Structure and processes of interdisciplinary geriatric consultation teams in acute care hospitals: A scoping review

International Journal of Nursing Studies 55 (2016) 98–114

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Review

Structure and processes of interdisciplinary geriatric consultation teams in acute care hospitals: A scoping review§ Mieke Deschodt a,b,1, Veerle Claes a,1,2, Bastiaan Van Grootven a,b, Koen Van den Heede c, Johan Flamaing b,d, Benoit Boland e,f, Koen Milisen a,b,* a Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, Leuven B-3000, Belgium b Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, Leuven B-3000, Belgium c Belgian Health Care Knowledge Centre, Administrative Centre Botanique, Doorbuilding (10th Floor), Boulevard du Jardin Botanique 55, Brussels B-1000, Belgium d Department of Clinical and Experimental Medicine, KU Leuven, Campus Gasthuisberg O&N1, Herestraat 49 Box 701, Leuven BE-3000, Belgium e Geriatric Medicine, Cliniques Universitaires Saint-Luc, Hippokrateslaan 10, Sint-Lambrechts-Woluwe B-1200, Belgium f Research Institute of Health and Society UCLouvain, Clos Chapelle-aux-Champs 30, Sint-Lambrechts-Woluwe B-1200, Belgium

A R T I C L E I N F O

A B S T R A C T

Article history: Received 4 June 2015 Received in revised form 2 September 2015 Accepted 25 September 2015

Background and objectives: Interdisciplinary geriatric consultation teams are implemented in the acute hospital setting in several high-income countries to provide comprehensive geriatric assessment for the increasing numbers of older patients with a geriatric profile hospitalized on non-geriatric units. Given the inconclusive evidence on this care model’s effectiveness to improve patient outcomes, health care policy and practice oriented recommendations to redesign the structure and process of care provided by interdisciplinary geriatric consultation teams are needed. A scoping review was conducted to explore the structure and processes of interdisciplinary geriatric consultation teams in an international context. As nurses are considered key members of these teams, their roles and responsibilities were specifically explored. Design: The revised scoping methodology framework of Arksey and O’Malley was applied. Data sources: An electronic database search in Ovid MEDLINE, CINAHL and EMBASE and a hand search were performed for the identification of descriptive and experimental studies published in English, French or Dutch until April 2014. Review methods: Thematic reporting with descriptive statistics was performed and study findings were validated through interdisciplinary expert meetings. Results: Forty-six papers reporting on 25 distinct interdisciplinary geriatric consultation teams in eight countries across three continents were included. Eight of the 12 teams (67%) reporting on their composition, stated that nurses and physicians were the main core members with head counts varying from 1 to 4 members per profession. In 80% of these

Keywords: Aged Geriatric assessment Geriatric nursing Health services for the aged Hospitals Referral and consultation Scoping review

§ This paper was submitted as an entry for the European Academy of Nursing Science’s Rosemary Crow award, sponsored by the International Journal of Nursing Studies. The award is open to current doctoral students or recent graduates of the academy’s programme. * Corresponding author at: Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, B-3000 Leuven, Belgium. Tel.: +32 16 336975. E-mail addresses: [email protected] (M. Deschodt), [email protected] (V. Claes), [email protected] (B. Van Grootven), [email protected] (K. Van den Heede), johan.fl[email protected] (J. Flamaing), [email protected] (B. Boland), [email protected] (K. Milisen). 1 Joint first authorship. 2 Present address: Institute of Nursing Science, Faculty of Medicine, University of Basel, Bernouillistrasse 28, CH-4056 Basel, Switzerland.

http://dx.doi.org/10.1016/j.ijnurstu.2015.09.015 0020-7489/ß 2015 Elsevier Ltd. All rights reserved.

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teams nurses were required to have completed training in geriatrics. Advanced practice nurses were integrated in eleven out of fourteen interdisciplinary geriatric consultation teams from the USA. Only 32% of teams used formal screening to identify patients most likely to benefit from their intervention, using heterogeneous screening methods, and scarcely providing information on the responsibilities of nurses. Nurses were involved in the medical, functional, psychological and social assessment of patients in 68% of teams, either in a leading role or in collaboration with other professions. Responsibilities of interdisciplinary geriatric consultation teams’ nurses regarding in-hospital follow-up or transitional care at hospital discharge were infrequently specified (16% of teams). Conclusions: This scoping review identified that the structure and processes of care provided to geriatric patients by interdisciplinary geriatric consultation teams are highly heterogeneous. Despite nurses being key team members, only limited information on their specific roles and responsibilities was identified. More research in this area is required in order to inform health care policy and to formulate practice oriented recommendations to redesign the interdisciplinary geriatric consultation team care model aiming to improve its effectiveness. ß 2015 Elsevier Ltd. All rights reserved.

What is already known about the topic?  Interdisciplinary geriatric consultation teams (IGCT) provide comprehensive geriatric assessment (CGA) for geriatric patients admitted on non-geriatric hospital units.  IGCTs are structurally implemented in healthcare systems in a limited number of countries, despite inconclusive evidence on its effectiveness to improve patient outcomes.  Although nurses are considered key members of IGCTs, no overview of their specific roles and responsibilities in these teams is available in the literature. What this paper adds  IGCTs providing care for geriatric patients show highly heterogeneous structures and processes of care.  Although nurses are key members of IGCTs, only limited information on their specific roles and responsibilities in IGCT care is reported.  More research in this area is warranted in order to inform health care policy and to formulate practice oriented recommendations aiming to improve the effectiveness of the IGCT care model. 1. Introduction Demographic changes with an increasing aging of the population and the growing burden of chronic conditions affect the number and proportion of older patients in the acute hospital setting (Organization for Economic Cooperation and Development (OECD) Health, 2004). A specific subset of these older patients, namely those with a geriatric profile (hereafter called ‘geriatric patients’), are at an increased risk for adverse outcomes both during and after hospital admission (Covinsky et al., 2003, 2011). According to the ‘European Union of Medical Specialists’ geriatric patients present with a multitude of complex and interrelated problems such as frailty, active multiple pathology, atypical appearances of diseases, polypharmacy, functional decline and psychosocial problems. This

patient profile requires a holistic and interdisciplinary approach to care, including a key contribution of the nursing profession (European Union of Medical Specialists – Geriatric Medicine Society, 2008). Therefore, to address the complex care needs of these geriatric patients the process of ‘comprehensive geriatric assessment’ (CGA) has been developed, which was defined by Rubenstein et al. as ‘‘a multidimensional interdisciplinary diagnostic process focusing on determining a frail elderly person’s medical, functional, psychological and social capability in order to develop a coordinated and integrated plan for treatment and long term follow up’’ (Rubenstein et al., 1991). Hence, CGA encompasses phases of patient identification, assessment and implementation of interventions (e.g. a plan for treatment and follow-up) (Deschodt, 2013). To date, CGA is considered one of the cornerstones of modern geriatric medicine (Rubenstein et al., 1991). Different models of care can be applied to offer CGA to hospitalized patients. First, it can be delivered in geriatric units where specialist interdisciplinary care is organized for geriatric patients. Care on these dedicated units has been shown beneficial: as compared with conventional care it has been associated with a decrease in falls (Fox et al., 2012), delirium (Fox et al., 2012), in-hospital mortality (Ellis et al., 2011a,b), functional decline (Baztan et al., 2009; Van Craen et al., 2010), and new nursing home admissions (Van Craen et al., 2010). However, not all hospitals have implemented acute geriatric units, and the capacity of such units is often insufficient to accommodate the high number of admitted older patients (Deschodt et al., 2015; Malone et al., 2014). In Belgium for example, where acute geriatric units are implemented since 1984, 81% of all patients aged 75 years were hospitalized on non-geriatric acute care units in 2011 (Deschodt et al., 2015). Interdisciplinary geriatric consultation teams (IGCTs) are therefore proposed as an alternative or complementary model of care for providing inhospital CGA (Deschodt, 2013). IGCTs are mobile teams with the following main activities: the provision of an interdisciplinary CGA for patients with a geriatric profile; the formulation of recommendations to the care team of the non-geriatric unit during the hospitalization period; the formulation of

