RESUMEN
BACKGROUND: The Patient Journey Record system (PaJR) is an application of a complex adaptive chronic care model in which early detection of adverse changes in patient biopsychosocial trajectories prompts tailored care, constitute the cornerstone of the model. AIMS: To evaluate the PaJR system's impact on care and the experiences of older people with chronic illness, who were at risk of repeat admissions over 12 months. DESIGN: Community-based cohort study - random assignment into intervention and usual care group, with process and outcome evaluation. STUDY POPULATION: Adult and older patients with multiple morbidity, one or more chronic diseases with one or more overnight hospitalizations, and seven or more general practice visits in the past 6 months. COMPLEX INTERVENTION: PaJR lay care guides/advocates call patients and their caregivers. The care guides summarize their semi-structured conversations about health concerns and well-being. Predictive modelling and rules-based algorithms trigger alerts in relation to online call summaries. Alerts are acted upon according to agreed guidelines. ANALYSIS: Descriptive and comparative statistics. OUTCOMES: Impact on unplanned emergency ambulatory care sensitive admissions (ACSC) with an overnight stay; sensitivity of alerts and predictions; rates of care guides-supported activities. FINDINGS: Five part-time lay care guides and a care manager monitored 153 intervention patients for 500 person months with 5050 phone calls. The 153 patients in the intervention group were comparable to the 61 controls. The intervention group reported in 50% of calls that their health limited their social activities; and one-third of calls reported immediate health concerns. Predictive analytics were highly sensitive to risk of hospitalization. ACSC admissions were reduced by 50% compared to controls across the sites. DISCUSSION: The initial implementation of a complex patient-centred adaptive chronic care model using lay care guides, supported by machine learning, appeared sensitive to risk of hospitalization and capable of stabilizing illness journeys in older patients with multi-morbidity. CONCLUSION: Actions based on alerts produced in this study appeared to significantly reduce hospitalizations. This paves the way for further testing of the model.
Asunto(s)
Enfermedad Crónica/terapia , Manejo de la Enfermedad , Servicios de Salud/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Algoritmos , Inteligencia Artificial , Protocolos Clínicos , Estudios de Cohortes , Servicio de Urgencia en Hospital/estadística & datos numéricos , Ambiente , Femenino , Promoción de la Salud , Estado de Salud , Humanos , Masculino , Persona de Mediana Edad , Apoyo SocialRESUMEN
RATIONALE: Complex adaptive chronic care (CACC) is a framework based upon complex adaptive systems' theory developed to address different stages in the patient journey in chronic illness. Simple, complicated, complex and chaotic phases are proposed as diagnostic types. AIMS: To categorize phases of the patient journey and evaluate their utility as diagnostic typologies. METHODS: A qualitative case study of two cohorts, identified as being at risk of avoidable hospitalization: 12 patients monitored to establish typologies, followed by 46 patients to validate the typologies. Patients were recruited from a general practitioner out-of-hours service. Self-rated health, medical and psychological health, social support, environmental concerns, medication adherence and health service use were monitored with phone calls made 3-5 times per week for an average of 4 weeks. Analysis techniques included frequency distributions, coding and categorization of patients' longitudinal data using a CACC framework. FINDINGS: Twelve and 46 patients, mean age 69 years, were monitored for average of 28 days in cohorts 1 and 2 respectively. Cohorts 1 and 2 patient journeys were categorized as being: stable complex 66.66% vs. 67.4%, unstable complex 25% vs. 26.08% and unstable complex chaotic 8.3% vs. 6.52% respectively. An average of 0.48, 0.75 and 2 interventions per person were provided in the stable, unstable and chaotic journeys. Instability was related to complex interactions between illness, social support, environment, as well as medication and medical care issues. CONCLUSION: Longitudinal patient journeys encompass different phases with characteristic dynamics and are likely to require different interventions and strategies - thus being 'adaptive' to the changing complex dynamics of the patient's illness and care needs. CACC journey types provide a clinical tool for health professionals to focus time and care interventions in response to patterns of instability in multiple domains in chronic illness care.
Asunto(s)
Enfermedad Crónica/terapia , Cuidados a Largo Plazo/organización & administración , Adulto , Anciano , Anciano de 80 o más Años , Enfermedad Crónica/psicología , Estudios de Cohortes , Ambiente , Femenino , Servicios de Salud/estadística & datos numéricos , Estado de Salud , Humanos , Cuidados a Largo Plazo/psicología , Masculino , Cumplimiento de la Medicación , Salud Mental , Persona de Mediana Edad , Investigación Cualitativa , Autoinforme , Apoyo SocialRESUMEN
CASE PRESENTATION: We present the case of a pregnant woman who experienced a cerebral venous sinus thrombosis resulting in brain death at 13 weeks gestation. We discuss the management of the mother and foetus following this tragic event. We also discuss the complex medical, legal and ethical issues that arose following maternal brain death. The central question is whether continuing maternal organ supportive measures in an attempt to prolong gestation to attain foetal viability is appropriate, or whether it constitutes futile care. DISCUSSION: Successful maintenance of maternal brain somatic function to facilitate foetal maturation in utero has been reported. While the gestational age of the foetus is central to resolving this issue, there is no clear upper physiological limit to the prolongation of somatic function following brain death. Furthermore, medical experience regarding prolonged somatic support is limited. Finally, the legal rights conferred on the foetus may vary significantly depending on the jurisdiction in which the maternal brain death occurs and may have important implications. CONCLUSIONS: A consensus building approach, involving the family, is essential to resolving these potentially conflicting issues.