bluuebunny/crossref_metadata_2025_split huggingface dataset:
EU NAVIGATE: Developing a European navigation intervention for older people with cancer and their family caregivers
Authors: Smets Tinne , Chambaere Kenneth , Miranda Rose , Pivodic Lara , Caluwaerts Anneleen , Vinckier Chelsea , Van Campe Fien , Van den Block Lieve 
Published: January 2024

Background: Most people who have cancer are older people, and this affects millions of Europeans yearly. Integrating high-quality, equitable, and cost-effective care across the continuum of supportive, palliative, end-of-life, and survivorship care for both patients and family caregivers is highly relevant from a healthcare, prevention, and economic perspective.
Aims: EU NAVIGATE is an interdisciplinary, cross-country, and intersectoral project funded by the European Union and aiming to evaluate the effectiveness and cost-effectiveness of a patient and family navigation intervention (NavCare-EU) for older people with cancer and their family caregivers in different healthcare systems in Europe. It focuses on reaching underserved individuals, supporting and empowering them to access their own networks and available resources within their community. As the first step, the existing and promising Canadian Nav-Care intervention from will be adapted, contextualized, standardized and pilot-tested across six European countries.
Concept and methods and anticipated results: NavCare-EU is a person- and family-centered non-pharmacological intervention in which volunteer navigators collaborate with patients and families to facilitate timely and equitable access to health and social care services and resources as needed. The Nav-CARE intervention involves a navigation model, including international blended training, and various tools to support navigators. We will share the model, different roles involved and training packages. Following the ADAPT guidance, the Nav-Care intervention will be translated and adapted in close collaboration with Local Adaptation Teams diverse users, and other stakeholders (according to principles of Patient and Public Involvement). To contextualize the original intervention, we follow the extended Normalization Process Theory. An International Oversight Group will safeguard the original intervention’s integrity and key components using the Model for Adaptation Design and Impact (MADI) to guide decision-making around the design of adaptations. The feasibility of the Nav-CARE intervention within local settings will be reviewed across countries in a pilot study to understand the practicalities of implementation, maximize feasibility, and troubleshoot issues that arise during implementation. Effectiveness and cost-effectiveness will be evaluated through an international pragmatic randomized controlled trial.
Impact: The EU NAVIGATE will shift the state of the art of cancer care in Europe by providing an innovative solution to the complex care needs experienced by older cancer patients and their families. we pay particular attention to local healthcare contexts to ensure optimal implementation. We will present the final program ready for testing at the conference.
Engaging healthcare professionals in refining the target group of a new care type: The Acute Geriatric Community Hospital (AGCH) referral decision study
Authors: Kroeze Eline , De Groot Aafke , Smorenburg Susanne , Van Vught Anneke , Buurman B.M. 
Published: January 2024

Background: The acute geriatric community hospital (AGCH) is an alternative to conventional hospitalisation of older adults. At the AGCH, patients receive acute medical specialist treatment in combination with early rehabilitation in an fitting environment by an interdisciplinary team of professionals. Ambiguity exists on the exact definition of the target group for the AGCH and the difference with the target groups for bed-based intermediate care and geriatric hospital care models.
Objective: Limited guidelines and methods exist to refine the target group of new care model or (complex) health interventions. The aim of this study was to provide refined assessment criteria for the AGCH by using a target-group refinement procedure with case vignettes.
Design: A design based research using qualitative research techniques.
Setting: Two pioneer sites who have an AGCH in their region and seven pioneer sites who have the ambition to implement an AGCH in their region.
Subjects: A total of 20 healthcare professionals (elderly care physicians, clinical geriatricians and other medical specialists, physician assistants, nurse specialists) participated in the AGCH target group refinement project, either active in hospitals (n=10) or intermediate care facilities (n=7) or skilled nursing facilities (n=3), and all involved in the implementation of an AGCH in their region.
Methods: The developed target-group refinement procedure consisted of three phases. 1) Healthcare professionals from the pioneer sites were asked to submit case vignettes for a specific care type or an ambiguous boundary between the AGCH and other care models. These case vignettes were reviewed during 2) web-based vignette questionnaires and 3) two online working sessions. Both during phase 2 and 3, participants were asked to make a referral decision for the case vignettes they were presented with and to report their considerations during this process.

