Restricted Access
Contract No IST-2004-026968
Acronym: K4CARE
Knowledge-Based HomeCare eServices
for an Ageing Europe
FP 6 Specific Targeted Research or Innovation Project
Thematic Priority 2:”Information Society Technology”
The K4CARE Model Validation
Authored by
Fabio Campana, CAD RMB
Co-Authored by
Erika Cerracchio, CAD RMB
Roberta Annicchiarico, IRCCS S. Lucia
Alessia Federici, IRCCS S. Lucia
October, 2007
Rome, Italy
1
Document information
project name:
K4CARE
contract no.:
IST-2004-026968
type of document:
Deliverable
file name:
The_K4CARE_Model_Validation
version:
2.0
authored by:
Fabio Campana
co-authored by
Erika Cerracchio
28.10.2007
Roberta Annicchiarico
Alessia Federici
released by:
Fabio Campana
approved by:
Co-ordinator
EC Project Officer
distribution list:
via restricted access
to www.k4care.net
secrecy:
30.10.2007
David Riaño
TABLE OF CONTENTS
1.
INTRODUCTION
4
2.
OBJECTIVES OF THE VALIDATION
4
3.
METHODS AND METRICS
4
4.
MATERIAL
5
A.
B.
C.
THE DOCUMENT “THE K4CARE MODEL”
THE QUESTIONNAIRE
THE PANEL OF EXPERTS
5
5
6
5.
RESULTS
7
6.
DISCUSSION
9
7.
APPENDIX 1: THE QUESTIONNAIRE
10
8.
APPENDIX 2: THE DOCUMENT “THE K4CARE MODEL”
12
-3-
K4CARE Consortium 2006
1. INTRODUCTION
The K4CARE Model is the prototype of home care (HC) service developed inside the K4CARE
project and supported by ICT technologies. The model wants to deal with the complexity of HC and
to provide an effective paradigm to implement ICT supported HC in European countries. The main
purpose of the K4CARE Model is to guide the activities that foster the realization of an integrated
system of HC services for the care of the elderly, the disabled persons, and the patients with
chronic diseases. This objective has the direct implication of helping people partially, temporary or
totally dependent to live in their environment as long as possible, and to contrast the improper use
of institutionalization.
The K4CARE Model has been realized providing proposals based on widely shareable
principles and established knowledge. The K4CARE Model was defined on the basis of published
experiences and on the basis of a concept of well known knowledge and commonly accepted
practice of geriatric medicine in the realm of HC. As a result, it is strongly influenced by ongoing,
working experiences, from the literature, from legislations, and from field experiences.
Reassuming, the principles that informed the definition of the K4CARE Model were:
1.
2.
3.
4.
knowledge: published literature and professional knowledge;
rules: national models and national laws in EU;
efficiency;
possible implementation.
The respect of these principles has to be validated in order to express an opinion about the
model.
2. OBJECTIVES OF THE VALIDATION
According to the principles that informed the definition of the K4CARE Model, it was mainly to
be ascertained the quality of the K4CARE Model with respect to:
1.
5.
6.
7.
knowledge: fulfil the indications of the literature and the professional knowledge about HC;
rules: fulfil the indications of national models of HC and national laws ruling HC in EU;
efficiency: satisfy the requirements of an efficient HC;
implementation: possibility of being effectively implemented.
3. METHODS AND METRICS
Since it was not possible to go through a real clinical trial, the validation of the model was
pursued submitting the K4CARE Model to a panel of Experts in the field, by analogy with the
established peer reviewing procedures of the scientific literature.
-4-
K4CARE Consortium 2006
Each participant was asked to read the document “The K4CARE Model” and state his/her
opinion filling the questionnaire. To obtain comparable opinions, the Experts were asked to fill in a
questionnaire containing structured answers, scoring form zero to four.
It was accepted that a “good opinion” was achieved in case of a general mean scoring >2. In
this case, the K4CARE Model could be considered as “validated”.
Scoring has been analyzed as mean scores (plus Standard Deviation, SD) according to
individual Experts and single items. Scoring is anonymized with respect to the name of the
individual Experts.
The validation process consisted of the following steps:
1. realize an abridged and commented version of the first deliverable of the project “D01 - The
K4CARE Model”, to present the model;
2. realize a questionnaire for a semi-structured interview of the experts;
3. define a panel of experts;
4. submit the questionnaire;
5. collect the answers;
6. analyze results;
7. write a report.
4. MATERIAL
a. The document “The K4CARE Model”
To make the readers aware of the background of the choices, it was realized an abridged and
commented version of the first deliverable of the project “D01 - The K4CARE Model”; for each of
the sections has been provided selected information. This information contains:
1. a selection of published works on the issue of home care that have been taken into
account to propose the K4CARE Model structures;
2. abstracts of the regulations proposed by national laws and rules, since the K4CARE
Model has been filtered through such indications;
3. were the published evidence resulted scarce or incomplete, the experience of the
medical partners in the K4CARE project was considered and enclosed in the shape of
general comments.
The extended version of “D01 - The K4CARE Model” has been made available and
downloadable at the project website www.k4care.net . The document “The K4CARE Model” is
enclosed as appendix 2.
b. The questionnaire
To obtain homogeneous and comparable reviews, it has been proposed a semi-structured
interview through a questionnaire in order to obtain comments and to summarize opinions. The
questionnaire consists of eighteen items, presenting statements about the different sections of the
model and about the general model in terms of respect of the knowledge and of the national
models, criteria of efficiency and possibility of implementation. For each item, the Expert could
score the statement itself and was asked to mark the cell which more corresponded to his/her
-5-
K4CARE Consortium 2006
opinion in terms of agreement: “No, 0; Scarcely, 1; Partially, 2; To a good extent, 3; Completely, 4;
Don’t know.” The questionnaire is enclosed as appendix 1.
c. The Panel of Experts
A Panel of eleven Experts from seven European Countries – Czech Republic, Finland, France,
Hungary, Italy, Spain, UK – was defined. The participants have been chosen among Experts in the
field of geriatrics, home care, health care systems, on the medical, social, and administrative side.
The Experts contacted are:
1. Dr Albert Alonso
MD, PhD
Postgraduate on Management and Organisation of Information Systems
Responsible of the Technological Innovation Unit (Information Systems)
Hospital Clinic
Barcelona
Spain
2. Professor Paolo Cascavilla
City Councillor Social Policy Commitee
Comune di Manfredonia
Italy
3. Dr Piero Ciccarelli
Direttore NHS ASUR Marche Zona Territoriale 9
Macerata
Italy
4. Dr Maria Elena Cingolani
Direttore NHS Distretto
ASUR Zona Territoriale 9
Macerata
Italy
5. Professor Janos Feher
MD, DSc.
2nd Dept. of Medicine
Semmelweis University
Budapest
Hungary
6. Professor John Gladman
Professor in Medicine for the Elderly
Rehabilitation & Ageing
Community Health Sciences
Queen's Medical Centre
-6-
K4CARE Consortium 2006
Nottingham
UK
7. Dr Marcela Kropíková,
Social, home-care and continuous care professional,
General University Hospital of Charles University in Prague,
Prague
Czech Republic
8. Professor Anne-Sophie Rigaud
MD, PhD
Department of Geriatrics
Broca Hospital
Paris
France
9. Professor Hilkka Soininen
MD, PhD
Department of Neurology
University of Kuopio
Finland
10. Professor Eva Topinkova
MD, DSc.
Head of the Department of Geriatrics
1st Faculty of Medicine
Prague
Czech Republic
11. Professor John Young
Head of Academic Unit of Elderly Care and Rehabilitation
St Luke's Hospital
Bradford
West Yorkshire
UK
5. RESULTS
Ten out of the eleven Experts contacted provided a completed questionnaire. The eleventh
declared that the document did not provide enough information to answer differently from “don’t
know”.
The mean overall score (SD) was 3.2 (.3). According to the individual Experts, the lowest mean
score was 2.2 (1.2), the highest 4.0 (.0). Scores according the anonymized Experts are in Table 1;
scores according to the single items are in Table 2.
-7-
K4CARE Consortium 2006
Table 1: Mean scores according to individual Experts.
Expert
A
B
C
D
E
F
G
H
I
J
Mean
3.5
3.5
3.0
2.6
3.7
4.0
3.4
2.2
4.0
2.4
SD
.5
.5
.8
.5
.5
.0
.9
1.2
.0
.5
Table 2: Mean scores according to single items.
1
2
The set of Actors proposed meets the criteria of an efficient HC model
The set of Actors proposed respects the general criteria applied in my Country
for HC
The Professional Actions proposed meet the criteria of an efficient HC model
The Professional Actions proposed respect the general criteria applied in my
Country for HC
The list of Services proposed meets the criteria of an efficient HC model
The list of Services proposed respects the general criteria applied in my
Country for HC
The proposal of Procedures to rule the Services meets the criteria of an
efficient HC model
The proposal of Procedures to rule the Services respects the general criteria
applied in my Country for HC
The use of Information Documents to share information during the process of
care meets the criteria of an efficient HC model
The use of Information documents to share information during the process of
care respects the general criteria applied in my Country for HC
The set of Evaluation Scales proposed for the MultiDimensional Evaluation
proposed meets the criteria of an efficient HC model
The set of Evaluation Scales proposed for the MultiDimensional Evaluation
respects the general criteria applied in my Country for HC
The K4CARE Model has been developed fulfilling the indications of the
literature and the professional knowledge about HC
The K4CARE Model has been developed fulfilling the indications of national
models of HC and national laws ruling HC in EU
The K4CARE Model satisfies the requirements of an efficient HC in my Country
The K4CARE Model satisfies the requirements of an efficient HC in Europe
The K4CARE model could be implemented in my Country
The K4CARE model could be implemented in Europe
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Overall
-8-
Mean score
3.7
3.2
SD
.5
.9
3.4
3.1
.7
.7
3.5
3.1
.5
.7
3.7
.7
3.2
.8
3.5
.8
2.9
1.0
3.6
.9
2.7
1.0
3.4
1.1
3.6
.5
3.3
3.5
2.9
3.2
1.0
.8
1.0
.7
3.2
.3
K4CARE Consortium 2006
The individual item with the lowest score is n°12 “The set of Evaluation Scales proposed for the
MultiDimensional Evaluation respects the general criteria applied in my Country for HC” with 2.7
(1.1), while the individual items with the highest score are n°7 “The proposal of Procedures to rule
the Services meets the criteria of an efficient HC model” with 3.7 (.7), and n°1 “The set of Actors
proposed meets the criteria of an efficient HC model” with 3.7 (.5).
6. DISCUSSION
The questionnaire quantifying and summarizing the opinion of the Panel of Experts reported an
overall mean score of 3.2 (.3). The actual score was substantially higher than the accepted
threshold of 2, score that indicated a “good opinion” about the model. According to this result, the
K4CARE Model could be considered as “validated”.
The lowest scoring individual Expert provided a mean score of 2.2 (1.2), and also this score
classified just upon the threshold of 2. Even if we can not concluded the this expert is fully
convinced by the model, on the other hand such a scoring allows the interpretation that the
K4CARE Model is not rejected even by the worst appraisal of the Panel.
Each single item scored >2, suggesting that there are not individual sections of the model
particularly weak. The individual item with the lowest score – n°12 “The set of Evaluation Scales
proposed for the MultiDimensional Evaluation respects the general criteria applied in my Country
for HC” – seems to reflect the already known fact that, even if the multidimensional approach is
accepted and also encouraged worldwide, a lack of consensus regarding the actual set of
instruments to be used is still real. The set of scale proposed for the MDE of the K4CARE Model
has a more than good acceptance, being item n°11 – “The set of Evaluation Scales proposed for
the MultiDimensional Evaluation proposed meets the criteria of an efficient HC model” – one of the
item scoring higher 3.6 (.9).
Two main issues of a HC model, Actors and Services, are at the basis of the whole service. The
K4CARE proposals – particularly Actors – have been highly appreciated (respectively, item n°1
and item n°5) suggesting that, apart from the ICT structure that will implement the K4CARE Model,
the HC model per se provides a paradigm for an efficient health care structure.
