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The purpose of this paper is to draw attention to the discursive construction of multimorbidity. The study illustrates how the social reality of multimorbidity and the agency of patients are discursively constructed in scientific articles addressing care for people with multiple chronic conditions.

The study is based on the postmodern assumptions about the power of talk and language in the construction of reality. Totally 20, scientific articles were analysed by critically oriented discourse analysis. The interpretations of the findings draw on the agency theories and principals of critical management studies.

Four discourses were identified: medical, technical, collaborative and individual. The individual discourse challenges patients to become self-managers of their health. It may, however, go too far in the pursuit of patients’ active agency. The potential restrictions and consequences of a “business-like” orientation must be paid careful attention when dealing with patients with multimorbidity.

The data consisted solely of scientific texts and findings therefore serve as limited illustrations of the discursive construction of multimorbidity. In future, research focusing for example on political documents and practice talk of professionals and patients is needed.

The findings highlight the power of talk and importance of ethical considerations in the development of care for challenging patient groups.

By identifying the prevailing discourses the study attempts to cast doubt on the taken-for-granted understandings about the agency of patients with multimorbidity.

Three types of payment methods have been introduced across European countries in attempts to encourage better, more integrated care of persons with multimorbidity: pay-for-performance; pay-for-coordination; and an all-inclusive payment method. We examine whether there are differences in the way these payment methods affect health and healthcare use in persons with multimorbidity.

Using individual-level survey data from twenty European countries, we examine unadjusted differences in average outcomes for the years 2011–2015 by whether countries adopted new payment methods for integrated care. We then test for a differential effect for multimorbid persons using linear, individual random effects regressions, including country and time fixed effects and clustering standard errors at the country level.

We find little effect of varying payment methods on key outcomes for multimorbid individuals despite the theoretical predictions and the rhetoric in many policy documents.

Policymakers should bear in mind that the success of the payment method relies on the specific design of the incentives and their implementation. New effective models of care and how to incentivise these for multimorbid patients is an ongoing research priority.

This paper is the first to study the effects of payments for integration on the dimensions and populations these schemes intend to affect; health and healthcare use at the individual level for multimorbid individuals.

The purpose of this paper is to assess frailty, geriatric conditions and multimorbidity in people experiencing homelessness (PEH) using holistic evaluations based on comprehensive geriatric assessment (CGA) and draw comparisons with general population survey data.

Cross-sectional observational study conducted in a London-based hostel for single PEH over 30 years old in March–April 2019. The participants and key workers completed health-related questionnaires, and geriatric conditions were identified using standardised assessments. Frailty was defined according to five criteria in Fried’s phenotype model and multimorbidity as the presence of two or more long-term conditions (LTCs). Comparisons with the general population were made using data from the English Longitudinal Study of Ageing and the Health Survey for England.

A total of 33 people participated with a mean age of 55.7 years (range 38–74). Frailty was identified in 55% and pre-frailty in 39%. Participants met an average of 2.6/5 frailty criteria, comparable to 89-year-olds in the general population. The most common geriatric conditions were: falls (in 61%), visual impairment (61%), low grip strength (61%), mobility impairment (52%) and cognitive impairment (45%). All participants had multimorbidity. The average of 7.2 LTCs (range 2–14) per study participant far exceeds the average for even the oldest people in the general population.

To the best of authors’ knowledge, this is the first UK-based study measuring frailty and geriatric conditions in PEH and the first anywhere to do so within a CGA-type evaluation. It also demonstrates the feasibility of conducting holistic evaluations in this setting, which may be used clinically to improve the health outcomes for PEH.

Integrated health and social care initiatives are increasing and health and social care systems are aiming to improve health and social outcomes in disadvantaged groups. There is a global dialogue surrounding improving services by shifting to an integrated health and social care approach. There is consensus of what is “health care”; however, the “social care” definition remains less explored. The authors describe the state of “social care” within the current integrated care literature and identify the depth of integration in current health and social care initiatives.

A narrative literature review, searching Medline, PsychINFO, CINAHL, PubMed, Scopus and Cochrane databases and grey literature (from 2016 to 2021), employing a search strategy, was conducted.

