Conceptual framework for acute community health care services:Illustrated by assessing the development of services in Denmark

Acute community health care services can support continuity of care by acting as a bridge between the primaryand secondary health care sectors in the early detection of acute disease and provision of treatment and care.Although acute community health care services are a political priority in many countries, the literature on theirorganization and effect is limited.We present a conceptual framework for describing acute community health care services that can be used tosupport the policies and guidelines for such services. For illustrative purposes, we apply the framework to theDanish acute community health care services using implementation data from 2020 and identify gaps and op-portunities for learning.The framework identifies two key pairs of dimensions: (1) capacity & capability, and (2) coordination &collaboration. These dimensions, together with the governance structure and quality assurance initiatives, are ofkey importance to the effect of acute community health care services. While all Danish municipalities haveimplemented acute community health care services, application of the framework indicates considerable vari-ation in their approaches.The conceptual framework provides a systematic approach supporting the development, implementation,evaluation, and monitoring of acute community health care services and can assist policymakers at both nationaland local levels in this work

Prevention of AcuTe admIssioN algorithm (PATINA):study protocol of a stepped wedge randomized controlled trial

Background: The challenges imposed by ageing populations will confront health care systems in the years to come. Hospital owners are concerned about the increasing number of acute admissions of older citizens and preventive measures such as integrated care models have been introduced in primary care. Yet, acute admission can be appropriate and lifesaving, but may also in itself lead to adverse health outcome, such as patient anxiety, functional loss and hospital-acquired infections. Timely identification of older citizens at increased risk of acute admission is therefore needed. We present the protocol for the PATINA study, which aims at assessing the effect of the ‘PATINA algorithm and decision support tool’, designed to alert community nurses of older citizens showing subtle signs of declining health and at increased risk of acute admission. This paper describes the methods, design and intervention of the study. Methods: We use a stepped-wedge cluster randomized controlled trial (SW-RCT). The PATINA algorithm and decision support tool will be implemented in 20 individual area home care teams across three Danish municipalities (Kerteminde, Odense and Svendborg). The study population includes all home care receiving community-dwelling citizens aged 65 years and above (around 6500 citizens). An algorithm based on home care use triggers an alert based on relative increase in home care use. Community nurses will use the decision support tool to systematically assess health related changes for citizens with increased risk of acute hospital admission. The primary outcome is acute admission. Secondary outcomes are readmissions, preventable admissions, death, and costs of health care utilization. Barriers and facilitators for community nurse’s acceptance and use of the algorithm will be explored too. Discussion: This ‘PATINA algorithm and decision support tool’ is expected to positively influence the care for older community-dwelling citizens, by improving nurses’ awareness of citizens at increased risk, and by supporting their clinical decision-making. This may increase preventive measures in primary care and reduce use of secondary health care. Further, the study will increase our knowledge of barriers and facilitators to implementing algorithms and decision support in a community care setup. Trial registration: ClinicalTrials.gov, identifier: NCT04398797. Registered 13 May 2020.</p

Structured decision support to prevent hospitalisations of community-dwelling older adults in Denmark (PATINA):an open-label, stepped-wedge, cluster-randomised controlled trial

