: We constructed a conceptual framework consisting of eight themes of barriers explaining the extent to which change in NPS-management can be achieved: 'organizational barriers', 'personal barriers', 'deficiency of staff knowledge', 'suboptimal communication', 'inadequate (multidisciplinary) collaboration', 'disorganization of processes', 'reactive coping' and 'differences in perception'. Addressing 'organizational barriers' and 'deficiency of staff knowledge' is a precondition for change. 'Suboptimal communication' and 'inadequate (multidisciplinary) collaboration' play a key role in the extent of change achieved via the themes 'differences in perception' and 'disorganization of processes'. Furthermore, 'personal barriers' influence all themes - except 'organizational barriers' - and may cause 'reactive coping', which in turn may lead to 'difficulties to structure processes'. Conclusions: A conceptual framework was created explaining the relationships between barriers towards achieving change focused on improving management of NPS in nursing homes. After this framework has been confirmed and refined in additional research, it can be used to study the interrelatedness of barriers to change, and to determine the importance of addressing them for achieving change in the provided care.
... Life in these small-scale living facilities is meant to closely resemble normal life outside the nursing home. An elderly care physician is usually responsible for the medical treatment of the residents and is employed by the nursing home (29). Nursing staff comprises different levels of nursing and education levels, the European Qualification Framework (EQF) provide a framework to describe involved nurses (30). ...
Preprint
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Background. Several efforts have been made to change management of neuropsychiatric symptoms (NPS) in nursing homes, however only few were successful. Numerous barriers to change in healthcare were identified, yet only one conceptual model is known to study their interrelationships . Unfortunately, this model does not discuss specific barriers encountered in nursing home practice. The aim of this study is to explore perceived barriers to change in the management of NPS in nursing homes and to construct a conceptual framework providing insight into the relative importance and interrelationships of these barriers when improving quality of care. Methods. Four focus groups were conducted in different dementia special care units of one Dutch nursing home. Participants were either nursing staff, treatment staff or relatives of residents. Qualitative thematic analysis was conducted according to the five phases defined by Braun & Clarke. Finally, a conceptual framework showing the interrelations of barrier-themes was constructed using text fragments of the focus groups. Results. We constructed a conceptual framework consisting of eight themes of barriers explaining the extent to which change in NPS-management can be achieved: 'organizational barriers', 'personal barriers', 'deficiency of staff knowledge', 'suboptimal communication', 'inadequate (multidisciplinary) collaboration', 'disorganization of processes', 'reactive coping' and 'differences in perception'. Addressing 'organizational barriers' and 'deficiency of staff knowledge' is a precondition for change. 'Suboptimal communication' and 'inadequate (multidisciplinary) collaboration' play a key role in the extent of change achieved via the themes 'differences in perception' and 'disorganization of processes'. Furthermore, 'personal barriers' influence all themes - except 'organizational barriers' - and may cause 'reactive coping', which in turn may lead to 'difficulties to structure processes'. Conclusions. A conceptual framework was created explaining the relationships between barriers towards achieving change focused on improving management of NPS in nursing homes. After this framework has been confirmed and refined in additional research, it can be used to study the interrelatedness of barriers to change, and to determine the importance of addressing them for achieving change in the provided care.
... Life in these small-scale living facilities is meant to closely resemble normal life outside the nursing home. An elderly care physician is usually responsible for the medical treatment of the residents and is employed by the nursing home (29). Nursing staff comprises different levels of nursing and education levels, the European Qualification Framework (EQF) provide a framework to describe involved nurses (30). ...
Preprint
Full-text available
Background. Several efforts have been made to change management of neuropsychiatric symptoms (NPS) in nursing homes, however only few were successful. Numerous barriers to change in healthcare were identified, yet only one conceptual model is known to study their interrelationships . Unfortunately, this model does not discuss specific barriers encountered in nursing home practice. The aim of this study is to explore perceived barriers to change in the management of NPS in nursing homes and to construct a conceptual framework providing insight into the relative importance and interrelationships of these barriers when improving quality of care. Methods. Four focus groups were conducted in different dementia special care units of one Dutch nursing home. Participants were either nursing staff, treatment staff or relatives of residents. Qualitative thematic analysis was conducted according to the five phases defined by Braun & Clarke. Finally, a conceptual framework showing the interrelations of barrier-themes was constructed using text fragments of the focus groups. Results. We constructed a conceptual framework consisting of eight themes of barriers explaining the extent to which change in NPS-management can be achieved: 'organizational barriers', 'personal barriers', 'deficiency of staff knowledge', 'suboptimal communication', 'inadequate (multidisciplinary) collaboration', 'disorganization of processes', 'reactive coping' and 'differences in perception'. Addressing 'organizational barriers' and 'deficiency of staff knowledge' is a precondition for change. 'Suboptimal communication' and 'inadequate (multidisciplinary) collaboration' play a key role in the extent of change achieved via the themes 'differences in perception' and 'disorganization of processes'. Furthermore, 'personal barriers' influence all themes - except 'organizational barriers' - and may cause 'reactive coping', which in turn may lead to 'difficulties to structure processes'. Conclusions. A conceptual framework was created explaining the relationships between barriers towards achieving change focused on improving management of NPS in nursing homes. After this framework has been confirmed and refined in additional research, it can be used to study the interrelatedness of barriers to change, and to determine the importance of addressing them for achieving change in the provided care.
... It also appears RAC practice is not an area the GPs felt prepared for. Rather, they had to draw on their own experience and networks (Pearson et al. 2018), confirming other research that GP training and preparation to work in RAC varies widely, but overall is wanting (Koopmans et al. 2017;McGregor 2017). The relatively ad hoc manner in which participants became involved in RAC work and thus end-of-life practice requires further investigation and analysis, especially given variation in GP training and preparation to work in RAC (McGregor 2017), and predicted increasing future demand for palliative care in many resource-rich countries, including New Zealand (McLeod 2016). ...
Article
This exploratory study examined general practitioners' (GPs) perspectives on delivering end-of-life care in the New Zealand residential aged care context. A general inductive approach to the data collected from semi-structured interviews with 17 GPs from 15 different New Zealand general practices was taken. Findings examine: (1) GPs' life experience; (2) the GP relationship with the facilities and provision of end-of-life care; (3) the GP interaction with families of dying residents; and (4) GP relationship with hospice. The nature of the GP relationship with the facility influenced GP involvement in end-of-life care in aged care facilities, with GPs not always able to direct a facility's end-of-life care decisions for specific residents. GP participation in end-of-life care was constrained by GP time availability and the costs to the facilities for that time. GPs reported seldom using hospice services for residents, but did use the reputation (cachet) associated with hospice practices to provide an authoritative buffer for their end-of-life clinical decisions when talking with families and residents. GP training in end-of-life care, especially for those with dementia, was reported as ad hoc and done through informal mentoring between GPs.
... Data collection took place between April 2012 and July 2015 and was carried out by the researcher (AvdB) and a research assistant (MdV). Both are certified elderly care physicians (Koopmans, Pellegrom, & van der Geer, 2017). Beforehand they were trained in administering the assessment instruments. ...
Article
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Objective: Aging societies will bring an increase in the number of long-term care patients with mental-physical multimorbidity (MPM). This paper aimed to describe the natural course of neuropsychiatric symptoms (NPS) in patients with MPM in the first 8 months after admission to a geronto-psychiatric nursing home (GP-NH) unit. Methods: Longitudinal cohort study among 63 patients with MPM no dementia living in 17 GP-NH units across the Netherlands. Data collection consisted of chart review, semi-structured interviews, and brief neuropsychological testing, among which our primary outcome measure the Neuropsychiatric Inventory (NPI). Descriptive and bivariate analyses were conducted. Results: Our study showed a significant increase of the NPI total score (from 25.3 to 29.3, p = 0.045), and the total scores of a NPI hyperactivity cluster (from 9.7 to 11.8, p = 0.039), and a NPI mood/apathy cluster (from 7.7 to 10.1, p = 0.008). Just over 95% had any clinically relevant symptom at baseline and/or six months later, of which irritability was the most prevalent and persistent symptom and the symptom with the highest incidence. Hyperactivity was the most prevalent and persistent symptom cluster. Also, depression had a high persistence. Conclusions: Our results indicate the omnipresence of NPS of which most were found to be persistent. Therefore, we recommend to explore opportunities to reduce NPS in NH patients with MPM, such as creating a therapeutic milieu, educating the staff, and evaluating patient's psychotropic drug use.
... The CGA was provided by a nurse or an elderly care physician, with the latter reserved for the most complex and frail older adults (ie, care profile 4). 33 The focus of these assessments was well-being, including social and functional participation, physical and psychological needs, and the living situation. A pharmacist also performed a risk assessment of drug-related problems based on the triage score system 34 and the Structured History-Taking of Medication Use tool. ...