The proposal of using well defined Procedures to rule the Services collected an enthusiastic
approval (item n°7 scoring highest), possibly reflecting a need of structured ways of organizing and
providing services.
It as to be noted that, with regards to the couples if items investigating the complementary
aspects of efficiency ( “… meets the criteria of an efficient HC model”) and of respect of national
criteria ( “… respect the general criteria applied in my Country …”) of different sections, the first set
of items – efficiency – scored always higher. That seems to reflect a gap between a strongly
designed model and the actual national models. As a matter of facts, the highest difference is
shown by the MDE topic, with the characteristics discussed above.
The K4CARE model has been designed with the aim of possibly being implemented in real
environments. To these regards, items 15 to 18 play a critical role. Once again, reviewers feel
more confident with the possible realization of the model in Europe than in their own Countries.
The crucial item “The K4CARE model could be implemented in Europe” reported a score of 3.2
(.7), indicating the main goal of the design – a European model for HC – has been accomplished
and positively validated by the Panel of Experts.
-9-
K4CARE Consortium 2006
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
The set of Actors proposed meets the criteria of an efficient
HC model
The set of Actors proposed respects the general criteria
applied in my Country for HC
The Professional Actions proposed meet the criteria of an
efficient HC model
The Professional Actions proposed respect the general
criteria applied in my Country for HC
The list of Services proposed meets the criteria of an
efficient HC model
The list of Services proposed respects the general criteria
applied in my Country for HC
The proposal of Procedures to rule the Services meets the
criteria of an efficient HC model
The proposal of Procedures to rule the Services respects
the general criteria applied in my Country for HC
The use of Information Documents to share information
during the process of care meets the criteria of an efficient
HC model
The use of Information documents to share information
during the process of care respects the general criteria
applied in my Country for HC
The set of Evaluation Scales proposed for the
MultiDimensional Evaluation proposed meets the criteria of
an efficient HC model
The set of Evaluation Scales proposed for the
MultiDimensional Evaluation respects the general criteria
applied in my Country for HC
The K4CARE Model has been developed fulfilling the
indications of the literature and the professional knowledge
about HC
The K4CARE Model has been developed fulfilling the
indications of national models of HC and national laws ruling
HC in EU
The K4CARE Model satisfies the requirements of an
efficient HC in my Country
The K4CARE Model satisfies the requirements of an
- 10 -
K4CARE Consortium 2006
Don’t know
Completely
4
To a good extent
3
Partially
2
No
0
Please, mark (X) the cell which more corresponds to your
opinion about the statement
Scarcely
1
7. APPENDIX 1: THE QUESTIONNAIRE
17
18
efficient HC in Europe
The K4CARE model could be implemented in my Country
The K4CARE model could be implemented in Europe
Comments
- 11 -
K4CARE Consortium 2006
Don’t know
Completely
4
To a good extent
3
Partially
2
Scarcely
1
No
0
Please, mark (X) the cell which more corresponds to your
opinion about the statement
8. APPENDIX 2: THE
K4CARE MODEL”
DOCUMENT
“THE
Knowledge-Based HomeCare eServices
for an Ageing Europe
The K4CARE Model
- 12 -
K4CARE Consortium 2006
A Introduction
The K4CARE project (Knowledge-Based HomeCare eServices for an Ageing Europe – FP6
IST-2004-026968) is an EC project about the development, integration and use of several
Information and Communication Technologies (ICT) and intelligent Computer Science (CS)
technologies in the framework of Home Care (HC). The main objective of the K4CARE project is to
improve the capabilities of the new EU society to manage and respond to the needs of the
increasing number of senior population requiring a personalized HC assistance. K4CARE will
develop:
-
a model for HC service which can be shared by the EU countries;
an Electronic Home Care Record;
a telematic and knowledge-based CS platform;
a multi-agent system;
Actor Profile Ontologies for representing the profiles of the subjects involved in the
K4CARE model;
Case Profile Ontologies for representing symptoms, diseases, syndromes;
Formal Intervention Plans.
The K4CARE project is developed by thirteen EU partners: eight centres with geriatric, medical
and healthcare competencies and five ICT and CS centres1.
This document introduces the HC model developed inside the project and supported by ICT
technologies, capable to deal with the complexity of HC and aiming at providing an effective model
of how HC should be addressed in European countries and in the context of the European Union
recommendations. This model will be referred to as the K4CARE Model.
The main purpose of the K4CARE Model is to guide the activities that foster the realization of an
integrated system of HC services for the care of the elderly, the disabled persons, and the patients
with chronic diseases. This objective has the direct implication of helping people partially,
temporary or totally dependent to live in their environment as long as possible, and to contrast the
improper use of institutionalization.
BACKGROUND
Each of the structures has been realized providing proposals based on commonly accepted practice of geriatric
medicine in the realm of home care, widely shareable principles and established knowledge. Published works on the
issue of home care have been taken into account to provide reasons for the choices proposed in terms of staff, services,
methodology. Were the published evidence resulted scarce or incomplete, the experience of the medical partners in the
K4CARE project was considered. As a result, the description is strongly influenced by ongoing, working experiences,
1
Centro Assistenza Domiciliare Azienda Sanitaria Locale RM B – Italy – medical management; Geriatric Department of University of
Perugia – Italy; Ana Aslan International Academy of Aging – Romania; IRCCS Fondazione Santa Lucia – Italy; The Research Institute
for the Care of the Elderly – UK; General University Hospital in Prague - Czech Republic; Szent Janos Hospital – Hungary;
Amministrazione Comunale di Pollenza – Italy; Universitat Rovira i Virgili – Spain – coordinator; Czech Technical University in Prague –
Czech Republic – technical management; Telecom Italia S.p.A. – Italy; European Research and Project Office GmbH – Germany;
Computer and Automation Research Institute of the Hungarian Academy of Sciences – MTA SZTAKI – Hungary). The project is a three
st
year project with starting date on March, 1 2006.
- 13 -
K4CARE Consortium 2006
both from the literature and from field experiences. All the proposed structures were filtered according to national laws, in
order to recommend a model having the possibility of being realized in real environments.
- 14 -
K4CARE Consortium 2006
B The K4CARE Model
THE K4CARE MODEL
...
HCNS
Service
Actor
Action
Data/Information
Procedure
Figure 1: The K4CARE Model
In different European Countries, and in different areas of the same Countries, HC is structured
in different ways, according to local rules, laws, and funding. The different prototypes reflect
different approaches to HC, particularly referring to the kind of services provided, human resources
organization and dependences. The K4CARE Model provides a paradigm easily adoptable in any
of the EU countries to project an efficient model of HC.
The model proposes that the services be distributed by local health units and integrated with the
social services of municipalities, and eventual other organizations of care or social support. It is
aimed at providing the patient with the necessary sanitary and social support to be treated at
home; the K4CARE Model is designed to give priority to the support of the HC patient (HCP), his
relatives and Family Doctors as well.
The K4CARE project recommends a modular structure that can be adapted to different local
opportunities and needs. As shown in Figure 1, the K4CARE Model is based on a nuclear structure
which comprises the minimum number of common elements needed to provide a basic HC service:
the Home Care Nuclear Structure (HCNS). These elements are:
1.
2.
3.
4.
5.
the actors involved;
the actions and liabilities of such actors;
the services available;
the procedures;
the documents.
The HCNS can be extended with an optional number of HC Accessory Services (HCAS) that
can be modularly added to the nuclear structure. These services will respond to specialized care,
specific needs, opportunities, means, etc. of either the users of the K4CARE Model or the health-
- 15 -
K4CARE Consortium 2006
care community where the model is applied2. Each of the HC structures (i.e. HCNS and HCASs)
consist of the same elements (actors, actions, services, procedures,documents).
BACKGROUND
“The home is an important setting for health care delivery for the growing numbers of frail and disabled individuals,
offering the advantages of maintaining patients in the community as part of an intact family, delaying or preventing
reliance on public financial support, promoting the use of voluntary caregiver services and obviating the non-medical
3 4
costs of institutional care” .
In Italy “HC, hospital at home, home visits of GPs are part of the essential and uniform levels of care (LEA), to be
5
equally guaranteed in amount and intensity over the whole nation (DPCM 29/11/2001) .”
The K4CARE model has been realized according to the purposes of both providing a paradigm easily adoptable in
any of the current EU countries and also a working and efficient health-care model at the same time.
The K4CARE model proposes a prototype of an accessory service – namely, a rehabilitation unit – to show the
interaction among the basic service and more specialized ones.
The K4CARE Model can be mainly used for three purposes: use the model (actors, actions, services, procedures,
documents) to organize a HC service; use the model in order to foresee a possible future implementation with an ICT
structure; use the model to organize a HC service according to the K4CARE proposal from the start. In either of the
above settings, the contents of the model can be taken as a source of ideas, as a place to seek solutions to concrete
problems, as an explanation of how to organise some partial aspects (or functionality) in a HC system, or as a guide to
construct a complete healthcare system to assist patients at home.
2
The distinction between the HCNS and the complementary HCASs must be interpreted as a way of introducing flexibility and
adaptability in the K4CARE model and also as an attempt to provide practical suggestions for standards to be used when projecting and
realizing new services in largely different contexts.
3
Alecxih LMB, Lutzky S, Corea J. Estimated Savings from the Use of Home and Community-Based Alternatives To Nursing Facility
Care in Three States. Washington, D.C.: American Association of Retired Persons, 1996.
4
U.S. General Accounting Office. Medicaid and Long-Term Care: Successful State Efforts to Expand Home Services While Limiting
Costs. Washington, D.C.: U.S. GAO, 1994.
5
Ministero della Salute, Dipartimento della Qualità, Direzione Generale della programmazione sanitaria, dei livelli di assistenza e dei
principi etici di sistema. Commissione nazionale per la definizione e l’aggiornamento dei Livelli essenziali di assistenza.
- 16 -
K4CARE Consortium 2006
B.1 Actors
Actors are the human figures included in the
structure of HC: patients, relatives, physicians,
social
workers,
nurses,
rehabilitation
professionals, informal care givers, citizens, social
organisms, etc. In the HCNS, these individuals are
structured in three different groups of actors: the
patient6; the stable members of HCNS (the family
doctor, the physician in charge of HC, the head
nurse, the nurse, the social worker); the additional
care givers. The family doctor, the physician in
charge of HC, the head nurse, and the social
worker join in a temporary structure – the
Evaluation Unit (EU) – devoted to assess the
Figure 2 Actors
patient’s problems and needs.
Other groups
of professionals and non professional actors are usually part of the HC (Additional Care Givers:
ACG). Their presence is almost ubiquitous, even if their position can hardly be comprised inside
the core structure of HC. ACG do not have an exact and definite position in the context of the HC
network, but their role results, in most case, fundamental for the continuous care of the HCP.
A list of the actors:
- Patient (HCP)
- Family Doctor (FD)
- Physician in Charge of the HC (PC)
- Head Nurse (HN)
- Social Worker (SW)
- Nurse (Nu)
- Specialist Physician (SP)
- Social Operator (SO)
- Continuous Care Provider (CCP)
- Informal Care Giver (ICG)
BACKGROUND
The K4CARE model works thanks to an interdisciplinary team defined – according to the Merck Manual of Geriatrics7
as “an approach to care of the elderly patient in which team members from different disciplines collectively set goals and
share resources and responsibilities”. This organization is especially effective for patients who have complex medical,
psychological, and social needs. Teams are more effective in assessing patient needs and creating an effective care
plan than professionals working alone are. Frail elderly patients benefit from interdisciplinary teams, as do caregivers,
whose strengths and needs can be incorporated into the care plan. Core members of a geriatric interdisciplinary team
represent geriatric medicine, nursing, social work. Other members may represent physical or occupational therapy,
6
The average patient is an elderly patient, with co-morbid conditions and diseases, cognitive and/or physical impairment, functional loss
from multiple disabilities, and impaired self-dependency.