Baggrund Aldrende befolkninger og mangel på sundhedspersonale fordrer et fokus i primærsektoren på opsporing og forebyggelse af sygdomsforværring og hospitalsindlæggelser blandt ældre hjemmeplejemodtagere. PATINA-algoritmen og beslutningsstøtteværktøjet advarer kommunale sygeplejersker om ældre hjemmeplejemodtagere, der er i risiko for at udvikle et akut indlæggelsesbehov. Formålet med undersøgelsen var at teste, om brugen af PATINA-værktøjet var forbundet med ændringer i brugen af sundhedsydelser. Metoder Der blev gennemført et open-label stepped-wedge klynge-randomiseret kontrolleret forsøg i tre danske kommuner, som omfattede 20 hjemmeplejeenheder, der leverede hjemme- og sygepleje til ca. 7000 ældre. Over en periode på 12 måneder blev hjemmeplejeenhederne og deres ældre hjemmeplejemodtagere (65 år eller ældre) tilfældigt udvalgte til interventionsfasen. Det primære undersøgelsesmål var indlæggelse af ældre hjemmeplejemodtagere inden for 30 dage efter at de blev identificerede ved algoritmen. Algoritmen opsporer risiko for indlæggelse. Sekundære undersøgelsesmål var genindlæggelser og andre hospitalskontakter, ambulante kontakter, kontakt med praktiserende læger, midlertidig kommunal aflastning og død inden for 30 dage efter identificering ved algoritmen. Resultater I alt deltog 2464 ældre hjemmeplejemodtagere i undersøgelsen: 1216 (49·4%) i kontrolfasen og 1248 (50·6%) i interventionsfasen. I kontrolfasen blev 102 personer indlagt på hospitalet inden for 30 dage med 33 943 dage i risiko (incidens 0·09 pr. 30 dage) sammenlignet med 118 personer med 34 843 dage i risiko (0·10 pr. 30 dage) i interventionsfasen. Interventionen var ikke forbundet med en reduktion i antallet af førstegangsindlæggelser inden for 30 dage (incidensrate-ratio [IRR] 1·10 [90% CI 0·90–1·40]; p=0·28). Desuden var interventionen ikke forbundet med reducerede rater for andre hospitalskontakter (IRR 1·10 [95% CI 0·90–1·40]; p=0·28), ambulante kontakter (1·10 [0·88–1·40]; p=0·42) eller dødelighed (0·82 [0·58–1·20]; p=0·25). Interventionen var forbundet med en reduktion på 59% i genindlæggelsesraten inden for 30 dage efter udskrivelse (IRR 0·41 [95% CI 0·24–0·68]; p=0·0007), en stigning på 140% i kontakter med praktiserende læger (2·40 [1·18–3·20]; pFortolkning På trods af at interventionen ikke havde nogen effekt på det primære undersøgelsesmål, viste PATINA-værktøjet andre fordele for ældre hjemmeplejemodtagere. Algoritmer har potentiale til at flytte brugen af sundhedsydelser fra sekundær- til primærsektoren, men skal testes i andre lande med anden organisering af hjemmepleje. Implementering af algoritmer i klinisk praksis bør baseres på en analyse af omkostningseffektiviteten, potentielle skader samt fordele. Finansiering Innovationsfonden og Region Syddanmark. Copyright © 2023 Forfatteren(e). Udgivet af Elsevier Ltd. Dette er en Open Access-artikel under CC BY-NC-NDBackground: Ageing populations and health-care staff shortages encourage efforts in primary care to recognise and prevent health deterioration and acute hospitalisation in community-dwelling older adults. The PATINA algorithm and decision-support tool alerts home-based-care nurses to older adults at risk of hospitalisation. The study aim was to test whether use of the PATINA tool was associated with changes in health-care use. Methods: An open-label, stepped-wedge, cluster-randomised controlled trial was done in three Danish municipalities, covering 20 area teams providing home-based care to around 7000 recipients. During a period of 12 months, area teams were randomly assigned to an intervention crossover for older adults (aged 65 years or older) who received care at home. The primary outcome was hospitalisation within 30 days of identification by the algorithm as being at risk of hospitalisation. Secondary outcomes were hospital readmission and other hospital contacts, outpatient contacts, contact with primary care physicians (PCPs), temporary care, and death, within 30 days of identification. This study was registered at ClinicalTrials.gov (NTC04398797). Findings: In total, 2464 older adults participated in the study: 1216 (49·4%) in the control phase and 1248 (50·6%) in the intervention phase. In the control phase, 102 individuals were hospitalised within 30 days during 33 943 days of risk (incidence 0·09 per 30 days), compared with 118 individuals within 34 843 days of risk (0·10 per 30 days) during the intervention phase. The intervention was not associated with a reduction in the number of first hospitalisations within 30 days (incidence rate ratio [IRR] 1·10 [90% CI 0·90–1·40]; p=0·28). Furthermore it was not associated with reduced rates of other hospital contacts (IRR 1·10 [95% CI 0·90–1·40]; p=0·28), outpatient contacts (1·10 [0·88–1·40]; p=0·42), or mortality (0·82 [0·58–1·20]; p=0·25). The intervention was associated with a 59% reduction in readmissions within 30 days of hospital discharge (IRR 0·41 [95% CI 0·24–0·68]; p=0·0007), a 140% increase in contacts with PCPs (2·40 [1·18–3·20]; p&lt;0·0001), and a 150% increase in use of temporary care (2·50 [1·40–4·70]; p=0·0027). Interpretation: Despite having no effect on the primary outcome, the PATINA tool showed other benefits for older adults receiving home-based care. Such algorithms have the potential to shift health-care use from secondary to primary care but need to be tested in other home-based care settings. Implementation of algorithms in clinical practice should be informed by analysis of cost-effectiveness and potential harms as well as the benefits. Funding: Innovation Fund Denmark and Region of Southern Denmark. Translations: For the Danish, French and German translations of the abstract see Supplementary Materials section.</p