In total. 276 studies were eligible for full-text review, and 33 studies were included and categorised in types: “social care as community outreach dialogues”, “social care as addressing an ageing population”, “social care as targeting multimorbidity and corresponding social risks factors” and “social care as initiatives addressing the fragmentation of services”. Most initiatives were implemented in the United Kingdom. In total, 21 studies reported expanding integrated governance and partnerships; 27 studies reported having health and social care staff with clear integrated governance; 17 had dedicated funding and 11 used data-sharing and the integration of systems’ records.

The authors' demonstrate that social care approaches are expanding beyond the elderly, and these models have been used to respond to multimorbidity [including coronavirus disease 2019 (COVID-19)], targeting priority groups and individuals with complex presentations.

Polypharmacy, the concurrent use of multiple medicines by one individual, is a common and growing challenge driven by an ageing population and the growing number of people living longer with chronic conditions. Up to 11% of unplanned hospital admissions in the UK are attributable to, mostly avoidable, harm from medicines. However, this topic is not yet central to integrated practice. This paper reviews the challenge that polypharmacy presents to the health and care system and offers lessons for integrated policy and practice.

Two commonly encountered scenarios illustrate the relevance of addressing inappropriate polypharmacy to integrated practice. An overview of the literature on polypharmacy and frailty, including two recent large studies of policy and practice in Europe, identifies lessons for practitioners, managers, policy makers and commissioners.

Comprehensive change strategies should extend beyond pharmacist led deprescribing initiatives. An inter-professional and systems thinking approach is required, so all members of the integrated team can play their part in realising the value of holistic prescribing, appropriate polypharmacy and shared decision making.

Awareness and education about polypharmacy should be embedded in inter-professional training for all practitioners who care for people with multimorbidity or frailty.

This paper will help policy makers, commissioners, managers and practitioners understand the value of addressing polypharmacy within their integrated services. Best practice national guidance developed in Scotland illustrates how to target resources so those at greatest risk of harm from polypharmacy can benefit from effective pharmaceutical care as part of holistic integrated care.

Homeless people experience extreme health inequalities and high rates of morbidity and mortality (Aldridge et al., 2017). Use of primary care services are low, while emergency healthcare use is high (Mathie, 2012; Homeless Link, 2014). Duration of admission has been estimated to be three times longer for homeless patients who often experience poor hospital discharge arrangements (Mathie, 2012; Homeless Link, 2014). This reflects ongoing and unaddressed care and housing needs (Blackburn et al., 2017). The paper aims to discuss these issues.

This paper reveals how GPs employed in secondary care, as part of Pathway teams, support improved health and housing outcomes and safe transfer of care into community services. It draws on published literature on role of GPs in working with excluded groups, personal experience of working as a GP in secondary care, structured interviews with Pathway GPs and routine data collected by the team to highlight key outcomes.

The expertise of GPs is highlighted and includes holistic assessment, management of multimorbidity or “tri-morbidity” – the combination of addictions problems, mental illness and physical health (Homeless Link, 2014; Stringfellow et al., 2015) and research and teaching.

The role of the GP in the care of patients with complex needs is more visible in primary care. This paper demonstrates some of the ways in which in-reach GPs play an important role in the care of multiply excluded groups attending and admitted to secondary care settings.

The COVID-19 outbreak has profoundly plagued the world, and current health efforts are focused on providing prevention and ensuring access to intensive services for people with the most severe symptomatology. Many reports have already described substantial psychological distress in the general population. Nevertheless, disasters tend to affect vulnerable subjects disproportionately, and individuals with intellectual disabilities/autism spectrum disorder with high and very high support needs (PwID/ASD-HSN) seem to be counted among the hardest hit populations. The present paper aims to provide a comprehensive discussion and evaluation of COVID-19 related issues specific to PwID/ASD-HSN.

Commentary on available literature and analysis of new preliminary data on PwID/ASD-HSN’s physical and psychic vulnerability factors. This knowledge is fundamental to provide families and caregivers special advice to counteract the risks associated with the current pandemic.

PwID/ASD-HSN represent one of the most vulnerable population to the COVID-19 outbreak and the associated factors of mental distress for several reasons, including multimorbidity, low levels of health literacy, difficulties to understand and communicate, reliance on other people for care, low compliance with complex hygiene rules, the strong need of routine/sameness and low adaptive skills.

In the present work, the authors analyze the specific factors of physical and mental vulnerability in PwID/ASD-HSN, corroborating the dissertation with a discussion on the first data published worldwide and with preliminary data collected on the Italian territory for what concerns prevalence rates of COVID-19 and complications in persons with PwID/ASD-HSN and signs and symptoms of psychic distress during the mass quarantine period.