Article
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Background: Older adults and care professionals advocate a more integrated and proactive care approach. This can be achieved by proactive outpatient assessment services that offer comprehensive geriatric assessments to better understand the needs of older adults and deliver person-centered and preventive care. However, the effects of these services are inconsistent. Increased involvement of the older adult during the assessment service could increase the effects on older adult's well-being. Methods: We studied the effect of an assessment service (Sage-atAge) for community-dwelling frail adults aged ≥65 years. After studying the local experiences, this service was adapted with the aim to increase participant involvement through individual goal setting and using motivational interviewing techniques by health-care professionals (Sage-atAge+). Within Sage-atAge+, when finishing the assessment, a "goal card" was written together with the older adult: a summary of the assessment, including goals and recommendations. We measured well-being with a composite endpoint consisting of health, psychological, quality of life, and social components. With regression analysis, we compared the effects of the Sage-atAge and Sage-atAge+ services on the well-being of participants. Results: In total, 453 older adults were eligible for analysis with a mean age of 77 (± 7.0) years of whom 62% were women. We found no significant difference in the change in well-being scores between the Sage-atAge+ service and the original Sage-atAge service (B, 0.037; 95% CI, -0.188 to 0.263). Also, no change in well-being scores was found even when selecting only those participants for the Sage-atAge+ group who received a goal card. Conclusion: Efforts to increase the involvement of older adults through motivational interviewing and goal setting showed no additional effect on well-being. Further research is needed to explore the relationship between increased participant involvement and well-being to further develop person-centered care for older adults.
... This medical discipline, called "elderly care medicine" (formerly known as nursing home medicine), is dedicated to patient-centered care for the elderly, but also for young patients with the severest sequelae of neurological diseases. 25,26 Dutch elderly care medicine has a tradition of research whose topics include VS/UWS. Specifically, decision-making and end-of-life scenarios in VS/UWS have been studied retrospectively and in case reports since the 1990s. ...
... Each general practice participating in Embrace set up a multidisciplinary Elderly Care Team comprising a general practitioner, an elderly care physician and two case managers. Elderly care physicians are doctors trained in, and consulted for, problems in the complex geriatric care pathway [27,28]. The case managers were a social worker (for older adults with the frail risk profile) or a district nurse (for older adults with the complex care needs risk profile). ...
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Purpose: Care for older adults should preferably be provided in a person-centred way that includes goal planning. The aim of the present cohort study is to gain an insight into the results of goal planning, in a person-centred care setting for community-living older adults. Materials and methods: Within Embrace, a person-centred and integrated care service, older adults set goals with the aim to improve health-related problems. For every goal, they rated severity scores ranging from 0 (no problem) to 10 (extremely severe): a baseline score, a target score and, within one year, an end score to evaluate these goals. The differences between baseline and end scores (goal progress) and target and end scores (goal attainment), and the percentage of goals attained were calculated and compared between health-related domains (i.e., mental health, physical health, mobility, and support). Results: Among 233 older adults, 836 goal plans were formulated of which 74% (95% Confidence Interval: 71–77) were attained. Goals related to physical health were the most likely to be attained and goals for mobility and pain the least likely. Conclusions: Older adults are able to attain health-related goals through collaborative goal planning. We recommend future integrated care programmes for older adults to incorporate goal-planning methods to achieve person-centred care. • IMPLICATIONS FOR REHABILITATION • Older adults experiencing frailty or complex care needs and receiving individual support within an integrated care setting are able to formulate and attain goals using goal planning with severity scores. • Goal plans of community-living older adults mostly aim at improving health-related problems concerning physical health, mobility, or support. • Goals related to physical health are the most likely to be attained, while goals for mobility and pain are the least likely to be attained.
... Er is inmiddels een aanzienlijk aantal opleidingstrajecten waar aios in opleiding tot huisarts of specialist ouderengeneeskunde ook een promotietraject doorlopen. 2,3 De werelden van academie en praktijk met elkaar verbinden wordt als belangrijk gezien, maar over de activiteiten van arts-onderzoekers als bruggenbouwer is niet zo veel bekend. [4][5][6] Om zicht te krijgen op die activiteiten en op de factoren die ze belemmeren of bevorderen, interviewden we ervaren onderzoekers die tevens werkzaam zijn als huisarts of specialist ouderengeneeskunde. ...
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Inleiding Arts-onderzoekers zijn praktiserende dokters die ook een academische rol hebben. Zij zijn bij uitstek degenen die wetenschap en praktijk kunnen verbinden. Wij onderzochten hoe arts-onderzoekers binnen de huisartsgeneeskunde en de ouderengeneeskunde aankijken tegen deze verbindende activiteiten, en welke belemmerende of bevorderende factoren ze daarbij ervaren. Methode Kwalitatief onderzoek door middel van interviews met zeventien ervaren arts-onderzoekers. De interviews werden opgenomen, getranscribeerd en thematisch geanalyseerd. Resultaten Arts-onderzoekers faciliteren de samenwerking tussen onderzoekers en clinici, wisselen informatie uit met beide zijden, hebben uitgebreide netwerken en betrekken actief de praktijk in het onderzoek en het onderzoek in de praktijk. Belangrijke factoren zijn een flexibele werkomgeving en voldoende tijd, geld en erkenning in de organisatie. Essentiële persoonlijke eigenschappen zijn goed kunnen netwerken, prioriteren en focussen. Conclusie Om de klinische relevantie van wetenschappelijk onderzoek én de implementatie van academische inzichten in de praktijk te bevorderen, moet de verbindende functie van de arts-onderzoeker worden herkend, gefaciliteerd en gewaardeerd. Extra aandacht voor de vaardigheden die een bruggenbouwer nodig heeft, zou goed zijn, ook in de training van aios-onderzoekers.
... . Nursing homes mostly consist of three types of units: units for patients with physical disabilities, dementia special care units, and geriatric rehabilitation units. Multi-disciplinary teams are employed by the nursing homes, including nursing home physicians (called "elderly care physicians" [ECPs]), nurses, physiotherapists, dieticians, and psychologists (Koopmans, Pellegrom, & Van der Geer, 2017). ...
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Nursing home physicians face heavy workloads, because of the aging population and rising number of older adults with one or more chronic diseases. Skill mix change, in which professionals perform tasks previously reserved for physicians independently or under supervision, could be an answer to this challenge. The aim of this study was to describe how skill mix change in nursing homes is organized from four monodisciplinary perspectives and the interdisciplinary perspective, what influences it, and what its effects are. The study focused particularly on skill mix change through the substitution of nurse practitioners, physician assistants, or registered nurses for nursing home physicians. Five focus group interviews were conducted in the Netherlands. Variation in tasks and responsibilities was found. Despite this variation, stakeholders reported increased quality of health care, patient centeredness, and support for care teams. A clear vision on skill mix change, acceptance of nurse practitioners, physician assistants, and registered nurses, and a reduction of legal insecurity are needed that might maximize the added value of nurse practitioners, physician assistants, and registered nurses.
... All older adults with a substantial frailty level (GFI > 2) were invited for a CGA (n = 708). The CGA consisted of a consultation with a geriatric nurse or elderly care physician [15] and focused on multiple domains (physical, functional, psychological, social and living). By protocol, the assessor was advised to extend the assessment with measurement instruments for psychological, social or functional needs. ...
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Introduction Pro-active assessment programs are increasingly used to improve care for older adults. These programs include comprehensive geriatric tailored to individual patient preferences. Evidence for the effects of these programs on patient outcomes is nevertheless scarce or ambiguous. Explaining these dissatisfying results is difficult due to the multi-component nature of the programs. The objective of the current study was to explore and explain the experience of older adults participating in a pro-active assessment program, to help to clarify the effects. Methods Semi-structured in-depth interviews were held with 25 participants of a pro-active assessment program for frail community-dwelling adults aged 65+. This study was part of an evaluation study on the effects of the program. Transcripts were analysed with thematic analysis and cross-case analysis. Results The participants’ mean age was 78.5 (SD 6.9) and 56% was female. The majority of the participants were satisfied with the program but based this on communication aspects, since only a few of them expressed real program benefits. Participant experiences could be clustered in six themes: (1) All participants expressed the need for a holistic view which was covered in the program, (2) the scope of the CGA was broader than expected or unclear, (3) the program delivered unexpected but valued help, (4) participants described a very low sense of ownership, (5) timing of the program implementation or the CGA was difficult and(6), participants and care workers had a different view on what to consider as a problem. These experiences could be explained by three program components: the degree of (the lack of) integration of the program within usual care, the pro-active screening method and the broader than expected, but appreciated multi-domain approach. Conclusion Older adults’ need for a holistic view is covered by this outpatient assessment program. However, their engagement and the correct timing of the program are hampered by the pro-active recruitment and the limited integration of the program within existing care. Furthermore, satisfaction seems an insufficient guiding factor when evaluating CGA programs for older adults because it does not reflect the impact of the program. Electronic supplementary material The online version of this article (10.1186/s12877-018-1025-7) contains supplementary material, which is available to authorized users.