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recommendations to the general practitioner with the aim to prevent hospital readmissions and other negative outcomes post-discharge; and the dissemination of a geriatric approach throughout the hospital (Deschodt et al., 2015). Importantly, IGCTs are not directly responsible for the care management and clinical outcomes (Braes et al., 2009). They provide recommendations for patient care, which should be carried out by the team of the non-geriatric unit. Examples of frequently provided recommendations are treating fluid overload or dehydration; performing additional laboratory or technical investigations; preventing or treating postoperative delirium; prevention of pressure ulcers, discontinuing or starting-up medication, regulation of bowel or bladder function, adjusting nutritional intake, and arranging discharge management (Deschodt et al., 2011a). IGCTs are considered to have a high face validity by IGCT members, their clients (patients and relatives, teams of non-geriatric units), nursing managers, health policy and governmental decision-makers (Braes et al., 2009; Deschodt et al., 2015). Hence, the IGCT care model is currently structurally implemented in the health care system of European highincome countries such as Belgium, France and the Netherlands (Belgisch Staatsblad, 2014; Ministe`re de la Sante´ et des Solidarite´s, 2007; Unie Katholieke Bond van Ouderen et al., 2014). Moreover, the care model is being applied on a regional level in the Ontario province, Canada (Lewis, 2008). On the other hand, results on the efficacy and effectiveness of IGCTs are inconclusive. More specifically, a recent meta-analysis showed no effect of IGCTs on patient’s functional status, length of stay, and readmission rates, and an inconclusive effect on mortality (Deschodt et al., 2013). The suboptimal adherence to IGCT recommendations by non-geriatric unit teams (Agostini et al., 2001; Deschodt, 2013; McVey et al., 1989) and heterogeneity in the structure and process of IGCT care (Deschodt et al., 2013; Hogan and Fox, 1990) can potentially explain this lack of evidence. Consequently, a more comprehensive perspective on IGCTs in different health care systems is needed to allow key stakeholders in clinical practice (e.g. careworkers and managers in the in-hospital setting) and health policy developers to further fine-tune and improve the IGCT care model. Because to date no comprehensive review summarizing the state of the art in this regard is available, we conducted a scoping review aiming to explore the structure and processes of IGCTs in acute care hospitals within an international context. As nurses are put forward as key members of IGCTs (Deschodt et al., 2012a), we explicitly explored the roles and responsibilities of nurses within these teams. 2. Materials and methods Given our aim to examine the extent rather than the depth of evidence regarding the structure and processes of IGCTs (Davis et al., 2009), a scoping review was performed. Scoping reviews are considered especially useful in policy directed nursing research (Davis et al., 2009; Harris et al., 2015; Sun and Larson, 2015). Our review process was based on the refined version of the methodological model of Arksey and O’Malley (2005) and is visualized in Fig. 1

(Levac et al., 2010; Armstrong et al., 2011) Conducting a systematic review was not considered suitable since a focused research question with narrow parameters could not be formulated a priori, and as the explorative nature of our study required developing and refining in- and exclusion criteria for papers during the review process (i.e. post hoc instead of a priori) (Levac et al., 2010; Armstrong et al., 2011). 2.1. Identification of relevant papers A twofold comprehensive search strategy was performed. First, we conducted a systematic search for relevant papers in the electronic databases Ovid MEDLINE, CINAHL and EMBASE. Search strings tailored to the thesaurus of each database were developed iteratively. The final search strings (Supplementary Material 1) included restrictions regarding the papers’ language (i.e. English, Dutch, French), publication date (i.e. published between 1999 and April 22, 2014) and study design (i.e. no editorials and letters to the editor). Second, we handsearched the reference lists of all included papers and relevant reviews for additional literature. 2.2. Selection of relevant papers Initial in- and exclusion criteria were formulated and further refined during the entire study selection process for the patient population, care model, content, and design of identified papers. The final version of the selection criteria can be found in Supplementary Material 2. After removing duplicates we screened all records for suitability based on title and abstract. Potentially relevant papers were subsequently screened based on their full text. Two researchers (MD, VC) independently performed the selection process, each screening half of the identified studies. In case of ambiguity or uncertainty about study suitability, a final inclusion decision was made through consensus meetings with three other researchers (JF, BB, KM) (Supplementary Material 3). Since reference lists of reviews and included studies indicated that studies regarding IGCT were also conducted between 1980 and 1999, we also considered studies published 1999 for additional inclusion during the hand-searching process. 2.3. Data charting An initial data charting format was developed and independently tested by two researchers (MD, VC) for ten included papers. Iterative discussions within the research team guided small adjustments during the data charting process. The final version entailed information concerning the general characteristics of included studies and the structure and process of IGCTs, in line with the thematic reporting presented in Fig. 2. 2.4. Sorting, summarizing and reporting of results Descriptive analyses (e.g. measures of central tendency and dispersion, depending on the measurement level of data) were used for data synthesis and reporting. Thematic

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Step 1

• Formulation of the research aim • Based on stakeholder meeting organized by Belgian Health Care Knowledge Centre (fall 2013) • Based on iterative discussion within research team

Step 2

• Identification of relevant papers • Systematic search in Medline, Cinahl & Embase, resulting in 8208 hits • Hand-search of reference lists and relevant reviews, resulting in 101 hits

Step 3

Step 4

Step 5

Step 6

101

• Selection of relevant papers • Iterative refinement of in- and exclusion criteria through discussion within research team • Independent screening by two researchers, concensus decision of research team in case of ambiguity, resulting in 46 included papers reporting on 25 distinct IGCT services.

• Data charting • Initial data charting form: development & independent testing by two researchers • Refinement of data charting form through discussion within research team

• Sorting, summarizing and reporting of results • Thematic reporting, iterative refinement of (sub)themes through discussion within research team • Structure of IGCT care • Process of IGCT care

• Consultation phase • Two interdisciplinary expert meetings (fall 2014 and spring 2015) • Discussion & validation of content, perspectives, relevance & applicability of scoping review's results

Fig. 1. Scoping review process.

reporting was performed, by clustering information on the structure and process of IGCT care, including a specific focus on the roles and responsibilities of nurses in each domain (see Fig. 2). Quantitative analyses regarding the effectiveness or efficacy of the IGCT care model were not performed as this was outside the scope of this review.

Based on title and abstract evaluation, 6851 papers were excluded. An additional 259 papers were excluded based on their full text, of which eight due to non-availability of the full text. Hence, the database and hand search resulted in the inclusion of 46 papers (Supplementary material 3). 3.2. Characteristics of included studies

2.5. Consultation phase Two interdisciplinary expert meetings with members of the Belgian College of Geriatricians, the Belgian Association for Gerontology and Geriatrics (BVGG/SBGG) and professional nursing associations were organized. The expert group included health care professionals with research, clinical and/or management functions in the field of geriatrics. All experts were requested to provide feedback on the content, perspectives, relevance and applicability of the scoping review’s results. The insights gained through these consultations were used to strengthen the final reporting on this scoping review. 3. Results 3.1. Identification and selection of relevant papers After removal of duplicates (n = 1153), the database and hand search resulted in 7156 potentially relevant papers.

