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Keywords:

  • community dwelling;
  • inter-professional working;
  • interventions;
  • older people;
  • team work

Abstract

  1. Top of page
  2. Abstract
  3. What is known about the topic
  4. Introduction
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. List of included studies and related papers (listed in Tables S1–S6)
  12. Supporting Information

Health and social care policy in the UK advocates inter-professional working (IPW) to support older people with complex and multiple needs. Whilst there is a growing understanding of what supports IPW, there is a lack of evidence linking IPW to explicit outcomes for older people living in the community. This review aimed to identify the models of IPW that provide the strongest evidence base for practice with community dwelling older people. We searched electronic databases from 1 January 1990–31 March 2008. In December 2010 we updated the findings from relevant systematic reviews identified since 2008. We selected papers describing interventions that involved IPW for community dwelling older people and randomised controlled trials (RCT) reporting user-relevant outcomes. Included studies were classified by IPW models (Case Management, Collaboration and Integrated Team) and assessed for risk of bias. We conducted a narrative synthesis of the evidence according to the type of care (interventions delivering acute, chronic, palliative and preventive care) identified within each model of IPW. We retrieved 3211 records and included 37 RCTs which were mapped onto the IPW models: Overall, there is weak evidence of effectiveness and cost-effectiveness for IPW, although well-integrated and shared care models improved processes of care and have the potential to reduce hospital or nursing/care home use. Study quality varied considerably and high quality evaluations as well as observational studies are needed to identify the key components of effective IPW in relation to user-defined outcomes. Differences in local contexts raise questions about the applicability of the findings and their implications for practice. We need more information on the outcomes of the process of IPW and evaluations of the effectiveness of different configurations of health and social care professionals for the care of community dwelling older people.


What is known about the topic

  1. Top of page
  2. Abstract
  3. What is known about the topic
  4. Introduction
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. List of included studies and related papers (listed in Tables S1–S6)
  12. Supporting Information
  •  There is policy commitment to closer working between professionals to improve health and social care but the benefits of this are poorly understood at the user/patient level.
  •  Language and terminology used to capture the process of inter-professional working are imprecise.
  •  There is little evidence linking inter-professional working to explicit outcomes for older people.
  •  It is not clear how different contexts, systems, professionals, agencies, roles and services influence the effectiveness of inter-professional working.

What this paper adds

  •  There are different ways to document the process of inter-professional working.
  •  Studies should measure effectiveness and cost effectiveness of inter-professional working.
  •  Integrated models of inter-professional working have the potential to improve processes of care and to reduce hospital use or long-term care moves.
  •  The role and place of case/care management within different models of inter-professional working may be important and need further research.

Introduction

  1. Top of page
  2. Abstract
  3. What is known about the topic
  4. Introduction
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. List of included studies and related papers (listed in Tables S1–S6)
  12. Supporting Information

Inter-professional working (IPW) is advocated for older people with complex and multiple needs (Department of Health 2005a,b, 2006a,b, 2010). Types of IPW vary according to context, intensity of need, workforce availability and pragmatism (West & Markiewicz 2004, Drennan et al. 2005a). It is not clear how differences in contexts, systems, and the mix of professionals, agencies, roles and services influence IPW and outcomes for community dwelling older people (Eklund & Wilhelmson 2009, Zwarenstein et al. 2009). Research focusing on IPW (as opposed to education of and collaboration between professionals) has explored professional co-location, integrated teams, shared assessment processes, shared records, patient/user-held records and use of quality improvement tools to develop collaborative working (Goodman 2000, Iliffe & Drennan 2000, Drennan et al. 2003, 2005b, Goodman et al. 2003a,b, 2005, 2007, Manthorpe & Iliffe 2003, Davey et al. 2005, Iliffe et al. 2005, Chew-Graham et al. 2007).

While there is extensive discussion of theoretical frameworks, pre-requisites, facilitators, barriers and processes for IPW (Glendinning et al. 2003, 2004, West & Markiewicz 2004, Dickinson 2006, Reeves et al. 2011) there is less about its effectiveness, or how it is experienced by older people and caregivers. In this paper we report the findings of a systematic review examining the effectiveness of IPW for community-dwelling older people with multiple health and social care needs.

Objectives

  1. Top of page
  2. Abstract
  3. What is known about the topic
  4. Introduction
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. List of included studies and related papers (listed in Tables S1–S6)
  12. Supporting Information

This review was part of a larger study (Goodman et al. 2011) and addressed the following questions:

  • • 
    What types of IPW interventions are described in the literature?
  • • 
    How is IPW organised?
  • • 
    What are the outcomes of different models of IPW?

Methods

  1. Top of page
  2. Abstract
  3. What is known about the topic
  4. Introduction
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. List of included studies and related papers (listed in Tables S1–S6)
  12. Supporting Information

The focus of the review was the process of IPW, which was defined as having one or more of the following features:

  • 1
     A shared care plan that involved joint decision making by an inter-professional/multidisciplinary team.
  • 2
     A shared protocol or documents (e.g. care pathways) that involved joint input from an inter-professional/multidisciplinary team.
  • 3
     Face to face team meetings or routine team communications about individuals’ care plans.

This reflects the subsequent definition of inter-professional practice by Reeves et al. (2011) as activities or procedures incorporated into regular practice to improve collaboration and the quality of care. A preliminary practice-based classification of IPW models was based on two sources: (i) the theoretical literature on IPW (Ovretveit et al. 1997, Leutz 1999, Glendinning et al. 2004, Glasby 2008), and (ii) interviews with health and social care professionals about their experiences of IPW. This informed an initial analytic framework on how studies were reviewed, categorised (Figure 1), and further refined (see section on IPW Models).

image

Figure 1.  Methodology of typology development for Inter-professional working.

