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Address correspondence to Robert Oliver Barker, MBBS, MPH, Institute of Health & Society, Newcastle University, Level 2, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, United Kingdom.
Across the world, health care for residents in long-term care facilities (LTCFs) is provided by a range of different professionals, and there is no consensus on which professional group(s) deliver the best outcomes for residents. The objective of this review is to investigate how the health outcomes of older adults in LTCFs vary according to which professional group(s) provides first-line medical care.
Design
A systematic review and narrative synthesis were performed. Medline, Embase, the Cochrane Central Register of Controlled Trials, and Scopus were searched for studies from high-income countries, of any design, published after 2000. Quality was assessed using the Cochrane Risk of Bias and ROBINS-I tools. The exposure of interest was the professional group(s) involved in the delivery of first-line primary care.
Setting and participants
Older adults living in LTCFs.
Measures
The principal outcomes were unplanned transfer to hospital, prescribing quality, and mortality.
Results
Searches identified 10,532 citations after removing duplicates. Twenty-six publications (across 24 studies) met the inclusion criteria. A narrative synthesis was conducted of the 20 experimental and 4 observational studies, involving approximately 98,000 residents. Seven studies were set in the USA, 6 in Australia, 3 in Canada, 2 in New Zealand, and 6 in European countries. Interventions were varied, complex and multi-faceted. Nineteen interventional studies, including 4 randomized trials, involved the addition of a specialist practitioner, either a doctor or nurse, to supplement usual primary care. The most commonly reported outcomes were unplanned hospital transfer and prescribing quality. Interventions based on specialist nurses were associated with reductions in unplanned hospital transfers in 10 out of 12 publications. There was no consistent evidence of a positive impact of specialist doctor interventions on unplanned hospital transfers. However, specialist doctors were associated with improvements in prescribing quality in all 7 relevant studies. There was a paucity of evidence on the impact of specialist nurse interventions on prescribing, and of specialist practitioners on mortality, and no improvements were reported.
Conclusions
Addition of specialist doctors or nurses to the first-line medical team has the potential to improve key health outcomes for residents in LTCFs.
Health care in long-term care facilities (LTCFs) is a challenging area of clinical practice, where comorbidities, frailty, and polypharmacy are common.
British Geriatrics Society Quest for quality: An inquiry into the quality of healthcare support for older people in care homes: A call for leadership, partnership and improvement; 2011.
Concerns have been voiced about the quality of acute and scheduled medical care for residents, and in particular, the high rates of in-hospital mortality,
In the search for ways to enhance health care in LTCFs, a key question is which professional group(s) achieves the best outcomes for residents when delivering first-line health care.
The expertise of the medical professional involved in managing acute illness is thought to be one of the key influences on hospitalization of nursing home residents.
Potentially avoidable hospitalizations of nursing home residents: Frequency, causes, and costs: [see editorial comments by Drs. Jean F. Wyman and William R. Hazzard, pp 760–761].
A retrospective notes review of 235 ED attendances from residential facilities in Australia suggested that nearly one-third could have been avoided with improved primary care.
Quantification of the proportion of transfers from residential aged care facilities to the emergency department that could be avoided through improved primary care services.
Prescribing is influenced by training and disciplinary background, and can be associated with adverse outcomes for nursing home residents, including falls, hospital admission, and mortality.
Primary care generalists, such as family physicians and general practitioners, are commonly responsible for the delivery of first-line health care to LTCF residents. Primary care generalists provide first-line care without prior vetting for a variety of conditions across the whole age range.
) look after residents of LTCFs, but the Netherlands is the only country in the world where “elderly care physicians” in nursing homes have a stand-alone 3-year training program.
Specialist nurses or nurse practitioners may also deliver first-line primary care, often with delegated clinical responsibility. The level of involvement of nurse practitioners varies widely from country to country. Nurse practitioners have worked in US long-term care homes for approximately 30 years,
where they have performed diverse roles including first-line clinical assessments of residents (acting as the clinician), care manager, coach, and educator for nursing staff.
There is no international consensus on which professional group should provide care for residents in LTCFs. Specialist practitioners with enhanced training and experience in the medical needs of residents in LTCFs may be better placed to manage the medical complexity of residents.
Practitioners with a specific remit for nursing home residents may be able to prioritize advanced care planning and develop expertise in complex prescribing to enhance chronic disease management.