Geriatric Interdisciplinary Teams in The Merck Manual of Geriatrics. Ed: Mark H. Beers, MD Copyright© 2000-2006 by Merck & Co.
2005. Chapter 7.
7
- 17 -
K4CARE Consortium 2006
psychiatry or psychology, or nutritional counselling as needed (on an ongoing basis or for consultation). Patients and non
professional caregivers are part of the team8.
There is some evidence that a more integrated healthcare system may improve efficiency and patient treatment9.
“The multidisciplinary team of health professionals working in Primary Health Care (PHC) settings includes
physicians, nurses … physiotherapists, social workers, etc. … the physicians and nurses working in PHC settings … are
10
the two professions which are at the hub of the network of services.”
“A well trained family health nurse … is another key PHC professional by spending a large part of their time working
in patients’ homes and with their families.”11
Particular attention has been taken over the integration of medical and social issues. Prevention, maintenance and
recovering of senior population’s health is one of the most important goals of these services12. Services are organized
and integrated in a socio sanitary network that includes multi disciplinary activities provided by professional operators.
In Czech Republic: “Home care is a combination of health and social (sometimes referred to as Home Help) care13.”
“The Italian HC service is a model of care capable of providing co-ordinate and continuous delivery of integrated
services - sanitary and social - at home, from functionally coordinated different professional figures14.”
In Czech Republic “HC is delivered on high professional level and the team consists of qualified and well-experienced
members: physicians, nurses, physiotherapists, social workers etc.“ and “Home care … is based on close team
cooperation between physicians, nurses, physiotherapists, logopedists (speech therapists), psychologists, other
professionals in the field of health and social care on the one hand, and the client and his family or friends on the other
hand. Each member of the team is indispensable and his/her responsibilities result from his/her qualifications and the
length of working experience15.”
“NGOs are essential partners for health; they are a vital component of a modern civil society … and their role in
health should be strengthened. They can provide significant health and social care services to complement those of the
public and private sectors, thus mobilizing important untapped resources. In particular, their role in fostering self-help, i.e.
in helping people. … However, the strengths and potential of NGOs need to be more closely coordinated with organized
public efforts at community or national level to improve the health of population groups16.”
8
Ibidem
9
Ouwens M, Wollersheim H, Hermens R, Hulscher M, Grol R. Integrated care programmes for chronically ill patients: a review of
systematic reviews. International Journal of Quality in Health Care 2005 Apr; 17(2):141-6.
10
Health21: the health for all policy framework for the WHO European Region. (European Health for All Series ; No. 6).
http://www.euro.who.int/document/health21/wa540ga199heeng.pdf
11
http://www.see-educoop.net/education_in/pdf/family_health_nurse-oth-enl-t06.pdf
12
G. Bissolo, L. Fazzi (eds). Costruire l’integrazione sociosanitaria. Carrocci Faber; Rome 2005; 261-268.
13
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
14
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
15 15
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
16
Health21: the health for all policy framework for the WHO European Region. (European Health for All Series ; No. 6).
http://www.euro.who.int/document/health21/wa540ga199heeng.pdf
- 18 -
K4CARE Consortium 2006
B.2 Professional Actions and Liabilities
A number of professional liabilities are linked to each of the profiles of the professionals
included as Actors in the model; Professional Actions and Liabilities are the actions each actor
performs to provide a service within the HC structure. Among these general actions, a certain
amount correspond to those needed to perform the K4CARE Model services. The latter actions
have been categorized and coded to be enclosed in the ICT platform. In Table 3 is the list of HCNS
actions.
A brief description of the professional liabilities of the actors, related to HC:
The Family Doctor (FD) is the physician who is in charge of the patient. He/she provides primary
contact and continuous care toward the management of patients' health.
The Physician in Charge of the HC (PC) is a supervisor in the EU and the medical responsible
of the HC service; in some countries or areas he/she may correspond to the FD.
The Head Nurse (HN) mainly coordinates the work of the nurses to accomplish the intervention
plan.
The Social Worker (SW) identifies and evaluates social needs, manages the social implication
of the intervention plan.
The Nurse (Nu) is the provider of therapeutic procedures.
The Specialist Physician (SP) is a medical doctor specialized in one branch of medicine; the
most frequently employed SPs are Geriatricians, Cardiologists, Surgeons, Neurologists, Urologists
and they mostly operate as consultants.
The Social Operator (SO) usually works for local municipalities, or is hired from private
companies. SO represents the operative branch to support social needs of the HCP directly at
home, with special regard to ADLs and IADLs.
The Continuous Care Provider (CCP) is the actor who is in charge of the continuous care of the
HCP, usually 24 hours a day.
The Informal Care Giver (ICG) is a person who provides the HCP with a more or less relevant
amount of support, not being tied by professional or familiar relationships. ICG can be part of
citizen’s organizations, religious communities, or simply a neighbour.
The Evaluation Unit is composed by the Family Doctor, the Physician in Charge of the HC, the
Head Nurse, and the Social Worker. The EU is a team of HC professionals which assesses the
problem(s), defines an individual intervention plan (IIP), identifies the proper procedures, evaluates
the results and verifies the achievement of the goals defined by the IIP. The EU selects the
professional to cover the role of Case Manager (CM) played by the person who manages the
overall accomplishment of the Individual Intervention Plan (IIP) (usually the HN).
BACKGROUND
“The network model defines specific activities for each of the participants17.”
“Physicians share responsibility for the outcomes of care in the home and must be actively involved in the leadership
and direction of home care. With the evolution of sophisticated capabilities in home care and the tendency to use the
home setting as an alternative to institutional care, there is an increasing demand for direct physician supervision and
17
Geriatric Interdisciplinary Teams in The Merck Manual of Geriatrics. Ed: Mark H. Beers, MD Copyright© 2000-2006 by Merck & Co.
2005. Chapter 7
- 19 -
K4CARE Consortium 2006
involvement. Although non-physician members of the home care team can accomplish much of the actual delivery of
care, the physician must provide medical supervision and direction of that team in the management of care18.”
“The primary care physician should … have a family health profile, being able to recognize problems in terms of their
patients’ physical, psychological and social perspectives, and in particular those that are related to their family
circumstances or to deficiencies in their social support19.”
In Czech Republic “HC needs to be indicated by physicians. Physicians most often indicate HC to those clients who
are fully or partially dependant on another person’s assistance, who need to be given continued long-term or post-acute
care, or rehabilitation. As far as indication of HC is concerned, the “relevant physician” is usually a general practitioner.
… The relevant physician estimates the client’s overall health condition and the state of the client’s social environment
… including all the required health information about the client and the degree of his mobility.”20
In Hungary “The home care is an activity done by a trained nurse on the physician’s prescription in the home of the
patient. Home care activities can be done by nurses. Therapeutic gymnastics prescribed by physician can be done by
graduate physiotherapist. Ultrasound- and electro-therapy prescribed by physician can be done by physiotherapist
assistant and/or by physiotherapist. Speech rehabilitation prescribed by physician can be done by speech therapist21.”
In Italy “The GP is the figure in charge of the overall process of care22.”
“A well trained family health nurse, as recommended by the 1988 Vienna Conference on Nursing can make a very
substantial contribution to health promotion and disease prevention, besides being a care giver. Family health nurses
can help individuals and families to cope with illness and chronic disability, or during times of stress, by spending a large
part of their time working in patients’ homes and with their families. Such nurses give advice on lifestyle and behavioural
risk factors, as well as assisting families with matters concerning health. Through prompt detection, they can ensure that
the health problems of families are treated at an early stage. With their knowledge of public health and social issues and
other social agencies, they can identify the effects of socioeconomic factors on a family’ s health and refer them to the
appropriate agency. They can facilitate the early discharge of people from hospital by providing nursing care at home,
and they can act as the lynchpin between the family and the family health physician, substituting for the physician when
23
the identified needs are more relevant to nursing expertise .”
In Czech Republic “The degree of the client’s social disadvantage is assessed by a social worker24.“
The home care patient (or his family) has an active role in the intervention plan definition. This interaction aims to
obtain not only the patient’s compliance but proper solutions for his social needs. In prevention, rehabilitation and health
care best practice implies best medical solutions in a sustainable process for the patient and his social network. The
social worker evaluates the social sustainability of a course of health care25. The efficacy of an intervention plan for an
elderly patient ensues to the capability of his family or care providers group to support all the social implications of it. The
social worker’s task is to coach the patient’s network in two directions: bridging towards the social service providers and
26
bonding inside his family . The social worker makes a contextual assessment of the patient’s social needs and of his
social network in order to define the intervention plan objectives and activities together with the possible familiar
27
resources and abilities . The patient’s family and the care providers’ group can replace, help, improve and supervise his
abilities to perform ADLs and IADLs or to satisfy his social needs. Then the social worker must define a priority list of the
patient’s social needs and verify the availability and resources of the social service providers in order to fulfil them.
18
Journal of the American Geriatrics Society 37:1065-1066, 1989. Revised November 1990. Reviewed April 1993. Revised May 1999.
Revised November 2003. http://www.americangeriatrics.org/products/positionpapers/cmpsPF.shtml
Health21: the health for all policy framework for the WHO European Region. (European Health for All Series ; No. 6).
http://www.euro.who.int/document/health21/wa540ga199heeng.pdf
20
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
21
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
22
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
23
Health21: the health for all policy framework for the WHO European Region. (European Health for All Series ; No. 6).
http://www.euro.who.int/document/health21/wa540ga199heeng.pdf
24
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
25
O. Casale, P. Di Santo, P. Toniolo Piva. Il ritorno del sociale in sanità. Se il sistema sanitario vuole produrre salute. Animazione
Sociale 2006; 4:18-28.
26
R. Putnam. Bowling alone. The collapse and revival of American community. Simon & Schuster; New York 2000; 21.
27
E. Ripamonti. Coordinare le reti sociali. Animazione Sociale 2006; 6/7:72-83.
19
- 20 -
K4CARE Consortium 2006
In the United Kingdom: “A social worker or care manager will assess the needs of the person (and of any carers or
other family members) and develop a care plan to meet those needs28.”
“Caregivers, including family members, can also enhance the team's goals by identifying realistic and unrealistic
expectations based on the patient's habits and lifestyle29.”
In Italy “some Regions emphasize the role of the evaluation unit, for its ability to read the different dimensions of the
problems; others rely more often upon the decision of the MMG, for its acquaintance with the patient30.”
In Italy “the range of services in HC comprises:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Blood specimen collection
Execution of routine biologic surveys
Intramuscular injective therapy
Subcutaneous injective therapy
Vescical Catheterism (periodic substitution)
Instruction to use of aid for ambulation
Education of the care giver to use of aid for the mobilization of the patient
Education of the care giver to the activity of nursing (hygienic care, administration of therapies, etc)
Education of the care giver to the management of urinary derivations
Education of the care giver to the enterostomy management
Education of the care giver to the corrected mobilization/corrected positioning of the patient
Education of the care giver to the prevention of pressure lesions
Prescription of aid or prosthesis
Specialist physician consultation
31
Programmed visit of the GP .”
In Italy, the basic professional supplies for HC programs are classified as follows:
Professional supplies for clinical diagnostic evaluation
1. First visit to domicile (compilation of health record, anamnesis, physical examination, vital parameters)
2. Scheduled controls
3. Emergency visit
4. Test/evaluation scales (pain, self-dependency etc)
5. Clinical diary (monitoring signs and symptoms)
6. Blood specimen collection
7. Capillary blood specimen collection
8. Execution of routine biologic surveys
9. ECG
10. Specialist Physician consultation
11. Scheduled visits of GP
Professional supplies for educational/relational/environmental activities
12. Instruction to the care giver for the management of therapy
13. Education of the care giver to the activity of nursing (hygienic care, attendance to primary needs etc)
14. Education of the care giver to the use of aid for the mobilization of the patient
15. Education of the care giver to the management of urinary derivations
16. Education of the care giver to the management of enterostomy
17. Education of the care giver to the correct mobilization/correct positioning of the patient
18. Education of the care giver to the prevention of pressure lesions
19. Application of protective measures to the patients with reduced compliance
20. Hygiene of bedridden persons or with pressure lesions, assisted bathing
28
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
Geriatric Interdisciplinary Teams in The Merck Manual of Geriatrics. Ed: Mark H. Beers, MD Copyright© 2000-2006 by Merck & Co.