... This system has existed since 1990. Physicians caring for frail older people living in nursing homes and the community undergo a 3 years training programme [11]. ...
Article
Introduction Nursing home residents are complex, vulnerable and have been historically neglected. The EuGMS is committed to improving their care, and is currently developing a curriculum of core competencies. Integral to these efforts is identifying the physicians, for whom, education in these competencies needs to be directed. Method A survey was distributed to European national geriatrics societies, asking members their perceptions of proportions of nursing home medical care delivered by various physician specialties, and the main functions carried out in nursing homes. Results Responses were received from 22 of 32 national geriatrics societies. The vast majority of care (estimated at 69%), is delivered by general practitioners, rather than geriatricians or specialist nursing home physicians. Nursing homes have acquired important roles in rehabilitation, respite and palliative care. Conclusion Education and training to achieve the highest standards of care must be designed for general practitioners who do not have specialist training. Education and infrastructure must be developed for the evolving roles of nursing homes.
... 13 In the Netherlands, nursing home residents with YOD reside on special care units (SCUs) because they have specific care needs regarding daytime activities, social contacts, and mobility. 17,18 Care is provided by a multidisciplinary team, consisting of an elderly care physician, 19 health care psychologist, and nursing staff, all with specific expertise on care and treatment of YOD. ...
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Objective: To evaluate the cost-consequences of an intervention for the management of neuropsychiatric symptoms in nursing home residents with young-onset dementia. Methods: A stepped wedge design was used. The intervention consisted of an educational program and a multidisciplinary care program and was implemented in 13 nursing homes from September 2015 to March 2017. Costs outcomes included the time investment of the elderly care physician and healthcare psychologists regarding the management of neuropsychiatric symptoms, residents' psychotropic drug use, nursing staff absenteeism and costs of the educational program. Composite cost measure contained the sum of costs of staff absenteeism, costs on psychotropic drugs and costs of the educational program. Costs of time investment were investigated by comparing means. Costs of psychotropic drug use were analyzed with mixed models at resident level and as part of the composite cost measure on unit level. Staff absenteeism was also analyzed at unit level. Results: Compared to care as usual, the mean costs of time invested decreased with €36.79 for the elderly care physician but increased with €46.05 for the healthcare psychologist in the intervention condition. Mixed model analysis showed no effect of the intervention compared to care as usual on the costs of psychotropic drug use, staff absenteeism and the composite cost measure. The costs of the educational program were on average €174.13 per resident. Conclusion: The intervention did not result in increased costs compared to care as usual. Other aspects, such as the lack of a structured working method, should be taken into account when considering implementation of the intervention.
... In the Netherlands, nursing home care for people with dementia is organized differently than in most countries. Those people reside at dementia special care units (DSCUs), and medical care is usually provided by physicians who have been educated as elderly care physicians and are employed by the nursing home, and by nurses (Koopmans et al., 2017). Nursing education is divided into five levels, which we consider comparable with nursing assistant (level 1 and 2), certified nursing assistant (level 3), and registered nurse (level 4 and 5). ...
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Objectives To evaluate the effect of the PROPER intervention in nursing home residents with dementia on the prevalence of psychotropic drug use and neuropsychiatric symptoms. Design A cluster-randomized controlled design with two parallel groups (intervention versus usual care) and assessments at 0, 6, 12, and 18 months. Setting Thirty-one dementia special care units within 13 long-term care organizations in the Netherlands. Participants Three hundred eighty nursing home residents with dementia Intervention The PROPER intervention consisted of a structured and repeated multidisciplinary medication review, supported by education and continuous evaluation. Measurements Prescriptions of antipsychotics, antidepressants, anxiolytics, and hypnotics, and occurrence of neuropsychiatric symptoms. Results The prescription of any type of psychotropic drugs increased in the intervention group, and decreased in the control group, with an estimated difference of 3.9 percentage points per 6 months ( p = 0.01). Effects for the individual drug groups were minor (differences of 1.6 percentage points and below per 6 months) and not statistically significant. The occurrence of neuropsychiatric symptoms remained stable in both the intervention and control groups during the follow-up of 18 months. Conclusions The PROPER intervention failed to demonstrate effectiveness in reducing the prevalence of psychotropic drugs. It may be interesting to enrich the intervention with components that address personal attitudes and communication between nursing home professionals, not only with respect to the prescription of psychotropic drugs, but also to neuropsychiatric symptoms. The study has been registered in The Netherlands Trial Register (NTR3569).
... W Holandii, gdzie jakość komunikacji między lekarzem a rodziną umierającego pacjenta została wysoko oceniona przez rodzinę niezależnie od rodzaju placówki, zarówno certyfikowani lekarze sprawujący opiekę nad osobami starszymi (ang. elderly care physicians), jak i lekarze ogólni są szkoleni w zakresie komunikacji z mieszkańcami [72,73]. ...
... Types of wards on which they can be accommodated include; somatic wards (i.e., for persons with mainly physical issues), psychogeriatric wards (i.e., for persons with cognitive disorders, mainly dementia), rehabilitation wards, and palliative care wards. Medical care is generally provided by elderly care physicians-a separate medical discipline in the Netherlands-who are employed by, and have their principal site of practice in the NH (Koopmans et al., 2017). ...
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We aimed to assess the contribution of a- and presymptomatic residents and healthcare workers in transmission of SARS-CoV-2 in nursing homes. We conducted two serial point-prevalence surveys, including standardized symptom assessment and nasopharyngeal and oropharyngeal testing for SARS-CoV-2, among 297 residents and 542 healthcare workers of three Dutch nursing homes (NHs) with recent SARS-CoV-2 introduction. At the first point-prevalence survey, 15 residents tested positive of which one was presymptomatic and three remained asymptomatic. At the second point-prevalence survey one resident and one healthcare worker tested SARS-CoV-2 positive and both remained asymptomatic. Although a limited number of SARS-CoV-2 positive cases were identified, this study confirms a- and presymptomatic occurrence of Covid-19. We additionally describe factors that may contribute to the prevention of transmission. Taken together, our study complements the discussion on effective SARS-CoV-2 screening in NHs.
... Comprehensive geriatric assessments were provided by a nurse or an elderly care physician (Koopmans et al., 2017), with the latter only performing assessments for the most complex and frail cases. The focus of these assessments was well-being, including social and functional participation, physical and psychological needs, and the living situation. ...
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Objectives: Goal setting and motivational interviewing (MI) may increase well-being by promoting healthy behavior. Since we failed to show improved well-being in a proactive assessment service for community-dwelling older adults applying these techniques, we studied whether implementation processes could explain this. Methods: Goals set during the comprehensive geriatric assessment were evaluated on their potential for behavior change. MI and goal setting adherence wasassessed by reviewing audiotaped interactions and interviewing care professionals. Results: Among the 280 goals set with 230 frail older adults (mean age 77 ± 6.9 years, 59% women), more than 90% had a low potential for behavior change. Quality thresholds for MI were reached in only one of the 11 interactions. Application was hindered by the context and the limited proficiency of care professionals. Discussion: Implementation was suboptimal for goal setting and MI. This decreased the potential for improved well-being in the participating older adults.
... EIN involves 25 therapy sessions a week and is coordinated by physiatrists, while elderly care physicians (ECP), previously known as nursing home Fig. 1 Intensive neurorehabilitation for PDOC patients in the Netherlands [51] physicians, are in charge of PIN, which consists of 10 therapy sessions a week. ECPs are particularly specialized in the management of severe chronic conditions, shared decisionmaking and end-of-life care [52]. At any point during EIN or PIN, patients may be discharged, depending on their neurologic and functional outcomes, to either regular rehabilitation centers, other care facilities like long-stay nursing home, hospice or home. ...