The 46 papers reported on 25 distinct IGCTs in eight different countries: fourteen in the USA, three in France, two in both Canada and the UK, and one in Belgium, Germany, Taiwan and the Netherlands, respectively (Table 1). All studies published before 2002 were conducted in the USA (n = 10) and Canada (n = 2). The remaining more recently established IGCTs (n = 13) mostly originated from European countries. With regard to the study design, we included ten descriptive studies (Bloch et al., 2007; Blumenfield et al., 1982; Clift, 2012; Couturier et al., 2008, 2009; Cudennec and Galiano, 2007; Cudennec et al., 2006; Dellasega et al., 2001; Fallon et al., 2006; Harvey and Wilson, 2009; Miracle, 1992; Morin et al., 2012; Sennour et al., 2009; Steenpass et al., 2012), three multicenter randomized controlled trials (Borok et al., 1994; Buurman et al., 2010; Kircher et al., 2007; Reuben et al., 1995, 1996) and three single center randomized controlled trials (Hogan and Fox, 1990; Hogan et al., 1987; Shyu et al., 2005, 2008, 2010, 2013a,b; Thomas et al., 1993;

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102

IGCT professions

25

Team size

12

Care settings

25

Detection & selection of patients - formal screening

8

Detection & selection of patients - other procedures

8

Patient assessment: domains & instruments

21

Patient assessment: professions involved

IGCTs included (n and %)

18

IGCTs not included (n and %) Recommendations for patient care & role(s) of IGCT

25

In-hospital follow-up

15

Transition to primary care

13

IGCT team meetings

16

Barriers impacting IGCT intervention

14

Self-evaluation & quality assessment of IGCT intervention

8

0%

20%

40%

60%

80%

100%

Fig. 2. Number of teams reporting on the different structure and process domains of IGCT care.

Tseng et al., 2012), one multicenter (Gayton et al., 1987) and three single center controlled studies (Arbaje et al., 2010; Campion et al., 1983; Tucker et al., 2006), and one pre-post intervention study (Barker et al., 1985). Five studies combined a descriptive and experimental design (Allen et al., 1986; Becker et al., 1987; Braes et al., 2009; Cohen et al., 1992; Deschodt et al., 2011a, 2012b; Inouye et al., 1993a,b; McVey et al., 1989; Saltz et al., 1988; Winograd et al., 1988, 1993; Winograd, 1987). 3.3. Structure of IGCT care A graphical overview of the number of IGCTs reporting on the different structure and process domains is provided in Fig. 2. 3.3.1. IGCT composition: represented professions & educational requirements Except for two IGCTs from the UK and Taiwan which only included two professions, most IGCTs (92%, n = 22) consisted of at least three health care professions, with teams from Canada, France and the USA being the most interdisciplinary in nature (i.e. inclusion of at least five different professions). Of note, nurses were indicated as core members of all included teams (100%, n = 25). Twenty IGCTs (80%) required IGCT nurses to have completed training in geriatrics. In American IGCTs, this requirement was often (n = 11 out of 14 teams) combined with the requisite of being licensed as an advanced practice nurse (APN) in geriatrics. Two IGCTs from other countries (i.e. the UK and the Netherlands) required an APN educated nurse (Table 1). Alongside nurses, physicians were core members in all but two IGCTs (92%, n = 23). In all teams including

physicians (n = 23) there was at least one geriatrician. Other core members included social workers (64% of teams, n = 16), physical therapists (32%, n = 8), occupational therapists (32%, n = 8) and dieticians (24%, n = 6). Figures regarding other types of availability (e.g. on call, not clearly specified) are presented in Table 1. 3.3.2. Team size Data regarding team size were available for 12 IGCTs (48%) (Table 1). Eight of these teams (67%) reported nurses and physicians as their main core members with head counts varying from 1 to 4 members per profession. Five IGCTs provided information on their total team size expressed in full-time equivalents (FTE), ranging from 2.5 to 5.0 FTE. 3.4. Processes of IGCT care 3.4.1. Hospital units The majority of the IGCTs (76%; n = 19) intervened at medical units whereas only 36% (n = 9) provided consultations at surgical units, and 16% (n = 4) at the emergency department or intensive care units. Only one team operated at psychiatry units. Intervention units were either not or only vaguely described for seven teams (Table 2). 3.4.2. Selection of patients for IGCT intervention Sixteen IGCTs (64%) provided information on their procedures for selecting patients for IGCT intervention. All IGCTs specified a minimum patient age which varied from 60 to 75 years of age. Patients in a terminal stage of illness and nursing home patients were excluded by seven and five teams, respectively.

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Table 1 Structure of IGCT care. Country

Study

Team composition

Team size

PH

N

OT

PT

SW

D

Other

Head count

FTE

+

Psychiatrist, pastor & speech therapist +

PH: 1; N:3; OT: 2, PT: 1; SW: 1

N: 1.3; OT: 0.5; SW: 0.25; Total: – –

BE

Braes et al. (2009), Deschodt et al. (2011a, 2012b)

++

++

++

++

++

CA

Gayton et al. (1987)

++

++

++

++

?

++

++

++

++

++

F

Hogan et al. (1987), Hogan and Fox (1990) Bloch et al. (2007)

++

++

++

++

Cudennec et al. (2006), Cudennec and Galiano (2007)

++

++

++

++

Secretary ++

PH: 2; N: 1

Couturier et al. (2008, 2009), Morin et al. (2012), Steenpass et al. (2012) Kircher et al. (2007) Shyu et al. (2005, 2008, 2010, 2013a, 2013b), Tseng et al. (2012) Buurman et al. (2010)

++

++

++

Secretary ++

–

++ ++

++ ++

++

++

++

G TW

NL

UK

USA

Clift (2012) Harvey and Wilson (2009)

++

++

Allen et al. (1986), Becker et al. (1987), Cohen et al. (1992), Saltz et al. (1988), McVey et al. (1989) Arbaje et al. (2010) Barker et al. (1985) Blumenfield et al. (1982) Borok et al. (1994), Reuben et al. (1995, 1996) Campion et al. (1983)

++

++

++ ++ ++

++ ++ ++

++

++

++

++

Dellasega et al. (2001) Fallon et al. (2006) Inouye et al. (1993a, 1993b) Winograd (1987), Winograd et al. (1988, 1993) a Miracle (1992) Sennour et al. (2009)

++

++

++ ++

++ ++

++

++

++ ++

++ ++

++

++

Thomas et al. (1993)

–

? +

++

++

GN

–

Total: 5.0

–

GN

–

PH: 0.5; N: 1.0; OT: 0.5; PT: 0.5; Total: 2.5 –

+ ++ ++

PH: 1; N: 1 – –

– – –

GNP – GNP

++

–

–

GNP

–

–

–

–

GN; discharge planning N CNS

– PH: 2; N: 1

– –

GNP CNS

PH: 3–4; N: 1; SW: 1

–

CNS

– –

– PH: 0.65; N: 1.0; Total:/ –

CNS GNP

Therapists (not specified) ++

Care coordinator +

++

++

++

++

? +

+

++

+

++ +

++ +

++

++

++

++

? +

GN

–

++

++

PH: 1.0, N: 0.5, OT: 0.5; SW: 1.0 Total: 3.0 PH: 1.0; N: 1.0; OT: 0.5; SW: 0.5; other: 0.5 Total: 3.5 PH: 1.5; Total: 4.0

PH: 1; N: 2

++

++

+

–

– –

++ ++

Pastor ++

2 GN Bachelor degree 1 GN Master degree

– –

++

++

++

PH: 2; N: 1; OT: 1; PT: 1 –

Educational requirements nurses

Gerontopsychiatrist ++ Speech therapist ++ Pharmacist ++

Care coordinator & Pharmacist + Psychologist?