Results: In total, 23 case vignettes were collected and reviewed by 18 healthcare professionals. Triage dilemmas were identified and discussed during online working sessions, following from which the AGCH assessment criteria were refined. We found that the final referral outcome is the result of an interplay of clinical and organisational triage factors.
Conclusions: This target group refinement procedure enabled involving of a variety of healthcare professionals and was suitable to refine the AGCH assessment criteria. In a short time period, it provided us further insight into (1) the required changes to the AGCH assessment criteria; (2) the (ambiguous) boundaries between the AGCH and other care models, and (3) the considerations made by healthcare professionals during referral decision-making for older adults with an acute care need. We recommend to use this novel procedure as a tool for specifying the target group of (new) care models or healthcare interventions.
Exploratory Short Stay: Regaining Perspective on Optimal Home Care
Authors: Logist Rudi 
Published: January 2024

A beautiful old age, at home in your own environment, enjoying life. But what if an acute crisis situation arises? Fortunately, this does not always have to be the end of the dream of living at home for as long as possible. An exploratory short stay in a residential care center can then be an appropriate solution.
The Exploratory Short Stay is aimed at elderly people who find themselves in a crisis situation, for example due to a fall, the sudden death of the partner or the loss of the caregiver. This new offer focuses on the future and a safe return home.
The elderly can count on the years of experience of experts here. A team of nurses, healthcare professionals, occupational therapists, physiotherapists, psychologists, general practitioners and social workers will set out the right trajectory in a multidisciplinary consultation. Offering the psychological component is precisely this added value compared to the classic short stay. Furthermore, the strength of this team is that it can respond flexibly to specific needs of the client.
On the basis of personalized and tailor-made advice, they offer the person perspective to return to their own environment. Even during that temporary stay in the residential care center, the home care services will examine how the necessary care and support can be organized at home. At the end of the stay, all possible future plans are discussed with the resident, family, informal carers and primary care staff.
An exploratory short stay opens up new perspectives for family and carers. Combined 'care' forms are possible without the client losing independence. If a return home is not the best option, the possibility of a long term stay is also open.
The Exploratory Short Stay was regulated by the Flemish government in 2020, building on years of experience in the elderly care sector. Crucial are the involvement of a multidisciplinary team in the residential care center on the one hand, and close cooperation with primary care actors and family/caregivers on the other.

Together we choose quality of life:
Comfort and social relationships, care and support in a trusted environment.
Utilizing Community Health Ambassadors to improve COVID-19 vaccine uptake in equity priority neighborhoods in Toronto, Canada
Authors: Shearkhani Sara , Wojtak Anne , Powis Jeff , Quinlan Jen 
Published: January 2024

East Toronto Health Partners (ETHP) is comprised of 100+ health and social organizations, with a leadership council consisting of patient/caregivers and six anchor organizations representing the continuum of care. During the pandemic ETHP implemented a Community Health Ambassador (CHA) Model to increase access to COVID19 vaccinations in underserved neighborhoods through health promotion activities and referral to COVID19 outreach Centers (CoCs).
The intervention focuses on equity priority neighborhoods with significant concentrations of underserved populations including but not limited to newcomers and households with low incomes.
Early in the COVID-19 pandemic it became apparent that the impact was disproportionally high in equity priority neighbourhoods. Once COVID19 vaccine became available to the public, it became evident that the wealth of knowledge residing within the community was essential to improve vaccine uptake, particularly in priority neighbourhoods. ETHP partnered with the community to co-design outreach strategies. A particularly meaningful partnership was the collaboration with community members who assisted us in designing our CHA model. The CHAs program was administered through one of the community ETHP health service providers.
CHAs were localized to the neigbourhood where they lived and utilized their knowledge of the community to identify and address misinformation and barriers to vaccination. CHAs were able to engage in individualized educational interventions locally and escalate systemic barriers to the ETHP. These issues were addressed through rapid cycle change quality improvement methodology by the members of the ETHP.
From December, 2021 to March, 2022, we engaged and deployed 197 CHAs to conduct outreach activities. They reached out to over 25,000 individuals in our priority neighbourhoods. Their work bridged the equity gap in vaccination. In September 2021, there was a 20% point difference in 1st dose coverage between the most vaccinated and least vaccinated neighborhoods in East Toronto; in March 2022, this difference decreased to 16% partly as the result of CHA outreach in priority neighborhoods.
Barriers to vaccine uptake could best be identified by hyper-local strategies implemented by CHA with a deep understanding of the local neighborhood. The barriers identified by CHAs could be addressed with the help of an integrated health system to improve equitable delivery of COVID-19 vaccine.
Based on the success of the CHA model were are co-designing a strategy to utilize CHAs to assist with health care recovery focusing on other preventive interventions that not equitably delivered such as cancer screening.
Development of a toolkit to improve interprofessional collaboration and integration in primary care using qualitative interviews and co-design workshops.
Authors: Sirimsi Muhammed Mustafa , De Loof Hans , Van den Broeck Kris , Van Bogaert Peter , De Vliegher Kristel 
Published: January 2024

