Assessing the impact of a restorative home care service in New Zealand: a cluster randomised controlled trial

Due to the ageing population, there is an increased demand for home care services. Restorative care is one approach to improving home care services, although there is little evidence to support its use in the community setting. The objective of this trial was to evaluate the impact of a restorative home care service for community-dwelling older people. The study was a cluster randomised controlled trial undertaken at a home care agency in New Zealand. The study period was from December 2005 to May 2007. Older people were interviewed face-to-face at baseline, four and 7 months. A total of 186 older people who received assistance from a home care agency participated in the study, 93 received restorative home care and 93 older people received usual home care. The primary outcome measure was change in health-related quality of life (measured by the Short Form 36 [SF36] Health Survey). Secondary outcomes were the physical, mental, and social well-being of older people (Nottingham Extended Activities of Daily Living, Timed Up and Go, Mastery scale, Duke Social Support Index). Findings revealed that compared with usual care, the intervention demonstrated a statistically significant benefit in health-related quality of life (SF36) at 7 months for older people (mean difference 3.8, 95% CI -0.0 to 7.7, P = 0.05). There were no changes in other scale measurements for older people in either group over time. There was a statistically significant difference in the number of older people in the intervention group identified for reduced hours or discharge (29%) compared with the control group (0%) (P < 0.001). In conclusion, a restorative home care service may be of benefit to older people, and improves home care service efficacy.     

Means without ends: justifying supportive home care for frail older people in Canada, 1990-2010

The challenges associated with ageing populations are very much on the policy and research agenda of many nations, with significant discussions focused on establishing appropriate, acceptable parameters of home care for those who are older and frail. This paper develops an analysis of changing justifications of home care in Canada (1990-2010) through examination of governmental and non-governmental home care policy documents and position papers, as well as observations from recent fieldwork in home care. Boltanski and Thévenot's sociology of justification provides a framework for analysis of these situations where competing and irreducible pluralities of goods complicate discussions of the 'right' way to proceed.     

A comparison of the home‐care and healthcare service use and costs of older Australians randomised to receive a restorative or a conventional home‐care service

Restorative home‐care services, or re‐ablement home‐care services as they are now known in the UK, aim to assist older individuals who are experiencing difficulties in everyday living to optimise their functioning and reduce their need for ongoing home care. Until recently, the effectiveness of restorative home‐care services had only been investigated in terms of singular outcomes such as length of home‐care episode, admission to hospital and quality of life. This paper reports on a more complex and perhaps more significant measure – the use and cost of the home‐care and healthcare services received over the 2‐year period following service commencement. Seven hundred and fifty older individuals referred for government‐funded home care were randomly assigned to a restorative or standard service between June 2005 and August 2007. Health and aged care service data were sourced and linked via the Western Australian Data Linkage System. Restorative clients used fewer home‐care hours (mean [SD], 117.3 [129.4] vs. 191.2 [230.4]), had lower total home‐care costs (AU$5570 vs. AU$8541) and were less likely to be approved for a higher level of aged care (N [%], 171 [55.2] vs. 249 [63.0]) during follow‐up. They were also less likely to have presented at an emergency department (OR = 0.69, 95% CI = 0.50–0.94) or have had an unplanned hospital admission [OR (95% CI), 0.69 (0.50–0.95)]. Additionally, the aggregated health and home‐care costs of the restorative clients were lower by a factor of 0.83 (95% CI 0.72–0.96) over the 2‐year follow‐up (AU$19,090 vs. AU$23,428). These results indicate that at a time when Australia is facing the challenges of population ageing and an expected increase in demand for health and aged care services, the provision of a restorative service when an older person is referred for home care is potentially a more cost‐effective option than providing conventional home care.     