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Selection criteria

We included randomised controlled trials (RCT) and qualitative studies linked to RCTs that described IPW care for community-dwelling older people aged 65 and over, with multiple long-term conditions. We excluded studies of specific physical diseases but included mental health disorders which are age-related. Studies involving care home residents were included only if the intervention was delivered by primary care practitioners. Studies involving hospital in-patients were excluded unless the intervention was concerned with improving the interface between primary and secondary care for older people. Where the form of IPW was not clear, and the paper met all other criteria for inclusion, we requested further information from authors.

We took editorial advice and excluded hospital at home trials in this review because the diversity of their interventions made incorporation of their data extremely difficult. We selected outcome measures that were patient/user relevant and self-reported or validated and consistently given as measures of effectiveness across the studies reviewed. These included changes in health status (e.g. clinical/functional), mortality, quality of life, service utilisation (e.g. admissions to hospital, costs, etc.), patient/user satisfaction and experiences, as well as those related to processes of care (Tables S4–6).

Search procedures

We searched the following English language electronic databases from 1 January 1990–31 March 2008: Medline (PubMed), CINAHL, BNI, EMBASE, PsycInfo, DH Data, King’s Fund, Web of Science (WoS incl. SCI, SSCI, HCI), TRIP, Cochrane Library including DARE, NTIS, SIGLE, NRR, Dissertation Abstracts, DH and similar websites. In addition, we checked reference lists of relevant papers and reviews and conducted some lateral searching, using the ‘Cited by’ option on WoS, Google Scholar and Scopus, and the ‘Related articles’ option on PubMed and WoS’. We applied a British/European/NHS/State Medicine filter to retrieve as many studies as possible relevant to the UK. Searching was conducted by an informaticist (RW), according to our inclusion and exclusion criteria, using terms for community-dwelling elderly people, health services and IPW (see Box 1). Subsequently in December 2010, we updated the searches on PubMed, Cochrane and Campbell Collaboration for systematic reviews published since 2008.

Box 1 Search strategy for inter-professional working

MEDLINE, EMBASE, HMIC 1990 – 2008 OVID

(collaboration or cross-organisation* or interagency or multi-professional or multi-professional or intermediate care or multi-disciplinary or multidisciplinary multi-agency or team* or case manag* or (primary care and secondary care) or cooperation or co-operation or ((individual or separate) and budget*) or co-location or cross organisational or interprofessional or inter-professional or joint-working).ti. OR Case Management/OR Interprofessional Relations.mp. or exp Interprofessional Relations/OR Case Management.mp. or exp Case Management/OR Delivery of Health Care, Integrated.mp. or exp ‘Delivery of Health Care, Integrated’/OR Organizational Policy.mp. or exp Organizational Policy/OR Managed Care Programs.mp. or exp Managed Care Programs/OR ((shared or joint) and assessment).mp. [mp=ti, ab, sh, hw, tn, ot, dm, mf, nm] OR pooled.mp. [mp=ti, ab, sh, hw, tn, ot, dm, mf, nm]

AND

(geriatric* or older or middleage* or middle-age or elderly or elder or senior or frail).ti. OR Frail Elderly.mp. or Frail Elderly/OR Middle Aged.mp. or exp Middle Aged/OR Aged.mp. or exp Homes for the Aged/or exp ‘Aged, 80 and over’/or exp Health Services for the Aged/or exp Aged/or exp Middle Aged/OR (Aged, 80 and over).mp. [mp=ti, ab, sh, hw, tn, ot, dm, mf, nm] OR Geriatric Nursing.mp. or exp Geriatric Nursing/OR Geriatric Assessment.mp. or exp Geriatric Assessment/

AND

community.ti. OR Community-Institutional Relations.mp. or exp Community-Institutional Relations/OR Community Health Planning.mp. or exp Community Health Planning/OR Community Health Services.mp. or exp Community Health Services/OR *Health Care Coalitions/OR Health Care Coalitions.mp. or exp Health Care Coalitions/OR Community Mental Health Services.mp. or exp Community Mental Health Services/OR Long-Term Care.mp. or exp Long-Term Care/OR Home Care Services.mp. or exp Home Care Services/OR Advance Care Planning.mp. or Advance Care Planning/OR Intermediate Care Facilities.mp. or exp Intermediate Care Facilities/OR Community Health Centers.mp. or Community Health Centers/OR Assisted Living Facilities.mp. or Assisted Living Facilities/

AND

(England or Scotland or Wales or London or Bristol or Great Britain or UK or United Kingdom).tw,ab,cp,in. OR state medicine.mp. or State Medicine/

Search formulation include text and subject headings for several databases. Source: Informaticist (RW)

Screening for study selection

Records identified by the searches were downloaded into Endnote bibliographic database. Titles and abstracts were screened by one author (DT) with a random 10% of records independently screened by another researcher (CG) to check for agreement. Uncertainties were resolved by consensus and discussion with members of the research team. Full papers were assessed jointly by DT, CG, VMD, with at least 10% independently screened by two authors (CG, FB). The extraction of service use and cost data was independently checked (HG). Relevant reviews identified from the updated search were screened independently by DT, CG, SI.

