Functional ability and health complaints among older people with a combination of public and informal care vs. public care only

The aim of the study was to investigate functional ability and health complaints of people, 65+, living in special accommodation (equivalent to nursing home) and their counterparts who live at home and receive municipal care or a combination of municipal and informal care. Persons (n = 1958) receiving municipal care were assessed in terms of functional ability, health complaints, and level of informal and municipal care and services. The results showed that more home care, services and help with Instrumental Activities of Daily Living (IADL) were provided to those receiving only municipal care at home, while more home care and services associated with Personal Activities of Daily Living (PADL) as well as nursing care were provided to those receiving informal care in addition to formal care. Cohabitation was a predictor of a combination of municipal and informal care in the home (OR: 5.935), while assistance with IADL provided by municipal home care and services predicted municipal care only (OR: 0.344). Care in special accommodation was predicted by advanced age (OR: 1.051), dependency in IADL (OR: 19.883) and PADL (OR: 2.695), and impaired cognitive ability (OR: 3.849) with receiving municipal care only as a reference. Living alone (OR: 0.106), dependency in IADL (OR: 11.348) and PADL (OR: 2.506), impaired cognitive ability (OR: 3.448), impaired vision or blindness (OR: 1.812) and the absence of slowly healing wounds (OR: 0.407) were predictors of special accommodation with a combination of informal and municipal care at home as a reference. The distribution of municipal care divided older people into three distinct groups. The most frail and elderly people who had no cohabitants received care in special accommodation, determined by their level of physical and cognitive dependency. The frailest individuals living at home were cohabiting and received a combination of municipal and informal care, while those who were less dependent mainly had help with IADL from municipal care only. The results indicate that there is a shift from the substitution to the complementary model and highlights that attention to the family carers is needed.     

Primary health care resources for rehabilitation and secondary prevention after myocardial infarction – a questionnaire survey

Scand J Caring Sci; 2013; 27; 260–266 Primary health care resources for rehabilitation and secondary prevention after myocardial infarction – a questionnaire survey Background: During the first year after a cardiac event, many patients are offered participation in a cardiac rehabilitation programme, after which the patients are often not given the opportunity to continue to attend rehabilitation and secondary prevention programmes. Aim: This study describes the primary health care centres’ (PHCC) resources regarding cardiac rehabilitation/secondary prevention programmes for coronary heart disease (CHD) patients in a southern Swedish region. Method: A questionnaire containing 26 dichotomous or multiple choice questions was sent to the responsible manager of all 137 public and private PHCCs in Region Skåne. Questionnaires from 91 (66%) of the PHCCs were completed and returned. Result: Few nurses at the PHCCs had special training regarding CHD (10%), cardiac rehabilitation (8%) or heart failure (32%). Twenty‐one per cent of the physicians had special training regarding CHD. One third of the PHCCs did not offer long‐term secondary prevention programmes, and few (6%) had any routines for offering socio‐economic support to CHD patients. Comparison of private and public PHCCs showed that the private centres could not offer a physiotherapist (61 vs. 84%) or dietician (32 vs. 73%; p = 0.03) to the same extension as the public ones. Furthermore, the majority (91%) of PHCCs had no cooperation with patient organizations. Conclusions: The PHCCs need to improve the strategies and long‐term rehabilitation programmes. Furthermore, they need to focus on education programme for the staff. The result revealed that the PHCCs lack resources, strategies and long‐term care programmes for CHD patients.     

'Finding home': a grounded theory on how older people 'find home' in long-term care settings

cooney a. (2011) ‘Finding home’: a grounded theory on how older people ‘find home’ in long‐term care settings. International Journal of Older People Nursing 7 , 188–199
doi: 10.1111/j.1748‐3743.2011.00278.x Background. A link between residents ‘feeling at home’ in long‐term care facilities and ‘quality of life’ is emerging in the literature. Few studies, however, have focused on what helps residents to find a home in long‐term care settings. This study aimed to fill this gap. Aim. This study aimed to understand older peoples’ perceptions of ‘being at home’ in long‐term care settings and the factors that influence these perceptions. Design. Grounded theory guided the study design. Residents (n = 61) living in public or private long‐term care settings were interviewed using unstructured interviews. Findings. Four categories were identified as critical to finding a home in long‐term care settings: ‘continuity’, ‘preserving personal identity’, ‘belonging’ and ‘being active and working’. ‘Finding Home’ was conceptualised as the core category. The potential to ‘find home’ was influenced by mediating and facilitating/constraining factors. Conclusions. The Theory of Finding Home was generated from the data. This theory describes the factors critical to ‘finding home’ in long‐term care settings. Implications for practice. The Theory of Finding Home gives insight into what matters to older people living in long‐term care settings. Strategies to help generate a feeling of home in long‐term care settings are shared.     