The American Geriatrics Society Geriatric Medicine: A clinical imperative for an ageing population, part 1A policy statement from the American Geriatrics Society.
It is an international priority to improve health care for residents in LTCFs and find the most effective way of delivering primary medical care. The aim of this review is to systematically identify and synthesize evidence on which professional group should provide first-line medical care (routine and/or unscheduled) for residents in LTCFs to enhance health outcomes. In doing so we will address the question of how the health outcomes of residents vary according to which professional group (primary care generalist, generalist specialist, nurse practitioner, and specialist multidisciplinary team) provides first-line medical care. We will also ask how health outcomes for residents who receive first-line primary care from primary care generalists differ from those who receive care from specialist practitioners. The hypothesis is that improved health outcomes will be observed when practitioners, with enhanced expertise and experience relevant to this patient population, are involved in the delivery of first-line primary care.
Methods
Search Strategy
We searched for empirical research involving adults aged 65 years or older and living in LTCFs that compared health outcomes for different practitioners involved in the delivery of first-line primary care. The following bibliographic database searches were initially conducted in October 2016: Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus. An individual search strategy was used for each database. The keywords used were common for Medline, Embase, and CENTRAL but the MeSH headings were individually tailored to the different databases. The searches were updated in October 2017 to identify any further studies published in the period of undertaking the review. Bibliography searches and citation searches were performed for publications included in the final synthesis. A gray literature search was conducted for articles published by key organizations: the British Geriatrics Society, King's Fund and Nuffield Trust. The review protocol was registered on PROSPERO (CRD42016049019).
Eligibility Criteria
Studies of any design conducted in high-income countries, published after 2000 in any language, were included if they focused on older adults in LTCFs (including institutions with and without on-site nursing input) and represented quantitative data. The exposure or intervention of interest is the professional group(s) involved in the delivery of first-line primary care. Studies without a defined comparator group were excluded as they do not allow comparison between different professional groups. To be included, the practitioner had to have the expertise to respond to, and manage, primary care problems, that is, to act as the main first-line primary care figure, either with autonomous or delegated clinical responsibility.
This includes specialist doctors such as care home physicians and geriatricians, primary care generalists including general practitioners and family physicians, and specialist multidisciplinary teams. Nurse practitioners and physician assistants, who may receive support in decision making from a doctor, are also eligible for inclusion. Exposures or interventions based solely on medication review by a clinical pharmacist, who then makes a prescribing recommendation to the responsible clinician, were excluded.
The health outcomes of interest were quantitative and those expected to be influenced by first-line medical care providers. The principal outcomes were unplanned transfer to hospital (such as ED visits or unplanned hospitalization), prescribing quality outcomes (including appropriateness of prescribing and number of medications prescribed), chronic disease management indicators, and mortality. Other important quality indicators (eg, fall frequency and restraint use) that are dependent on other factors such as the quality of nursing care were only included if reported in conjunction with one of the principal outcomes described above. Inclusion criteria were tested independently by 2 researchers on 10% of the records and minor revisions made before proceeding with study selection.
Study Screening and Data Extraction
At the title and abstract screening phase, all citations were screened by a single author, and one-third of citations were double-screened. Screening discrepancies (less than 5%) were discussed individually. If a consensus was not achieved, the citation was put forward for full text review. Full texts were then read and assessed for inclusion in the review by 2 authors independently. Study details and data were extracted into an Excel spreadsheet for the included studies. Data extraction was performed by one researcher and independently checked for accuracy by a second researcher.
Methodologic Quality
Quality assessment was performed independently by 2 members of the research team. The Cochrane Risk of Bias tool was chosen for the 5 randomized studies. For the nonrandomized studies, the Cochrane ROBINS-I (Risk Of Bias In Non-randomized Studies of Interventions) tool was employed.
Data Synthesis
The possibility of pooling data for a meta-analysis was explored but this was not possible because of the high degree of heterogeneity in study setting, exposures/interventions, and the outcomes reported. Therefore, only a narrative synthesis was performed.
Results
After the removal of duplicates, the searches produced 10,532 citations. Following title and abstract screening, 125 full-text articles were assessed for eligibility. Twenty-six publications
Bringing back the house call: How an emergency mobile nursing service is reducing avoidable emergency department visits for residents in long-term care homes.
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
Hospital in the Nursing Home program reduces emergency department presentations and hospital admissions from residential aged care facilities in Queensland, Australia: A quasi-experimental study.
Mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents.