Data extraction and quality assessment

Data were extracted using a piloted form which included types of intervention or service models, providers, participants, outcomes (used at longest follow-up), study design and types of inter-professional teams, location, organisation and processes of care. Descriptive and outcome data were extracted by two reviewers and checked by a third. Data on resource/service use and costs were extracted by HG. Quality assessment and applicability were conducted on all RCTs by DT in accordance with National Institute for Clinical Excellence (NICE) Methodology Checklists and criteria and each study was assigned a quality rating (NICE 2006). Independent data extraction on functional/clinical outcomes and quality assessment was further conducted in 12% of the studies. Where necessary, we sought further information from authors (Evidence Tables S1–6).

Data synthesis

We synthesised the evidence according to our key research questions and findings are discussed according to the type of care identified within each model of IPW (e.g. acute, chronic, palliative and preventive care). Due to the heterogeneity of participants, follow-up periods and outcomes, an overall meta-analysis was not appropriate and data are presented narratively. For resource use and cost data, we extracted selected key data from the studies. We updated the findings of this review using systematic reviews identified after March 2008.

Results

  1. Top of page
  2. Abstract
  3. What is known about the topic
  4. Introduction
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. List of included studies and related papers (listed in Tables S1–S6)
  12. Supporting Information

We screened 3211 citations published up to March 2008, of which 358 were deemed to be potentially relevant and obtained the full text for further screening. We identified 37 RCTs (reported in 66 papers). Our updated search for systematic reviews retrieved 259 records, of which we obtained full papers for 14 relevant records (Figure 2).

image

Figure 2.  Flow chart of study selection process.

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IPW models

We identified three models of IPW capturing the breadth of literature reviewed (see Table S7):

Included studies were assigned to one of three IPW models of care on the basis of the description in the paper of how the delivery of care was organised and the intervention.

Consequently, studies that described the intervention as case management but described different alignments and configurations of the professionals involved could be allocated to different models of IPW. This could mean that a study that described itself as case management but was reliant on IPW within a set group of professionals having mechanisms for working together (e.g. joint care planning/reviewing) was categorised as integrated care with case management (e.g. Bernabei et al. 1998).

Characteristics of included studies

Almost half the studies were from the United States (US); the rest from mainland Europe, Australasia, Canada, UK and Hong Kong. Tables S1–3 show descriptive data according to the IPW model, types of care and interventions. Nineteen studies and 11 studies described ‘integrated team’ and ‘collaboration’ models respectively. Seven studies described the ‘case management’ model. Even with the broad categorisation of IPW models used, some ‘hybrid’ studies combined one or more IPW models.

Twenty five studies were graded as having high risk of bias (−) (low quality), six as medium risk of bias (+) (medium quality) and six as having a low risk of bias (++) (good quality). Comparison groups, study size and follow-up period and rates varied considerably and not all studies provided power calculations (Tables S4–6).

Evidence synthesis by IPW models

Findings are presented according to our stated research questions.

What types of IPW interventions are described?

We found considerable heterogeneity in types of service models (Tables S1–3, S7). They ranged from acute care (aiming to shorten stay and provide rehabilitation (e.g. discharge planning and care), chronic care (for complex/long-term conditions), palliative care and preventive care (e.g. geriatric evaluation and management (GEM) with comprehensive geriatric assessment (CGA), falls prevention). Most interventions included assessment, education and monitoring and some studies delivered more than one type of care (Nikolaus et al. 1999, Hughes et al. 2000). Comparison groups were offered ‘usual care’ or ‘uncoordinated care’ without the specified intervention. Although focused on primary care, IPW interventions included diverse groups and settings.

How is IPW organised?

IPW within each model was organised according to the type of care being delivered and not how IPW was named. This varied considerably in studies describing similar interventions. The organisation was often unclear, particularly in relation to dimensions such as leadership, responsibility, accountability, input by different professionals, frequency of meetings, contacts, history and funding). Key organisational elements are summarised in Table S7.

Key characteristics and organisation of IPW are detailed for each study according to case management model (Table S1), collaboration model (Table S2) and the integrated team model (Table S3).

What are the outcomes of different models of IPW?

Outcome data are shown in Tables S4–6. There was considerable heterogeneity in the outcomes reported and how they were measured at different follow-up periods. The results are organised according to outcomes and type of care within the IPW models, with a summary of findings in Tables S4–6 for the three models respectively. (Related papers are shown in the evidence tables).

Case management model

Four studies described chronic care, one palliative care and two preventive home care with mixed evidence of effect. Four showed some improvement in health outcomes, most improved patient/user satisfaction, with mixed evidence for service use/costs (Table S4).

Effectiveness on health, function and quality of life outcomes

None of the five studies reporting on mortality showed any significant group differences (Stuck et al. 1995, 2000, Engelhardt et al. 1996, Marshall et al. 1999, Aiken et al. 2006).

The studies targeted mostly older women (Marshall et al. 1999, Beland et al. 2006a,b), with moderate to high impairments in activities of daily living (ADL), recently discharged from hospital or people within a ‘managed care’ system (Kaiser-Permanente) at high risk for poor outcomes (Marshall et al. 1999), high service users (Enguidanos & Jamison 2006), and women from low socioeconomic groups (Stuck et al. 2000).

Chronic care.