Partnership working by default: district nurses and care home staff providing care for older people

Older people residents in care homes that only offer residential care rely on primary healthcare services for medical and nursing needs. Research has investigated the demands that care homes staff and residents make on general practice, but not the involvement of other members of the primary healthcare team. This paper describes two consecutive studies completed in 2001 and 2003 that involved focus groups and survey methods of enquiry conducted in two settings: an England shire and inner London. The research questions that both studies had in common were (1) What is the contribution of district nursing and other primary care services to care homes that do not have on‐site nursing provision? (2) What strategies promote participation and collaboration between residents, care home staff and NHS primary care nursing staff? and (3) What are the current obstacles and aids to effective partnership working and learning? A total of 74 community‐based nurses and care home managers and staff took part in 10 focus groups, while 124 care home managers (73% of the171 surveyed) and 113 district nurse team leaders (80% of the 142 surveyed) participated in the surveys. Findings from both studies demonstrated that nurses were the most frequent NHS professional visiting care homes. Although care home managers and district nurses believed that they had a good working relationship, they had differing expectations of what the nursing contribution should be and how personal and nursing care were defined. This influenced the range of services that older people had access to and the amount of training and support care home staff received from district nurses and the extent to which they were able to develop collaborative and reciprocal patterns of working. Findings indicate that there is a need for community‐based nursing services to adopt a more strategic approach that ensures older people in care homes can access the services they are entitled to and receive equivalent health care to older people who live in their own homes.     

Enabling frail older people with a communication difficulty to express their views: the use of Talking Mats as an interview tool

The aim of the present study was to obtain the views of frail older people with communication impairments using an innovative interviewing method, Talking Mats. People with a communication disability are often omitted from qualitative research studies since they cannot respond to the more traditional methods of interviewing. However, their views are important and they may, in fact, have additional insights because of their communication situation. The 10 participants in this study were frail older people with a range of communication difficulties with causes including stroke, dementia and hearing loss. They had all recently (within 6 months) moved into care homes. Each participant was interviewed using Talking Mats to obtain their views on four aspects of their life: activities, people, environment and self. The findings are presented in a visual way, and the four life themes are discussed with reference to the different participants. Many insights were gained, such as the participants' views of the activities which they like and dislike, and the views of some of the people in the study about their nursing home environment. The advantages of the Talking Mats as an interview method for research, practice and policy in the care of frail older people are described. The study concludes that Talking Mats is a useful and enjoyable method of allowing frail older people with a communication disability to express views which they have difficulty conveying otherwise.     

Using older home care user experiences in performance monitoring

Home care services play a fundamental role in England in supporting older and disabled people in their own homes. In order to identify and monitor the degree to which these services are providing good quality services, in 2003 the government required all councils with social services responsibilities (CSSR) to undertake user experience surveys among older service users. The questionnaire was required to include four questions, two of which were designed to be used as Best Value Performance Indicators (BVPI) reflecting the quality of home care of older people. Thirty‐four local authorities participated in an extension study providing data from 21 350 home care users. The aim of the study was to answer three questions: (1) Do the performance indicators reflect home care quality? (2) Are the performance indicators using the most appropriate cut‐off points? (3) What are the underlying constructs of home care quality? Evidence was found to support the use of two of the performance indicators and the current cut‐off point being used for the satisfaction indicator. Factor analysis identified indicators of important dimensions of quality that were associated with overall satisfaction.     

A randomised controlled trial of the Home Independence Program,an Australian restorative home‐care programme for older adults