Bringing back the house call: How an emergency mobile nursing service is reducing avoidable emergency department visits for residents in long-term care homes.
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
Hospital in the Nursing Home program reduces emergency department presentations and hospital admissions from residential aged care facilities in Queensland, Australia: A quasi-experimental study.
Mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents.
publications (across 24 studies), involving approximately 98,000 residents in 9 different countries. Eight publications (7 studies) were set in the United States,
Bringing back the house call: How an emergency mobile nursing service is reducing avoidable emergency department visits for residents in long-term care homes.
Quantification of the proportion of transfers from residential aged care facilities to the emergency department that could be avoided through improved primary care services.
Hospital in the Nursing Home program reduces emergency department presentations and hospital admissions from residential aged care facilities in Queensland, Australia: A quasi-experimental study.
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
Mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents.
Mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents.
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
Bringing back the house call: How an emergency mobile nursing service is reducing avoidable emergency department visits for residents in long-term care homes.
Hospital in the Nursing Home program reduces emergency department presentations and hospital admissions from residential aged care facilities in Queensland, Australia: A quasi-experimental study.
Mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents.
Bringing back the house call: How an emergency mobile nursing service is reducing avoidable emergency department visits for residents in long-term care homes.
Mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents.
Hospital in the Nursing Home program reduces emergency department presentations and hospital admissions from residential aged care facilities in Queensland, Australia: A quasi-experimental study.
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
Bringing back the house call: How an emergency mobile nursing service is reducing avoidable emergency department visits for residents in long-term care homes.
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
Mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents.
Bringing back the house call: How an emergency mobile nursing service is reducing avoidable emergency department visits for residents in long-term care homes.
Hospital in the Nursing Home program reduces emergency department presentations and hospital admissions from residential aged care facilities in Queensland, Australia: A quasi-experimental study.
Interventions, summarized in Table 2, are diverse, complex, and multifaceted, incorporating the input of geriatricians, geriatrician-led MDTs, nurse practitioners, geriatric nurse specialists, ED-trained nurses, and general practitioner–led MDTs. No studies of physician assistants were identified. All but one study
involved an intervention or exposure comprising a specialist practitioner, either a doctor or nurse, being compared against usual primary care. We define a specialist practitioner as a professional with a specific remit for older patients or nursing home residents, and/or specialist training (such a geriatrics) relevant to this patient population. Specialist practitioner is an umbrella term used to describe medically trained “specialist doctors” and “specialist nurses.” In all studies, the comparator group is the usual primary care provider. This is a primary care generalist in the majority of cases—either specifically stated,
Mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents.
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
Hospital in the Nursing Home program reduces emergency department presentations and hospital admissions from residential aged care facilities in Queensland, Australia: A quasi-experimental study.
Geriatric multidimensional assessment every 3 mo (web-based tool); care plan discussed with resident, family, family physician; twice-a-year MDT meetings for complex residents: family physician, nursing home physician, nurse, psychotherapist, and other disciplines
Tool for comprehensive geriatric assessment Staff education
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
Baseline facility assessment (gerontology nurse specialist); monitoring and benchmarking of resident indicators; three 1-h MDT meetings including medication review by the geriatrician, gerontology nurse specialists, GP, pharmacists, and nurse manager
Gerontology nurse specialist performing staff education and coaching
Two multidisciplinary case conferences conducted 6-12 wk apart; GP formulated a problems list and did a medication review prior to the MDT; MDT GP (chair), geriatrician, pharmacist, care staff, representative of the Alzheimer's Association; problems discussed including behavioral problems
Pharmacist, education sessions on challenging behavior
Three-year intervention: comprehensive geriatric assessments and follow-up visits for those patients with most complex needs, on a regular basis and on demand, regular meetings with medical and nursing staff
Extended clinical investigations, staff training and protocol development, joint case management with specialists
Geriatrician-led multidisciplinary model of care including assessment, care planning, arrange interventions, referral to hospital in the home if required, develop long-term care plan with primary care, physician, and care home staff
Mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents.
Geriatricians and geriatric medicine fellows used tools, eg, Beers criteria, to identify potentially inappropriate medications; primary care physician contacted with recommendations
Use of the MDS QI instrument
Nursing home primary care physician (frequently a faculty geriatrician)
Nurse practitioners: one-third time spent with clinical contact, one-fourth communicating with families, primary care physician; nurse practitioners also train the care home staff
Payments for care home to deliver some hospital-level treatments
Bringing back the house call: How an emergency mobile nursing service is reducing avoidable emergency department visits for residents in long-term care homes.