Introduction: Despite numerous attempts to improve interprofessional collaboration and integration in primary care, patients, care providers, researchers, and governments are still looking for tools and guidance to do this more efficiently. To address these issues, we decided to develop a generic toolkit, based on sociocracy and psychological safety principles, to guide care providers in their collaboration within and outside their practice. Finally, we reasoned that different strategies should be combined to obtain integrated primary care.
Who is it for, and who did we involve and engage with? The results of this study and subsequently the toolkit are ‘directly’ useful for care providers, academics and policymakers. Development of the toolkit consisted of a multiyear co-development process. Data originating from 65 care providers, through 13 in-depth interviews and five focus groups were analysed and subsequently evaluated in eight co-design workshop sessions, organised with a total of 40 academics, lecturers, care providers and members of the Flemish patient association. Findings from the qualitative interviews and co-design workshops were gradually, and inductively adapted and transformed into the content for the IPCI toolkit.
Results: Ten themes were identified: (i) awareness of the importance of interprofessional collaboration, (ii) the need for a self-assessment tool to measure team performance, (iii) preparing a team to use the toolkit, (iv) enhancing psychological safety, (v) developing and determining consultation techniques, (vi) shared decision making, (vii) developing workgroups to tackle specific (neighbourhood) problems, (viii) how to work patient-centred, (ix) how to integrate a new team member, and (x) getting ready to implement the IPCI toolkit. From these themes, we developed a generic toolkit, consisting of eight modules.
What is the learning for the international audience?
What are the next steps?
In this study, we describe the multiyear co-development process of a generic toolkit for the improvement of interprofessional collaboration and integrated care. Inspired by a mix of interventions from in and outside healthcare, a modular open toolkit was produced that includes aspects of Sociocracy, concepts such as psychological safety, a self-assessment tool and other modules concerned with meetings, decision-making, integrating new team members and person and population-centred care. Upon implementation, evaluation and further development and improvement, this compounded intervention should benefit the complex problem of interprofessional collaboration in primary care.
“Nothing about us, without us”. Practical elaboration of experience experts in primary care
Authors: Van Laere Stien 
Published: January 2024

The health care sector sensed already for several years a shift in primary care to more complex situations and support questions. Tackling these challenges requires an integrated collaboration between health, wellbeing and social care. There was an urge to bring in a different approach of care. In order to fulfill that need Flanders was defined into 60 geographical areas in 2020: ‘The primary care zones’. Capturing local needs and working bottom-up became the foundation of the organization. The focus on goal-oriented, customized and integrated care made it possible to fill out the gap created by more complex situations.
Representatives from health providers, welfare workers, local authorities and the person in need of care are brought together. The primary care zone promotes collaboration between these different partners. This extensive network ensures that primary care regions can as well pick up and unroll local needs as charges unrolled by the government.
Person-centered care is the key to success of this new approach. Care and support goals from the people itself, depending on their quality of life, are the starting point. This in combination with more recognition for informal care, makes sure that socially vulnerable people are able to take control of their own life and the necessary care to sustain this. In order to realize a care policy in function of person-centered care, we need to listen to the people who live in our primary care zone. There’s continually increased attention and effort to cocreate and build our organization with socially vulnerable people. Self-determination and autonomy are ever highly valuated. As organization there’s the expectation of building bridges between professionals, but also between the professional and the client.
The focus in the relationship between clients and professionals shifted the past years. There’s more attention for participation and democratic decision making and for the perspective of the people itself. Clients are not to be seen as passive recipients anymore. They say: ‘nothing about us, without us.’ and who are we to protest?
In order to do so we established a group of 15 experts. From October 22 until November 23 we will meet up monthly to exchange ideas. The group has experience in different domains: informal care, chronic illnesses, poverty, addiction, psychic vulnerability, elderly care and disabilities. The experts hope to dive deeper into our participation process to show and explain to you how to co-design a care journey that responds to people’s needs.
Taking their experience in account, will help our board to pick up local needs and to adjust primary care to them. Focus on strength and possibilities of the people in the group are hereby necessary to accomplish our goal. Together with the group we strive to share the ownership on our plan of action We want them to have an impact on the policy and to cocreate an organization not only for them, but with them.
Towards more goal-oriented care through care coordination and care planning.
Authors: Fredrix Karen 
Published: January 2024

