Long-Term Care: Managing Across the Continuum - A Practical Handbook for Long-Term Care Professional

As providers across the continuum prepare for the future network based on the Common Agreement, they will need to take a number of factors into consideration. They will want to take stock of their current approach to information exchange and evaluate how greater access to simplified health information exchange could support care and care coordination. Similarly, they will want to review existing and planned efforts to engage in value-based care with an eye toward needed information exchange to best manage populations.

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The RCE is committed to taking a practical approach to implementation that will seek to minimize burden and build on what is working today. This includes establishing timelines that are sensitive to the scope of any necessary changes that QHINs and Participants need to undertake. We encourage providers across the continuum of care and other stakeholders to engage with us as the community works together to realize nationwide health information exchange.

STH Chew is a Senior Consultant Geriatrician and the Principal Investigator for the SHIELD study [17, 18] in community dwelling older adults in Singapore, G Kayambu (PhD) is a Senior Physiotherapist and Director for Departmental Research, National University Hospital Singapore, C Lew (PhD) is a Principal Dietitian and Researcher in Nutrition, TP Ng is a Medical Epidemiologist in Academia, Researcher and the Principle Investigator for the Singapore Longitudinal Ageing Study (SLAS, ClinicalTrials.gov Identifier: NCT03405675), F Ong is a Principal Dietitian with extensive clinical experience supporting nutrition in older patients across the continuum of care, J Tan is a Senior Consultant Anaesthetist, a founding member of and the current Scientific Chair for the Singapore Society for Parenteral and Enteral Nutrition (SingSPEN), NC Tan is a Senior Consultant Family Physician, clinician-innovator cum the Director of Research for Singhealth Polyclinics with funded studies on sarcopenia in the geriatric population, and SL Tham is a Consultant and Program Director for Rehabilitation Medicine at Tan Tock Seng Hospital.

To optimize muscle health in older adults in Singapore, we have proposed evidence-based practical guidance on screening, diagnosis and multi-modal interventions encompassing RET and nutrition across the continuum of care. Our concise and harmonized recommendations highlight the importance of a holistic multidisciplinary approach to muscle health in the older adults, and provides a unique, explicit, evidence-based progressive RET protocol as an intervention to improve muscle strength and mass. While tailored for the Singapore population, these recommendations may also be applicable in similar countries across Asia.

Collaborative efforts are required to curb the NCD burden and mortality in these countries. A continuum of care approach is an important public health tool that can provide crucial understanding into all stages of disease progression, from prevention through to long-term care, and would enable consolidation of efforts to control NCDs (Figure 1). While the model has been widely used in managing chronic conditions such as HIV [5], it has not been optimally used to monitor the impact across the various spectra of NCD care.

There is already compelling evidence for targeting services across the continuum of care for NCDs: prevention, diagnosis, treatment and long-term care. Ford et al. reported that evidence-based medical and surgical treatments reduced cardiovascular deaths deaths in USA by 47%, while reductions in major risk factors reduced cardiovascular deaths by 44% [6]. Owolabi proposed a stroke quadrangle comprising primary and secondary prevention, access to well-equipped care and rehabilitation and research networks to address the burden of stroke in Africa [7]. Countries in Sub-Saharan Africa, Central and South Asia still face a challenge across the continuum as routine health check-ups and/or long-term follow up care are not part of the regular health system. Similarly, poverty and other social determinants of health is contributing to poor access to diagnosis and treatment of chronic conditions in Sub-Saharan Africa [3].

The information needs of people living with brain cancer, and their carers, change according to their phase of disease [5, 6]. The Australian National Service Improvement Framework for Cancer [7] identifies key intervention points across the cancer care continuum, namely: reducing risk, finding cancer early, care between and after treatment, and end of life care. People diagnosed with high grade glioma and other cancers find it difficult to process complex prognostic information, and experience a strong and pressing need for information including treatment options, side effects and prognosis [5, 6, 8].

Practical self-management resources for people living with brain cancer, including information about disease, should be clearly supported by reliable evidence to enable them to rapidly discern and adopt high quality resources, and be regularly updated to reflect current evidence. Co-designing new brain cancer resource with those affected will ensure that future resources address this populations specific information needs across the brain cancer continuum.

This systematic environmental scan has demonstrated that there is a plethora of consumer resources. However, none address all of the needs of adults living with brain cancer or their carers across the cancer care continuum, very few are evidence-based and only a small number meet the recommended readability standards. Very few of the resources were designed for people with cognitive impairment or for people from culturally and linguistically diverse backgrounds or First Nations people. There is a significant gap in online resources that provide practical self-management advice, especially in relationship to: survivorship; living with uncertainty; managing behavioural changes; rehabilitation; recurrence; and transition to palliative care.

Many primary care providers across the country have gained NCQA recognition as Patient-Centered Medical Homes. While it is certainly useful to achieve this recognition, it is only the beginning of real practice transformation, which is more of a journey than a single step. Real achievement of the Triple Aim, that is, improved care, greater patient satisfaction, and lower costs, calls for a long-term commitment by senior staff. It calls for culture change as well as investment in tools which over time will empower clinical transformation and the delivery of value-based healthcare.

The current environment within acute and long-term and post-acute care settings is fraught with silos of data and differing levels of maturity with regard to data exchange capabilities. In addition, there are multiple stakeholders that contribute to the overall exchange limitations and availability of information at the point of transition. Long-term and post-acute care providers are well aware of these difficulties and have become accustomed to receiving paper documents and faxes, or making phone calls to the sending provider in order to gather necessary information about the patient. This information can be incomplete, or instead contain so much extraneous information that the receiving provider must spend extra time reviewing and locating the desired information needed for treatment. A study published in the Journal of the American Medical Association Open Network highlighted these challenges. The study's authors noted that over 80% of the skilled nursing facilities surveyed cited one or more shortcomings across the domains of timeliness, completeness, and usability of shared data associated with acute care transitions.

In an attempt to mitigate the difficulties detailed above, long-term and post-acute care settings are often provided an opportunity to log into one of multiple EHRs or health system portals as part of accessing the information needed. This solution addresses the issue of data access but falls short in terms of addressing the needs of the people being cared for and relieving the resource burden of the receiving provider. In addition, this approach requires administrative resource support from both providers involved in the transition as part of managing the security, credentials, training and volume of care team members that rely on this information from outside systems. 2ff7e9595c