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Development of a Care Delivery Model for High-Need Older Adults in the Community

Hsu, Hui-Fen; Chen, Kuei-Min; Chen, Yu-Ming; Chang, Chiang-Ching; Chen, Meng-Chin; Kuo, Chuan-Feng

doi: 10.1097/NNR.0000000000000374
FEATURE ARTICLES
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Background High-need older adults have multiple needs and require different types of care services. Care coordinators in community care centers in Taiwan, however, often experience difficulties in providing sufficient care services because of the inadequate capacity of case management.

Objective The aim of this study was to develop a realistic care delivery model for the care coordinators to manage the care of high-need, community-dwelling older adults.

Methods Focus-group interviews concerning elements and process for establishing a care delivery model were conducted with 12 care management experts in two groups: the practical work group (three registered nurses and three social workers) and the care management group (three care managers and three care management supervisors). The interviews were video-recorded and subjected to content analysis.

Results A five-stage care delivery model was formulated: case screening, case assessment, care plan, care delivery, and follow-up evaluation. Six types of high-need older adults were identified: those living with disability, solitude, dementia, depression, elder abuse, and poverty. A list of categorized care services, including care resources, social welfare resources, and caregiver resources, was then used as a guide for case management and care delivery.

Discussion The developed model—consisting a classification of services for different types of high-need older adults—serves as a guide for care coordinators in community care centers to make better decisions on service linkages, resource management, and care plan monitoring.

Hui-Fen Hsu, PhD, is Postdoctoral Fellow, Kaohsiung Medical University Center of Long-Term Care Research, Kaohsiung, Taiwan.

Kuei-Min Chen, PhD, RN, FAAN, is Professor, Kaohsiung Medical University College of Nursing, and Kaohsiung Medical University Hospital Department of Medical Research, Kaohsiung, Taiwan.

Yu-Ming Chen, PhD, is Assistant Professor, Kaohsiung Medical University Master Program of Long-Term Care in Aging, Kaohsiung, Taiwan.

Chiang-Ching Chang, PhD Candidate, is Lecturer, Kaohsiung Medical University Department of Medical Sociology and Social Work, Kaohsiung, Taiwan.

Meng-Chin Chen, PhD Candidate, RN, is Lecturer, Yuhing Junior College of Health Care and Management Department of Nursing, and Kaohsiung Medical University College of Nursing, Kaohsiung, Taiwan.

Chuan-Feng Kuo, MS, is Research Assistant, Kaohsiung Medical University Center of Long-Term Care Research, Kaohsiung, Taiwan.

Accepted for publication December 1, 2018.

Research reported in this publication was supported by the Ministry of Science and Technology, Taiwan (MOST 107-2314-B-037-009-MY3). The funding source supported the study financially and had no involvement in the study design, data collection, analysis and interpretation of data, writing of the report, and decision to submit the paper for publication.

The authors thank Professor Frank Belcastro for his superlative manuscript editing and the 12 experts in care management for their generous participation.

The authors have no conflicts of interest to report.

The Institutional Review Board of Kaohsiung Medical University Chung-Ho Memorial Hospital approved this study (KMUHIRB-F(I)-20170070).

Corresponding author: Kuei-Min Chen, PhD, RN, FAAN, Kaohsiung Medical University College of Nursing, and Kaohsiung Medical University Hospital Department of Medical Research, 100 Shih-Chuan 1st Rd., Sanmin District, Kaohsiung, Taiwan 80708 (e-mail: kmc@kmu.edu.tw).

Online date: July 8, 2019

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