The increasing aging of our society is putting increasing pressure on the current organization of care and support. This moved the Flemish government to a thorough reform of primary care in Flanders. This was started in 2017. The reform involves changes in terms of content, structural support and instrumental support. All these changes should lead to care and support that can be organized using the principles of integrated care and goal-oriented care. The major challenges are:
- bring about a change in mentality among care providers toward these principles of integrated care and goal-oriented care;
- make a connection between health care and welfare care, as well as between primary care and more specialized care, and align the processes of care and support.
In addition, it is necessary to translate the principles of goal-oriented care into practical tools and accelerate methodology development. We are working together with several partners in Flanders for this purpose.
In goal-oriented care, an important role is reserved for the care coordinator. The care coordinator is the focal point of the care team who, as a member of the care team, takes on the task of:
- maintain an overview of the care process;
- ensure that all care and support, determined on the basis of the person's care or support needs and translated into life goals and care and support goals, is coordinated, monitored and evaluated.
Care coordination in a care process maintains a focus on goals, both the person's own life goals and the care and support goals of the care team.
For implementing qualitative care coordination, the care and support plan is an indispensable tool within the Flemish reform. This care and support plan must:
- allow an overview of the sometimes multitude of care and support goals;
- be a means of communication between the members of the care team (including the person himself and his informal care);
- reflect the extent to which care agreements are met;
- allow the care process to be monitored, evaluated and adjusted if necessary.

In the near future we want to design this care and support plan in a digital way.
The care coordinator must have a wide range of competencies in order to coordinate the care process in a quality manner, including:
- mastering to perfection the methodology of goal-oriented care, interview techniques, conflict management, process guidance, process analysis, coordination and organization skills;
- being the point of contact for the person with a care and support need;
- be able to play the bridge between the person, informal care and professional care providers.
In this presentation, we focus on the role of the care coordinator throughout the care process and the planning aspect. We propose how the Flemish government want to develop this role in the future. We also reflect on the preconditions that are necessary to achieve a solid implementation of this role, and indicate what opportunities we see to promote and accelerate the change in mentality in this regard.
Impact of multimorbidity on health care utilisation in Australian older adults aged 45 years and over: a large population-based data linkage cohort study
Authors: Kabir A Y M Alamgir , Conway Damian , Rhee Joel , Ansari Sameera , Tran An , Barr Margo 
Published: January 2024

Background: Multimorbidity (MM), co-occurrence of two or more chronic health conditions in an individual, is often used in the assessment of complex healthcare needs and their impact on health outcomes. Management of MM is complex, but little is known about the impact of MM on health care services.
Methods: We conducted a cross-sectional study among people aged 45+ years in New South Wales, Australia, who completed baseline questionnaires in the 45 and Up Study between 2005-2009. Baseline questionnaire data were linked to hospital, primary care Medicare billings, emergency department (ED), and deaths registry data. Our outcome of interest was high use of health care services within the 3-year baseline period (averaged over the years before, during and after recruitment). People who died during that period were excluded. High use was defined as: ≥11 General Practice (GP) visits, ≥2 ED visits, and ≥2 hospital admissions. Prevalence ratios (PRs) were used to measure the impact of MM, and Poisson regression models were used to estimate adjusted and unadjusted PRs with 95% confidence intervals.
Results: Among 251,689 participants (46.5% male, and 46.1% aged <60 years), the overall prevalence of MM was 44.1% and prevalence increased with age: 32.2% in 45-59 years, 50.3% in 60-74 years, and 63.3% in 75+ years. After adjusting for confounding, MM was associated with high service use: adjusted PR (95% CI) was 2.27 (2.06-2.51) for high hospital use, 2.02 (1.98-2.06) for high GP use, and 2.04 (1.90-2.21) for high ED use. The impact of MM on health care utilisation was higher among the younger age group.
Conclusion: This study illustrates the burden of multimorbidity on service use within the health system. It also highlights the need to examine and rationalise service provision and utilisation across the health system to assist people with multimorbidity efficiently manage their conditions.