Pharmacist ++ Care coordinator & pharmacist + Pharmacist ++

PH: 1; N: 2; PT: 1; SW: 1; Ph: 1

GN

CNS + N without geriatric training CNS

CNS

GN + home health N

M. Deschodt et al. / International Journal of Nursing Studies 55 (2016) 98–114

104 Table 1 (Continued ) Country

Study

Team composition PH

Tucker et al. (2006)

N

OT

PT

++

?

?

Team size SW

D

Other

Head count

FTE

?

Speech therapist, wound care, pastor, care coordinator & pharmacist?

–

–

Educational requirements nurses CNS

BE: Belgium; CA: Canada; F: France; G: Germany; TW: Taiwan; UK: United Kingdom; USA: United States of America; –: data not available; n/a: not applicable; FTE: full-time equivalent; ++ = core member of IGCT; + = profession available on call;? = type of availability not clearly indicated; D = dietician; N = nurse (specified as GN = nurse with geriatric training; CNS = clinical nurse specialist in geriatrics/gerontology; GNP = geriatric nurse practitioner); OT = occupational therapist; PH = physician; PT = physiotherapist; PA = pharmacist; SW = social worker. a Reporting figures from 2nd study (IGCT composition was expanded for the 2nd study).

In addition to the aforementioned criteria, 50% of the teams (n = 8) used a formal screening process for detecting patients at risk for functional decline (e.g. high-risk patients) (Table 2). Screening was frequently performed by IGCT members and not by the non-geriatric unit team (n = 5, 63% of screening teams), with the IGCT nurse being primarily responsible in two teams. The timeframe for screening was stated for six teams and varied widely (from 24 to 96 hours of hospital admission). Two teams (one from both the Netherlands and Belgium) indicated the use of an international recognized screening tool to detect older hospitalized patients at risk for functional decline (i.e. Identification of Seniors At Risk-Hospitalized Patients (ISAR-HP) and Geriatric Risk Profile (GRP), respectively). Other teams used self-defined sets of screening criteria (Table 2), which were highly heterogeneous and based on various medical, functional, psychological and/or social factors and geriatric syndromes. The eight remaining IGCTs (50% of those that specified their strategy to select patients for IGCT intervention) performed case-finding through (combining) various forms of contact with the non-geriatric unit (Bloch et al., 2007; Blumenfield et al., 1982; Clift, 2012; Couturier et al., 2008, 2009; Cudennec and Galiano, 2007; Cudennec et al., 2006; Gayton et al., 1987; Miracle, 1992; Morin et al., 2012; Sennour et al., 2009; Steenpass et al., 2012), in which neither the roles of IGCT nurses nor those of non-geriatric unit nurses were specified (Table 2). Seven of these eight teams (88%) acted upon a request for intervention from the nongeriatric unit care team, whereas bedside rounds (n = 3), patient chart review (n = 1), and IGCT members attending non-geriatric unit interdisciplinary team meetings (n = 1) were only used occasionally. 3.4.3. Patient assessment: domains and instruments Four IGCTs did not report information regarding the content of their patient assessment. Of the other IGCTs (n = 21), 86% evaluated at least one item in all four domains of a CGA (i.e. medical, functional, psychological and social). Specific assessment items captured in this scoping review (n = 22 items; Table 3) refer to important domains of a comprehensive anamnesis of hospitalized patients and/or to geriatric syndromes that commonly occur in older patients. Four teams (19%), being more recently established teams from European countries, evaluated more than half of these items during their patient assessment (Table 3). Sixteen of the 21 aforementioned teams used validated, internationally recognized assessment instruments,

mostly for the functional and psychological domain (Barker et al., 1985; Borok et al., 1994; Braes et al., 2009; Buurman et al., 2010; Campion et al., 1983; Couturier et al., 2008, 2009; Cudennec and Galiano, 2007; Cudennec et al., 2006; Dellasega et al., 2001; Deschodt et al., 2011a; Fallon et al., 2006; Inouye et al., 1993a,b; Miracle, 1992; Morin et al., 2012; Reuben et al., 1995, 1996; Sennour et al., 2009; Steenpass et al., 2012; Thomas et al., 1993; Tucker et al., 2006; Winograd et al., 1988, 1993; Winograd, 1987). Although a myriad of instruments were cited, the Basic and Instrumental Activities of Daily Living scale (B/I-ADL), the Confusion Assessment Method (CAM, delirium assessment) and Geriatric Depression Scale (GDS) were frequently applied across studies. 3.4.4. Patient assessment: professions involved Eighteen IGCTs (72%) specified the professionals responsible for performing the patient assessment (Allen et al., 1986; Arbaje et al., 2010; Becker et al., 1987; Blumenfield et al., 1982; Borok et al., 1994; Braes et al., 2009; Buurman et al., 2010; Campion et al., 1983; Cohen et al., 1992; Couturier et al., 2008, 2009; Cudennec and Galiano, 2007; Cudennec et al., 2006; Dellasega et al., 2001; Deschodt et al., 2011a, 2012b; Fallon et al., 2006; Hogan and Fox, 1990; Hogan et al., 1987; Inouye et al., 1993a,b; McVey et al., 1989; Miracle, 1992; Morin et al., 2012; Reuben et al., 1995, 1996; Saltz et al., 1988; Sennour et al., 2009; Shyu et al., 2005, 2008, 2010, 2013a,b; Steenpass et al., 2012; Tseng et al., 2012; Tucker et al., 2006; Winograd et al., 1988, 1993; Winograd, 1987). The assessment was a shared responsibility of all IGCT members in four teams (Blumenfield et al., 1982; Dellasega et al., 2001; Inouye et al., 1993a,b; Miracle, 1992). IGCT nurses were involved in almost all (n = 13, 93%) of the fourteen remaining teams that specified assessment responsibilities. Thereby, they had a leading role in performing assessments in three teams (Buurman et al., 2010; Arbaje et al., 2010; Tucker et al., 2006), or independently performed part of the assessment alongside physicians (Allen et al., 1986; Becker et al., 1987; Borok et al., 1994; Braes et al., 2009; Cohen et al., 1992; Cudennec and Galiano, 2007; Cudennec et al., 2006; Deschodt et al., 2011a, 2012b; McVey et al., 1989; Reuben et al., 1995, 1996; Saltz et al., 1988; Sennour et al., 2009; Shyu et al., 2005, 2008, 2010, 2013a,b; Tseng et al., 2012; Winograd et al., 1988, 1993; Winograd, 1987), social workers (Allen et al., 1986; Becker et al., 1987; Borok et al., 1994; Cohen

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Table 2 Process of IGCT care: hospital units, selection of patients for IGCT intervention & team meetings. Country

Study

BE

Braes et al. (2009), Deschodt et al. (2011a, 2012b)

CA

Gayton et al. (1987) Hogan et al. (1987), Hogan and Fox (1990)

F

Bloch et al. (2007)

G

Cudennec et al. (2006), Cudennec and Galiano (2007) Couturier et al. (2008, 2009), Morin et al. (2012), Steenpass et al. (2012) Kircher et al. (2007)

TW

NL

Shyu et al. (2005, 2008, 2010, 2013a, 2013b), Tseng et al. (2012) Buurman et al. (2010)

UK

Clift (2012)

Harvey and Wilson (2009)

USA

Allen et al. (1986), Becker et al. (1987), Cohen et al. (1992), Saltz et al. (1988), McVey et al. (1989) Arbaje et al. (2010)

Hospital units

Medical and surgical units, ED, ICU Medical units Medical units, ED?