Evidence from four low quality (−) studies showed no overall group differences for chronic care, although one reported less decline in mental functioning from before/after comparisons (Leung et al. 2004) and one based within a US health maintenance organisation (HMO) reported significant improvements in health and functional status in the intervention group at 2 years, with baseline differences affecting the results (Marshall et al. 1999). One Geriatric Care Management (GCM) intervention reported a significant reduction in depression, with a trend towards reduced depression in the group offered support, although only a small proportion used this benefit (Enguidanos & Jamison 2006).

Palliative care.

Phoenix care improved Quality of Life (QoL), with less decline in physical function and general health (Aiken et al. 2006).

Preventive care.

Home based GEM prevention with CGA reported some evidence of effect on improving function (ADL/instrumental ADL) (Stuck et al. 1995) and reduced disabilities among people at low risk of impairment from one good quality study (Stuck et al. 2000), with no significant effects on general health or cognitive function. This intervention had favourable effects on ADL/IADL among older people visited by two nurses but not by another, who identified fewer problems, suggesting that the home visitor’s performance may be important.

Effectiveness on resource use

One study reported reduced hospital admissions, emergency room visits, and acute bed days, with overall cost savings (despite using more community resources) (Leung et al. 2004).

A Kaiser-Permanente study showed higher service use and costs in the last month of life (Long & Marshall 1999). The SIPA intervention (System of Integrated care for older People) reduced delays in hospital discharge with no difference in overall costs. It reduced hospitalisations among the most disabled and apparently delayed nursing home moves by lower risk people (Beland et al. 2006a,b).

Geriatric evaluation and management can delay the development of disability and reduce nursing home admissions (Stuck et al. 1995). Patients with low baseline risk had lower ADL risk for nursing home admissions, whereas high baseline risk patients showed no favourable intervention effects on ADL, but had more nursing home admissions. In a good quality study, the intervention reduced nursing home use, resulting in net cost savings in the third year (Stuck et al. 2000). The favourable effects were seen in low risk subjects visited by two nurses but not by another, suggesting that personal input may be important.

One palliative case management programme involving multi-professionals (Phoenix care) reported no differences in emergency visits (Aiken et al. 2006).

Processes of care

Geriatric care management significantly reduced caregiver burden in all groups although a minority of participants used the purchase of services (Enguidanos & Jamison 2006). SIPA improved access to health and social care, increased perceived quality of care and greater patient and caregiver satisfaction (with no supporting data), Other studies reported good satisfaction (Stuck et al. 2000, Aiken et al. 2006) whereas a managed care programme reported increased satisfaction at 12 months but not at 24 months (Marshall et al. 1999). Qualitative data from the SIPA model reported better clinical responsibility over the span of services and agencies, information sharing, rapid and flexible use of resources, physician involvement in inter-disciplinary working, and to some extent, financial responsibilities (Beland et al. 2006c).

Collaboration model

Eleven studies described collaboration. Three focused on acute care, four described chronic care, three preventive home-based care and one outpatient care. Around half reported improved health/functional outcomes; most detecting improved process measures and patient/user satisfaction, with mixed evidence on service use/costs (Table S5).

Effectiveness on health, function and quality of life outcomes
Acute care.

Three studies delivered acute care, which were medium/low quality. They included people at risk of admissions, recently discharged from hospital or in need of hospital care (Mcinnes et al. 1999, Naylor et al. 1999, Garasen et al. 2008). No significant effect on any outcomes was reported (Naylor et al. 1999, Garasen et al. 2008).

Chronic care.

Four studies covered chronic care: one of good quality, targeted people at high risk of ‘institutionalisation’ (Ollonqvist et al. 2008). The South Australian Health Plus trial targeting diverse patient groups reported improved physical function in the intervention group over time (Battersby 2005, Battersby et al. 2007), whereas a network rehabilitation model showed no effect on function but improved subjective health (Ollonqvist et al. 2008). Two collaborative models improved depression (Llewellyn-Jones et al. 1999, Chew-Graham et al. 2007), the former reporting no effect on functional ability.

Preventive care.

Three home based studies were of low (−), medium (+) and good (++) quality respectively (Hogan et al. 2001, Byles et al. 2004, Hendriks et al. 2008a).

There is no evidence of effect from falls prevention programmes where similar professionals followed a systematic approach to assessment (Hogan et al. 2001, Hendriks et al. 2008a). Frequent home assessments and reports to general physician (GP) may have positive effects on QoL in older Australian women (Byles et al. 2004). One good quality study of older women with functional impairment receiving outpatient CGA improved physical functioning and QoL, but had no effect on falls despite good adherence to recommendations (Reuben et al. 1999).

There were no differences in mortality from nine studies, except one (+) study of intermediate care at community hospital significantly reduced mortality (Garasen et al. 2008).

Effectiveness on resource use
Acute care.

Discharge planning and follow-up home care reduced readmissions, increased the time between discharge and readmissions and reduced costs (Naylor et al. 1999). A pre-discharge GP visit in one (+) study showed no effect on length of stay (LoS) or hospital readmissions, and significantly more patients were recommended for support services such as home nursing (Mcinnes et al. 1999), although costs implications are unknown. Intermediate care at a community hospital was associated with short-term reductions in use of primary care services and hospital readmissions, but there were no long-term differences in either outcome (Garasen et al. 2008).

Chronic care.

The South Australian generic model reduced admissions, but with no net savings and high coordination costs, although potential gains in survival, QoL and financial savings could be achieved in the longer term (Battersby 2005, Battersby et al. 2007). Funding re-allocation reduced emphasis on secondary care and increased primary level support. A network rehabilitation programme showed no effect on outcomes, despite more frequent home visits by health and social care staff, although increases in support/social care were reported (Ollonqvist et al. 2008).