A randomised controlled trial was conducted to test the effectiveness of the Home Independence Program (HIP), a restorative home‐care programme for older adults, in reducing the need for ongoing services. Between June 2005 and August 2007, 750 older adults referred to a home‐care service for assistance with their personal care participated in the study and received HIP or ‘usual’ home‐care services. Service outcomes were compared at 3 and 12 months. Subgroups of 150 from each group were also compared on functional and quality of life measures. Data were analysed by ‘intention‐to‐treat’ and ‘as‐treated’. The intention‐to‐treat analysis showed at 3 and 12 months that the HIP group was significantly less likely to need ongoing personal care [Odds ratio (OR) = 0.18, 95% CI = 0.13–0.26, P < 0.001; OR = 0.22, 95% CI = 0.15–0.32, P < 0.001]. Both subgroups showed improvements on the individual outcome measures over time with the only significant differences being found at 12 months for Instrumental Activities of Daily Living (IADL) in the as‐treated analysis. Contamination of the control group by an increased emphasis on independence across the home‐care agency involved, together with other methodological problems encountered, is thought to account for the few differences between groups in individual outcomes. Despite no difference between the groups over time in their overall ADL scores, a significantly smaller proportion of the HIP group required assistance with bathing/showering, the most common reason for referral, at 3 and 12 months. The results support earlier findings that participating in a short‐term restorative programme appears to reduce the need for ongoing home care. The implementation of such programmes more broadly throughout Australia could substantially offset the projected increase in demand for home care associated with the five‐fold projected increase in numbers of the oldest old expected over the next 40 years.     

The feasibility and acceptability of a specialist health and social care team for the promotion of health and independence in 'at risk' older adults

Population ageing, escalating costs in pensions, health-care and long-term care have prompted a new policy agenda for active ageing and quality of life in old age across the European Union and other developed countries. In England, the National Service Framework for Older People (NSF OP) explicitly demands for the first time that the NHS and local authorities, in partnership, agree programmes to promote health ageing and to prevent disease in older people. These programmes are expected to improve access for older people to mainstream health promotion services and also to develop multiagency initiatives to promote health, independence and well-being in old age. This paper describes the evaluation of one interagency project team established to test out mechanisms for addressing health promotion for older people through primary care. A mixed methodology was used to understand the processes of service development, the impact of the team's intervention, and the primary and secondary outcomes for older people. The project demonstrated that multi-agency partnerships have the potential to improve the quality of the lives of older people deemed 'at risk' by their general practitioners, particularly through income generation but also in the identification of medical problems such as unrecognised hypertension, hearing loss and visual loss. It also offered some key learning points for other multi-agency groups developing similar services.     

Estimation of a multiproduct cost function for physically frail older people

Using the theory of multiproduct cost functions, this paper derives a cost function for physically frail older people living in private households, based on data collected between 1991 and 1995, for 472 subjects aged 65 years of age or over in four areas of England. The main characteristic of the cost function is that output categories are classified in terms of movements between different health states. These were measured by changes in activities of daily living (ADL) over 2 years, with ‘low’ ADL representing better functional ability than ‘high’ ADL. Empirical application of the approach, using four states defined in terms of worsening progression (stable low ADL; deteriorated or improved ADL; stable high ADL; deceased), indicated more favourable states were associated with lower costs. Multivariate analysis showed that the derived states were significantly related to costs which, when combined with variables indicating presence of particular chronic health conditions (diabetes or previous stroke), admission to continuing care accommodation and household structure, explained one-fifth of the variation in log average costs per week. Variables such as age, sex, carer input, social networks and level of cognitive functioning had no independent impact on costs. These findings could be used as a starting point for those interested in predicting the cost implications associated with the ageing population.Copyright © 1998 John Wiley & Sons, Ltd.     

Negotiating sexuality in home care settings: older lesbians and bisexual women's experiences

There is evidence that lesbians and bisexual women often face prejudice and stigma when accessing routine primary healthcare services. However, limited research to date has examined their experiences outside of primary healthcare contexts or the perspectives of older healthcare users. This paper presents findings from a qualitative study of older lesbians and bisexual women in Ontario who accessed publicly-funded home care services. In qualitative in-depth interviews, 16 women responded to questions about their decision making around disclosure of their sexuality, home care workers' reactions to disclosure and their experiences of receiving care. The thematic analysis of participants' responses demonstrated that they experienced isolation and ongoing anxiety, as well overt and subtle examples of heterosexism and discrimination. However, there was also evidence of participants' resilience and resistance to heteronormativity and sexual minority stress. These findings have implications for our understanding of lesbians' and bisexual women's healthcare experiences and for policy recommendations.     