A space apart: an architecture of possibilities

Bibliography: p. 41-45

Ruskin's Decay: Architecture, Geology, and Wisdom

John Ruskin had a life-long love of architecture, especially old buildings. He valued them for their age and longevity in the face of decay. As much as he loved old buildings, he loved mountains even more. Mountains were the closest thing Ruskin had to tangible evidence of God’s intention. But mountains were also falling apart before his eyes, prompting him to ask if we were witnesses to the “earth’s prime” or the “wreck of Paradise.” In a world Ruskin saw as being divinely ordained, the question was not about how mountains eroded but why they were permitted to do so. His dilemma was reconciling the splendour and beauty of mountain and architectural form with the material and symbolic process of erasure and degradation. The question emerged: how was decay to be understood? This thesis identifies the material and spirito-theological connections between architecture, mountain form, and wisdom through the concept of decay in the works of John Ruskin. It establishes a running cross-dialogue with existing aesthetic, architectural, and wisdom scholarship by Rosenberg, Landow, Hewison, Fitch, Birch, Wheeler, and O’Gorman, and argues a contiguous perspective on decay that is often overlooked. The thesis traces Ruskin’s awareness of decay across his long creative life of observing aging buildings, unsculptured mountain peaks, and personified natural forces, demonstrating a predilection towards organic decay that is creative and beautiful. Ruskin’s aesthetic and geological investigations reveal how divine wisdom governs decay and emerges as a common link in shaping architectural and mountain forms. Wisdom unites the ruling intention of the creative act, a physical force impacting the degradation of material form, and prudential guidance in the activities of humanity. Ruskin visualizes decay not as a destructive act but a creative one—a becoming ordained by the divine mind, affirming that mountains, like buildings, are designed to decay

Next time, with empathy: revisiting the studio pedagogy for transitional housing for refugees

PurposeShowing empathy can be, at best, a tricky prospect; teaching empathy is downright daunting. The authors taught an interior design studio project that designed hypothetical transitional housing for refugees coming to Canada. As the project evolved, it became imperative that students needed to address tangible issues experienced by the refugee client, namely trauma, rootlessness and marginalization and authentically empathize with their client. Hence, instructors needed to accurately structure and facilitate this engagement. The purpose of this paper is to present a summary of the evolution of this studio project as a case study, the revision of the project's pedagogical goals and establishing a new set of design parameters that engage the “self” and the “other” through alternate modes of thinking and reasoning.Design/methodology/approachThe paper is centered on a reflective case study of the studio project and the student's work. The results of the reflection are contextualized within pedagogical framework that emphasize alternate forms of teaching and learning that promotes authentic empathetic engagement.FindingsThe summary of these reflections arises from organically questioning the nature of traditional design studio pedagogy. It proposes divergent approaches, such as “abductive reasoning”, posing the project as a “wicked problem” to encourages lateral explorations and connections.Originality/valueThis paper questions the value of prescriptive design process and guides student learning by providing an experimental toolkit that encourages alternative exploration, research and thinking.</jats:sec