Preventive care.

Home assessments may increase probability of nursing home use. The intensity and frequency of intervention appear important, although the veterans in this study may already have greater access to services and therefore may have lower baseline need for intervention (Byles et al. 2004). The intervention may not be considered cost-effective unless targeted to specific groups. Falls prevention showed no effect on any outcomes (Hogan et al. 2001, Hendriks et al. 2008a,b). The cost-effectiveness of a CGA outpatient intervention compared favourably with other medical interventions (Keeler et al. 1999).

Processes of care

Discharge planning improved patient satisfaction, quality of care and collaboration (Mcinnes et al. 1999). The South Australian chronic care model improved access to services. Qualitative data suggested that coordination processes improved confidence, enablement and patient outcomes (Kalucy et al. 2000 (related to Battersby 2005), Battersby et al. 2007). Other qualitative reports showed that rehabilitation key workers exercised autonomy, but had immense workloads and inadequate resources (Ollonqvist et al. 2007). A UK collaborative model was effective and acceptable, although patients reported difficulty engaging with a self-help intervention. It is unclear what contributed to effectiveness (Burroughs et al. 2006 (related to Chew-Graham et al. 2007)). Preventive care interventions showed that effective collaboration can be achieved through IPW with greater confidence in abilities to improve user well-being, and greater assurances that GPs were following recommendations and benefiting from collaborative working (Byles et al. 2002).

Integrated team model

Of the 19 studies describing an integrated team model, many showed improved health/functional ability, reduced caregiver burden, user satisfaction and process measures, including quality of care. Evidence about service use and costs was mixed but around half the studies showed reduced hospital or nursing/care home use (Table S6).

Effectiveness on health, function and quality of life outcomes
Acute care.

Five studies covered acute care, of which only one was medium quality (Cunliffe et al. 2004). They included people at high risk of hospital admissions or recently discharged.

Discharge planning improved IADL (Melin et al. 1993, Nikolaus et al. 1999), general health and ADL (Cunliffe et al. 2004), one showed no QoL effect (Weinberger et al. 1996); others reduced falls, with improved self-perceived health (Nikolaus & Bach 2003). A team managed home based primary care intervention, delivering both discharge and palliative care reported improved QoL only among people who were dying (Hughes et al. (2000).

Two studies reported a significant reduction in caregiver strain (Cunliffe et al. 2004), with most participants co-resident with caregivers (Hughes et al. 2000).

Chronic care.

Two low quality studies delivered case management with integrated care and included participants recently discharged from hospital with good social support. The SWING (South Winnipeg Integrated programme) showed no overall improvement in ADL/EADL but improved MMSE scores, increased prescriptions and no greater caregiver strain (Montgomery & Fallis 2003). Bernabei et al. (1998) showed a significant improvement in mental health, and ADL and IADL, with less deterioration in the intervention group and a reduction in drug use. One good quality study showed a favourable effect on depression from a psycho-geriatric team, having an extra doctor for people receiving home care, but cost implications are unknown (Banerjee et al. 1996), whereas the Senior Care Connection model had no overall effect on health (Sommers et al. 2000). However patients with the greater contacts with nurse/social worker improved function.

Palliative care.

Two low quality studies targeted older people living with caregivers and people from low socioeconomic and black and minority ethnic groups respectively (Hughes et al. 2000, Brumley et al. 2007). The former reported no improvement in physical function, although positive effects on general and mental health were seen and a significant reduction in caregiver burden was reported.

Preventive care.

A low quality study targeting the frail elderly [GRACE (Geriatric Resources for Assessment and Care for Elders)] found an improvement in mental and general health but not physical function (Counsell et al. 2007). A low quality study of a home intervention team (HIT) for older people recently discharged from hospital reported an improvement in cognitive health and IADL, and a reduction in falls and 60% compliance with recommendations (Nikolaus & Bach 2003).

Eight US studies delivered GEM outpatient care but most were of low quality. Participants were older, high risk or vulnerable, recently discharged or at risk of hospitalisation (Epstein et al. 1990, Engelhardt et al. 1996, Fordyce et al. 1997, Burns et al. 2000, Boult et al. 2001, Phelan et al. 2007).

Most studies showed no improvement in any functional or health outcomes at the longest follow-up, although Epstein et al. (1990) reported a significant effect at 3 months. Four studies showed no overall group effect (Silverman et al. 1995, Engelhardt et al. 1996, Burns et al. 2000, Cohen et al. 2002), although one reported fewer impairments in IADL, improved QoL and cognitive health over time (Burns et al. 2000). Another reported significant effect on ADL at 12 months (not maintained at 24 months), with a significant improvement in mental health (Phelan et al. 2007). Boult et al. (2001) reported that the GEM group was less likely to lose functional ability or experience health-related restrictions in ADL. Cohen et al. (2002) showed no overall effect on physical functioning but some significantly improved QoL measures. Others reported improved health/function, but showed no data (Fordyce et al. 1997), improved depression (Burns et al. 2000), diagnosis of common problems, reduced family strain in a study reporting family conferences (Silverman et al. 1995), and a reduction in adverse drug reactions and in suboptimal prescribing through access to pharmacists (Schmader et al. 2004 (related to Cohen et al.2002)).

There were no overall group differences in 15 studies reporting mortality, except one (−) GEM study showing an increase in mortality (Phelan et al. 2007).

Effectiveness on resource use
Acute care.

