Definition and Measurements | Categories | |
---|---|---|
Demographic Characteristics | ||
Age | At the moment of entering the HC program | 65–74 75–84 > 85 |
Gender | Male | Female | |
Health Status | ||
Caregiver | At the time of entering the HC program | Yes | No |
Level of dependency | Scale defined by Royal Decree 174/2011; Law 39/2006 of Promotion of Personal Autonomy and Care for People in Situations of Dependency. | Grade I (25–49): Moderate dependency Grade II (50–74): Severe dependency Grade III (75–100): Great dependency |
Decubitus ulcer | At physician’s discretion | Presence | absence |
Drugs prescribed | By active substance. | Not polymedicated (< 5) Polymedicated (5–10) Hyperpolymedicated (> 10) |
Comorbidity burden | Measured by Adjusted Morbidity Groups (GMA) risk assessment tool. GMA considers the type of disease (i.e. acute or chronic), number of systems affected, and complexity of each disease, which is coded by the International Classification of Diseases (ICD-9-CM) and stratify depending on the complexity. | 31 qualitative ordinal GMA levels. |
Mortality | Death during follow-up | Yes | No |
Realization of CGA | Yes | No | |
Assessments included in CGA | ||
Performance of normal daily tasks | Barthel Scale [27] | Total dependency (< 20) Severe dependency (20–60) Moderate dependency (61–90) Mild dependency (91–99) Autonomous (100) |
Mental health | Pfeiffer’s Test [28] | High risk (≤2) Mild cognitive impairment (3–4) Moderate cognitive impairment (5–7) Severe cognitive impairment |
Decubitus ulceration risk | Braden Test [29] | High risk (< 12) Moderate risk (13–14) Low risk (15–18) |
Social risk | TIRS [30] | There is social risk when one indicator over 6 is positive |
Anxiety | Goldberg Scale [31] | Probable anxiety (≥4 positive responses) Probable depression (≥2 positive responses) |
Geriatric depression scale | Yesavage Scale [32] | No depression (1) Possible depression (≥ 2) |
Mobility | Timed Up and Go Test [33] | Normal (< 10) Very little impaired (10–19) Moderately impaired (20–29) Severely impaired (≥30) |
Comorbidity | Charlson Index [34] | No comorbidity (0–1) Low comorbidity burden (2) High comorbidity burden (> 3) |
Social state | Social Scale [35] | No social risk (≤9) Social risk (10–14) Social problem (≥15) |
Overburden of the caregiver | Zarit Test [25] | No overburden (< 46) Intense overburden (> 56) |
Nutritional state evaluation | MNA [36] | Malnutrition (≤7) Malnutrition risk (8–11) Normal nutritional status (≥12) |
Home adequacy | Revision of home adequacy to determine the need of social worker intervention | Social worker is recommended when at least one item is positive |
Falls | Number of falls in the last year | – |
Frailty | Gérontopôle Frailty Screening Tool [37] | Frailty identification if one item of the scale is positive. |
Social services cost | Number and cost of social worker visits | – |
Quality of life | No problems (Level 1) Some problems (Level 2) Extreme problems (Level 3) | |
Quality of Care | ||
Physicians PQI | Prescription Quality Index of the physician [40] | Include assessment of three categories: More adequate therapeutic alternatives Hyper prescription of a particular group of drugs Selection indicators to promote safer and more effective alternatives available |
Prescriptions | Number of prescription events per patient | – |
Alternative drugs with therapeutic benefit | Percentage of use of the alternative drug as assessed by the physician | – |
Shared Interdisciplinary Individual plan | Yes | No | |
Chronicity | Number of Complex Chronic Patients and Advanced Chronic Disease patients in the program | – |
Satisfaction with health care received | IEXPAC Scale [23] | Satisfactory (=10) Unsatisfactory (< 10) |
Overburden of the caregiver | Zarit Scale [25] | No overburden (< 46) Intense overburden (> 56) |
Resource Utilization | ||
Family doctor visits | Number of at-home visits, other medical professional, primary care center or virtual appointments of the patient or the caregiver | – |
Nursing staff visits | Number of at-home visits, other medical professional and primary care center appointments of the patient or the caregiver. Also, number of virtual consultations, including remote evaluation or by phone of medical record | – |
Hospitalizations | Number of programmed, emergency and daycare admissions | – |
Readmissions | Number of successive hospitalizations due to the same pathology in less than 30 days | – |
Admissions to other public health care centers | Number of admissions, including convalescence, subacute, long-lasting and palliative units | – |
Hospitalizations per year | Days hospitalized | – |
Intermediate resources | Number and cost of laboratory tests, Radiology and interconsultations | – |
Pharmaceutical costs | Expenditure per patient and medical professional during a year | – |
Hospitalization-at-home device use | Number of activations per year and total of hospitalization days | – |
Social services intensity | Monthly hours spent by the social worker. Costs derived from teleassistance, cleaning and cooking aid, reused orthopedic material and family worker | – |
Call to emergency services | Number of patient intervention requests per year. | – |
Perception of healthcare professionals | Qualitative, self-administered questionnaire of difficulties in HC practice, based on the survey reported by Linares et al. [20] |