Registered nurses with expertise in geriatric care and emergency care working with the physician; visiting care homes to identify residents with health issues early; conducting rounds alongside care home nurses; performing assessment to identify signs of acute illness
Primary care service provided by ED-based nurses (not aged care training); direct clinical review/procedures for acute illness, eg, intravenous fluid, management of urine infection; education of staff was also provided
Additional procedures normally associated with secondary care
Hospital in the Nursing Home program reduces emergency department presentations and hospital admissions from residential aged care facilities in Queensland, Australia: A quasi-experimental study.
ED-based nurses; components to the intervention: (1) Clinical staff allocated to manage acute illness in the care home; (2) Support and education for care staff and GPs
Bringing back the house call: How an emergency mobile nursing service is reducing avoidable emergency department visits for residents in long-term care homes.
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
Mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents.
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
Mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents.
reported on 11 and 6 occasions, respectively. There was a wide range of prescribing outcomes reported with minimal replication across multiple studies, although psychotropic medication prescribing was reported on 5 occasions,
reported other quality indicators acknowledged as important for nursing home residents, such as falls and the presence of a urinary catheter, which are dependent on a range of other influences, such as nursing care. There were some noteworthy outcomes not reported, for example, chronic disease outcomes for key conditions, such as stroke, diabetes, hypertension, and heart failure.
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
Blinding of personnel or participants was not possible in any of the studies because of the nature of the intervention. According to the Cochrane ROBINS-I tool,
Hospital in the Nursing Home program reduces emergency department presentations and hospital admissions from residential aged care facilities in Queensland, Australia: A quasi-experimental study.
Mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents.
Bringing back the house call: How an emergency mobile nursing service is reducing avoidable emergency department visits for residents in long-term care homes.
The studies were grouped according to whether the intervention involved a specialist doctor or a specialist nurse. Although there was a high degree of heterogeneity in study setting and intervention, the heterogeneity was particularly marked for the outcomes reported. Within the most commonly reported outcome domain of unplanned hospital transfer, there was ambulance callouts, ED room attendance, admission to hospital, and length of stay. In addition, the way of measuring the same outcome varied widely. In the prescribing domain, there were 2 specialist doctor studies reporting psychotropic use, which was the most commonly used prescribing indicator. One study reported the use of antipsychotics
Overall, this heterogeneity meant that pooling would not have been possible for more than 2 studies reporting the same outcome and using sufficiently similar units of measurement. Hence, we performed a narrative synthesis.
Interventions Involving a Specialist Doctor
Ten publications with an experimental study design
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
Mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents.
compared an intervention, in which a specialist doctor is involved in delivering first-line primary care. There was a mixture of low- and moderate-quality studies; 3 well-conducted randomized trials,
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
Mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents.
whereas all of the rest were based on a geriatrician. The aim of the interventions was to supplement, rather than supplant, the existing primary care model. The interventions were complex and involved more than simply supplementing usual care with a specialist doctor. Co-interventions were wide-ranging, as shown in Table 2, and included specialist nurses,
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
Mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents.
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
The comparator group is the usual primary care provider in all studies. There were 2 occasions when the normal primary care provider appeared to have generalist and specialist geriatrics training,
which would tend to attenuate the observed effect of the intervention. There was a spectrum of collaborative working, ranging from formal MDTs incorporating geriatricians
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
The main findings from interventions involving a specialist doctor are summarized in Figure 3 (and detailed in supplementary online material). First, although the majority of studies showed specialist doctor input to be associated with reduced unplanned hospital transfer, the 2 well-conducted randomized trials conducted by Boorsma
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
The “Big Five.” Hypothesis generation: A multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: A post hoc analysis of the ARCHUS cluster-randomised controlled trial.
did subsequently report improvements in hospital admission specifically for 5 common conditions in a post hoc analysis. Second, a consistent association with improved prescribing practice was demonstrated. This reaches statistical significance in 2 randomized trials,
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
Mobile geriatric consultant services for rest homes. Study of the effects of consultations by internal medicine specialists in the medical care of rest home residents.
Bringing back the house call: How an emergency mobile nursing service is reducing avoidable emergency department visits for residents in long-term care homes.
The Aged Residential Care Healthcare Utilization Study (ARCHUS): A multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities.
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