Discharge planning with a home intervention team reduced LoS, readmissions and overall costs (Nikolaus et al. 1999) (preventive care). Melin et al. (1993) showed improved diagnosis and function, greater outpatient care, with no differences in readmissions or cost, but no cost-effectiveness analysis.

The EDRS (Early Discharge and Rehabilitation Service) showed no significant effect on hospital or nursing home readmissions but decreased hospital stay and day hospital use (Cunliffe et al. 2004). A study of discharge planning and care (Weinberger et al. 1996) reported higher readmissions and longer rehospitalisation in the intervention group but no differences in other service use. A team managed home based primary care intervention, delivering both discharge and palliative care, reduced readmissions at 6 months (but not 12 months) only for the non-terminal severely disabled group, with overall high costs (see Palliative care) (Hughes et al. 2000).

Chronic care.

Bernabei et al.’s (1998) model suggests a cost-effective approach to reduce admissions to nursing home or hospital and functional decline in older people without increases in health service use. Montgomery & Fallis (2003) reported significantly faster deployment of home services, greater day hospital use, reduction in LoS, and delayed long-term care usage. The Senior Care Connection model showed potential for reduced service use, reducing hospital admissions, readmissions and office visits, with overall savings (Sommers et al. 2000). The largest number of contacts had the lowest hospital admissions and improved physical function. It is possible that people with more contacts could be at ‘higher risk’ for admissions which declined following professional attention.

Palliative care.

In one study patients were less likely to visit the emergency department or be admitted to hospital, resulting in significantly lower costs (Brumley et al. 2007). The team managed home based primary care intervention reduced the number of readmissions only for the non-terminal group with overall high costs, attributed to home care and nursing home costs (Hughes et al. 2000). Higher costs should be weighed against the improved QoL, satisfaction and carer benefits. Although about half of the control group received private home care (Medicare mainly) they did not report the same satisfaction and QoL gains as the intervention group.

Preventive care.

Geriatric Resources for Assessment and Care for Elders reduced acute care use among a high risk group, but it is unclear whether this offset programme costs (Counsell et al. 2007). CGA followed by a home intervention, prevented falls and increased community services up-take, with lower LoS, fewer days in long-term care, with overall savings. It had the potential to reduce direct costs of in-patient care and emergency nursing home admissions (Nikolaus et al.1999).

The GEM studies showed mixed evidence on resource use. Eight studies reported on service use of which three provided some economic evaluation with cost data. Some reported no effect on overall service use (Boult et al. 2001) or nursing home admissions, with higher clinic use and outpatient costs (Engelhardt et al. 1996 (related to Toseland et al. 1996, 1997)), increased service use with no effect on hospitalisations (Burns et al. 2000), improved diagnosis with no effect on resource use (Silverman et al. 1995), hospitalisations (Phelan et al. 2007) or any outcomes (Epstein et al. 1990).

Processes of care.

There was significant patient satisfaction with discharge planning (Melin et al. 1993, Weinberger et al. 1996, Hughes et al. 2000) and chronic and palliative care interventions (Sommers et al. 2000, Montgomery & Fallis 2003, Brumley et al. 2007) and preventive interventions (e.g. GRACE) significantly improved the quality of care (Counsell et al. 2007). GEM studies showed mixed evidence: on patient satisfaction with two showing no overall effect (Epstein et al. 1990, Silverman et al. 1995) and two reporting improved satisfaction (Morishita et al. 1998 (related to Boult et al. 2001), Engelhardt et al. 1996). In one study, providers screened significantly more and viewed the IP team favourably (Phelan et al. 2007). Improved quality of care was reported by Epstein et al. (1990) and Engelhardt et al. (1996). A good quality study of home palliative care found the users of this were more likely to die at home (Brumley et al. 2007).

Training and preparation across IPW models

Whilst the review did not consider studies on inter-professional education (IPE), some studies mentioned training in delivering the interventions, a component of IPW that may contribute to better outcomes. In the case management model, Beland et al. (2006a,b,c) described prior training/competencies of professionals with continuous quality assessment. Stuck et al. (2000) reported that two nurses had a favourable effect on function, nursing home admissions and costs compared with a third nurse, suggesting that the effect could be related to the home visitor’s performance.

Two studies in the collaboration model described prior training workshops for professionals delivering chronic care models. The South Australian Health Plus trial had a Co-ordinated Care Training Unit that trained and supervised coordinators with competency assessment and accreditation, reviewed annually. They worked with trained GPs and the model improved processes of care, whereas a shared care model involving training workshops improved patient outcomes (Llewellyn-Jones et al. 1999). Professionals delivering frequent home based preventive care and who attended regular training workshops may improve quality of life, but may not be cost effective unless targeted to specific groups (Byles et al. 2004). In the integrated team model, various studies mentioned training, of which two acute care interventions improved some short-term health outcomes (Hughes et al. 2000, Cunliffe et al. 2004). The SWING model (case management), reported significantly faster deployment of home services with improved access and less long-term care (Montgomery & Fallis 2003). The Senior Care Connection model with training workshops showed potential for reduced service use and hospital admissions whilst maintaining health, with overall cost savings (Sommers et al. 2000). The largest number of contacts had the lowest hospital admissions and improved physical function. Two preventive studies describing trained professionals and a senior resource team showed some improved outcomes (Epstein et al. 1990, Phelan et al. 2007) although the latter reported adverse effect on mortality.

