Predictors of adverse outcomes and factors associated with a risk-stratification based community virtual ward model for older persons with complex health and social care needs
Creators: name: Lewis, Clare
Publisher: name: Royal College of Surgeons in Ireland
Year: 2020
Subjects: subject: 111099 Nursing not elsewhere classified
subject: FOS: Health sciences
subject: FOS: Health sciences

description: <b>Introduction</b>Population ageing is occurring rapidly worldwide, particularly in more developed<br>countries. As a result, a greater proportion of frail older adults are expected to be livingin the community but at increased risk of emergency department (ED) presentation andhospital admission. While risk-stratification is useful in allocating limited resources, fewinstruments or models are available to support healthcare professionals to manage thecomplex health and social care needs of these patients. The recent introduction of aCommunity Virtual Ward (CVW) for older persons with complex healthcare needs,reduced ED presentations and unplanned hospital admissions. The research presentedin this thesis expands on previous studies examining predictors of adverse healthcareoutcomes in community-dwellers. It also investigates the impact of health trajectories(transient health states defined as ‘unstable’, ‘deteriorated’ and ‘stable’) and factorsassociated with the risk-stratification model including individual screening andassessment scale scores on the risk of hospitalisation, institutionalisation and deathamong patients admitted to a CVW.<b><br></b><b>Methods</b>This study is a longitudinal non-experimental descriptive and correlational designinvestigating patients selected for admission to a CVW in a single centre in Ireland. Thetheoretical principles of a Markov model informed the study design. Correlations andassociations were examined using Chi-square, and Spearman’s rho tests. To examinerelationships between risk scores, health states and adverse outcomes a univariate,multinomial and multivariable regression analysis was performed.<br><b>Results</b>In total, 88 community-dwellers, with a mean age (+/- standard deviation) of 82.8 +/-6.4years were included. Most were severely frail on the Rockwood Clinical Frailty Scale(mean 6.8/9 +/-1.33) and highly dependent on the Barthel Index (2.7/20 +/-0.8). Healthstates were predictive of adverse outcomes 60 observed up to 90 days. Reaching alevel of stability (‘stable’ state) within 60 days of admission to the CVW was a predictorfor stability at 90 days and remaining at home. Stability was also associated with lessepisodes of care (&lt;2), lower risk of experiencing delirium, and fewer numbers of healthcare professional direct involvement in care (&lt;7). In contrast an ‘unstable’ health stateobserved at 60 days was predictive of institutionalisation or death with an increase inthe number (&gt;2) of episodes of care, and higher numbers of healthcare professionals(&gt;7) direct involvement in care. Several screening and assessment instruments scorescovering pressure ulcer risk, functional and frailty status, mobility, nutrition and cognitionwere predictive of reaching stability and risk of institutionalisation.<br><b>Conclusion</b>The CVW provides a framework for case management as a conceptual model of risk tosupport older people at home or identify those at risk of institutional care. The use ofdefined health states assisted in stratifying those at lower or higher risk in a high-riskfrail population. The selection of brief, targeted screening and assessment instrumentsused to monitor risk in this CVW model were also helpful in stratifying participants.Further research is needed to confirm these findings and refine this model.<br>