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Background Prolonged disorders of consciousness (PDOC) are amongst the severest sequelae of acquired brain injury. Evidence regarding epidemiology and rehabilitation outcomes is scarce. These knowledge gaps and psychological distress in families of PDOC patients may complicate clinical decision-making. The complex PDOC care and associated moral dilemmas result in high workload in healthcare professionals. Since 2019, all PDOC patients in the Netherlands have access to intensive neurorehabilitation up to 2 years post-injury provided by one rehabilitation center and four specialized nursing homes. Systematic monitoring of quantitative rehabilitation data within this novel chain of care is done in a study called DOCTOR. The optimization of tailored PDOC care, however, demands a better understanding of the impact of PDOC on patients, their families and healthcare professionals and their views on rehabilitation outcomes, end-of-life decisions and quality of dying. The T rue O utcomes of PDOC (TOPDOC) study aims to gain insight in the qualitative outcomes of PDOC rehabilitation and impact of PDOC on patients, their families and healthcare professionals. Methods Nationwide multicenter prospective cohort study in the settings of early and prolonged intensive neurorehabilitation with a two-year follow-up period, involving three study populations: PDOC patients > 16 years, patients’ family members and healthcare professionals involved in PDOC care. Families’ and healthcare professionals’ views on quality of rehabilitation outcomes, end-of-life decisions and dying will be qualitatively assessed using comprehensive questionnaires and in-depth interviews. Ethical dilemmas will be explored by studying moral deliberations. The impact of providing care to PDOC patients on healthcare professionals will be studied in focus groups. Discussion To our knowledge, this is the first nationwide study exploring quality of outcomes, end-of-life decisions and dying in PDOC patients and the impact of PDOC in a novel chain of care spanning the first 24 months post-injury in specialized rehabilitation and nursing home settings. Newly acquired knowledge in TOPDOC concerning quality of outcomes in PDOC rehabilitation, ethical aspects and the impact of PDOC will enrich quantitative epidemiological knowledge and outcomes arising from DOCTOR. Together, these projects will contribute to the optimization of centralized PDOC care providing support to PDOC patients, families and healthcare professionals.
... These professions are responsible for primary care for persons with dementia, with elderly care physicians usually being on the staff of a nursing home or also practicing in the community in collaboration with general practitioners (GPs). 26 Further, we thus sampled for large variation in experience and a population of practitioners who may be early adopters. ...
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Objectives In oncology and palliative care, patient question prompt lists (QPLs) with sample questions for patient and family increased patients’ involvement in decision-making and improved outcomes if physicians actively endorsed asking questions. Therefore, we aim to evaluate practitioners’ perceptions of acceptability and possible use of a QPL about palliative and end-of-life care in dementia. Design Mixed-methods evaluation study of a QPL developed with family caregivers and experts comprising a survey and interviews with practitioners. Setting Two academic medical training centres for primary and long-term care in the Netherlands. Participants Practitioners (n=66; 73% woman; mean of 21 (SD 11) years of experience) who were mostly general practitioners and elderly care physicians. Outcomes The main survey outcome was acceptability measured with a 15–75 acceptability scale with ≥45 meaning ‘acceptable’. Results The survey response rate was 21% (66 of 320 participated). The QPL was regarded as acceptable (mean 51, SD 10) but 64% felt it was too long. Thirty-five per cent would want training to be able to answer the questions. Those who felt unable to answer (31%) found the QPL less acceptable (mean 46 vs 54 for others; p=0.015). We identified three themes from nine interviews: (1) enhancing conversations through discussing difficult topics, (2) proactively engaging in end-of-life conversations and (3) possible implementation. Conclusion Acceptability of the QPL was adequate, but physicians feeling confident to be able to address questions about end-of-life care is crucial when implementing it in practice, and may require training. To facilitate discussions of advance care planning and palliative care, families and persons with dementia should also be empowered to access the QPL themselves.
... In the US and The Netherlands, Mrs. S would most likely be living in a nursing home, while in Israel, she would be living in the community [21][22][23][24]. In The Netherlands, long-term care is mostly funded through public funding [25], while in the US and Israel, long-term care is funded through a mix of public and private funding. ...
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Palliative care including hospice care is appropriate for advanced dementia, but policy initiatives and implementation have lagged, while treatment may vary. We compare care for people with advanced dementia in the United States (US), The Netherlands, and Israel. We conducted a narrative literature review and expert physician consultation around a case scenario focusing on three domains in the care of people with advanced dementia: (1) place of residence, (2) access to palliative care, and (3) treatment. We found that most people with advanced dementia live in nursing homes in the US and The Netherlands, and in the community in Israel. Access to specialist palliative and hospice care is improving in the US but is limited in The Netherlands and Israel. The two data sources consistently showed that treatment varies considerably between countries with, for example, artificial nutrition and hydration differing by state in the US, strongly discouraged in The Netherlands, and widely used in Israel. We conclude that care in each country has positive elements: hospice availability in the US, the general palliative approach in The Netherlands, and home care in Israel. National Dementia Plans should include policy regarding palliative care, and public and professional awareness must be increased.
... Our study showed that only 1.8% of people dying from dementia died in hospital; a percentage that is much lower than what was found in Belgium, where 25.1% of dementia decedents died in hospital in 2015 [13]. This difference is probably due to policy in Dutch LTCFs, where elderly care physicians work who are trained to provide palliative care for nursing home residents until death [28,29]. ...
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Background A high percentage of people dying at home, and a low percentage of people being admitted to hospital and dying there are regarded as indicators of appropriate care at the end of life. However, performance standards for these quality indicators are often lacking, which makes it difficult to state whether an indicator score falls between the ranges of good or poor quality care. The aim of this study was to assess quality indicators concerning place of death and hospital care utilization in people with diseases relevant for palliative care, and to establish best practice performance standards based on indicator scores in 31 regions in the Netherlands. Methods A retrospective nationwide population-based observational study was conducted, using routinely collected administrative data concerning persons who died in 2017 in the Netherlands with underlying causes relevant for palliative care ( N = 109,707). Data from four registries were linked for analysis. Scores on eight quality indicators concerning place of death and hospital care utilization were calculated, and compared across 31 healthcare insurance regions to establish relative benchmarks. Results On average, 36.4% of the study population died at home (range between regions 30.5%-42.6%) and 20.4% in hospital (range 16.6%-25.5%). Roughly half of the population who received hospital care at any time in the last year of life were found to (also) receive hospital care in the last month of life. In the last month, 32.0% of the study population were admitted to hospital (range 29.4-36.4%), 5.3% to an Intensive Care Unit (range 3.2-6.9%) and 23.9% visited an Emergency Department (range 21.0-27.4%). In the same time period, less than 1% of the study population was resuscitated in hospital or received tube or intravenous feeding in hospital. Conclusions The variation between regions points towards opportunities for practice improvement. The best practice performance standards as set in this study serve as ambitious but attainable targets for those regions that currently do not meet the standards. Policymakers, healthcare providers and researchers can use the suggested performance standards to further analyze causes of variance between regions and develop and test interventions that can improve practice.
... Eligible residents (or their legal representative in case the NH resident was incompetent to make the decision) were approached by elderly care physicians (ECPs) in training. ECPs are medical specialists responsible for the medical care of NH residents in the Netherlands (Koopmans et al., 2017). ECPs in training approached the positive tested NH residents, starting with the most recent, until they reached a maximum of ten residents per ECP in training. ...
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Introduction Many nursing homes (NHs) are affected by COVID-19 and 30-day mortality is high. Knowledge on recovery of NH residents after COVID-19 is limited. Therefore, we investigated the trajectory in the first three months after a COVID-19 infection in NH residents. Methods Retrospective observational cohort study of Dutch NH residents with COVID-19 between 1 September 2020 and 1 March 2021. Prevalence of COVID-19 symptoms and functioning was determined using interRAI (ADL-Hierarchy Scale (ADL-HS), Cognitive Performance Scale (CPS) and Revised Index of Social Engagement (RISE)) at four time points. Descriptive and pattern analyses were performed. Results Eighty-six residents were included. Symptom prevalences after three months were higher than at baseline. At group level, functioning on all domains deteriorated and was followed by recovery towards baseline, except for ADL functioning. There were four trajectories; 9.3% had no deterioration. Total and partial recovery occurred in respectively 30.2% and 55.8% of the residents. In 4.7% there was no recovery. Conclusion In 86% of NH residents surviving three months after COVID-19, occurrence of COVID-19 symptoms and deterioration in functioning was followed by recovery. COVID-19 symptoms fatigue and sleeping behaviour were significantly more prevalent, and ADL functioning was significantly lower, at three months compared to baseline.
... The Dutch government raised the threshold for admission to a NH in 2015 and the Netherlands has trained elderly care physicians who are mostly hired by long-term care organizations. 18 The excellently trained Dutch elderly care physicians ensure that hospitalisation at the end-of-life stage is unnecessary and 92.3% of older people with dementia died in a longterm care facility in the Netherlands in 2003, which is significantly higher than the percentages in the UK and Belgium. 19 Since a higher proportion of older people with dementia live in NHs at the end-oflife stage, the prescription rates of psychotropic drugs might differ from those in other European countries. ...