Findings from recent reviews

Our updated search of systematic reviews since 2008 confirmed sustained interest in IPW and a continuing desire to understand how the components and characteristics of IPW affect outcomes. Further conceptual frameworks of inter-professional education, practice and organisation in various settings and populations are emerging (Ehrlich et al. 2009, Reeves et al. 2010, 2011). These highlight the atheoretical nature of the IPW literature and the need to explore how different components and processes impact on practice. Reeves et al.’s (2010a) observation that IPW is too often represented as the outcome supports the starting premise of our review that we need to discriminate between the process of IPW and its effectiveness. Our review complements and extends their findings by focusing on the impact of IPW on community dwelling older people. It provides a population-specific analysis of the effectiveness of different models of IPW. Whilst training may improve the effectiveness of multidisciplinary teams in acute care, there is little high quality evidence of effect on outcomes (Buljac-Samardzic et al. 2010).

Inter-professional collaboration has the potential to improve outcomes, although studies are few and flawed with methodological limitations and mixed results (Martin et al. 2010). Boult et al. (2009) identified 15 models of comprehensive care from 123 studies, including meta-analysis, reviews and all study types. Interdisciplinary primary care was reported to reduce health service use, improve survival, and, in heart failure patients, reduce costs. The model included a primary care physician with one or more other health professionals who ‘communicated frequently with each other’. Evidence for a collaborative case management model was mixed, improved quality of care, QoL and survival were documented. Their review did not examine other IPW care models for community dwelling older people (Boult et al. 2009). The authors highlight the need to have statutory flexibility to reimburse costs to providers in the US who may not be eligible for payment by health care organisations.

As in our review, teams in different contexts, with various definitions and compositions, were described by Johansson et al. (2010). They reviewed 37 qualitative and quantitative studies of various designs and settings, with less than half being RCTs. They reported benefit from team assessments and interdisciplinary interventions in different contexts, highlighting that mutually accepted agreements, common goals and guidelines may promote interdisciplinary team approaches, although the impact on outcomes remains uncertain.

Our review updates a recent review that showed some evidence of benefit for frail older people and reduced health care utilisation from seven RCTs of varying quality (identified until 2007) but did not discuss IPW models (Eklund & Wilhelmson 2009). Only two trials comparing home-based multidisciplinary rehabilitation with usual inpatient care found some benefit for caregivers. Increasing contact at home had no effect, and the cost implications of long periods of rehabilitation are unknown (Handoll et al. 2009). Multidimensional preventive home visits have the potential to improve functional outcomes among older adults, but the reviews include studies of single and multi-professionals (Bouman et al. 2008, Huss et al. 2008). One review showed that multifactorial and some single intervention falls prevention programmes for community dwelling older people may be effective, but it did not look at IPW. For example, home hazard assessment, described as a ‘single intervention’, actually involved several professionals (Costello & Edelstein 2008). Øvretveit (2011a,b) suggests that integrated teams provide greater value in terms of lower costs and higher quality, although evidence is largely based on disease-specific programmes and not community focused.

Discussion

  1. Top of page
  2. Abstract
  3. What is known about the topic
  4. Introduction
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. List of included studies and related papers (listed in Tables S1–S6)
  12. Supporting Information

We evaluated 37 RCTs describing three models of IPW: case management, collaboration and integrated team, where practitioners from varied disciplines worked together differently according to the type of care being delivered, although the organisation of IPW varied considerably in studies describing similar interventions. IPW may have the potential to positively influence outcomes and improve processes of care.

Differentiating between different models of IPW

The IPW and integrated care literature highlights the multiplicity of terms and titles used to describe IPW. By focusing on how IPW is organised and delivered we offer a different perspective to evaluating effectiveness that takes account of context, and the configurations and processes of IPW available for community dwelling older people. By considering the process of care we began to investigate the impact of different types of IPW for older people living at home.

For example, of the two studies of discharge planning in the collaboration model one evaluated GP input and reported improved quality of care through better collaboration (Mcinnes et al. 1999). The other study evaluating comprehensive discharge planning led by an advanced nurse showed little effect on function, but reduced hospital use (Naylor et al. 1999). In the integrated model, most studies delivering discharge planning and home care reported some positive outcomes.

For those with ongoing care needs intensive case management, through inter-organisational agreements, multi-professional support involving protocols and, joint care plans may achieve longer term benefits. However, the role of the case manager within some of the integrated models of care reviewed may have been an important element of the intervention. Other information about how different professionals work together within the different models reinforces the overall finding of the review about the need for more detail. For example, the systematically coordinated South Australian trials in the collaboration model had GPs and service coordinators working together empowering the patients (Battersby et al. 2007). Integrated team models had professionals (including key workers) within a community GEU and GPs designing and implementing care plans (Bernabei et al. 1998), increased contacts (Senior Care Connection model, Sommers et al. 2000), faster deployment of services (SWING, Montgomery & Fallis 2003) and having additional doctors as key workers with an established team-patient relationship (Banerjee et al. 1996). The diversity of participants could further affect service coordination models and capacity to benefit from the IPW in the models. Research could explore how the components and patterns of IPW affect patient/user outcomes.

Rigorous evaluations are scarce, especially of UK based interventions, despite the policy emphasis on evidence and the necessity of cross-organisational, public-private collaborations and IPW to support older people. The collaboration model which characterises the organisation of UK primary health care not surprisingly showed that effective collaboration can be achieved through IPW and joint working with GPs (Byles et al. 2004, Battersby et al. 2007). Two UK chronic care models were effective, but their cost implications or effective components of IPW are unclear (Banerjee et al. 1996, Chew-Graham et al. 2007).