2005. Chapter 7
30
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
31
Ministero della Salute, Dipartimento della Qualità, Direzione Generale della programmazione sanitaria, dei livelli di assistenza e dei
principi etici di sistema. Commissione nazionale per la definizione e l’aggiornamento dei Livelli essenziali di assistenza.
29
- 21 -
K4CARE Consortium 2006
21. Instruction of the patient or the care giver to the use of aid for the ambulation and environmental evaluation
22. Interview with familiar/care giver
23. Interview with GP
24. Interview with Specialist Physician
25. Prosthesis prescription
Professional supplies for therapeutic clinical activities
a. Services for pharmacological treatments and for maintenance of the steady state
26. Prescription
27. Intramuscular injective therapy
28. Subcutaneous injective therapy
29. Intravenous injective therapy
30. Management of peripheral venous catheter
31. Management of central venous catheter; Port-a-cath
b. Professional supplies for excretory functions
32. Positioning/substitution management of urinary catheter
33. Appraisal of the urinary stagnation
34. Management of suprapubic catheter or other urinary derivations
35. Management of evacuation (hygienic-alimentary educational participation)
36. Enema/manual evacuation)
37. Management of enterostomy
c. Professional supplies for the treatment of the skin lesions
38. Simple medications (pressure, vascular, neoplastic, post-surgical, post actinic skin lesions)
39. Complex medications (pressure, vascular, neoplastic, post-surgical, post actinic skin lesions)
40. Local anesthesia
41. Wound suture
42. Removal of suturing stitches
43. Surgical Courettage
44. Elastic bandage
d. Services for rehabilitative treatments
45. Treatment of motor rehabilitation
46. Respiratory Rehabilitation
47. Language Rehabilitation
48. Recovery of the abilities connected with daily activities
Professional supplies for management
49. Definition of intervention plan
50. Periodic team meetings
51. Certifications
32
52. Report of the activity
In Hungary basic “HC activities are:
1. Doing and teaching of feeding through nasogastric, nasojejunal and PEG tubes.
2. Doing and teaching of trachea canule care (clearing and changing).
3. Changing of urine catheter and irrigation of the urine bladder.
4. Applying of intravenous infusions and parenteral medications.
5. Qualified care activities after surgical procedures.
6. Stoma care.
7. Pressure ulcer care.
8. Teaching of the use of prosthesis and other medical appliances.
9. Special activities:
a. ECG,
b. oxigene therapy,
c. respiration therapy,
d. use of suction,
e. use of lamps with therapeutic effects.
32
Ministero della Salute, Dipartimento della Qualità, Direzione Generale della programmazione sanitaria, dei livelli di assistenza e dei
principi etici di sistema. Commissione nazionale per la definizione e l’aggiornamento dei Livelli essenziali di assistenza.
- 22 -
K4CARE Consortium 2006
10.
11.
12.
13.
14.
Use of TENS machines.
Permanent assuaging of pain.
Speech therapy, medical gymnastics, electrotherapy.
Care of dying patient.
During the home care activities:
a. mental care, dietetic advise and all the necessary patient education have to be done,
b. care history has to be recorded,
c. permanent communication has to be assured with the general practitioner or with other physician in
charge33.”
In Czech Republic “In the framework of HC, socially disadvantaged clients are most frequently given the following
types of social help: simple nursing tasks, … dressing aid, help with getting on a wheel chair, to the toilette, on bed,
delivery of drugs, food and beverages, making breakfast, snack, lunch, dinner, help with serving food and drink, tidying
up, house chores, washing, ironing and minor mending of clothes, accompanying to a doctor, shopping, running errands.
Social help services, which ensure basic living necessities of socially disadvantaged clients, such as complete bathing
including washing hair, are provided free of charge34.“
In the United Kingdom “Local Authority Social Services departments (in Scotland this is the Social Work Department
and in Northern Ireland this is the Health and Social Services Trust) are responsible for arranging services which help
older and disabled people remain in their own homes. They can provide help with things like:
- getting in and out of bed
- bathing and washing
- preparing meals
- shopping
- cleaning
- equipment and adaptations to the home such as grab rails and bath seats
The local NHS can provide help with
- continence advice and equipment
- chiropody
- occupational therapy
- physiotherapy
- medical equipment such as wheelchairs and special beds
Many voluntary organisations provide services such as visiting, meals-on-wheels, shopping, gardening and transport
schemes35.”
33
34
35
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
- 23 -
K4CARE Consortium 2006
B.3 Services
Services are all the utilities provided by the HC structure for the care of the HCP.
The HCNS provides a set of services, classified into Access services, Patient Care services,
and Information services. Access services see the actors of the HCNS as elements of the K4CARE
model and they address issues like patient's admission and discharge from the HC model. Patient
Care services are the most complex services of the HC model, directly addressing the care of the
patient. Finally, Information services cover the needs of information that the actors require in the
K4CARE model. A complete list of this classification of services is reported in Table 1.
Table 1: Services of the HCNS
A. ACCESS SERVICES
ii. Special Medical Services
1. Individual Services
iii. Nursing Care
i. HC Request
iv. Social Assistance
ii. HCP Admission
v. Counselling
iii. HCP Discharge
C. INFORMATION SERVICES
iv. Professional Admission
1. Service Monitoring
v. Professional Discharge
i. Patient Record Overview
vi. Edit HCP/Professional information
ii. Patient Record Social Overview
2. Structural Services
iii. IIPs Overview
i. EU Constitution
iv. Schedule Overview
ii. EU-HCP Binding
v. Waiting List
B. PATIENT CARE SERVICES
2. HC Practice
1. Problem Assessment and Re-Evaluation
i. Guide Line Consultation
i. Comprehensive Assessment (CA)
ii. FIP Overview
ii. Multi-Dimensional Evaluation
iii. Pharmacological Therapy Handbook
iii. Clinical Assessment
iv. Best Practice Handbook
iv. Physical Examination
v. Brochure Consultation
v. Request of Diagnostic Examination
3. Database Inquiring
vi. Request of Laboratory Analysis
i. Activities Report
vii. Consultation
ii. Database Queries – services
viii. Social Needs and Social Network Assessment
iii. Database Queries – clinical
ix. Follow-up
4. Personal Information
2. Intervention Plan Definition
i. Individual Scheduling Overview
i. Planning Intervention Plan
ii. P2P Messages
ii. Prescription of Pharmacological Treatment
iii. Prescription of Non-Pharmacological Treatment
iv. Prescription of Nursing Care
v. Prescription of Assistive Devices
3. Intervention Plan Performance
i. Case Management
- 24 -
K4CARE Consortium 2006
HC is based upon the synergic actions of the
actors, including the assessment of the problem and
the identifying of the needs of the HCP, the definition
of
an
Individual
Intervention
Plan,
the
accomplishment of it through the proper procedures,
the evaluation of the results. This step-by-step
process can be executed several times, until the
achievement of proper results (Figure 3).
Following this work cycle, Patient Care services
are classified into Problem Assessment, Intervention
Plan Definition, and Intervention Plan Performance.
All the HCNS services for assessing the problem
aim at diagnosing the patient situation and reevaluating over time the results of the intervention;
core services of this section are Comprehensive
Assessment, Multi-Dimensional Evaluation, Social
Needs and Social Network Assessment, in addition
Figure 3
to the general medical and nursing approach. The
services to define the IIP aim at choosing the most promising course of actions (i.e. treatment)
based on the individualization of best practice; the same IIP defines periodical or end-treatment reevaluations, means and modalities aimed at evaluating results and measuring the implications of
the application of the intervention plan itself. The services to perform the intervention plan are
those addressed to the application of the IIP to the concrete HCP; they enclose general and
Special Medical Services, Nursing Care, Social Assistance, Counselling. A special attention is
given to the Case Management, the service which organizes, coordinates, and controls the specific
actions of specific actors on the individual HCP.
Information Services are those services which allow direct access to the information and the
knowledge that the system contains; information and knowledge provided can be used for different
purposes, mainly service monitoring, social issues, clinical issues, and health care related topics.
BACKGROUND
As stated in ‘Health21 - The health for all policy framework for the WHO European Region’36 “families (households)
are the basic unit of society where health care providers will be able not only to address patients’ somatic physical
complaints but also to take into account the psychological and social aspects of their condition. It is important for PHC
providers to know the circumstances in which patients live: their housing, family circumstances, work, and social or
physical environment may all have a considerable bearing on their illness. Unless care providers are aware of these
circumstances, presenting symptoms may be misinterpreted and conditions may go unrecognized and untreated. The
result may be unnecessary diagnostic and treatment procedures, thus increasing costs without helping to address the
real problems.”
In Italy “The HC consists in medical services, nursing services, rehabilitation, provided by qualified staff for the care
and the attendance of the dependent and frail persons, with active pathologies or functional outcomes, in order to
stabilize the health state, to limit the functional decline and to improve the quality of life. Fundamental is the integration
with the social services of the municipalities. The needs – medical and social – have to be evaluated through suitable
instruments that concur to the definition of care program and consequent commitment of resources37.”
In Hungary “Home care includes professional nursing care, physiotherapy, speech therapy and hospice care, and it is
provided in the home of the patient instead of at hospital. Thus, this type of service belongs to health care and not to
social care38.”
36
Health21 - The health for all policy framework for the WHO European Region.
http://www.euro.who.int/document/health21/wa540ga199heeng.pdf
37
Ministero della Salute, Dipartimento della Qualità, Direzione Generale della programmazione sanitaria, dei livelli di assistenza e dei
principi etici di sistema. Commissione nazionale per la definizione e l’aggiornamento dei Livelli essenziali di assistenza
38
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
- 25 -
K4CARE Consortium
In Romania HC services enclose: “social services regarding the caring of the elder, the preventing of the social
isolation of the elders, the support for the social reintegration, juridical and administrative counselling, financial support
for the services and current expenses payment, help for housekeeping, for food preparation … socio-medical services for
the personal hygiene, physical and psychic ability rehabilitation, home living improvement adequate for the elders’ needs
medical services like medical caring and investigations at home … drugs administration, to provide medical devices,
apparatus, appliances39.”
Comprehensive Geriatric Assessment (CGA) served as model for the process of assessment: it is a multidimensional
process designed to assess an elderly person's functional ability, physical health, cognitive and mental health, and socioenvironmental situation. The multidimensional process differs from a standard medical evaluation by including nonmedical domains, by emphasizing functional ability and quality of life, and by relying on interdisciplinary teams. This
assessment aids in the diagnosis of health-related problems, development of plans for treatment and follow-up,
coordination of care, determination of the need for and the site of long-term care, and optimal use of health care
resources. A multidisciplinary comprehensive approach to geriatric assessment has evolved over the past 20 years as a
40,41,42,43,44,45
. CGA of frail or chronically ill patients
way to improve the care of frail elderly patients with complex conditions
can improve their care and clinical outcomes. Several studies show benefits from this approach; these include greater
diagnostic accuracy, improved functional and mental status, reduced mortality, decreased use of nursing homes and
acute care hospitals, greater likelihood of living at home, and greater satisfaction with care46,47,48,49.
Thanks to Comprehensive Assessment (CA), the caregiver’s needs for counselling, training, support, and education
50,51
and environmental modifications can be recommended to improve function52.
can also be identified and addressed
CA has been defined by the 1987 National Institutes of Health Consensus Conference on Geriatric Assessment
Methods for Clinical Decision-making53 as a “multidisciplinary evaluation in which the multiple problems of older persons
are uncovered, described, and explained, if possible, and in which the resources and strengths of the person are
catalogued, need for services assessed, and a coordinated care plan developed to focus interventions on the person's
54,55, 56
.”
problems
“CA is an intervention that seeks to identify and remediate the causes and effects of disability. When remediation is
not possible, CA seeks to slow functional decline and bolster independence by mobilizing available medical,
psychological and social resources57.”