Pre-discharge home visits with older people: time to review practice

The present review paper uses the available evidence to make a case for a reconsideration of the practice of undertaking pre-discharge home visits with frail older people as part of decisions regarding a return home. This practice is embedded into the routine activity of acute medical wards for older people and occupies a large proportion of the time of hospital employed therapy staff, with consequent financial and resource implications. Assessments are often conducted to provide information on safe discharge rather than being located in the interests of the older person and their carer. The introduction of a new range of services bridging hospital and home raises the need for an urgent, critical appraisal of this practice.     

Food provision for older people receiving home care from the perspectives of home‐care workers

Malnutrition is a significant cause of morbidity and mortality, particularly among older people. Attention has focused on the inadequacies of food provision in institutions, yet the majority suffering from malnutrition live in the community. The aim of this study was to explore barriers and facilitators to food provision for older people receiving home care. It was a qualitative exploratory study using semi‐structured interviews with nine home‐care workers in June 2013 employed by independent agencies in a large city in northern England. Data were analysed thematically, based on the principles of grounded theory. Findings showed that significant time pressures limited home‐care workers in their ability to socially engage with service users at mealtimes, or provide them with anything other than ready meals. Enabling choice was considered more important than providing a healthy diet, but choice was limited by food availability and reliance on families for shopping. Despite their knowledge of service users and their central role in providing food, home‐care workers received little nutritional training and were not involved by healthcare professionals in the management of malnutrition. Despite the rhetoric of individual choice and importance of social engagement and nutrition for health and well‐being, nutritional care has been significantly compromised by cuts to social care budgets. The potential role for home‐care workers in promoting good nutrition in older people is undervalued and undermined by the lack of recognition, training and time dedicated to food‐related care. This has led to a situation whereby good quality food and enjoyable mealtimes are denied to many older people on the basis that they are unaffordable luxuries rather than an integral component of fundamental care.     

The (cost‐)effectiveness of preventive,integrated care for community‐dwelling frail older people: A systematic review

Integrated care is increasingly promoted as an effective and cost‐effective way to organise care for community‐dwelling frail older people with complex problems but the question remains whether high expectations are justified. Our study aims to systematically review the empirical evidence for the effectiveness and cost‐effectiveness of preventive, integrated care for community‐dwelling frail older people and close attention is paid to the elements and levels of integration of the interventions. We searched nine databases for eligible studies until May 2016 with a comparison group and reporting at least one outcome regarding effectiveness or cost‐effectiveness. We identified 2,998 unique records and, after exclusions, selected 46 studies on 29 interventions. We assessed the quality of the included studies with the Effective Practice and Organization of Care risk‐of‐bias tool. The interventions were described following Rainbow Model of Integrated Care framework by Valentijn. Our systematic review reveals that the majority of the reported outcomes in the studies on preventive, integrated care show no effects. In terms of health outcomes, effectiveness is demonstrated most often for seldom‐reported outcomes such as well‐being. Outcomes regarding informal caregivers and professionals are rarely considered and negligible. Most promising are the care process outcomes that did improve for preventive, integrated care interventions as compared to usual care. Healthcare utilisation was the most reported outcome but we found mixed results. Evidence for cost‐effectiveness is limited. High expectations should be tempered given this limited and fragmented evidence for the effectiveness and cost‐effectiveness of preventive, integrated care for frail older people. Future research should focus on unravelling the heterogeneity of frailty and on exploring what outcomes among frail older people may realistically be expected.     

The general practitioner and older people: strategies for more effective home visits?