Medical and surgical units, ED, ICU Medical and surgical units, ED, ICU Medical and surgical units, ED Medical and psychiatry units –

Medical units

Medical and surgical units, ED? Medical units

Medical and surgical units, ED?

Barker et al. (1985)

Medical units –

Blumenfield et al. (1982)

Medical units

Borok et al. (1994), Reuben et al. (1995, 1996)

Medical units, ED?

Selection of patients for IGCT intervention

IGCT meetings

Screening: profession responsible, timeframe, type of instrument

Other type of case finding

Frequency per week

Content

Non-G unit team, 48 h of admission, 2 on Geriatric Risk Profile (GRP) No

No

5

New patients + followup

Informal contact Bedside rounds No

5

New patients + followup New patients (bedside rounds)

Request non-G unit Attendance daily ED meetings (by IGCT PH)

–

–

No

Request non-G unit

–

–

No

Request non-G unit

5

New patients

IGCT PH, –, selfdeveloped instrument –

No

1

New patients + followup

–

–

–

IGCT N, 48 h of admission, 2 on ISAR-HP or selfdeveloped instrument for critically ill/cognitive impaired patients No

No

–

New patients

Request non-G unit

–

–

IGCT member, 24 h of admission (excluding weekends), selfdeveloped instrument –

No

5

New patients (including decision on ambiguous screening results) + follow-up

–

2

New patients + followup

–

–

–

–

IGCT member, –, selfdeveloped instrument No

No

–

–

Request non-G unit Chart review Bedside rounds

1

No

5

New (bedside rounds) Involvement team non-G unit (complex cases) New patients + followup

IGCT N, 48 h of admission, selfdeveloped instrument No

–, 24–72 h of admission, selfdeveloped two-step instrument

5

M. Deschodt et al. / International Journal of Nursing Studies 55 (2016) 98–114

106 Table 2 (Continued ) Country

Study

Hospital units

Selection of patients for IGCT intervention

IGCT meetings

Screening: profession responsible, timeframe, type of instrument

Other type of case finding

Frequency per week

Content

New patients Involvement N + SW non-G unit New patients + followup Involvement PH non-G unit

Campion et al. (1983)

Medical units

–

–

–

Dellasega et al. (2001)

–

–

–

5

Fallon et al. (2006)

Surgical units, ICU Medical units

–

–

–

–

–

2

Winograd (1987), Winograd et al. (1988, 1993)

Medical and surgical units

No

–

Miracle (1992)

–

Project coordinator (discussion with IGCT), 96 h of admission, selfdeveloped instrumenta No

Request non-G unit PH

5

Sennour et al. (2009)

Medical units, surgical units?

No

–

Thomas et al. (1993) Tucker et al. (2006)

– Medical units

– –

Request non-G unit Daily meetings (IGCT & non-G unit PH) Bedside rounds – –

Inouye et al. (1993a, 1993b)

– 5

New patients (bedside rounds) Involvement GRNs + N non-G unit (education and support) New patients

New patients + followup Involvement team non-G unit (complex cases) –

– New patients + followup (bedside rounds)

BE: Belgium; CA: Canada; F: France; G: Germany; TW: Taiwan; UK: United Kingdom; USA: United States of America; -: Data not available; n/a: not applicable;? = not clearly indicated; GRN = geriatric resource nurse; N = nurse; PH = physician; SW = social worker; ED = emergency department; ICU = intensive care unit; non-G unit: non geriatric unit; ISAR-HP: identification for seniors at risk–hospitalized patients a Change of focus on solely ED 7 years after IGCT establishment; screening procedure added in Winograd et al. (1988).

et al., 1992; McVey et al., 1989; Reuben et al., 1995, 1996; Saltz et al., 1988; Winograd et al., 1988, 1993; Winograd, 1987) and/or an occupational therapist (Cudennec et al., 2006; Cudennec and Galiano, 2007). Only two IGCTs deliberately encouraged the contribution of nurses from the non-geriatric unit (Inouye et al., 1993a,b; Tucker et al., 2006). In four teams, physicians had a leading role (Campion et al., 1983; Couturier et al., 2008, 2009; Hogan and Fox, 1990; Hogan et al., 1987; Morin et al., 2012; Steenpass et al., 2012) or performed a mono-disciplinary assessment (Fallon et al., 2006). 3.4.5. Recommendations for patient care Seven teams (28%) indicated the involvement of either IGCT or non-geriatric unit nurses in the communication of recommendations (Bloch et al., 2007; Blumenfield et al., 1982; Braes et al., 2009; Couturier et al., 2008, 2009; Cudennec and Galiano, 2007; Cudennec et al., 2006; Deschodt et al., 2011a, 2012b; Inouye et al., 1993a,b; Morin et al., 2012; Steenpass et al., 2012; Winograd et al., 1988, 1993; Winograd, 1987). In contrast, ten IGCTs (40%) reported that solely physicians were involved. Two IGCTs specifically applied face-to-face communication (Blumenfield et al., 1982; Winograd et al., 1988, 1993; Winograd,

1987). Of notice, communication to the patient, to relative(s) (Arbaje et al., 2010; Buurman et al., 2010; Gayton et al., 1987) or to professional caregivers in primary care (Couturier et al., 2008, 2009; Morin et al., 2012; Steenpass et al., 2012) was only performed by 12% of the IGCTs (n = 3 teams for each respectively). For the remaining IGCTs, reporting on involved professions was lacking or insufficiently clear.Nine IGCTs (36%) communicated their recommendations to the care team of the non-geriatric unit both in written (added to patient’s file) and verbally (direct or telephone contact) (Allen et al., 1986; Arbaje et al., 2010; Becker et al., 1987; Braes et al., 2009; Campion et al., 1983; Cohen et al., 1992; Cudennec et al., 2006; Deschodt et al., 2011a, 2012b; Fallon et al., 2006; Gayton et al., 1987; McVey et al., 1989; Saltz et al., 1988; Sennour et al., 2009; Winograd et al., 1988, 1993; Winograd, 1987), whereas seven other teams (28%) only applied written formats (Barker et al., 1985; Bloch et al., 2007; Borok et al., 1994; Dellasega et al., 2001; Kircher et al., 2007; Reuben et al., 1995, 1996; Thomas et al., 1993; Tucker et al., 2006). Of the 14 studies published since 1994 (i.e. the start of the widespread use of internet), five teams (36%) used electronic communication (e-mail or electronic patient file) (Borok et al., 1994; Braes et al., 2009; Couturier et al.,

Table 3 Process of IGCT care: patient assessment. Country

BE

F

G TW

NL UK USA

Summary%

Braes et al. (2009), Deschodt et al. (2011a, 2012b) Gayton et al. (1987) Hogan et al. (1987), Hogan and Fox (1990) Bloch et al. (2007) Cudennec et al. (2006), Cudennec and Galiano (2007) Couturier et al. (2008, 2009), Morin et al. (2012), Steenpass et al. (2012) Kircher et al. (2007) Shyu et al. (2005, 2008, 2010, 2013a, 2013b), Tseng et al. (2012) Buurman et al. (2010) Clift (2012) Harvey and Wilson (2009) Allen et al. (1986), Becker et al. (1987), Cohen et al. (1992), Saltz et al. (1988), McVey et al. (1989) Arbaje et al. (2010) Barker et al. (1985) Blumenfield et al. (1982) Borok et al. (1994), Reuben et al. (1995, 1996) Campion et al. (1983) Dellasega et al. (2001) Fallon et al. (2006) Inouye et al. (1993a, 1993b) Winograd (1987), Winograd et al. (1988, 1993) Miracle (1992) Sennour et al. (2009) Thomas et al. (1993) Tucker et al. (2006)