39
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
Kane RA, Kane RL. Assessing the elderly: a practical guide to measurement. Lexington, Mass.: Lexington Books, 1981.
41
Epstein AM, Hall JA, Besdine R, et al. The emergence of geriatric assessment units: the “new technology of geriatrics.” Ann Intern
Med 1987;106:299-303.
42
Applegate WB, Deyo R, Kramer A, Meehan S. Geriatric evaluation and management: current status and future research directions. J
Am Geriatr Soc 1991;39:Suppl:2S-7S.
43
Stuck AE, Siu AL, Wieland D, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials.
Lancet 1993;342:1032-6.
44
Campion EW. The value of geriatric interventions. N Engl J Med 1995; 332:1376-8.
45
Unguru G, Feinberg M. Geriatric assessment teams: a review of the literature. Consult Pharm 1998;13:553-63
46
Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials.
Lancet. 1993 Oct 23;342(8878):1032-6.
47
Nikolaus T, Specht-Leible N, Bach M, Oster P and Schlierf G. A randomized trial of comprehensive geriatric assessment and home
intervention in the care of hospitalized patients. Age and Ageing,1999; Vol 28, 543-550
48
Fretwell MD, Raymond PM, McGarvey ST et al. The senior Care Study: a controlled trial of consultative/unit based geriatric
assessment programme in acute care. J Am Geriatr Soc 1990;38:1973-81
49
Landefeld CS, Palmer RM, Kresevic DM et al. A randomized trial of care in a hospital medical unit especially designed to improve the
functional outcomes of acutely ill older patients. N Engl J Med 1995; 332:1338-44)
50
Bodenheimer T. Long-term care for frail elderly people. On Lok model. N Engl J Med. 1999;341(17):1324–1328.
51
Boult C, Pacala JT. Integrating healthcare for older populations. Am J Managed Care. 1999;5:45–52.
52
Caplan GA, Ward JA, Brennan NJ, et al. Hospital in the home: a randomised controlled trial. Med J Aust. 1999;170(4):156–160.
53
National Institutes of Health Consensus Conference on Geriatric Assessment Methods for Clinical Decision-making, 1987.
54
Reuben DB. Frank JC. Hirsch SH. McGuigan KA. Maly RC. A randomized clinical trial of outpatient comprehensive geriatric
assessment coupled with an intervention to increase adherence to recommendations. J Am Geriatr Soc. 47(3):269-76, 1999 Mar.
55 Siu AL. Kravitz RL. Keeler E. Hemmerling K. Kington R. Davis JW. Mitchell A. Burton TM. Morgenstern H. Beers MH. Reuben DB.
Postdischarge geriatric assessment of hospitalized frail elderly patients. Arch Intern Med. 156(1):76-81, 1996 Jan 8.
56 Weuve JL. Boult C. Morishita L. The effects of outpatient geriatric evaluation and management on caregiver burden. Gerontologist.
40(4):429-36, 2000 Aug.
57
Boult C. Brummel-Smith K. Post-stroke rehabilitation guidelines. The Clinical Practice Committee of the American Geriatrics Society. J
Am Geriatr Soc. 45(7):881-3, 1997 Jul.
40
- 26 -
K4CARE Consortium 2006
“Research evaluating CA demonstrates its ability to improve the health status and quality of life of frail older adults
across the spectrum of health care settings58.”
“Randomized trials of CA, applied across multiple health service settings, show it to be a cost-effective intervention
that improves quality of life, quality of health, and quality of social care. Its benefits have been most robustly
demonstrated when applied in a hospital or rehabilitation unit, but its value is also evident when used in the following
settings: after hospital discharge, as an element of outpatient consultation, in home assessment services, and in
continuity care.59”
“Comprehensive assessment has demonstrated usefulness in improving the health status of frail, older patients.
60
Therefore, elements of CA should be incorporated into the care provided to these elderly individuals .”
Positive effects of outpatient geriatric evaluation and management (GEM) on high-risk older persons' functional ability
and use of health services have been shown. Targeted outpatient GEM slows functional decline61 62 63.
In Italy “The empowerment of the use of the multidimensional comprehensive assessment is presented as a
64
fundamental issue; it constitutes an important prerequisite to determine and personalize interventions .”
In Italy “The admission to HC is provided through a multidimensional approach with the following essential
characteristics:
- the comprehensive functional evaluation of the patient through evaluation instruments used and validated on a wide
scale, standardized and capable to provide a synthesis of the clinical, functional, and social condition for the elaboration
of an individual intervention plan, allowing, at the same time, the definition of the individual and population case-mix;
- the definition of the IIP;
- a care approach through a multi-professional and multidisciplinary team, enclosing social workers;
- the monitoring and evaluation of outcomes.
Inside the team is defined a case-manager who, in collaboration with the GP, coordinates interventions according to the
65
IIP, enclosing prosthesis and pharmaceutical care .”
In the United Kingdom “Commissioning services involves assessment and care planning alongside the procurement
of services66.”
Care management is an essential component of coordinated health care delivery for people with chronic diseases
67
and complex health care needs.
As the number of older people with complex health care needs increases, the demand for coordinated health care,
including medical care and personal services, is growing.68
“Care management is a process of needs identification and service coordination designed to maximize function and
independence while also recognizing an individual's right to self-determination. The fundamental components of care
58
Bula CJ. Berod AC. Stuck AE. Alessi CA. Aronow HU. Santos-Eggimann B. Rubenstein LZ. Beck JC. Effectiveness of preventive inhome geriatric assessment in well functioning, community-dwelling older people: secondary analysis of a randomized trial. J Am Geriatr
Soc. 47(4):389-95, 1999 Apr.
59
Boult C. Pualwan TF. Fox PD. Pacala JT. Identification and assessment of high-risk seniors. HMO Workgroup on Care Management.
Am J Manage Care. 4(8):1137-46, 1998 Aug.
60
Keeler EB. Robalino DA. Frank JC. Hirsch SH. Maly RC. Reuben DB. Cost-effectiveness of outpatient geriatric assessment with an
intervention to increase adherence. Med Care. 37(12):1199-206, 1999 Dec.
61
A randomized clinical trial of outpatient geriatric evaluation and management. Boult C, Boult LB, Morishita L, Dowd B, Kane RL,
Urdangarin CF. Department of Family Practice and Community Health, University of Minnesota School of Public Health, Minneapolis,
USA. J Am Geriatr Soc. 46(3):296-302, 1998 Mar.
62
Boult C. Boult LB. Morishita L. Dowd B. Kane RL. Urdangarin CF.A randomized clinical trial of outpatient geriatric evaluation and
management. J Am Geriatr Soc. 49(4):351-9, 2001 Apr.
63
Cohen HJ. Feussner JR. Weinberger M. Carnes M. Hamdy RC. Hsieh F. Phibbs C. Courtney D. Lyles KW. May C. McMurtry C.
Pennypacker L. Smith DM. Ainslie N. Hornick T. Brodkin K. Lavori P. A controlled trial of inpatient and outpatient geriatric evaluation and
management. N Engl J Med. 346(12):905-12, 2002 Mar 21.
64
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
65
Ministero della Salute, Dipartimento della Qualità, Direzione Generale della programmazione sanitaria, dei livelli di assistenza e dei
principi etici di sistema. Commissione nazionale per la definizione e l’aggiornamento dei Livelli essenziali di assistenza.
66
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
67
Journal of the American Geriatrics Society 37:1065-1066, 1989. Revised November 1990. Reviewed April 1993. Revised May 1999.
Revised November 2003. http://www.americangeriatrics.org/products/positionpapers/cmpsPF.shtml
68
Lynn J. Measuring quality of care at the end of life: a statement of principles [see comments]. J Am Geriatr Soc. 1997;45:526-7.
- 27 -
K4CARE Consortium 2006
management are screening, case finding, assessment, care plan development, implementation and monitoring. … the
care management components may actually be done by one qualified health professional (nurse, social worker,
physician, other), or a care management team.69”
“Effective care management is a dynamic process, allowing for change according to the individual's needs. It should
assure appropriate use of health and social services, coordinate these with family-provided care, ensure quality of care,
and help with controlling unnecessary utilization and cost. To effectively meet the needs of an individual the care
manager/care management team must address the medical, psychological, functional and social domains of health care.
… state and private funding sources must recognize and support the valuable role of care management teams to ensure
appropriate allocation of resources, improved health care outcomes and patient/family satisfaction. … Studies have
demonstrated benefits of care management to people receiving home and community based care and to patients with
certain complex medical problems. Benefits to patients include: increased services, reduced unmet needs, increased
confidence in receipt of care, and increased life satisfaction70.”
“A crucial function of care management is to link medical care to the broader health support and social services
required by a patient with complex health needs. The care manager/ care management team member is most typically a
nurse or a social worker. Other professionals, including primary care providers, pharmacists and physical therapists may
provide care management services. In all disciplines, care managers must have multidisciplinary insight into key medical,
functional and social issues important to the care of patients with complex medical and social problems. They must have
a solid working knowledge and clinical experience in geriatrics and gerontology, including geriatric syndromes, geriatric
assessment, evidence-based management of common chronic diseases, basics of rehabilitation, and components of
home and community based care. In addition, they should have training in cultural sensitivity. Regardless of their primary
discipline, these professionals must also have a clear understanding of the goal of care management and its
71
fundamental components .”
In the United Kingdom: “If a person needs help at home from the local Social Services Department or the NHS then
they must have their needs assessed by a Care Assessment . … The assessment should be carried out following a
personal visit and the individual should be given the name of a person who will be responsible for their care services (the
Care Manager) together with a care plan explaining what services can and will be provided72.”
In Italy “HC requires the definition of individual plans of care related to the needs of the person73.”
“Geriatric Care Counseling is an independent professional geriatric care management service which was established
in 1994 for the purpose of assisting older adults and their families or other concerned parties in realistically assessing
needs and creating personalized plans tailored to meet the unique needs of each individual. GCC is able to simplify and
streamline the process of defining the needs of each senior and identifying the resources to best meet those needs74.”
“A program of individual and family counselling sessions and ongoing support for people who are caring for a
husband or wife with Alzheimer's disease has a major impact on how long they can keep their spouses at home with
them. … The study found that the counselling program helped caregivers gain more support from family and friends,
alleviating depression among caregivers and helping them understand and tolerate the memory and behavioural
problems that accompany Alzheimer75”
69
The care of dying patients: a position statement from the American Geriatrics Society. AGS Ethics Committee. J Am Geriatr Soc.
1995;43:577-8.
70
Journal of the American Geriatrics Society 37. http://www.americangeriatrics.org/products/positionpapers/cmpsPF.shtml
71
Boult C. Rassen J. Rassen A. Moore RJ. Robison S. The effect of case management on the costs of health care for enrollees in
Medicare Plus Choice plans: a randomized trial. J Am Geriatr Soc. 48(8):996-1001, 2000 Aug.
72
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
73
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
74
Geriatric Care Counseling/Web Des by Caresource. Karen Elliott Griesdorf, www.kegphotography.com. Last Updated 3-21-06.
75
Counseling Alzheimer's Caregivers Postpones The Nursing Home. Main Category: Alzheimer's / Dementia News
Article Date: 15 Nov 2006 - 21:00 PDT
- 28 -
K4CARE Consortium 2006
B.4 Procedures
A procedure is the chain of events that leads an actor in performing actions to provide services.
For each service, the sequence of actions constituting the procedure has been described. A
special table (an excerpt is reported in Table 4) links the actors involved in the procedure to the list
of actions that configure the procedure of a particular service, and to the documents needed in that
peculiar context.
As an example, the procedure for Comprehensive Assessment is reported below.