This paper is based on findings from a pilot research project funded by the Primary Health Care Development Fund in Scotland. The researcher's remit was to examine home visiting patterns by general practitioners (GPs) to older people on Tayside following the community care reforms. Fieldwork was conducted in three general practices on Tayside, using an anthropological perspective. This research confirms that community care changes have not to date effected a significant shift in GP perceptions, which are that the probable destiny of frail older people is to enter some kind of residential setting. The researcher examines how and why GPs label certain patients as a “problem” and uses this categorization process to suggest that such patients are seen by GPs as having a “moral career”. It is argued that GPs may also see some older patients as a “problem”, the solution to which may be to recommend that the patient enter residential or nursing home care. The research identifies a point in the career of the older “problem” patient at which doctors could usefully refer to other agencies. A model for communication or collaboration is posited as a way of enabling GPs to continue to provide sensitive and individually appropriate care for frail older patients in collaboration with appropriate others. Funding has been obtained to pilot this model in selected general practices on Tayside in 1996/97.     

Intensive client-centred occupational therapy in the home improves older adults’ occupational performance. Results from a Danish randomized controlled trial

Background: There is growing interest in enabling older adults’ occupational performance. We tested whether 11 weeks of intensive client-centred occupational therapy (ICC-OT) was superior to usual practice in improving the occupational performance of home-dwelling older adults.

Methods: An assessor-masked randomized controlled trial among adults 60?+?with chronic health issues, who received or applied for homecare services. Recruitment took place September 2012 to April 2014. All participants received practical and personal assistance and meal delivery as needed. In addition, they were randomized to receive either a maximum 22 sessions of occupation-based ICC-OT (N?=?59) or to receive usual practice with a maximum three sessions of occupational therapy (N?=?60). The primary outcome was self-rated occupational performance assessed with the Canadian Occupational Performance Measure (COPM).

Results: No important adverse events occurred. ICC-OT was accepted by 46 participants (88%), usual practice by 60 (100%). After 3 months, the ICC-OT-group had improved 1.86 points on COPM performance; the Usual-Practice group had improved 0.61 points. The between-group difference was statistically significant (95% confidence interval 0.50 to 2.02), t-test: p?=?0.001.

Conclusions: ICC-OT improved older adults’ occupational performance more effectively than usual practice. This result may benefit older adults and support programmatic changes.     

A prospective baseline study of frail older people before the introduction of an intermediate care service

This paper describes the first part of a two-stage research project designed to investigate the clinical and service outcomes of a comprehensive intermediate care service. It is a baseline study of patients presenting to two elderly care departments as emergencies with the clinical syndromes of falls, incontinence, confusion or poor mobility before the introduction of a city-wide intermediate care service. The outcome measures were: mortality; disability (Barthel Index, BI); social activities (Nottingham Extended Activities of Daily Living); service use; and carer distress (General Health Questionnaire -28). These were measured at 3, 6 and 12 months after recruitment. Eight hundred and twenty-three patients were recruited (median age = 84 years; proportion of women = 70%; proportion with cognitive impairment = 45%; median BI score = 15). There was a high mortality rate (36%), evidence for incomplete recovery, a gradual decline in independence over 12 months and a high degree of carer stress. There was little use of rehabilitation services (< 5%), about 25% required readmission to hospital by each assessment point and there was a gradual increase in institutional care admissions. These findings support a needs-based argument for a more comprehensive community service for frail older people.     

Design and development of a mobile exercise application for home care aides and older adult medicaid home and community-based clients

ABSTRACT

We describe a community-engaged approach with Medicaid home and community-based services (HCBS), home care aide (HCA), client, and physical therapist stakeholders to develop a mobile application (app) exercise intervention through focus groups and interviews. Participants desired a short exercise program with modification capabilities, goal setting, and mechanisms to track progress. Concerns regarding participation were training needs and feasibility within usual care services. Technological preferences were for simple, easy-to-use, and engaging content. The app was piloted with HCA-client dyads (n = 5) to refine the intervention and evaluate content. Engaging stakeholders in intervention development provides valuable user-feedback on both desired exercise program contents and mobile technology preferences for HCBS recipients.     

Preventive home visits to older home‐dwelling people in Denmark: are invitational procedures of importance?