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Objective: Several European studies investigated the trends in psychotropic drug prescriptions (PDPs) among nursing home (NH) residents and reported a decline in antipsychotics prescriptions. Since the Dutch long-term care system differs from other European systems (e.g. higher threshold for NH admission and trained elderly care physicians), this study explores the trends in PDPs in Dutch NH residents with dementia. Methods: The study used data from nine studies, comprising two cross-sectional studies, one cohort study, and six cluster-randomized controlled trials, collected in Dutch NHs between 2003 and 2018. With multilevel logistic regression analysis, NHs as a random effect, we estimated the trends in PDPs overall and for five specific psychotropic drug groups (antipsychotics, antidepressants, anxiolytics, hypnotics, and anti-dementia drugs), adjusting for confounders: age, gender, severity of dementia, severity of neuropsychiatric symptoms, and length of stay in NHs. Results: The absolute prescription rate of antipsychotics was 37.5% in 2003 and decreased (OR = 0.947, 95% CI [0.926, 0.970]) every year. The absolute prescription rate of anti-dementia drugs was 0.8% in 2003 and increased (OR = 1.162, 95% CI [1.105, 1.223]) per year. The absolute rate of overall PDPs declined from 62.7% in 2003 to 40.4% in 2018. Conclusions: Among Dutch NH residents with dementia, the odds of antipsychotics prescriptions decreased by 5.3% per year while the odds of anti-dementia drug prescriptions increased by 16.2%. There were no distinct trends in antidepressants, anxiolytics, and hypnotics prescriptions. However, overall PDPs were still high. The PDPs in NH residents remain an issue of concern.
... 9,10 The 3-year vocational training for elderly care physicians focuses mainly on primary and specialized care for frail older people including ACP with patients and their surrogate decision makers. 10 Hence, elderly care physicians have broad experience in practicing ACP with nursing home residents. ...
Article
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Objectives To explore how physicians in Dutch nursing homes practiced advance care planning (ACP) during the first wave of the COVID-19 pandemic, and to explore whether and how ACP changed during the first wave of the pandemic. Design Qualitative analysis of an online, mainly open-ended questionnaire on ACP among physicians working in nursing homes in the Netherlands during the first wave of the COVID-19 pandemic. Setting and participants Physicians in Dutch nursing homes. Methods Respondents were asked to describe a recent case in which they had a discussion on anticipatory medical care decisions, and to indicate whether ACP was influenced by the COVID-19 pandemic in that specific case and in general. Answers were independently coded and a codebook was compiled in which the codes were ordered by themes that emerged from the data. Results A total of 129 questionnaires were filled out. Saturation was reached after analyzing 60 questionnaires. Four main themes evolved after coding the questionnaires: reasons for ACP discussion, discussing ACP, topics discussed in ACP and decision-making in ACP. COVID-19 specific changes in ACP indicated by respondents included: (1) COVID-19 infection as a reason for initiating ACP, (2) a higher frequency of ACP discussions, (3) less face-to-face contact with surrogate decision makers, and (4) intensive care unit admission as an additional topic in anticipatory medical decision making. Conclusions and implications ACP in Dutch nursing homes has changed due to the COVID-19 pandemic. Maintaining frequent and informal contact with surrogate decision makers fosters mutual understanding and aids the decision making process in ACP.
... Data was collected and pseudonymized by elderly care physicians (ECPs) in training, further referred to as 'ECPs'. 25 In May 2020, ECPs obtained patient characteristics, gender, age, and type of dementia from the medical chart. Severity of dementia was estimated by the ECP using the Global Deterioration Score (GDS). ...
Article
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Objective: To describe the course of neuropsychiatric symptoms in nursing home residents with dementia during the step-by-step lifting of restrictions after the first wave of the COVID-19 pandemic in the Netherlands, and to describe psychotropic drug use (PDU) throughout the whole first wave. Methods: Longitudinal cohort study of nursing home residents with dementia. We measured neuropsychiatric symptoms using the Neuropsychiatric Inventory-Questionnaire (NPI-Q). From May to August 2020, the NPI-Q was filled in monthly. Psychotropic drug use was retrieved from the electronic prescription system, retrospectively for the months February to April and prospectively for the months May to August. Results: We followed 252 residents with dementia in 19 Dutch nursing homes. Agitation was the most prevalent type of neuropsychiatric symptom at each assessment. Overall, the prevalence and severity of agitation and depression significantly decreased over time. When considering more in detail, we observed that in some residents specific neuropsychiatric symptoms resolved (resolution) while in others specific neuropsychiatric symptoms developed (incidence) during the study period. For the majority of the residents, neuropsychiatric symptoms persisted over time. Psychotropic drug use remained stable over time throughout the whole first wave of the pandemic. Conclusions: At group level, lifting the measures appeared to have beneficial effects on the prevalence and severity of agitation and depression in residents with dementia. Nevertheless, on an individual level we observed high heterogeneity in the course of neuropsychiatric symptoms over time. Despite the pressure of the pandemic and the restrictions in social contact imposed, PDU remained stable.
Article
Objectives The complex care needs of frail older persons living at home is a major challenge for health care systems worldwide. One possible solution is to employ a primary care physician (PCP) with additional geriatric expertise. In the Netherlands, elderly care physicians (ECPs), who traditionally work in nursing homes, are increasingly encouraged to utilize their expertise within primary care. However, little is known about how PCPs and ECPs collaborate. Therefore, we aimed to unravel the nature of the current PCP-ECP collaboration in primary care for frail older persons, and to identify key concepts for success. Design A qualitative multiple case study with semistructured interviews. Setting and participants A selection of 22 participants from 7 “established collaboration practices” within the primary care setting in the Netherlands, including at least 1 ECP, 1 PCP, and 1 other health care professional for every included established collaboration practice. Methods Transcripts of individual interviews were analyzed using largely double and independent open and axial coding, and formulation of themes and subthemes. Results Data analysis revealed 4 key concepts for success: (1) clarification of roles and expectations (ie, patient-centered care and embedding in existing care networks), (2) trust, respect, and familiarity as drivers for collaboration (ie, mutual trust through knowing each other and having shared goals); (3) framework for regular communication (ie, structural meetings and a shared vision); and (4) government, payer, and organization support (ie, financial support and emphasis on the collaboration’s urgency by organizations and national policy makers). Conclusions and Implications For a successful generalist-specialist collaboration, health care professionals need to invest in building relationships and mutual trust, and incorporating their efforts in the existing care networks to guarantee patient-centeredness. When provided with reimbursement and appreciation, this collaboration is a promising change in general practice to improve the care and outcomes of frail older persons.
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Objectives: To adequately monitor the course of cognitive functioning in persons with moderate to severe dementia, relevant cognitive tests for the advanced dementia stages are needed. We examined the ability of a test developed for the advanced dementia stages, the Severe Impairment Battery Short version (SIB-S), to measure cognitive change over time. Second, we examined type of memory impairment measured with the SIB-S in different dementia stages. Methods: Participants were institutionalized persons with moderate to severe dementia (N = 217). The SIB-S was administered at 6-month intervals during a 2-year period. Dementia severity at baseline was classified according to Global Deterioration Scale criteria. We used mixed models to evaluate the course of SIB-S total and domain scores, and whether dementia stage at baseline affected these courses. Results: SIB-S total scores declined significantly over time, and the course of decline differed significantly between dementia stages at baseline. Persons with moderately severe dementia declined faster in mean SIB-S total scores than persons with moderate or severe dementia. Between persons with moderate and moderately severe dementia, there was only a difference in the rate of decline of semantic items, but not episodic and non-semantic items. Conclusions: Although modest floor and slight ceiling effects were noted in severe and milder cases, respectively, the SIB-S proved to be one of few available adequate measures of cognitive change in institutionalized persons with moderate to severe dementia. (JINS, 2018, 00, 1-11).
Article
The use of schema therapy to treat personality disorders in older adults is gaining scientific attention. Personality disorders are prevalent in one out of ten older adults and have a detrimental effect on quality of life. Although 24% or more of nursing home residents may have personality disorders, psychotherapeutic treatment options in the case of comorbid cognitive impairment have not yet been studied. This study concerns a 63-year-old care-dependent male nursing home resident with a personality disorder, a substance use disorder, and several cognitive impairments due to cerebrovascular disease, who presented with complaints of loneliness, low self-esteem, sleeping problems and anger outbursts. Schema therapy was delivered based on the schema mode model for a period of 27 months. Post-treatment assessment demonstrated a decrease in early maladaptive schemas and dysfunctional schema modes and improved personality functioning overall. Although situational psychological distress fluctuated throughout treatment, quality of life improved after 7 months and remained stable onwards. Presented complaints either remitted or strongly diminished. Substance use was also addressed and was in remission for the last 20 months of therapy. This case study suggests that schema therapy is a viable treatment for older adults with personality disorders who present with cognitive impairments in nursing homes.