Comprehensive Assessment
a. The PC or the HN refers the admitted patient for a CA.
b. The HN assigns the members of the EU.
c. The HN sends a message to the patient to make an appointment.
d. The HCP confirms the appointment
e. The EU makes the patient’s assessment at home according to a standardized interview
(Multi-Dimensional Evaluation).
f. FD or PC performs Clinical Assessment and Physical Assessment.
g. The SW performs the Social Needs and Social Network Assessment.
h. The HCP provides the necessary information.
i. In case of a non-compliant or non reliable HCP, the CCP provides the necessary
information.
j. The HN performs Case Management or Back Office proper actions.
BACKGROUND
“The use of clinical practice guidelines and disease management protocols must be developed that will optimize
patient care yet allow for flexibility and tailoring services to the individual76.”
The use of procedures for the implementation of services and for the application of guidelines is recommended. As
an example, procedures have been developed to provide further guidance in relation to the Attendant Care Program
(ACP) Guidelines. They aim to assist service providers and clients to manage ACP services in line with the Guidelines
and current policies. The procedures apply to all ACP service providers and clients and are of relevance to Department
of Ageing, Disability and Home Care (DADHC) staff working in the Community Access and Contract Management areas
77
in Australia . Services explicitly run through procedures are:
- SERVICE ACCESS
o Applying for services
o Waiting list
o Prioritisation
o Withdrawal from waiting list
o Assessment
o The assessment report
o Re-assessments or reviews
o Approval & Allocation
- SERVICES DELIVERY
76
Journal of the American Geriatrics Society 37:1065-1066, 1989. Revised November 1990. Reviewed April 1993. Revised May 1999.
Revised November 2003. http://www.americangeriatrics.org/products/positionpapers/cmpsPF.shtml
Attendant Care Program (ACP) Procedures. Department of Ageing, Disability and Home Care March 2007.
http://www.dadhc.nsw.gov.au/NR/rdonlyres/F2249DF5-BB20-412E-8513-FED30662FFD9/2682/ACP_Procedures_March07.pdf
77
- 29 -
K4CARE Consortium 2006
-
-
o Commencing services
o Choosing a Service Provider
o Recruitment of attendant carers
o Use of attendant care hours
o Emergency Hours
o Counting rules
o Maximizing attendant care hours
o Change to the number of approved hours of service delivery
o Saving hours
o Pooling of hours
o Holidays
o Service interruptions
o Developing a Care Plan
o Review of services
o Discontinuation of services
o Changing Service Provider
o Access to Other Support Services
o Portability
o Compensable Clients
CONTRACT MANAGEMENT AND SERVICE MONITORING
o Performance Measures
o Quarterly
o Yearly
APPEALS AND COMPLAINTS.
The use of specific guidelines a defined procedures in HC is recommended and promoted by agencies providing
such services. As an example of good practice, can be indicated the case of the West Berkshire Council which has
clearly defined procedures for Home Care in an Assistants Handbook regarding Codes Of Conduct, Contract and
Personnel Records, Communication, Supervision & Training, Health and Safety, Policies & Procedures, Service
Standards & Practice Guidelines78.
The production of procedures is one of the efforts in planning telehealth in the emerging field of home healthcare
delivery79
78
79
West Berkshire Council at http://www.westberks.gov.uk/index.aspx?articleid=2237
http://www.informationfortomorrow.com/Fullviewoftelehealthpolicybook.pdf
- 30 -
K4CARE Consortium 2006
B.5 Information Documents
Information documents are required and produced by the actors to provide services in the HC
structure. The HCNS structure defines a set of information units whose main purpose is to provide
information about the care processes realized by the actors to accomplish a service. Different
types of actors will be supplied with specific information that will help them to carry out their duties
in the K4CARE Model. All these data are considered to be part of documents. At the same time,
those documents represent the basis of the Electronic Home Care Record, the electronic health
care record specifically realized inside the K4CARE project.
In particular, to support the actors taking part in the patient care services a list of documents
has been defined. Since these documents may have different general purposes inside the sets of
services and procedures, they can be sub-divided into:
- Request documents: contain information about a request of a service, an action of a
service, an appointment; they usually initiate a procedure for a service or a part of it.
- Authorization documents: are used to confirm and to authorize a certain action to be
performed; they are connected with key points in the development of a procedure.
- Prescription documents: contain the instructions deriving from a medical action.
- Anamnestic documents: contain information about the patient that will be historically used
in the process of care.
The actors involved can contribute to the generation of the document (write option) or may
require total or partial information the document hosts (read option). The interaction between
actors and documents is then defined by the options read (R), write (W) or both (RW).
Table 5 provides a description of the documents implied in the patient care services, subdividing
them into common documents, those which are used in different services, and service specific
documents, those which are specific for a definite service. For each document it is provided the
type (i.e. request, authorization, prescription, or anamnestic), the abbreviation (i.e. document code
for identification purposes), the name, and a description.
In order to support the information services a list of peculiar documents is defined (Table 6). In
general, information services documents report on underlying activities (e.g., Activities Report) –
even analyzed through semi-automatic queries – or on officially recognized information (e.g.,
Guidelines), related to HC. A special service is represented by the possibility of exchanging
messages among actors.
BACKGROUND
“To create, monitor, or revise the care plan, interdisciplinary teams must communicate openly, freely, and regularly.
Core team members must collaborate with trust and respect for the contributions of others and coordinate the care plan.
In usual care settings (i.e., care inside hospitals and other institutions) team members work together at the same site, so
communication can be informal and expeditious. This is not the case of home care, were the organization is distributed,
team members rarely meet each other, and the flow of information is neither constant nor complete. In the latter setting,
the role of ICT is essential80.”
80
Geriatric Interdisciplinary Teams in The Merck Manual of Geriatrics. Ed: Mark H. Beers, MD Copyright© 2000-2006 by Merck & Co.
2005. Chapter 7
- 31 -
K4CARE Consortium 2006
In Czech Republic “HC agencies are obliged to keep interim records about commencement, course, and completion
of home care including information about the client’s health condition, its changes, performed and planed services and
other facts that are important for a possible quality, extent and professional accuracy control81.“
81
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
- 32 -
K4CARE Consortium 2006
C MultiDimensional Evaluation
MultiDimensional Evaluation (MDE) is a multidimensional, interdisciplinary diagnostic process
to determine the medical, psychological and functional capabilities of a frail elderly person in order
to develop a coordinated and integrated plan for treatment and long-term follow-up. MDE
represents one of the fundamental features for the definition of the patient’s condition and needs.
For this reason it individuates a specific service inside the K4CARE Model. MDE in the K4CARE
model is based on a selected set of standardized evaluation scales largely accepted and used by
international teams for clinical, care, and research purposes.
In the K4CARE Model a two level approach is proposed: a first level which is common to all the
HCPs; and a second level which examines in depth those HCPs affected by one or both the main
syndromes considered in the model: immobility syndrome and cognitive impairment. As a result,
the MDE has a two-level structure:
-
1st level: to be performed for all the HCPs;
2nd level: to be performed in presence of immobility syndrome or cognitive impairment.
The instruments proposed are reported in Table 2.
Table 2: Evaluation scales for the MDE
Evaluation Scales I level
Barthel Index
Instrumental Activities Of Daily Living Scale (IADL)
Mini Mental State Examination (MMSE)
Mini Nutritional Assessment (MNA)
Tinetti Static Scale
Yesavage Geriatric Depression Scale (GDS)
Norton Scale
Modified Cumulative Illness Rating Scale (CIRS)
Home Assessment Checklist
Social Assessment Scale
Caregiver Burden Inventory (CBI)
Evaluation Scales II level Cognitive
GBS
Digit span
Clock Drawing Test (CDT)
Addenbrooke’s Cognitive Examination (ACE-R)
Neuropsychiatry Inventory (NPI-Q)
Evaluation Scales II level Immobility
S
SF-36
Rivermead Mobility Index (RMI)
Canadian Neurological Scale (CNS)
Motor Examination of Unified Parkinson’s Disease
R i S l (UPDRS)
Follow-up scales
CGIC-PF
Nursing Follow-up
BACKGROUND
“It is of great importance for the elderly patients to guarantee a continuous care from the hospital to home and vice
- 33 -
K4CARE Consortium 2006
versa with multi-dimensional evaluation82”.
MDE emphasizes quality of life and functional status, prognosis, and outcome that entail a workup of more depth and
breadth. MultiDimensional Evaluation of frail or chronically ill patients designed to optimize an older person's ability to
enjoy good health, improve their overall quality of life and improve their care and clinical outcomes. The possible benefits
include greater diagnostic accuracy, improved functional and mental status, reduced mortality, decreased use of nursing
homes and acute care hospitals, and greater satisfaction with care and enable them to live independently for as long as
possible. MDE differs from a standard medical evaluation by including non-medical domains, by emphasizing functional
ability and quality of life, and, often, by relying on interdisciplinary teams. This assessment aids in the diagnosis of
health-related problems, development of plans for treatment and follow-up, coordination of care, determination of the
need for and the site of long-term care, and optimal use of health care resources83.
Routine MDE “examines, at the very least, a patient's mobility, continence, mental status, nutrition, medications, and
personal, family, and community resources. It involves all disciplines responsible for providing care, as well as the patient
and family, in developing an appropriate care plan84.”
In the United Kingdom “the person who carries out the assessment should look at the emotional side of the
individual’s life as well as any physical difficulties. They take into account any health or housing needs and will contact
any other health and social care professionals who need to be involved. There may be a need for a specialist
assessment for a particular need (for example, for special adaptations to the home). This assessment may need to be
more comprehensive if it is to establish the different sorts of help that someone needs to stay in their own home. Such an
assessment might include several people such as a social worker, occupational therapist, nurse and perhaps even a
housing officer if there are special housing needs. If somebody already cares for the individual (for example a spouse)
85
then they should be involved in the assessment and can also ask for a separate assessment of their own needs .”
Barthel Index (BI): the BI was developed in 1965 and later modified by Granger and co-workers as a scoring
technique that measures the patient’s performance in 10 activities of daily life. The items can be divided into a group that
is related to self-care (feeding, grooming, bathing, dressing, bowel and bladder care, and toilet use) and a group related
to mobility (ambulation, transfers, and stair climbing). The maximal score is 100 if 5-point increments are used, indicating
that the patient is fully independent in physical functioning. The lowest score is 0, representing a totally dependent
bedridden state.
Instrumental Activities of Daily Living (IADL also called Lawton's scale) was developed by Lawton and Brody in 1969
and is based on a very useful questionnaire to evaluate the capacity of the subject to perform daily tasks governed by
cognitive functions (judgement, language, orientation, calculation, memory, planning). Thus, IADL measures the degree
of autonomy of an elderly individual.
The Mini-Mental State Examination (MMSE) is a brief 30-point questionnaire test that is used to assess cognition. It is
commonly used in medicine to screen for dementia. In the time span of about 10 minutes, it samples various functions,
including arithmetic, memory and orientation. It was introduced by Folstein et al in 1975, and is widely used with small
modifications. Any score over 24 (out of 30) is effectively normal. The normal value is also corrected for degree of
schooling and age. Low to very low scores correlate closely with the presence of dementia, although other mental
disorders can also lead to abnormal findings on MMSE testing.
The Mini Nutritional Assessment (MNA) provides a single, rapid assessment of nutritional status in the elderly of
different degrees of independence, allowing the prevalence of protein-energy malnutrition to be determined and to
evaluate the efficacy of nutritional intervention and strategies. Easy, quick and economical to perform, it enables staff to
check the nutritional status of elderly people.
Tinetti Static Scale assesses balance with 14 items (score out of 24) and gait with ten items (score out of 16) for a
total of 40 and predicts individuals who will fall at least once during the following year. The higher the score, the better
the performance (the lower the score, the higher the risk of falling). The cut-off score to identify individuals at risk of
falling from those not at risk of falling is 36 or greater with 70% sensitivity and 52% specificity (i.e. it identified 7 or 10
82
Di Gioacchino, Ronzoni, Mariano, Di Massimo, Porcino, Calvetti, Coen, L.M. Zuccaro, S.M. Zuccaro (2004): Home care prevents
cognitive and functional decline in frail elderly. Arch. Gerontol. Geriatri. Suppl. 9, 121
83
Darryl Wieland Comprehensive Geriatric Assessment http://www.medscape.com/viewarticle/465308_1
84
Journal of the American Geriatrics Society 37:1065-1066, 1989. Revised November 1990. Reviewed April 1993. Revised May 1999.