Medical assessment

Functional assessment

Actual medical problems

Medical history

Medication review

Laboratory tests

Skin condition

+

+

+

+

+

+

+

+

+

Physical examination

Osteoporosis

+

+

+

+

+

+

+

+

+

+

+

+ +

+

+

+ + + +

+

+

+ +

+

+

+

Fall risk/history

+ + + +

+

+

+ +

+ + +

+

+ + 52

52

71

24

Risk for pressure sores

Hearing and vision

+

+

+

+ +

+

+

+

+

+

+

+

+

+

+

+

+ + +

+

+

+

+ + +

33

+

+

+

24

+ +

+

+

+ + +

+

+

+

+

Mobility & balance

+

+ +

Activities of daily living

14

81

+

M. Deschodt et al. / International Journal of Nursing Studies 55 (2016) 98–114

CA

Study

+

+ + + 33

+ 38

+

14

+ 29 107

BE

CA

F

NL UK USA

Summary%

Braes et al. (2009), Deschodt et al. (2011a, 2012b) Gayton et al. (1987) Hogan et al. (1987), Hogan and Fox (1990) Bloch et al. (2007) Cudennec et al. (2006), Cudennec and Galiano (2007) Couturier et al. (2008, 2009), Morin et al. (2012), Steenpass et al. (2012) Kircher et al. (2007) Shyu et al. (2005, 2008, 2010, 2013a, 2013b), Tseng et al. (2012) Buurman et al. (2010) Clift (2012) Harvey and Wilson (2009) Allen et al. (1986), Becker et al. (1987), Cohen et al. (1992), Saltz et al. (1988), McVey et al. (1989) Arbaje et al. (2010) Barker et al. (1985) Blumenfield et al. (1982) Borok et al. (1994), Reuben et al. (1995, 1996) Campion et al. (1983) Dellasega et al. (2001) Fallon et al. (2006) Inouye et al. (1993a, 1993b) Winograd (1987), Winograd et al. (1988, 1993) Miracle (1992) Sennour et al. (2009) Thomas et al. (1993) Tucker et al. (2006)

Functional assessment

Psychological assessment

Nutritional status

Pain

Incontinence

Sleep disturbances

+

+

+

+

+

+ +

+

+

+

+

+ +

Social assessment

Cognitive assessment

Delirium

Depression

Living conditions

Care uses & needs + caregiver status

+

+

+

+

+

+

+ +

+ +

+

+

+

+

+ +

+

+

+

+

+

+

+ +

+

+ + +

+

+

+ + +

+ + +

+ +

+

+

+

+ +

+

+

+

+

+

+

+ +

+ +

Finances

+

+

+ +

+

29

29

29

14

+ + + + 91

+ + + 33

+ 57

+

33

+

+

62

14

BE: Belgium; CA: Canada; F: France; G: Germany; TW: Taiwan; UK: United Kingdom; USA: United States of America; –: data on patient assessment not available; + item included in patient assessment Summary: reporting the percentage of IGCTs who evaluated a specific medical, functional, psychological or social item during their patient assessment (calculated for the teams (n = 21) who provided information on their patient assessment).

M. Deschodt et al. / International Journal of Nursing Studies 55 (2016) 98–114

G TW

Study

108

Country

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2008, 2009; Cudennec and Galiano, 2007; Cudennec et al., 2006; Deschodt et al., 2011a, 2012b; Morin et al., 2012; Reuben et al., 1995, 1996; Steenpass et al., 2012; Thomas et al., 1993). Communication methods were not specified for seven IGCTs (Buurman et al., 2010; Clift, 2012; Harvey and Wilson, 2009; Hogan and Fox, 1990; Hogan et al., 1987; Inouye et al., 1993a,b; Miracle, 1992; Shyu et al., 2010, 2013a,b; Tseng et al., 2012). Of interest, 40% of the IGCTs (n = 10) indicated having a hybrid role (both advice and implementation), meaning that IGCT members also directly implemented part of their recommendations in the care for consulted geriatric patients (Arbaje et al., 2010; Blumenfield et al., 1982; Borok et al., 1994; Gayton et al., 1987; Harvey and Wilson, 2009; Kircher et al., 2007; Reuben et al., 1995, 1996; Sennour et al., 2009; Shyu et al., 2005, 2008, 2010, 2013a,b; Tseng et al., 2012; Tucker et al., 2006; Winograd et al., 1988, 1993; Winograd, 1987). No information on team role(s) was provided by 36% of the teams (n = 9) (Bloch et al., 2007; Buurman et al., 2010; Clift, 2012; Dellasega et al., 2001; Fallon et al., 2006; Hogan and Fox, 1990; Hogan et al., 1987; Miracle, 1992; Thomas et al., 1993). 3.4.6. In-hospital follow-up and transition to primary care After the initial patient assessment, 60% of all IGCTs (n = 15) provided in-hospital follow-up mostly consisting of evaluating the implementation rate of recommendations made after the initial assessment and/or patient reassessment (47%, n = 7 teams for both). A role for IGCT or non-geriatric unit nurses in patient follow-up was only indicated in four teams (Arbaje et al., 2010; Braes et al., 2009; Deschodt et al., 2011a, 2012b; Miracle, 1992; Shyu et al., 2005, 2008, 2010, 2013a,b; Tseng et al., 2012) (Supplementary material 4). Thirteen IGCTs (52%) stated their involvement in the preparation of the transition from the hospital to the primary care setting. For six teams, transitional care elements included either telephone follow-up of patients and relatives, or communication on the assessment and recommendations of the IGCT to professional services (e.g. general practitioner, home care services) in primary care. Five teams made referrals to outpatient services (e.g. fall clinic). Active participation in coordination of primary care (n = 3) and home visits (n = 2) was less often performed (Supplementary material 4). 3.4.7. IGCT team meetings The organization of team meetings was specified by sixteen teams (64%) with slightly more than half (n = 9) having a daily meeting. Four teams performed meetings as interdisciplinary bedside rounds and four teams invited team members of the non-geriatric unit to participate in the IGCT team meetings, for purposes such as discussing complex patient cases or education and support. Five IGCTs organized team meetings to discuss their initial patient assessments and separate meetings to discuss the followup evaluations of patients (Table 2). 3.4.8. Barriers impacting IGCT care Fourteen IGCTs (56%) reported barriers affecting their ability to provide high-quality care, including limited