Article
Introduction: Parkinson’s disease (PD) is a chronic multisystem disorder that causes a wide variety of motor and non-motor symptoms. Over time, the progressive nature of the disease increases the risk of complications such as falls and loss of independence, having a profound impact on quality of life. The complexity and heterogeneity of symptoms therefore warrant a holistic, multidisciplinary approach. Specific healthcare professionals, e.g. the movement disorders neurologist and the PD nurse specialist, are considered essential members of this multidisciplinary team. However, with our increasing knowledge about different aspects of the disease, other disciplines are also being recognized as important contributors to the healthcare team. Areas covered: The authors describe a selection of these relatively newly-recognized disciplines, including the specialist in vascular medicine, gastroenterologist, pulmonologist, neuro-ophthalmologist, urologist, geriatrician/elderly care physician, palliative care specialist and the dentist. Furthermore, they share the view of a person with PD on how patients and caregivers should be involved in the multidisciplinary team. Finally, they have included a perspective on the new role of the movement disorder neurologist, with care delivery via “tele-neurology”. Expert commentary: Increased awareness about the potential role of these ‘new’ professionals will further improve disease management and quality of life of PD patients.
Article
Background During the course of dementia, most people develop some type of neuropsychiatric symptoms (NPS), which result in lower quality of life, high caregiver burden, psychotropic drug use and a major risk of institutionalization. Studies on NPS in people with dementia have been mainly conducted in clinical centres or psychiatric services. Objectives To investigate the course of NPS in people with dementia in primary care. Methods Analysis of (cumulative) prevalence and incidence, persistence and resolution based on data collected during an assessment at home of a prospective naturalistic cohort study in primary care in a sample of 117 people with dementia and their informal caregivers. Subsyndromes of NPS were assessed with the Neuropsychiatric Inventory (NPI) and Cohen-Mansfield Agitation Inventory. Multivariate analyses were used to detect determinants for the course of NPS. Results The mean age of the people with dementia was 78.6 years, and 52% were female. Mean Mini-Mental State Examination total score was 19.5, mean NPI total score 15.7. The most prevalent clinically relevant subsyndromes of the NPI were hyperactivity and mood/apathy, and the most prevalent individual NPS were aberrant motor behaviour (28%), agitation/aggression (24%) and apathy/indifference (22%). Of the people with dementia, 72.3% had one or more symptoms of the mood/apathy and 75.3% of the hyperactivity subsyndrome. Conclusions GPs should be aware of NPS in people with dementia and should actively identify them when they visit these patients or when informal caregivers consult them. Timely diagnosing facilitates adequate professional care.
Article
Background: Tracing frequent users of health care services is highly relevant to policymakers and clinicians, enabling them to avoid wasting scarce resources. Data collection on frequent users from all possible health care providers may be cumbersome due to patient privacy, competition, incompatible information systems, and the efforts involved. Objective: This study explored the use of a single key source, emergency medical services (EMS) records, to trace and reveal frequent users' health care consumption patterns. Methods: A retrospective study was performed analyzing EMS calls from the province of Drenthe in the Netherlands between 2012 and 2017. Process mining was applied to identify the structure of patient routings (ie, their consecutive visits to hospitals, nursing homes, and EMS). Routings are used to identify and quantify frequent users, recognizing frail elderly users as a focal group. The structure of these routes was analyzed at the patient and group levels, aiming to gain insight into regional coordination issues and workload distributions among health care providers. Results: Frail elderly users aged 70 years or more represented over 50% of frequent users, making 4 or more calls per year. Over the period of observation, their annual number and the number of calls increased from 395 to 628 and 2607 to 3615, respectively. Structural analysis based on process mining revealed two categories of frail elderly users: low-complexity patients who need dialysis, radiation therapy, or hyperbaric medicine, involving a few health care providers, and high-complexity patients for whom routings appear chaotic. Conclusions: This efficient approach exploits the role of EMS as the unique regional "ferryman," while the combined use of EMS data and process mining allows for the effective and efficient tracing of frequent users' utilization of health care services. The approach informs regional policymakers and clinicians by quantifying and detailing frequent user consumption patterns to support subsequent policy adaptations.
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Aim: Establishing the prevalence of neuropsychiatric symptoms (NPS), quality of life and psychotropic drug use in people aged ≤65 years with acquired brain injury in nursing homes. Design: Cross-sectional, observational study among patients aged 18-≤65 years with acquired brain injury admitted to special care units in Dutch nursing homes. Methods: According to the Committee on Research Involving Human Subjects in January 2017 this study did not require ethics approval. Nursing homes will be recruited through the national acquired brain injury expertise network for patients with severe brain injury, the regional brain injury teams and by searching the internet. Patient characteristics will be collected through digital questionnaires. Neuropsychiatric symptoms will be assessed with the NeuroPsychiatric Inventory-Nursing Home version, the Cohen-Mansfield Agitation Inventory and the St. Andrews Sexual Behaviour Assessment; cognition with the Mini-Mental State Examination, quality of life with the Quality of Life after Brain Injury Overall Scale and activities of daily living with the Disability Rating Scale. Medication will be retrieved from the electronic prescription system. Data collection commenced in 2017 and will be followed by data analysis in 2019. Reporting will be completed in 2020. Discussion: Little is known about NPS among patients with acquired brain injury in nursing homes. In patients up to the age of 65 years, only six studies were found on prevalence rates of NPS. Impact: Patients with severe acquired brain injury experience lifelong consequences, that have a high impact on them and their environment. Although there is increasing attention for the survival of this vulnerable group of patients, it is also important to enlarge awareness on long-term consequences, specifically the NPS, quality of life and psychotropic drug use in acquired brain injury. Insight into the magnitude of these issues is necessary to achieve appropriate care for these patients.
Article
Objectives Before drawing conclusions on the contribution of an effective intervention to daily practice and initiating dissemination, its quality and implementation in daily practice should be optimal. The aim of this process evaluation was to study these aspects alongside a randomized controlled trial investigating the effects of a multidisciplinary biannual medication review in long-term care organizations (NTR3569). Design Process evaluation with multiple measurements. Setting Thirteen units for people with dementia in six long-term care organizations in the Netherlands. Participants Physicians, pharmacists, and nursing staff of participating units. Intervention The PROPER intervention is a structured and biannually repeated multidisciplinary medication review supported by organizational preparation and education, evaluation, and guidance. Measurements Web-based questionnaires, interviews, attendance lists of education sessions, medication reviews and evaluation meetings, minutes, evaluation, and registration forms. Results Participation rates in education sessions (95%), medication reviews (95%), and evaluation meetings (82%) were high. The intervention’s relevance and feasibility and applied implementation strategies were highly rated. However, the education sessions and conversations during medication reviews were too pharmacologically oriented for several nursing staff members. Identified barriers to implementation were required time, investment, planning issues, and high staff turnover; facilitators were the positive attitude of professionals toward the intervention, the support of higher management, and the appointment of a local implementation coordinator. Conclusion Implementation was successful. The commitment of both higher management and professionals was an important factor. This may partly have been due to the subject being topical; Dutch long-term-care organizations are pressed to lower inappropriate psychotropic drug use.
