Myco R.

Garces
BSN 4B Group 5

ST. PAUL UNIVERSITY MANILA

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

EVIDENCE-BASED NURSING CARE PROCESS

I. Clinical Question

QUESTION: What are the impact of model of integrated care and case management for
older people living in the community?

Citation:

BMJ 1998; 316 : 1348 (Published 2 May 1998),

http://www.bmj.com/content/316/7141/1348.full?sid=69b0d702-c4c7-4b89-a8a3-
b65b6f862492

Randomized trial of impact of model of integrated care and case management for older
people living in the community.

II. Study Characteristics

1. Patients included (population and sample)

-Participants
200 older people already receiving conventional community care services.

Interventions compared
- Random allocation to an intervention group receiving integrated social and medical care
and case management or to a control group receiving conventional care.

2. Outcomes monitored

- Main outcomes included admission to an institution, use and related costs of health
services, and physical and cognitive function. Information on outcomes such as
admission and use of health services was collected every 2 months by a research assistant
unaware of patients' assignments. In the event of admission to hospital or a nursing home
patients remained in the study. Vital status was obtained from general practitioners and
confirmed by the National Death Registry.

We estimated total expenditures for health services from the average cost per type of
service from national official statistics, applying it to the units (days or visits) each
individual required. We also considered the annual salary of case managers and the costs
of the team work in the intervention group. Other costs, such as the opportunity and
direct costs of informal care givers, were not considered.

3. Does the study focus on a significant problem in clinical practice?

- In 1995 we identified all people aged 65 and over who were recipients of home health
services or home assistance programmes (n=224). Usually, patients were receiving these
services because of multiple geriatric conditions (for example, dementia, immobility,
incontinence, and stroke deficits), but the evaluation preceding care planning was not
based on a comprehensive geriatric assessment. Among the total number 24 declined to
participate: six were not interested in the project; nine had been advised against it by
relatives; and nine had been advised against it by their general practitioner. The
remaining subjects were randomly stratified by age and sex according to a computer
generated list. One hundred subjects (control group) received primary and community
care with the conventional and fragmented organisation of services—that is, general
practitioner's regular ambulatory and home visits, nursing and social services, home aids,
and meals on wheels. Another hundred subjects (intervention group) received case
management and care planning by the community geriatric evaluation unit and general
practitioners. All the services considered necessary were provided in an integrated
fashion after a formal agreement between the municipality and the local health agency.
Twenty one of 24 general practitioners agreed to participate in the trial and to be
involved in care planning, meetings, and emergency situations. Informed consent was
obtained from all patients. The study was approved and monitored by the steering
committee of the National Research Council's aging project and the local state authority
(Provincia Autonoma of Trento).

IV Methodology/Design

1. Methodology Used

- Quantitative parameters are presented as means (SD). The impact of intervention on

functional outcomes was evaluated by analysis of covariance with follow up measures
adjusted for baseline values. The impact of the intervention on time to admission to
hospital or a nursing home was tested by comparing the survival curves obtained with the
Kaplan-Meier method. Differences between curves were evaluated with the log rank test.
A P<0.05 level was chosen for significance. Statistical analysis was performed with SAS
and SPSS software.

2. Design

- Randomised study with 1 year follow up.

3. Setting
- Town in northern Italy (Rovereto).

4. Data sources
-Source of funding: no external funding.

- For correspondence: Dr Roberto Bernabei, Istituto di Medicina Interna e Geriatria,

Universitá Cattolica del Sacro Cuore, 00168 Rome, Italy

5.Subject selection

a.) Inclusion criteria

- Inclusion criteria were to evaluate the impact of a program of integrated social and
medical care among elderly people living in the community because most of the elderly
un the community were weak and neglected by their own families and they were not took
care by their significant others.

b.) Exclusion criteria

-None

6. Has the original study been replicated?

-No, because as I have browse the internet I cant find another study like this.

7. What were the risks and benefits of the nursing action/ intervention tested in
the study?

- Nurses working in the community and giving their health services in the elderly was
very hard because we have only few community health nurses who were available in a
specific community and they were not able to take care of many elderly.

III. Results of the study

- Survival analysis showed that admission to hospital or nursing home in the intervention
group occurred later and was less common than in controls (hazard ratio 0.69; 95%
confidence interval 0.53 to 0.91). Health services were used to the same extent, but
control subjects received more frequent home visits by general practitioners. In the
intervention group the estimated financial savings were in the order of £1125 ($1800) per
year of follow up. The intervention group had improved physical function (activities of
daily living score improved by 5.1% v 13.0% loss in controls; P<0.001). Decline of
cognitive status (measured by the short portable mental status questionnaire) was also
reduced (3.8% v 9.4%; P<0.05).

If original study has been replicated, are the findings similar in a variety of situations?

-none

IV. Author’s Conclusion/s Recommendations

1. What contribution to client health status does the nursing action/intervention

make?

-By simply giving recognition to the elderly and giving them our time will be enough to
reduce their stress felt and also they will feel glad. There was also a study shows that
when someone is happy their immune system will boost that’s why they were not easily
invaded by sickeness.

2. What overall contribution to nursing knowledge does the study make?

- To know what will be the proper care to the elderly.

V. Applicability

1. Does the study provide a direct enough answer to your clinical question in
terms of type of patients, intervention and outcome?
-Yes, because this study will help me to take care the patients especially in the
community and it will help a lot in my elective area and that is CHN.

2. Is it feasible to carry out the nursing action in the real world?

-Yes, because most of our population today is the elderly and we should give more
importance to them because they were near to their last step of their life and also most of
them were not took care of their own family.