Revised November 2003. http://www.americangeriatrics.org/products/positionpapers/cmpsPF.shtml
85
F. Campana et al. D01 - The K4CARE Model - C. NATIONAL RULES AND LAWS. Pagg. 92-104.
- 34 -
K4CARE Consortium 2006
fallers). Aspects of balance measured are: standing and sitting balance, sit to stand, stand to sit, turn 360 degrees,
nudge on sternum, turn head, lean back, unilateral stance, reach object from high shelf, pick up object from floor.
Yesavage Geriatric Depression Scale (Short Form): the GDS is a self-report inventory, constructed to assess
depression and general well-being in the elderly (Yesavage et al., 1983). The GDS has been widely accepted by
clinicians because of its ease of use, and the absence of items assessing somatic and vegetative symptoms makes it
more appropriate for administration to the frail elderly than other symptom-based. To facilitate the use of the GDS as a
rapid screen for a clinically significant levels of depression in the elderly, shorter versions of the scale have been
published (Almeida & Almeida, 1999), the most widely used being a 15-item version (GDS-15) constructed by Sheikh
and Yesavage (1986). The items selected for this scale have content that is primarily focused on symptoms consistent
with a clinical diagnosis of depression, whereas the full scale includes a broader range of items and is more sensitive to
mild to moderate changes in mood.
The Norton scale was devised in 1960 as an additive scale to facilitate the prediction and prevention of pressure sore
development. The scale has been used both in the original version and in modified versions both in practice and as an
instrument in nursing research.The Norton scale assesses five domains: activity, incontinence, mental status, mobility,
and physical condition.
The Cumulative Illness Rating Scale (CIRS) is designed to measure the chronic medical illness burden in the elderly
persons. This is a 13-category scale measuring elderly persons' cardiovascular and respiratory system, gastrointestinal
system, genitourinary system, musculo-skeletal-integumentary system, neuro-psychiatric system, and general system.
Home Assessment Checklist: Factors that affect the patient's socio-environmental situation are complex and difficult
to quantify. They include the social interaction network, available social support resources, special needs, and
environmental safety. A checklist can be used to assess home safety.
The Social Assessment Scale has been specifically realized by the social experts of the Consortium, in order to
define an instrument capable of collecting all the relevant and pertinent information about social – and more in general
non medical – issues when facing European populations, actually living in substantially different environmental and social
conditions.
The Caregiver Burden Inventory (CBI) is a multidimensional scale to evaluate the impact of burden on different
aspects of caregiver’s life. CBI is a multiple-choice questionnaire that considers 5 burden dimensions: time-dependent
burden (TB), or objective burden, that evaluates stress caused by restriction of one’s personal time; developmental
burden (DB) that refers to the sense of failure regarding one’s hopes and expectations; physical burden (PB) that refers
to physical stress and somatic disorders; social burden (SB) caused by conflict of roles concerning one’s job or family;
emotional burden (EB) refers to the embarrassment or the feeling of shame caused by the patient. Each group includes
five items with a score system ranging from 0 (minimum stress) to 4 (maximum stress) and a total score ranging from 0
to 20 for each group.
The Gottfries-Brane-Steen (GBS) scale is a rating scale measuring three types of function (intellectual, emotional and
activities of daily living –ADL) and some behavioural and psychological symptoms common in dementia. The scale is
well established and has been in use for more than two decades. The scale presents a number of translations into
different European languages. GBS scale is a concrete Swedish rating scale for evaluating dementia syndromes. It can
be used by different types of professionals and it is easy to use after a short introduction/training. It is a comprehensive
semi-structured observer rating scale. An evaluation is made from an interview with the patient and observations of the
patient during the interview. Information from a caregiver or key person may also be needed. The scale includes 27 items
and has three subscales, the intellectual (12 items), the emotional (3 items) and the activities of daily living (ADL; 6
items) scales. It also has a section for rating of some behavioural and psychological symptoms that are common in
dementia (6 items).
Digit span: two items in the Wechsler and Stanford-Binet IQ tests are known as “forward digit span” and “backward
digit span.” Digit span is a common measure of short-term memory. As is usual in short-term memory tasks, here the
person has to remember a small amount of information for a relatively short time, and the order of recall is important. In
the forward version, the subject repeats a random sequence of one-digit numbers given by the examiner, starting with
two digits and adding another with each iteration. The subject’s score is the number of digits that he can repeat without
error on two consecutive trials. Digits-backward works exactly the same way except that the digits must be repeated in
the opposite order.
- 35 -
K4CARE Consortium 2006
Clock Drawing Test (CDT) is a simple test that can be used as a part of a neurological test or as a screening tool for
Alzheimer's and other types of dementia.
Addenbrooke’s Cognitive Examination (ACE-R) is a brief cognitive test that assesses five cognitive domains, namely
attention/orientation, memory, verbal fluency, language and visuospatial abilities. Total score is 100, higher scores
indicates better cognitive functioning.
Neuropsychiatric Inventory Questionnaire (NPI-Q) is a rapidly administered instrument that provides a reliable
assessment of behaviors commonly observed in patients with dementia. The NPI-Q may be a useful tool for family
physicians because it assesses the severity of the symptom in the patient and the distress the symptom causes in the
caregiver.
The Rivermead Mobility Index (RMI) is used to measure mobility in patients with head injury or stroke. The RMI
comprises a series of 14 questions and one direct observation, and covers a range of activities from turning over in bed
to running. It is short, simple, and clinically relevant, and can be used in hospital or at home.
The Canadian Neurological Scale (CNS) was designed to assess neurological function in conscious stroke patients.
It includes an assessment of level of consciousness, orientation, aphasia, and motor strength. Each domain is assigned
a score and a total score from 0 to 11.5 is calculated.
The Unified Parkinson’s Disease Rating Scale (UPDRS) was introduced in 1987 as an overall assessment scale that
would quantify all the motor and behavioural aspects of the disease as a single number. This allows the physician to
assess easily the worsening or improvement of PD with treatment and time. This scale is, therefore, widely used in
clinical research and drug trials. The UPDRS includes an evaluation of self-reported disability (i.e. the activities of daily
living, ADL) as well as clinical scoring by a physician (i.e. the motor examination). This rating scale compiles multiple
categories within the following areas:
* Mentation (mental activity), behaviour, and mood (I)
* Activities of daily living (ADL, II)
* Motor examination (III)
* Complications of therapy (IV)
* Hoehn and Yahr Stage scale (V)
* Schwab and England Scale (VI).
The model encloses only part III Motor examination and part V Hoen and Yahr Stage scale.
Clinical Global Impression of Change in Physical Frailty (CGIC-PF). The frailty syndrome derives from a cycle of
events that can be activated by many triggers. Frailty as a physical state should be distinguished from consequences of
frailty. Intrinsic frailty is due to physiologically based organ system impairments and physical performance limitations,
such as losses of strength, endurance, balance, body weight, and mobility. The consequences of frailty include changes
in functional independence, social roles, psychosocial factors, and healthcare utilization. Global frailty includes intrinsic
frailty and consequences. A similar situation exists with other conditions. For example, rheumatoid arthritis has intrinsic
elements, such as joint swelling and stiffness, and consequences, such as reduced function and social roles. For the
purpose of assessing Clinical Global Impressions of Change in Physical Frailty (CGIC-PF), the clinician is asked to
determine change in intrinsic frailty and in global frailty, separately.
The Nursing Follow-up Scale has been specifically realized by the experts of the Consortium, in order to define an
instrument capable of collecting all the relevant and pertinent information about nursing practice. The nurse has to asses
the needs of HCP for nursing and to define the nursing problem, the nursing diagnosis. This assessment is a systematic
and interactive process. The assessment conducted by nurses focus on specific individual characteristics, especially
functional abilities on the capacity to perform activities of daily living. This assessment process includes information, data
collection from different sources (patients, relatives, health personals and record etc), clinical judgement and evaluation,
validation of perceptions.
- 36 -
K4CARE Consortium 2006
Table 3: Actions in the K4CARE Model (HCNS)
BO
1
2
3
4
5
6
7
8
9
10
11
12
13
CM
14
15
16
P
17
18
19
20
21
EU
22
23
24
25
26
M
27
28
29
30
31
- 37 -
CODE
ACTION NAME
Back Office Activities
BO.1
provide information
BO.2
ask information
BO.3
refer the admitted patient for CA
BO.4
assign actor
BO.5
assign members of EU
BO.6
confirm or modify waiting lists
BO.7
schedule activity
BO.8
send message to the patient
BO.9
supervise HCP information
BO.10
authorize nursing care service
BO.11
forward the Blood Transfusion request
BO.12
send Transfusion Report
BO.13
actor confirmation
Case Management Activities
CM.1
supervise IP
CM.2
control performance of activities
CM.3
supervise achievement of outcomes
Patient Activities
P.1
confirm appointment
P.2
agree on interventions
P.3
give consent
P.4
request certification
P.5
ask intervention
EU Activities
EU.1
evaluate through scales
EU.2
define intervention plan
EU.3
define outcomes
EU.4
schedule controls
EU.5
schedule re-evaluations
Medical Activities
M.1
perform Clinical Assessment
M.2
perform Physical Examination
M.3
request Diagnostic Examination
M.4
request Laboratory Analysis
M.5
prescribe Pharmacological Treatment
ACTOR
ALL
ALL
PC
HN
HN
HN
HN
HN
HN
PC
PC
HN
ALL_CG
OR
OR
OR
SW
FD
SP
PC
HCP
SP
PC
CCP
CCP
CCP
CCP
CCP
ICG
PC
PC
PC
PC
PC
SP
SP
SP
SP
SP
HN
PC
PC
PC
HN
HN
HN
HCP
HCP
HCP
HCP
HCP
EU
EU
EU
EU
EU
FD
FD
FD
FD
FD
K4CARE Consortium
OR
32
33
34
35
36
37
38
39
MFD
40
41
42
43
44
45
MSP
46
47
48
49
50
51
S
52
53
54
55
56
57
58
- 38 -
CODE
ACTION NAME
prescribe non-Pharmacological Treatment
M.6
M.7
prescribe assistive devices
M.8
prescribe nursing care
M.9
refer to SP
M.10
write medical follow-up
M.11
write Certification
M.12
write INR Report
M.13
refer for transfusion
Medical FD Activities
M.FD.1
request HC
M.FD.2
request of re-evaluation
M.FD.3
authorize treatment proposed by SP or PC
M.FD.4
refer the HCP to SP for Certification
M.FD.5
refer the HCP for INR Follow-up
M.FD.6
authorize nursing care
Medical SP Activities
M.SP.1
write consultation report
M.SP.2
arterial blood collection
M.SP.3
takes specimen to laboratory
M.SP.4
collect blood bags
M.SP.5
perform the transfusion
M.SP.6
write tranfusion report
Social Activities
S.1
assess social needs and network
S.2
define social intevention
S.3
supervise achievement of social outcomes
S.4
contact social service providers
S.5
coach social network
S.6
write social report
S.7
perform assistive actions
ACTOR
FD
FD
FD
FD
FD
SP
FD
FD
OR
PC
PC
PC
PC
PC
FD
PC
PC
OR
SP
SP
SP
SP
SP
PC
SP
SP
SO
ICG
FD
FD
FD
FD
FD
FD
SP
SP
SP
SP
SP
SP
SW
SW
SW
SW
SW
SW
CCP
K4CARE Consortium 2006
OR
OR
CODE
ACTION NAME
Nursing Activities
N.1
Specimen Collection (blood, urine, faeces).
N.2
I.M. Injection.
N.3
Intravenous therapy .