109

adherence to recommendations for patient care by nongeriatric units (n = 6 teams) (Allen et al., 1986; Becker et al., 1987; Braes et al. 2009; Cohen et al., 1992; Couturier et al., 2008, 2009; Cudennec and Galiano, 2007; Cudennec et al., 2006; Dellasega et al., 2001; Deschodt et al., 2011a, 2012b; Inouye et al., 1993a,b; McVey et al., 1989; Morin et al., 2012; Saltz et al., 1988; Steenpass et al., 2012; Thomas et al., 1993; Winograd et al., 1988, 1993; Winograd, 1987), time constraints (n = 5) (Braes et al., 2009; Deschodt et al., 2011a, 2012b; Bloch et al., 2007; Blumenfield et al., 1982; Sennour et al., 2009; Inouye et al., 1993a,b) and negative stereotypes of healthcare workers regarding geriatric care (n = 4) (Barker et al., 1985; Braes et al., 2009; Cudennec and Galiano, 2007; Cudennec et al., 2006; Deschodt et al., 2011a, 2012b; Tucker et al., 2006). Also, IGCTs encountered problems regarding unclear divison of responsibilities between the IGCT and non-geriatric units (n = 3) (Blumenfield et al., 1982; Campion et al., 1983; Inouye et al., 1993a,b) and barriers regarding infrastructure, working procedures and support from the hospital management (n = 2 for both) (Blumenfield et al., 1982; Cudennec et al., 2006; Cudennec and Galiano, 2007; Barker et al., 1985; Inouye et al., 1993a,b). 3.4.9. Self-evaluation and quality assessment of IGCT care Eight IGCTs (32% of all teams) originating from Belgium, France and the USA (Allen et al., 1986; Barker et al., 1985; Becker et al., 1987; Braes et al., 2009; Cohen et al., 1992; Couturier et al., 2008, 2009; Dellasega et al., 2001; Deschodt et al., 2011a, 2012b; Inouye et al., 1993a,b; McVey et al., 1989; Morin et al., 2012; Saltz et al., 1988; Steenpass et al., 2012; Winograd et al., 1988, 1993; Winograd, 1987) performed self-evaluations of provided interventions. These were mostly oriented toward adherence of non-geriatric unit teams to IGCT recommendations for patient care. All reported mean adherence rates of individual studies were higher than 50%, but rates for individual types of recommendations varied considerably (between 12.5% and 100%). One IGCT evaluated the impact of their recommendations through balancing their frequency and adherence rate (Deschodt et al., 2011a). Only one study performed quantitative analyses regarding factors influencing adherence rates, reporting a statistically significant negative association of adherence rates with the number of recommendations made (in favor of focusing on a limited number of prioritized recommendations) (Morin et al., 2012) and a positive association with directly and personally feeding back the recommendations to care workers of the nongeriatric unit (Allen et al., 1986). Other influencing factors from narrative summaries largely correspond to the aforementioned barriers impacting IGCT care. Importantly, no IGCT reported on the use of quality criteria/indicators or annual performance reports to evaluate their service. Although 20% of all teams (n = 5) (Dellasega et al., 2001; Sennour et al., 2009; Borok et al., 1994; Shyu et al., 2005; Arbaje et al., 2010) indicated (future) plans to evaluate the cost-effectiveness of their IGCT, we did not identify published data on this topic.

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4. Discussion 4.1. Substantial findings This scoping review demonstrated that IGCTs provide care for geriatric patients through highly heterogeneous structures and processes of care. Despite confirmation of the notion that nurses are key members of these interdisciplinary teams, limited information on their specific roles and responsibilities is currently available in the international literature. Given that the IGCT model aims to provide CGA to geriatric patients, interpreting the study results according to the aforementioned definition of CGA (Rubenstein et al., 1991) provides an interesting framework. First, CGA is an interdisciplinary process, implying that at least two professions should be represented in the IGCT and integrate their individual expertise and skills into the provided care through continuous collaboration (Rubenstein et al., 1991). For example, the IGCT nurse, geriatrician, occupational and physical therapist may each (partly) assess the functional capacities of an older patient, but their collaboration and sharing of skills and expertise is needed to fully understand the patients’ functioning, and to subsequently formulate appropriate care recommendations. The composition of the 25 described IGCTs was rather heterogeneous both regarding team size and professions represented, but all appeared to be strongly driven by nurses. However, the minimal educational backgrounds of IGCT nurses varied widely, with Advanced Practice Nursing (APN) roles only being applied by a limited number of teams all originating from the USA. Hence, the potential roles, responsibilities and impact of APN in IGCTs in an international context warrant further research. As the health status of a geriatric patient is often dynamic and highly sensitive for change during hospitalization, interdisciplinary meetings and follow-up should occur frequently. This enables the timely and accurate formulation of recommendations and can increase the adherence to these advices by the nongeriatric unit care team (Deschodt et al., 2011a, 2012a, 2013). However, half of the identified IGCTs did not report any data on the organization of team meetings and only 60% of teams provided in-hospital follow-up. The latter could be related to the lack of direct responsibility of IGCTs for provided care, and the potentially high case-load of these teams. Also, further research could explore whether involving team members of the non-geriatric unit in IGCT meetings is a beneficial strategy to improve their adherence to provided recommendations. Second, as CGA is considered a gold standard approach for frail older persons (Cesari et al., 2014; Clegg et al., 2013), it should be preceded by patient screening to identify these frail patients. Of importance, this scoping review showed that only a minority of IGCTs used formal screening procedures with internationally recognized screening instruments, and that such procedures were mostly applied in the context of experimental studies. Other teams used a variety of broad patient eligibility criteria, which hinders targeted function of IGCTs and might considerably increase their workload. Taking into account high rates of false positives, related to low specificity of the

currently available formal screening instruments (Deschodt et al., 2011b), more in-depth practice-oriented research is needed to delineate the most optimal patient selection methods for IGCTs. Such research could importantly be informed by recent developments and international consensus in the conceptualization and assessment of the frailty syndrome (Clegg et al., 2013; Morley et al., 2013; Chen et al., 2014). Third, CGA is a multidimensional process, indicating that the medical, functional, psychological and social dimensions of a geriatric patient should be taken into account in the baseline IGCT assessment. Nevertheless, only few teams evaluated more than half of all assessment items captured for this scoping review. This is of specific concern, as captured items refer to essential domains of a holistic anamnesis and to geriatric syndromes that commonly occur in older inpatients. As such, ensuring a multidimensional assessment for older patients in the IGCT process likely warrants substantial improvements in daily clinical practice. Fourth, a CGA process should lead to the development of a coordinated and integrated treatment plan. Within the IGCT care model this is done through formulating recommendations regarding the in- and outpatient care for the consulted patient. However, non-adherence to these recommendations has been suggested as an important factor contributing to the lack of effectiveness of IGCTs to improve patient outcomes (Deschodt et al., 2013). The finding that adherence is often hampered by a variety of barriers at the provider-level (e.g. attitudes and knowledge of caregivers from non-geriatric units, quality and number of recommendations), hospital-, and healthcare systemlevel (e.g. infrastructure and working procedures, support from nursing management, financing, staffing levels), warrants the need to further map and subsequently address these barriers in clinical practice. Also, a hybrid role of IGCTs (e.g. allowing teams to directly order or implement part of their recommendations in patient care) has been proposed as a possible solution (Deschodt et al., 2013). As in the current scoping review problems regarding adherence were most often mentioned for IGCTs with a solely advisory role, the impact of this role adjustment should be further studied. Fifth, the development of a coordinated and integrated plan for long-term follow-up should be part of a CGA process. However, only slightly over half of all IGCTs reported on the provision of in-hospital patient follow-up, and less than a quarter of all IGCTs were involved in the preparation of the transition from the hospital to the primary care setting. This finding is alarming, as fragmentation, a lack of coordination and continuity of care during these transitions have been shown to confer an important risk for potentially preventable post-discharge adverse outcomes for both patients and their informal caregivers (Bray-Hall, 2012; Naylor et al., 2011, 2013; Verhaegh et al., 2014). These include early readmissions, non-adherence to the prescribed medical regimen, depression, anxiety, decreased quality of life, and caregiver burden, and lead to an increased use of healthcare resources and costs (BrayHall, 2012; Naylor et al., 2011, 2013; Verhaegh et al., 2014). Hence, more research is required to further develop and