The purpose of this paper is to investigate the impact of changes of medical condition burden index (MCBI) and stress on absenteeism and discuss implications for policy/program design.

Sample: US utility employees that participated in Health Risk Appraisals (HRA) during 2009 and 2010 (n=3,711). Methods: the MCBI was created by summing number of medical conditions. Absenteeism was measured from administrative records. Change in MCBI and stress and impact on absenteeism was assessed according to incremental change, by low/high categorizations, and by using multivariate regression.

Incrementally, greater changes in MCBI or stress generally resulted in corresponding absenteeism change. For both MCBI and stress, high categories were associated with greater absenteeism compared to those in low categories. Those remaining in the low MCBI category decreased absenteeism (−0.10 days/year; p=0.01). Changes from low to high MCBI resulted in increased absenteeism (+0.12 days/year; p=0.04. Changes in stress from low to high or from high to low categories resulted in concurrent changes in absenteeism (+0.21 days/year; p=0.04 and −0.31 days/year; p=0.01, respectively). Regression analyses indicated the interaction between stress and MCBI as a significant contributor to absenteeism change.

Conclusions: MCBI, stress and their interaction appear to be direct determinants of absenteeism. Companies should consider both physical and emotional health simultaneously in program interventions in order to reduce absenteeism.

Unlike most studies illustrating cross-sectional relationships, this study shows how changes in stress and medical conditions relate to changes in absenteeism. The interaction between MCBI and stress in this context is also a novel addition.

Older incarcerated persons are an especially vulnerable segment of the prison population, with high rates of multimorbidity. This study aims to determine the impact of the COVID-19 pandemic on older incarcerated persons’ mental and physical health.

Participants were 157 currently-incarcerated persons age ≥50 years who were enrolled in an ongoing longitudinal study before the pandemic. Anxiety symptoms (seven-item generalized anxiety disorder questionnaire), depressive symptoms (eight-item patient health questionnaire) and self-rated health (SRH) were assessed during in-person interviews completed before the pandemic and via mailed surveys during the pandemic (August–September 2020). A mediation model evaluated the relationship among anxiety, depression and SRH.

Participants were 96% male, racially diverse (41% White, 41% Black, 18% Hispanic/Other), with average age 56.0(±5.8) years. From before to during the pandemic, anxiety symptoms increased (worsened) (from 6.4 ± 5.7 to 7.8 ± 6.6; p < 0.001), depressive symptoms increased (worsened) (from 5.5 ± 6.0 to 8.1 ± 6.5; p < 0.001) and SRH decreased (worsened) (from 3.0 ± 0.2 to 2.6 ± 0.2; p < 0.001). The total effect of worsening anxiety symptoms on worsening SRH (−0.043; p < 0.001) occurs entirely because of worsening depressive symptoms, i.e. the direct effect was statistically non-significant −0.030 (p = 0.068).

Older incarcerated persons experienced worsening mental health during the COVID-19 pandemic which was associated with worsening SRH. These findings have implications for health-care costs and services needed to care for this vulnerable group.

This is the first study to evaluate change in older incarcerated persons’ mental health from before the COVID-19 pandemic to during the pandemic.

The purpose of this paper is to propose a unified definition of integrated palliative care (IPC), and to identify the elements that facilitate or hinder implementation of an integrated palliative care system (IPCS).

A scoping review of the conceptualization and essential elements of IPC was undertaken, based on a search of the PubMed, Scopus and ISI Web of Science databases. The search identified 79 unduplicated articles; 43 articles were selected for content analysis.

IPC is coordinated and collaborative across different health organizations, levels of care and types of providers. Eight key elements facilitate implementation of an IPCS: coordination, early patient identification, patient-centered services, care continuity, provider education and training, a standard implementation model and screening tool, shared information technology system, and supportive policies and funding. These elements were plotted as a “Circle of Integrated Palliative Care System Elements.”

This paper offers researchers an inclusive definition of IPC and describes the essential elements of its successful implementation.

This study provides evidence from researchers on five continents, offering insights from multiple countries and cultures on the topic of IPC. The findings of this thematic analysis could assist international researchers aiming to develop a standard evaluative model or assess the level of integration in a health care system’s delivery of palliative care.