Limitations of the study

As with many reviews, some limitations derive from available evidence. Many studies identified were of low quality, with short-term follow-up and high rates of attrition among participants. Our reporting has tried to make it clear which studies were of good quality. Cost-effectiveness evaluations did not generally include full economic appraisals or comparative data, making it difficult to comment on this aspect. Although some studies reported modest effects on outcomes, it is possible the evaluations did not capture the complexity of IPW. Equally, because of the lack of detail on the process of care it is possible that some of the studies included in the review were, evaluating packages of inter-disciplinary services rather than IPW.

We categorised studies in what we judged to be the predominant IPW model, as defined by the theoretical and empirical literature but this may be overly reductive. Our search also excluded disease specific studies because particular features of conditions may shape regimens, resources and care pathways. Although we located broad range material, we may have excluded studies that did not provide adequate detail of IPW.

Selection of papers for inclusion was judged on the processes of IPW not the name or descriptor given to the study. Consequently, due to the diversity of their interventions, different models of care may mean very different processes of IPW. This was the case for the research on Hospital at Home interventions. As noted earlier, to improve clarity these were not included in this paper. Interestingly, although these few papers were medium/good quality, their removal did not alter the overall conclusions of the review.

It is possible that new knowledge has emerged since our search, and the complexities of different forms of integration described in the papers are widely recognised (Reed et al. 2007) reflecting the different terminologies of IPW (Dickinson 2006). It was not possible to clearly identify the value, or effectiveness, of IPW which has several components in a complex intervention or system of care. Unpacking the nuances of complex interventions in various care and organisational contexts can vary according to the approach taken by each study.

Implications of the review

Although this review highlights the benefit of some IPW models in terms of improved quality of care and outcomes, there is a need to clarify what IPW is trying to achieve and how different models of IPW may determine different outcomes for different groups. Research designs that are more appropriate for complex interventions and examine active ingredients of IPW need to be developed (Campbell et al. 2000). IPW models have evolved as rationally-constructed mechanisms for achieving service or clinical objectives, which is why comparative evaluations of say, case management versus integrated team model, are difficult.

This review raises key questions about IPW in the delivery and organisation of care for older people with complex needs living at home. Funders might consider if there is a need for greater discrimination between the effects and outcomes of different IPW models for older people with multiple conditions.

The review demonstrates the importance of understanding the detail and organisation of IPW within different models of working that initially appear to have similar approaches and names. The literature on integrated work and IPW needs to acknowledge as Glasby et al. (2011) note, that structural solutions alone are not the answer. By considering the effectiveness of different models the review has demonstrated both the importance of understanding more about links between outcomes and how professionals structure their working practices and the need for this to be described in greater detail in interventions that rely on IPW to support older people at home.

Conclusion

  1. Top of page
  2. Abstract
  3. What is known about the topic
  4. Introduction
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. List of included studies and related papers (listed in Tables S1–S6)
  12. Supporting Information

This review sought to differentiate between the effectiveness of interventions that relied on different models of IPW for the benefit of community based older people. Overall, the proportion of studies demonstrating improved outcomes is similar across the three main IPW models. More than half reported improved health/functional/clinical, and process outcomes, including patient/user satisfaction, with only a few studies reporting favourable caregiver outcomes. The evidence on service use and costs is mixed, which is not unusual for complex care practices and IPW.

Acknowledgements

  1. Top of page
  2. Abstract
  3. What is known about the topic
  4. Introduction
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. List of included studies and related papers (listed in Tables S1–S6)
  12. Supporting Information

We are grateful to Reinhard Wentz who conducted the searches, Sam Norton (UH) who provided statistical advice, Lindsey Parker who provided administration support and members of the Study Steering Committee. This project was funded by the National Institute for Health Research Service Delivery and Organisation programme (project number 08/1819/216). Department of Health Disclaimer: The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the SDO programme, NIHR,NHS or the Department of Health.

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List of included studies and related papers (listed in Tables S1–S6)

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  2. Abstract
  3. What is known about the topic
  4. Introduction
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. List of included studies and related papers (listed in Tables S1–S6)
  12. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. What is known about the topic
  4. Introduction
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Conclusion
  10. Acknowledgements
  11. List of included studies and related papers (listed in Tables S1–S6)
  12. Supporting Information

Table S1. Case management model: key characteristics of included studies according to type of care (acute, chronic, palliative, preventive).

Table S2. Collaboration model: key characteristics of included studies according to type of care (acute, chronic, palliative, preventive).

Table S3. Integrated team model: key characteristics of included studies according to type of care (acute, chronic, palliative, preventive).

Table S4. Case management model: outcomes according to type of care (acute, chronic, palliative, preventive).

Table S5. Collaboration model: outcomes according to type of care (acute, chronic, palliative, preventive).

Table S6. Integrated team model: outcomes according to type of care (acute, chronic, palliative, preventive).

Table S7. Organisation of inter-professional working within models.

FilenameFormatSizeDescription
HSC_1067_sm_TableS1.doc99KSupporting info item
HSC_1067_sm_TableS2.doc119KSupporting info item
HSC_1067_sm_TableS3.doc160KSupporting info item
HSC_1067_sm_TableS4.doc62KSupporting info item
HSC_1067_sm_TableS5.doc82KSupporting info item
HSC_1067_sm_TableS6.doc136KSupporting info item
HSC_1067_sm_TableS7.doc39KSupporting info item

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