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evaluate the component of in-hospital patient follow-up by IGCTs, and to refine and improve its linkage with transitional care models to primary care settings. Specific attention to the roles and responsibilities of nurses in these care processes is warranted, given the identified scarcity of information in this regard. Although not included in the CGA definition (Rubenstein et al., 1991), a thorough evaluation of the quality of provided care plays an imperative role in current clinical practice, aiming at continuous improvements in care provision (Committee on Quality of Health Care in America, Institute of Medicine, 2001). Despite its importance and in line with the findings of the current study, evaluation of the quality of IGCT care has to date received little attention in the international literature. Although the use of quality indicators to evaluate IGCTs has been proposed by both professional organizations and governmental institutions (Deschodt et al., 2015; Inspectie voor de Gezondheidszorg, 2013; Ouderenbonden, 2012; Rousseau and Bastianelli, 2005), none of the included IGCTs applied this method. As this impedes comprehensive (inter)national comparisons across IGCTs, and subsequent investments in quality improvement, more evidence-based, practice-oriented research in this area is urgently needed. 4.2. Implementation of IGCTs and alternative care models in an international context Judging the considerable number of papers retrieved, it should be taken into account that included studies report solely on 25 distinct IGCT services originating from only eight countries across three continents. These papers were also published within a timeframe of over 30 years (1983– 2012), including a considerable number of older papers. Hence, we conclude that only a limited body of evidence regarding IGCT services has been published. Notwithstanding the fact that demographic changes with a steadily increasing older and multi-morbid population challenge the health care systems of most Western countries, this suggests that the IGCT care model has not been described or studied frequently, and that it has found no widespread use, both within and across countries. The latter assumption is in line with the findings of recent semi-structured interviews with key stakeholders in geriatric research and clinical practice and an international survey across IGCTs in various countries (Deschodt et al., 2015). Besides the inconclusive evidence on IGCTs effectiveness, several challenging contextual factors might explain the withering clinical and research interest in this care model across various health care systems after its more widespread consideration in the eighties and nineties. These factors include a lack of support at the broader health policy and hospital management level, a lack of financial profitability and incentives, a shortage of a workforce with adequate geriatric training among various healthcare professions, and several barriers at the hospital and provider level such as logistics, practicality, and those identified in the current study. Concomitantly, various alternative models (Malone et al., 2014) to introduce geriatric expertise on non-geriatric units are actively being researched and implemented, which

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might also partly explain the limited evidence found on the IGCT care model. Specifically, an increasing number of hospitals are implementing geriatric co-management models (Deschodt et al., 2015). This is the most far-reaching model of shared care between a medical specialist and a geriatrician, since they manage the patient together from admission until discharge, and are both responsible for the process and outcome of care. Typically, these models include a geriatrician and/or a geriatric nurse practitioner (Friedman et al., 2009; Mendelson and Friedman, 2014). Although no RCTs were published studying the impact of geriatric co-management, several factors for success can be hypothesized. First, there is a more productive use of geriatricians (i.e. they can work complementary to acute medical care). Second, there is a possibility to provide proactive care, as geriatric co-management models are mostly developed for populations with a known high susceptibility for geriatric syndromes and functional decline (e.g. hip-fracture, cardiac conditions). Third, geriatricians teaming up with medical specialists enables a culture of ‘helping and supporting’ rather than ‘finger pointing out’ mistakes. However, comparative effectiveness research on the IGCT and co-management model is needed in order to determine which model has the most beneficial impact. Other alternative care models that have been proven successful are Nurses Improving Care for Healthsystem Elders (NICHE) programs (Capezuti et al., 2013) and Hospital Elder Life Programs (HELP) (Inouye et al., 2000, 2006). NICHE is a nurse-driven program that aims to deliver sensitive and exemplary health care to all adults aged 65 years in hospitals and other healthcare facilities. In terms of clinical competence, geriatric resource nurses are essential in the NICHE implementation. These are staff nurses who completed an intensive continuing education program to be a unit-based geriatric clinical resource leader for promoting evidence-based geriatric care. The HELP intervention focuses on delirium as a common geriatric syndrome, but is designed to be a comprehensive model of care for hospitalized older adults. Patients aged 70 years or older are screened on admission for common delirium risk factors, and targeted interventions are subsequently implemented by an interdisciplinary team, including a geriatric nurse specialist, trained volunteers, and geriatricians working in close collaboration with staff nurses (Inouye et al., 2000). Lastly, an increasing number of acute medical hospital units in the UK is being supported by ‘geriatric liaison services’, which are mono-disciplinary interventions conducted by geriatricians (Conroy and Parker, 2014). Recommendations of the Royal College of Physicians (2012) stated that ‘geriatric liaison services’ might be a suitable CGA oriented care model for frail older people. 4.3. Methodological considerations The following methodological limitations should be taken into account when interpreting the results of this study. First, some steps in the review process could not be independently performed by two or more researchers for feasibility reasons. To counter for this potential source of researcher bias, regular and elaborate discussions within the

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research team were held. Next, we limited our database search to studies published 1999 to enhance the feasibility of study selection. Older studies were only identified through systematically hand-searching reference lists of included studies, systematic reviews and key-publications regarding IGCT care models. Also, publication bias may have occurred as the entire search strategy was limited to English, French and Dutch papers, based on the language skills of the research team. Last, the included experimental studies often only concisely reported on IGCT structure and processes and it should be noted that the interventions applied in these studies may not be directly transferable to daily clinical IGCT practice, as experiments tend to be tested in optimal conditions with more available financial and personnel resources. An important strength of this scoping review is the rigorous application of the methodological framework of Arksey and OMalley (2005), incorporating revisions suggested by Armstrong et al. and Levac et al. in 2010– 2011 (Armstrong et al., 2011; Levac et al., 2010). Although a standardized approach to conducting scoping reviews is to date non-existent, this is the most commonly applied framework. In line with a conceptual paper on scoping reviews previously published in this journal (Davis et al., 2009) we point at the need to develop an international consensus on the definition, methodology and reporting guidelines for scoping reviews in healthcare research. 5. Conclusions In conclusion, this scoping review indicates that IGCTs intervene through highly heterogeneous structures and processes, whereby several areas for future improvement and research are apparent. Despite the confirmation that nurses are key members of IGCTs, only limited information on their specific roles and responsibilities in IGCT care has been reported in the literature. Overall, this points out that the development of recommendations aiming to improve the effectiveness of the IGCT care model will require joint and collaborative efforts from stakeholders within the areas of healthcare research, practice and policy. Acknowledgements We thank the employees of the Belgian Health Care Knowledge Center and members of the Belgian College of Geriatricians and the Belgian Association for Gerontology and Geriatrics (BVGG/SBGG) who participated in the validation phase of this scoping review. Authors’ contributions: All authors substantially contributed toward the conception and design of the study and interpretation of the data. Study selection, data charting, data analyses and drafting of the manuscript were primarily performed by three authors (MD, VC, BVG). Final approval of manuscript submission was provided by all authors. KM, JF, BB, and KV supervised the study. Conflicts of interest: None declared. Ethical approval: Not applicable.

Funding: This study (project 2014 HSR ‘Comprehensive geriatric care in hospitals: the role of inpatient geriatric consultation teams’) was funded by the Belgian Healthcare Knowledge Center (KCE). The KCE is a federal institution which is financed by the Federal Public National Institute for Health and Disability Insurance (NIHDI, RIZIV–INAMI), the Federal Public Service of Health, Food chain safety and Environment, and the Federal Public Service of Social Security. The development of health services research studies is part of the legal mission of the KCE. Although the development of the studies is paid by KCE budget, the sole mission of the KCE is providing scientifically valid information.

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