Effectiveness of a nurse-led case management home care model in Primary Health Care. A quasi-experimental, controlled, multi-centre study

Background Demand for home care services has increased considerably, along with the growing complexity of cases and variability among resources and providers. Designing services that guarantee co-ordination and integration for providers and levels of care is of paramount importance. The aim of this study is to determine the effectiveness of a new case-management based, home care delivery model which has been implemented in Andalusia (Spain). Methods Quasi-experimental, controlled, non-randomised, multi-centre study on the population receiving home care services comparing the outcomes of the new model, which included nurse-led case management, versus the conventional one. Primary endpoints: functional status, satisfaction and use of healthcare resources. Secondary endpoints: recruitment and caregiver burden, mortality, institutionalisation, quality of life and family function. Analyses were performed at base-line, and at two, six and twelve months. A bivariate analysis was conducted with the Student's t-test, Mann-Whitney's U, and the chi squared test. Kaplan-Meier and log-rank tests were performed to compare survival and institutionalisation. A multivariate analysis was performed to pinpoint factors that impact on improvement of functional ability. Results Base-line differences in functional capacity – significantly lower in the intervention group (RR: 1.52 95%CI: 1.05–2.21; p = 0.0016) – disappeared at six months (RR: 1.31 95%CI: 0.87–1.98; p = 0.178). At six months, caregiver burden showed a slight reduction in the intervention group, whereas it increased notably in the control group (base-line Zarit Test: 57.06 95%CI: 54.77–59.34 vs. 60.50 95%CI: 53.63–67.37; p = 0.264), (Zarit Test at six months: 53.79 95%CI: 49.67–57.92 vs. 66.26 95%CI: 60.66–71.86 p = 0.002). Patients in the intervention group received more physiotherapy (7.92 CI95%: 5.22–10.62 vs. 3.24 95%CI: 1.37–5.310; p = 0.0001) and, on average, required fewer home care visits (9.40 95%CI: 7.89–10.92 vs.11.30 95%CI: 9.10–14.54). No differences were found in terms of frequency of visits to A&E or hospital re-admissions. Furthermore, patients in the control group perceived higher levels of satisfaction (16.88; 95%CI: 16.32–17.43; range: 0–21, vs. 14.65 95%CI: 13.61–15.68; p = 0,001). Conclusion A home care service model that includes nurse-led case management streamlines access to healthcare services and resources, while impacting positively on patients' functional ability and caregiver burden, with increased levels of satisfaction.

La sostenibilidad del sistema sanitario desde una perspectiva de redes sociales: una propuesta para la promoción de hábitos saludables y apoyo social

The search of new health management formulas focused to give wide services is one of the priorities of our present health policies. Those formulas examine the optimization of the links between the main actors involved in public health, ie, users, professionals, local socio-political and corporate agents. This paper is aimed to introduce the Social Network Analysis as a method for analyzing, measuring and interpreting those connections. The knowledge of people's relationships (what is called social networks) in the field of public health is becoming increasingly important at an international level. In fact, countries such as UK, Netherlands, Italy, Australia and U.S. are looking formulas to apply this knowledge to their health departments. With this work we show the utility of the ARS on topics related to sustainability of the health system, particularly those related with health habits and social support, topics included in the 2020 health strategies that underline the importance of the collaborative aspects in networks.

Oportunidades de mejora del servicio de metadona en atención primaria, desde el punto de vista profesional

Objective: To identify and prioritize improvement opportunities, according to the European Foundation for Quality Management model (EFQM) model, of the methadone dispensing service in Andalusian Primary Health Care, from the point of view of professionals. Method: Delphi consensus method, implemented from September 2007 to March 2008 by means of three rounds of interviews with questionnaires administered by electronic mail to 39 professionals. The Panel of experts was made up of Dispensers and Prescribers of methadone as well as Coordinators of welfare services from the Methadone Treatment Program (MTP). Selection criteria were: Being in active employment with a minimum of 3 years experience. Sample diversification variables: Professional role, geographical environment and type of habitat. Recruitment: By means of key professional bodies from different institutions. Results: 48 improvement opportunities were identified. Thirteen of these obtained a high level of agreement in the final round. According to the EFQM model, the dimensions that obtained the most consensus in relation to improving the care service were: Leadership, Alliances and Resources. The dimension that caused the greatest disagreement was Processes. Conclusions: In spite of its having been implemented since 1997 in Andalusian Primary Health Care, the methadone dispensing service is at an implementation phase, rather than what could be classed as a fully deployed stage