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Objective To evaluate whether C reactive protein point-of-care testing (CRP POCT) safely reduces antibiotic prescribing for lower respiratory tract infections in nursing home residents. Design Pragmatic, cluster randomised controlled trial. Setting The UPCARE study included 11 nursing home organisations in the Netherlands. Participants 84 physicians from 11 nursing home organisations included 241 participants with suspected lower respiratory tract infections from September 2018 to the end of March 2020. Interventions Nursing homes allocated to the intervention group had access to CRP POCT. The control group provided usual care without CRP POCT for patients with suspected lower respiratory tract infections. Main outcome measures The primary outcome measure was antibiotic prescribing at initial consultation. Secondary outcome measures were full recovery at three weeks, changes in antibiotic management and additional diagnostics during follow-up at one week and three weeks, and hospital admission and all cause mortality at any point (initial consultation, one week, or three weeks). Results Antibiotics were prescribed at initial consultation for 84 (53.5%) patients in the intervention group and 65 (82.3%) in the control group. Patients in the intervention group had 4.93 higher odds (95% confidence interval 1.91 to 12.73) of not being prescribed antibiotics at initial consultation compared with the control group, irrespective of treating physician and baseline characteristics. The between group difference in antibiotic prescribing at any point from initial consultation to follow-up was 23.6%. Differences in secondary outcomes between the intervention and control groups were 4.4% in full recovery rates at three weeks (86.4% v 90.8%), 2.2% in all cause mortality rates (3.5% v 1.3%), and 0.7% in hospital admission rates (7.2% v 6.5%). The odds of full recovery at three weeks, and the odds of mortality and hospital admission at any point did not significantly differ between groups. Conclusions CRP POCT for suspected lower respiratory tract infection safely reduced antibiotic prescribing compared with usual care in nursing home residents. The findings suggest that implementing CRP POCT in nursing homes might contribute to reduced antibiotic use in this setting and help to combat antibiotic resistance. Trial registration Netherlands Trial Register NL5054
Article
Background Challenging behavior is prevalent in people with dementia residing in nursing homes and places a high burden on the nursing staff of dementia special care units. This study evaluates an educational program for nursing staff for managing challenging behavior: The Educating Nursing Staff Effectively (TENSE) program. This program can be tailored to care organizations’ wishes and needs and combines various learning styles. Objective The aim of this cluster-randomized controlled trial was to examine the short-term (3 months) and long-term (9 months) effects of the TENSE training program on experienced stress, work contentment, and stress reactions at work in nursing staff working in dementia special care units. Design Cluster-randomized controlled trial. Methods Nursing staff members of 18 dementia special care units within nine nursing homes from different Netherlands regions were randomized into an intervention (n=168) or control (n=129) group. The TENSE program consisted of a three-day training course and two follow-up sessions after three and six months, respectively. The primary outcome was stress experienced by nursing staff measured with the Utrecht Burnout Scale - C. Secondary outcomes were work contentment and stress reactions at work. Furthermore, process evaluation data on the reach of and compliance with the program and the program's feasibility and relevance were collected. Data was collected between November 2012 and November 2014. Results In general, the participants appreciated the quality and relevance of the TENSE training and evaluated the content of the training as beneficial. The TENSE training had no effect on the components of experienced stress, i.e., emotional exhaustion (p=0.751), depersonalization (p=0.701), and personal accomplishment (p=0.182). Furthermore, no statistically significant effects of the intervention on work contentment and stress reactions at work were found. Conclusions The TENSE training program did not have an effect on experienced stress, work contentment, nor stress reactions at work of nursing staff working in dementia special care units. In future studies, more focus on practicing new skills seems needed. Trial registration: NTR (Dutch Trial Registration) number NTR3620
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This study explores the long-term care (LTC) reform in the Netherlands and its relation to the day-to-day integrated care for frail elderly people, from the perspective of general practitioners (GPs). We assessed GP perspectives regarding which elements of the LTC reform have promoted and hindered the provision of person-centred, integrated care for elderly people in the Netherlands. We performed case studies conducted by semi-structured interviews, using the Healthy Alliances (HALL) framework as a framework for thematic analysis. GPs reported that the ideals of the LTC reform (self-reliance) were largely achievable and listed a number of positive effects, including increased healthcare professional engagement and the improved integration of the medical and social domains through the close involvement of social support teams. The reported negative implications were a lack of co-ordination in the implementation of the reforms by the municipality, insufficient funding for multidisciplinary team meetings and the reinforced fragmentation of home care. In particular, the implementation of the system reforms took place with little regard for the local context. We suggest that the implementation of national care reforms should be aligned with factors operating at the micro level and make the following recommendations: use one central location for primary health and social services, integrate regional ICT structures to improve the exchange of patient information, and reduce fragmentation in home care.
Article
Objective The Act in case of Depression program showed effects on the quality of life and depression in nursing home (NH) residents. We aimed to explore the effects of this complex multidisciplinary program on job satisfaction, job demands, and autonomy in nursing home staff. Design Four data points from a stepped-wedge cluster-randomized trial on patient outcomes were used for secondary analyses on staff outcomes. Setting Sixteen dementia special care and 17 somatic care units in Dutch NHs. Participants were 717 (90.1%) care staff or trainees, 34 (4.3%) paramedical staff, and 45 (5.7%) other staff members. Intervention describes procedures for nursing staff, activity therapists, psychologists, and physicians. It contains evidence-based pathways for depression assessment, treatment, and monitoring treatment results. Results Mixed models for intention-to-treat analyses showed no significant changes in job demands, job satisfaction, or autonomy. Models corrected for the ratio of unit residents who received, when indicated, a specific program component revealed reduced job demands and improved job satisfaction and autonomy when treatment procedures were used. A better use of assessment procedures was associated with increased job demands, while conducting monitoring procedures was associated with increased job demands and decreased autonomy. Conclusions Components of complex care programs may affect the staff outcomes in opposite directions and, taken together, produce a zero-sum or a statistically insignificant effect. While implementing treatment protocols affecting patients directly can also improve job outcomes such as satisfaction and autonomy and decrease job demands, it is possible that other procedures of complex programs may have unfavorable effects on job outcomes. It is important to account for specific components of complex interventions when evaluating intervention effects.
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Providing quality end of life care to older people in the era of COVID-19: Perspectives from five countries - Maria I. Lapid, Raymond Koopmans, Elizabeth L. Sampson, Lieve Van den Block, Carmelle Peisah
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Objectives To mitigate the spread of COVID-19, a nationwide restriction for all visitors of residents of long-term care facilities including nursing homes (NHs) was established in the Netherlands. The aim of this study was an exploration of dilemmas experienced by elderly care physicians (ECPs) as a result of the COVID-19 driven restrictive visiting policy. Setting and Participants ECPs working in Dutch NHs. Methods A qualitative exploratory study was performed using an open-ended questionnaire. A thematic analysis was applied. Data were collected between April 17 and May 10, 2020. Results Seventy-six ECPs answered the questionnaire describing a total of 114 cases in which they experienced a dilemma. Thematic analysis revealed 4 major themes: (1) The need for balancing safety for all through infection prevention measures versus quality of life of the individual residents and their loved ones; (2) The challenge of assessing the dying phase and how the allowed exception to the strict visitor restriction in the dying phase could be implemented; (3) The profound emotional impact on ECPs; (4) Many alternatives for visits highlight the wish to compensate for the absence of face-to-face contact opportunities. Many alternatives for visits highlight the wish to compensate for the absence of face-to-face opportunities but given the diversity of NH residents, alternatives were often only suitable for some of them. Conclusions and Implications ECPs reported that the restrictive visitor policy deeply impacts NHs residents, their loved ones, and care professionals. The dilemmas encountered as a result of the policy highlight the wish by ECPs to offer solutions tailored to the individual residents. We identified an overview of aspects to consider when drafting future visiting policies for NHs during the COVID-19 pandemic.
Article
Objectives To explore changes in advance care plans of nursing home residents with dementia following pneumonia, and factors associated with changes. Second, to explore factors associated with the person perceived by older adult care physicians as most influential in advance treatment decision making. Design Secondary analysis of physician-reported PneuMonitor trial data. Setting and Participants The PneuMonitor trial took place between January 2012 and May 2015 in 32 nursing homes across the Netherlands; it involved 429 residents with dementia who developed pneumonia. Methods We compared advance care plans before and after the first pneumonia episode. Generalized logistic linear mixed models were used to explore associations of advance care plan changes with the person most influential in decision making, with demographics and indicators of disease progression. Exploratory analyses assessed associations with the person most influential in decision making. Results For >90% of the residents, advance care plans had been established before the pneumonia. After pneumonia, treatment goals were revised in 15.9% of residents; 72% of all changes entailed refinements of goals. Significant associations with treatment goal changes were not found. Treatment plans changed in 20.0% of residents. Changes in treatment decisions were more likely for residents who were more severely ill (odds ratio 1.5, 95% CI 1.2-1.9) and those estimated to live <3 months (odds ratio 3.3, 95% CI 1.9-5.8). Physicians reported that a family member was often (47.4%) most influential in decision making. Who is most influential was associated with the resident’s dementia severity. Conclusions and Implications Overall, changes in advance care plans after pneumonia diagnosis were small, suggesting stability of most preferences or limited dynamics in the advance care planning process. Advance care planning involving family is common for nursing home residents with dementia, but advance care planning with persons with dementia themselves is rare and requires more attention.
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Background: older people often experience complex problems. Because of multiple problems, care for older people in general practice needs to shift from a ‘problem-based, disease-oriented’ care aiming at improvement of outcomes per disease to a ‘goal-oriented care’, aiming at improvement of functioning and personal quality of life, integrating all healthcare providers. Feasibility and cost-effectiveness of this proactive and integrated way of working are not yet established. Design: cluster randomised trial. Participants: all persons aged ≥75 in 59 general practices (30 intervention, 29 control), with a combination of problems, as identified with a structured postal questionnaire with 21 questions on four health domains. Intervention: for participants with problems on ≥3 domains, general practitioners (GPs) made an integrated care plan using a functional geriatric approach. Control practices: care as usual. Outcome measures: (i) quality of life (QoL), (ii) activities of daily living, (iii) satisfaction with delivered health care and (iv) cost-effectiveness of the intervention at 1-year follow-up. Trial registration: Netherlands trial register, NTR1946. Results: of the 11,476 registered eligible older persons, 7,285 (63%) participated in the screening. One thousand nine hundred and twenty-one (26%) had problems on ≥3 health domains. For 225 randomly chosen persons, a care plan was made. No beneficial effects were found on QoL, patients' functioning or healthcare use/costs. GPs experienced better overview of the care and stability, e.g. less unexpected demands, in the care. Conclusions: GPs prefer proactive integrated care. ‘Horizontal’ care using care plans for older people with complex problems can be a valuable tool in general practice. However, no direct beneficial effect was found for older persons.