Since 1998 all municipalities in Denmark have been required by law to offer two annual preventive home visits to all home‐dwelling citizens aged 75 or over. The influence of invitational procedures on acceptance rates has not been investigated. The aim of this study was to describe and investigate whether different invitational procedures were associated with first preventive home visit acceptance rates. The study was based on secondary analyses of data from the Danish Intervention Study on Preventive Home Visits. Data were collected from 1998 to 2002. Of the 4060 participants in the main study, 3245 reported receiving an offer for an identifiable preventive home visit, of whom 2399 (73.9%) provided complete data for the main analyses in the present study. Invitational procedures were categorised as: (1) a letter with a proposed date and time for the visit, (2) a visitor telephone call, and (3) a letter with encouragement to phone the visitor for appointment (letter without a proposed date). Covariates included sex, age, experience with preventive interventions, functional ability, self rated health, social relations and psychosocial characteristics. Statistical analyses included chi‐square tests, and bi‐ and multivariable logistic regression analyses. Different invitational procedures were associated with first preventive home visit acceptance rates. Significantly more men (75.1%) than women (62.8%) declined the first preventive home visit regardless of the invitational procedure. Compared to ‘letter with a proposed date’, men had an odds ratio of 1.78 (95% CI: 1.16–2.74) for declining visits when ‘telephone call’ was used and an odds ratio 2.81 (95% CI: 1.79–4.40) when ‘letter without a proposed date’ was used as the invitational procedure. In women the odds ratios were 1.23 (95% CI: 0.91–1.68) and 1.87 (95% CI: 1.37–2.55), respectively.     

Battle on the home care front: perceptions of home care workers of factors influencing staff retention in Northern Ireland

The provision of home care services is a key component in avoiding inappropriate admission of older people to institutional care and preventing delayed discharge from hospital. However, there is a growing problem of retention of home care workers (HCWs), creating problems for delivering this increasingly essential service. The present study was based in a health and social services trust in Northern Ireland, and was designed to explore the growing problem of retention of HCWs from their own perspective. The cross-sectional survey design used a convenience sample and questionnaires were completed by 45 HCWs (response rate = 45 of 147, 31%). Responses to most questions were on five-point ordinal scales. Focus groups in which 12 HCWs participated were used to explore emerging themes. The variables studied were HCWs' perspectives on: (1) reasons for considering leaving; (2) working hours; (3) supervision and support, and qualifications and training; (4) workload pressures; (5) client attitudes; (6) pay; and (7) job satisfaction. The main reasons given by HCWs for dissatisfaction and considering leaving were (in rank order): (1) irregular and antisocial hours; (2) lack of management support; and (3) workload pressures. Commitment to caring seemed to be the reason why pay did not feature more highly for those who did not leave. Home care workers are being required to provide care for people with evermore-complex health and social care needs, and in an environment increasingly regulated in terms of quality and risk. This makes it an increasingly demanding job, which does not seem to be recognised in the training and working conditions of HCWs. The most significant factors identified give scope for service managers to improve the retention of HCWs.     

Implementing care programmes for frail older people: A project management perspective

ObjectiveTo examine the issues that influenced the implementation of programmes designed to identify and support frail older people in the community in the Netherlands.MethodsQualitative research methods were used to investigate the perspectives of project leaders, project members and members of the steering committee responsible for the implementation of the programmes. Interviews were conducted in 2009 (n = 10) and in 2012 (n = 13) and a focus group was organised in 2012 (n = 5).Main FindingsThe interviews revealed that the implementation was influenced by the extent and quality of collaboration between organisations, adaptation to existing structures, future funding for the programmes and project leadership. A good relationship between participating organisations and professionals is required for successful implementation. A lack of clear project leadership and structural funding hampers the implementation of complex programmes in primary care settings.Implications for practiceThe findings of this study are useful for organisations and professionals who are planning to implement complex programmes. Identifying barriers concerning institutional collaboration, adaptation to existing structures, leadership and continuation of financial support at an early stage of the implementation process can support practitioners in overcoming them.