N.4
Insertion, care and maintenance of peripheral intravenous infusion.
Catheter care (insertion or removal, including perineal/penile toilet and change of
N.5
drainage bag).
N.6
Stoma maintenance, including replacement of stoma bags and wafer maintenance.
N.7
Establishing and reviewing a stoma care program.
N.8
Care and maintenance of tracheostomy.
N.9
Care and maintenance of feeding tubes (nasogastric and PEG)
N.10
Care and maintenance of urostomic tubes
N.11
Care of analgesic pump
N.12
Care and fitting of prosthesis, and anti-embolic stockings
N.13
Assistance with nebulisers, metered aerosols, turbuhalers, canisters and inhalers
Monitoring of vital signs (checking the patient’s temperature, pulse, respiration, BP, and
N.14
pain)
N.15
Blood sugar measurement.
N.16
ECG
Maintenance of skin integrity, including changing of position of a chairfast or bedfast care
N.17
recipient.
N.18
Pressure Ulcer treatment
N.19
Treatment of other skin lesions
N.20
Simple wound dressings
N.21
Complex wound management
N.22
Insulin therapy
N.23
Suctioning airways
N.24
Enema administration
N.25
Training of CCP
N.26
write Nursing follow-up
N
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
- 39 -
K4CARE Consortium 2006
ACTOR
OR
OR
OR
OR
Nu
Nu
Nu
Nu
FD
FD
FD
FD
PC
PC
PC
PC
SP
SP
SP
SP
HN
HN
HN
HN
FD
FD
FD
FD
FD
FD
FD
FD
FD
PC
PC
PC
PC
PC
PC
PC
PC
PC
SP
SP
SP
SP
SP
SP
SP
SP
SP
HN
HN
HN
HN
HN
HN
HN
HN
HN
FD
FD
FD
PC
PC
PC
SP
SP
SP
HN
HN
HN
FD
FD
FD
FD
FD
FD
FD
FD
FD
PC
PC
PC
PC
PC
PC
PC
PC
PC
SP
SP
SP
SP
SP
SP
SP
SP
SP
HN
HN
HN
HN
HN
HN
HN
HN
HN
HN
Nu
Nu
Nu
Nu
Nu
Nu
Nu
Nu
Nu
Nu
Nu
Nu
Nu
Nu
Nu
Nu
Nu
Nu
Nu
Nu
Nu
Nu
Table 4: Example of procedure: the CA case
S3.1. Comprehensive Assessment (CA)
x a) The PC or the HN refers the admitted patient for a CA.
x (b) The HN assigns the members of the EU.
x
(c) The HN sends a message to the patient to make an
x appointment.
x (d) The HCP confirms the appointment
BO.3
refer the admitted patient for CA
BO.5
BO.13
assign members of EU
actor confirmation
BO.8
send message to the patient
P.1
confirm appointment
(e) The EU makes the patient’s assessment at home according
x to a standardized interview (Multi-Dimensional Evaluation).
(f) FD or PC performs Clinical Assessment and Physical
x Assessment.
x
(g) The SW performs the Social Needs and Social Network
x Assessment.
x (h) The HCP provides the necessary information.
(i) In case of a non-compliant or non reliable HCP, the CCP
x provides the necessary information.
(j) The HN performs Case Management or Back Office proper
x actions
EU.1
evaluate through scales
M.1
perform Clinical Assessment
M.2
perform Physical Examination
S.1
assess social needs and network
BO.1
provide information
BO.1
provide information
BO.6
confirm or modify waiting lists
x
BO.7
schedule activity
- 40 -
K4CARE Consortium 2006
D10
D1
D2
D5
Request of Comprehensive
Assessment
Actor Assignment
Actor Confirmation
Message to the Patient
D6
D11
Patient Confirmation
MDE Scales
D12
Clinical history
D13
D11
Physical Examination Report
MDE Scales
D3
Waiting List
D4
Daily Schedule
Table 5: Documents for the Patient Care Services (HCNS)
Type
Code
Name
Description
Common Documents
Request
Is the information that links an individual action to an individual HCP for an action (or series of actions) to
be performed.
Is the information that declares that the actor knows the assignment and accepts it.
The waiting list is automatically generated on the basis of requests, daily schedules, and priorities. Is
confirmed by the HN. Can be modified by the HN.
Daily Schedules are automatically generated on the basis of waiting lists and priorities. Different daily
schedules exist for different services and actors. They are confirmed by the HN. They can be modified by
the HN.
Is a message delivered to the HCP to inform that an action for a service is going to be to performed and
to make an appointment. Can be delivered by phone, via SMS or others.
Is a message delivered by the HCP to inform that he/she accepts the appointment for an action to
performed. Can be delivered by phone, via SMS or others.
Is the information which consents that a certain action (or series of actions) is accepted by the HCP and
can be performed.
Is the information which consents that a certain action (or series of actions) is accepted by the (legally
responsible) CCP and can be performed, in case of HCP non capable of giving consent.
Is the authorization that the FD (ultimate responsible of the HCP’s care) gives for certain actions to be
performed.
Actor Assignment
Authorization
Actor Confirmation
Authorization
Waiting List
Authorization
Daily Schedule
Request
Message to the Patient
Authorization
Patient Confirmation
Authorization
Patient Consent
Authorization
CCP Consent
Authorization
FD Authorization
Comprehensive Assessment
Request
Request of CA
Multi-Dimensional Evaluation
Anamnestic
MDE Scales
Clinical Assessment
Anamnestic
Clinical history
Physical Examination
Anamnestic
Physical Examination Report
Request of Diagnostic Examination
Request
Request
Examination
Request of Laboratory Analysis
Request
Request of Laboratory Analysis
Consultation
Request
Request of Consultation
Anamnestic
Consultation Report
Service Specific Documents
- 41 -
of
Diagnostic
Is the request that allows the HCP to undergo a comprehensive assessment. Is done by the PC or the HN,
after patient’s admittance to the service.
Set of forms filled in by the EU during the first problem assessment and/or in occasion of the periodical or
end-treatment re-evaluation.
All the available pertinent clinical information of the HCP (previous test results, discharge sheets,
consultations, previous treatment). It is written by the FD and PC; is read by EU and the other
professionals in charge of the patient (according to their competencies in the process of care of the
individual patient), by the patient him/herself.
The report contains signs and symptoms of diseases and/or conditions. It is written by FD, PC, SP; can be
updated in any occasion of evaluation. It is read by FD, PC, HN; SP and Nu in charge of the Patient.
Request of diagnostic examination necessary to define the actual clinical condition of the HCP; is written
by FD, PC, SP in charge of the patient.
Request of laboratory analysis necessary to define the actual clinical condition of the HCP; is written by
FD, PC, SP in charge of the patient.
Is the information to refer the HCP to a SP, to better define different aspects of care. It is usually done by
the SP, but can also be done by the PC or the SP.
Contains clinical observations and proposals made by the SP. Is usually addressed both to the patient and
K4CARE Consortium 2006
Type
Code
Name
Description
the FD.
Social
Needs
Assessment
Follow-up
and
Network
Planning Intervention Plan
Prescription
of
Pharmacological
Treatment
Prescription of Non-Pharmacological
Treatment
Prescription of nursing care
Anamnestic
Social Report
Contains the observations regarding social issues done by the SW at evaluation times.
Anamnestic
Anamnestic
Medical follow-up form
Nursing follow-up form
Anamnestic
CCP Report
Anamnestic
SO Report
Anamnestic
ICG Report
Anamnestic
HCP Report
Request
Request of Extra CA
Prescription
Prescription
Prescription
IP
Re-evaluation Plan
Prescription of Pharmacological
Treatment
Prescription
of
NonPharmacological Treatment
Prescription of nursing care
Authorization of
nursing care
Prescription of Assistive Devices
It is written by the FD or the PC during the follow-up activities.
It is written by the Nu or the HN during the follow-up activities.
It is written by the CCP during the follow-up activities. Can be used to indicate intervening difficulties or
changes.
It is written by the SO during the follow-up activities. Can be used to indicate intervening difficulties or
changes.
It is written by the ICG during the follow-up activities. Can be used to indicate intervening difficulties or
changes.
It is written by the HCP during the follow-up activities. Can be used to indicate intervening difficulties or
changes.
It is written by the FD when he detects such changes during the follow-up activities to deserve an extra CA
of the HCP.
Is written by members of the EU in order to define actions, actors and outcomes of the IP.
Defines times and modalities to evaluate the accomplishment of the IP in terms of goals and results.
Request
Request of Blood Gas Analysis
Request of BGA laboratory test.
Request
Request of Blood Transfusion
Request of BT.
Anamnestic
Document declaring that a BT has been performed.
Anamnestic
Request
Transfusion Report
Request of
Certification
Certification
Request of INR
Anamnestic
Request
INR Report
Request of Nursing Care
Contains the results of the INR test.
Request of activating nursing care, following the prescription of nursing care.
Prescription
Prescription
Prescription
Authorization
Prescription of Assistive Devices
Special Medical Services:
Blood Gas Analysis
Special Medical Services:
Blood Transfusion
Special Medical Services:
Certification
Special Medical Services:
INR follow-up
Nursing Care
- 42 -
Request
Medical instructions to treat diseases or disorders.
Medical instructions to treat diseases or disorders.
Medical instructions define nursing care to be used to treat diseases or disorders.
It is written by PC to authorize the performance of nursing care.
Medical definition of assistive devices to be used to support impairments and handicaps.
Request of a medical document to be used for legal purposes.
Medical document to be used for legal purposes.
Request of actions needed to perform an INR test .
K4CARE Consortium 2006
Social Assistance
Counselling
- 43 -
Type
Request
Anamnestic
Anamnestic
Code
Name
Social Support Request
Social Coaching Report
Information Sheet
Description
Request of actions of social support, written by the SW.
Definition of a series of social support action, written by the SW.
Information addressed to the care givers, mainly to the non-professional ones.
K4CARE Consortium 2006
Table 6: Documents for the Information Services.
SERVICE
Service Monitoring
Patient Record Overview
Patient Record Social Overview
IIPs Overview
Schedule Overview
Waiting List
HC Practice
Guide Lines Consultation
FIP Overview
Pharmacological Therapy Handbook
Best Practice Handbook
Brochure Consultation
Database Inquiring
Activities Report
Database Queries – services
Database Queries – clinical
Personal Information
Individual Scheduling Overview
P2P Messages
DOCUMENT
ACTOR
R
W
Patient Record
Patient Record
IIP
Daily Schedule
Waiting List
PC, HN, FD, HCP, CCP, SP
SW
PC, HN
PC, HN
PC, HN, FD, SP, Nu, SW, SO
=
=
=
=
=
*
*
*
*
*
Guide Lines Library
FIP Library
Pharmacological Therapy
Handbook
Best Practice Handbook
Information Sheet
PC, HN, FD, SP, Nu, SW, SO
PC, HN, FD, SP, Nu, SW, SO
PC, FD, SP
=
=
=
**
**
**
PC, HN, FD, SP, Nu, SW, SO
ALL
=
=
**
**
Activities Report
Semi-automatic query
Semi-automatic query
PC, HN
PC, HN, FD, SP, Nu, SW, SO
PC, HN, FD, SP, Nu, SW, SO
=
=
=
*
=***
=***
Daily Schedule
Message
HCP, PC, HN, FD
ALL
=
=
*
=
*the information derives from documents written during the services.
**introduced by the scientific committee
***modify existing queries
- 44 -
K4CARE Consortium

アメリカにおける救急看護の現状と将来 M.M.McMahon, RN,CEN,NP

3.2 –Management structure and procedures TABLE 3.2

Career Spotlight Interview with Hollee

Health Communication Partnership (HCP)

Nucleus 360®

Tuition Fees - Passaic County Technical Institute

Maastricht University Radboudumc Nijmegen University Medical

Nurses for Nursing Homes throughout the United Kingdom

FWPS Highly Capable Program Screening Process

Downriver Career Technical Consortium