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Background: The increasing number of community-dwelling frail elderly people poses a challenge to general practice. We evaluated the effectiveness of a general practitioner-led extensive, multicomponent program integrating cure, care, and welfare for the prevention of functional decline. Methods: We performed a cluster controlled trial in 12 general practices in Nijmegen, the Netherlands. Community-dwelling frail elderly people aged ≥70 years were identified with the EASY-Care two-step older persons screening instrument. In 6 general practices, 287 frail elderly received care according to the CareWell primary care program. This consisted of proactive care planning, case management, medication reviews, and multidisciplinary team meetings with a general practitioner, practice and/or community nurse, elderly care physician, and social worker. In another 6 general practices, 249 participants received care as usual. The primary outcome was independence in functioning during (instrumental) activities of daily living (Katz-15 index). Secondary outcomes were quality of life [EuroQol (EQ5D+C) instrument], mental health and health-related social functioning (36-item RAND Short Form survey instrument), institutionalization, hospitalization, and mortality. Outcomes were assessed at baseline and at 12 months, and were analyzed with linear mixed-model analyses. Results: A total of 204 participants (71.1%) in the intervention group and 165 participants (66.3%) in the control group completed the study. No differences between groups regarding independence in functioning and secondary outcomes were found. Conclusion: We found no evidence for the effectiveness of a multifaceted integrated care program in the prevention of adverse outcomes in community-dwelling frail elderly people. Large-scale implementation of this program is not advocated.
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Emotional development, an important component of nascent professional competence, is likely to be shaped by specific formative experiences. This study sought to identify and gauge the impact of highly evocative experiences occurring during medical school. A 34-item list of candidate formative experiences was developed through focus group meetings of "colleges program"-affiliated student-advising faculty. The resulting survey instrument was administered to 216 graduating medical students at the Johns Hopkins University School of Medicine in 2007 and 2008 in a cohort study. Primary outcomes were exposure rates for the experiences and students' ratings of impact for those that occurred. One hundred eighty-one students (84%) responded. All events were experienced by >25% of students. Two events were described by most as having tremendous impact: "finding an exceptional role model" and "identifying a perfect area of medicine." Other prevalent events with strong impact included "a special patient-care experience," "working well with a team," "seeing a patient whose life was saved," "encountering a negative role model," "seeing a patient die," "seeing a patient experience severe pain," and "a bad clinical experience." Factor analysis revealed three event clusters: "inspiring experiences," "mortality-related experiences," and "negative experiences relating to the learning environment." Specific formative experiences have especially strong impacts on medical students. Whereas the intrinsic value of such experiences should continue to drive educational design, increased awareness of the diversity and range of formative experiences will prepare educators to more effectively guide positive emotional development, enhancing personal and professional growth during medical school.
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We wanted to explore factors that influence Dutch and US physician treatment decisions when nursing home patients with dementia become acutely ill with pneumonia. Using a qualitative semistructured interview study design, we collected data from 12 physicians in the Netherlands and 12 physicians in North Carolina who care for nursing home patients. Our main outcome measures were perceptions of influential factors that determine physician treatment decisions regarding care of demented patients who develop pneumonia. Several themes emerged from the study. First, physicians viewed their patient care roles differently. Dutch physicians assumed active, primary responsibility for treatment decisions, whereas US physicians were more passive and deferential to family preferences, even in cases when they considered families' wishes for care as inappropriate. These family wishes were a second theme. US physicians reported a perceived sense of threat from families as influencing the decision to treat more aggressively, whereas Dutch physicians revealed a predisposition to treat based on what they perceived was in the best interest of the patient. The third theme was the process of decision making whereby Dutch physicians based decisions on an intimate knowledge of the patient, and American physicians reported limited knowledge of their nursing home patients as a result of lack of contact time. Physician-perceived care roles regarding treatment decisions are influenced by contextual differences in physician training and health care delivery in the United States and the Netherlands. These results are relevant to the debate about optimal care for patients with poor quality of life who lack decision-making capacity.
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Outcomes-based education in the health professions has emerged as a priority for curriculum planners striving to align with societal needs. However, many struggle with effective methods of implementing such an approach. In this narrative, we describe the lessons learned from the implementation of a national, needs-based, outcome-oriented, competency framework called the CanMEDS initiative of The Royal College of Physicians and Surgeons of Canada. We developed a framework of physician competencies organized around seven physician "Roles": Medical Expert, Communicator, Collaborator, Manager, Health Advocate, Scholar, and Professional. A systematic implementation plan involved: the development of standards for curriculum and assessment, faculty development, educational research and resources, and outreach. Implementing this competency framework has resulted in successes, challenges, resistance to change, and a list of essential ingredients for outcomes-based medical education. A multifaceted implementation strategy has enabled this large-scale curriculum change for outcomes-based education.
Article
Background All community-living older adults might benefit from integrated care, but evidence is lacking on the effectiveness of such services for perceived quality of care. Objective To examine the impact of Embrace, a community-based integrated primary care service, on perceived quality of care. DesignStratified randomized controlled trial. ParticipantsIntegrated care and support according to the “Embrace” model was provided by 15 general practitioners in the Netherlands. Based on self-reported levels of case complexity and frailty, a total of 1456 community-living older adults were stratified into non-disease-specific risk profiles (“Robust,” “Frail,” and “Complex care needs”), and randomized to Embrace or control groups. InterventionEmbrace provides integrated, person-centered primary care and support to all older adults living in the community, with intensity of care dependent on risk profile. MeasurementsPrimary outcome was quality of care as reported by older adults on the Patient Assessment of Integrated Elderly Care (PAIEC). Effects were assessed using mixed model techniques for the total sample and per risk profile. Professionals’ perceived level of implementation of integrated care was evaluated within the Embrace condition using the Assessment of Integrated Elderly Care. Key resultsOlder adults in the Embrace group reported a higher level of perceived quality of care than those in the control group (B = 0.33, 95 % CI = 0.15-0.51, ES d = 0.19). The advantages of Embrace were most evident in the “Frail” and “Complex care needs” risk profiles. We found no significant advantages for the “Robust” risk profile. Participating professionals reported a significant increase in the perceived level of implementation of integrated care (ES r = 0.71). Conclusions This study shows that providing a population-based integrated care service to community-living older adults improved the quality of care as perceived by older adults and participating professionals.
Article
To compare treatment of nursing home residents with dementia and lower respiratory tract infection (LRI) in Missouri and the Netherlands. Two separate but simultaneous prospective cohort studies. Nursing homes in Missouri (n=36) and the Netherlands (n=61). Selected residents (701 from Missouri and 551 from the Netherlands) diagnosed with LRI and dementia. Treatment, dementia severity, symptoms and signs of LRI, and general health condition were recorded at the time of diagnosis of LRI. Death was monitored at follow-up. Treatment and mortality, stratified for dementia severity, are reported. Treatment of nursing home-acquired LRI in Missouri residents involved a larger number of antibiotics, more frequent hospitalization, and greater use of intravenous antibiotics and rehydration therapy than in Dutch residents of equal dementia severity. Furthermore, for Missouri residents, intensive interventions were more often provided irrespective of severe dementia. By contrast, in both countries, treatments to relieve symptoms of LRI were provided for only a minority of residents. Dutch mortality rates were higher overall. Care for U.S. nursing home residents with LRI and dementia is more aggressive than care for Dutch residents, particularly in residents with severe dementia. These results are relevant to the debate on optimal care in relation to curative or palliative treatment goals.
Article
The introduction of competency-based postgraduate medical training, as recently stimulated by national governing bodies in Canada, the United States, the United Kingdom, The Netherlands, and other countries, is a major advancement, but at the same time it evokes critical issues of curricular implementation. A source of concern is the translation of general competencies into the practice of clinical teaching. The authors observe confusion around the term competency, which may have adverse effects when a teaching and assessment program is to be designed. This article aims to clarify the competency terminology. To connect the ideas behind a competency framework with the work environment of patient care, the authors propose to analyze the critical activities of professional practice and relate these to predetermined competencies. The use of entrustable professional activities (EPAs) and statements of awarded responsibility (STARs) may bridge a potential gap between the theory of competency-based education and clinical practice. EPAs reflect those activities that together constitute the profession. Carrying out most of these EPAs requires the possession of several competencies. The authors propose not to go to great lengths to assess competencies as such, in the way they are abstractly defined in competency frameworks but, instead, to focus on the observation of concrete critical clinical activities and to infer the presence of multiple competencies from several observed activities. Residents may then be awarded responsibility for EPAs. This can serve to move toward competency-based training, in which a flexible length of training is possible and the outcome of training becomes more important than its length.