The utilization of specialized healthcare services among frail older adults in the Helsinki Birth Cohort Study

BackgroundThe association between frailty and specialized healthcare utilization is not well studied. We, therefore, examined the utilization of specialized healthcare services among frail Finnish older adults.MethodsA sub-sample of 1060 participants of the Helsinki Birth Cohort Study were followed prospectively for specialized healthcare utilization from nationwide registers between the years 2013 and 2017. The participants’ frailty status was assessed according to Fried’s criteria at a mean age of 71.0 (2.7 SD) years between the years 2011 and 2013. A negative binomial regression model was used to examine the association between frailty and the total number of visits, emergency visits, outpatient appointments separating the first outpatient appointments and the follow-up appointments, inpatient care including elective and non-elective hospital admissions and the total number of hospital days. We also calculated average length of stay (ALOS) and used the Kruskal–Wallis test to examine the differences between the groups.ResultsAfter adjusting for covariates, frailty was significantly associated with the number of specialized healthcare visits (IRR 1.50, 95% CI = 1.04–2.15) and all subgroups of visits apart from follow-up outpatient appointments. Frailty was particularly strongly associated with the number of hospital days (IRR 5.24, 95% CI = 2.35–11.7) and notably with emergency visits (IRR = 2.26, 95% CI = 1.45–3.51) and hospital admissions (IRR 2.23, 95% CI = 1.39–3.56). Frail older adults had also higher ALOS compared to non-frail participants (p = .009).ConclusionsFrailty increases the use of most specialized healthcare services. Preventative interventions against frailty are needed to decrease the burden on specialized healthcare systems.

KEY MESSAGE

• Frailty is associated with the utilization of most specialized healthcare services, the most expensive part of the healthcare in most high-income countries.
• The association of frailty with inpatient care is particularly strong.
• Preventative interventions against frailty are needed to decrease the burden on specialized healthcare systems.

     

Economics of home vs. hospital breastfeeding support for newborns

AIM: This paper presents the findings of research comparing the incremental costs associated with the provision of home-based vs. hospital-based support for breastfeeding by nurse lactation consultants for term and near-term neonates during the first week of life. BACKGROUND: A consequence of both consumer demands and increasing health resource constraints is that alternative care delivery models for safe, efficacious and cost-effective breastfeeding programmes have steadily evolved. To date, the economic impact of the setting (home or hospital) where lactation support is delivered has received little research attention. METHODS: Mother-infant dyads were stratified by gestational age as term (>37 weeks gestational age; n = 101) or near term (35-37 weeks gestational age; n = 37) and randomized to standard hospital care and postpartum follow-up (standard care), or to standard hospital care plus home support from certified nurse lactation consultants (experimental). Data collection occurred at study entry, hospital discharge and at a seventh day postpartum follow-up session. Costs to the family (out-of-pocket and time costs) and to the healthcare system (during hospitalization and after hospital discharge) were measured. Total societal costs were defined as the sum of both family and healthcare system costs. RESULTS: Compared with standard hospital-based care, home support by nurse lactation consultants showed no statistically significant differences in either time costs to the family or total societal costs. Term infants who received home support had statistically significantly greater postdischarge system costs (P < 0.0001), with a trend towards lower out-of-pocket expenses to their families (P = 0.12). There were no statistically significant differences between the two groups in overall combined family and healthcare system costs. CONCLUSIONS: These results suggest that the cost of home lactation support programmes were comparable with the costs of hospital-based standard care. Breastfeeding support at home by lactation consultants should be considered as an option as it was no more costly than support from lactation consultants in the hospital setting. The findings for near-term infants need to be interpreted with caution, given the small sample size.     

Use of healthcare, patient satisfaction and burden of care in Guillain-Barre syndrome.

OBJECTIVE: The aim of this study was to investigate, in an unselected sample of patients with Guillain-Barré syndrome in Sweden, the utilization of healthcare resources, satisfaction with these resources, informal help and the burden of care on family caregivers during the first 2 years after onset. SUBJECTS: Forty-four patients were enrolled from 8 hospitals, and 42 of them were followed for 2 years. METHODS: Data on the utilization of hospital inpatient and outpatient care, primary care and community-based services were collected via computerized registry information, medical records and a specific protocol. Patient satisfaction and the burden on family caregivers were studied using questionnaires. RESULTS: Forty-one patients required inpatient hospitalization for a mean of 82 days. Patients with persistent dependency during activities of daily living had significantly longer hospital stays and more days of outpatient rehabilitation. The majority of patients were satisfied with their care, but dissatisfaction was found regarding information and finances. At 2 years after onset, 26% of patients still depended on informal help. The spouses expressed increased concern and responsibility for household and family. CONCLUSION: Patients with persistent disability due to Guillain-Barré syndrome were found to have long-term need for services from the healthcare system and informal help.     

Negotiations about helpfulness--the relationship between formal and informal care in home care arrangements

Scand J Caring Sci; 2011; 25; 706–715 Negotiations about helpfulness – the relationship between formal and informal care in home care arrangements Background: Informal caregiving by family members is the most common way of caring for sick people at home. However, the number of care arrangements, in which both formal (nurses) and informal (family members) caregivers are involved, is considerable and increasing. Despite implicit assumptions in research that the involvement of nurses in home care arrangements is inherently beneficial, there is evidence that their involvement may have a destabilising effect. Aims: The purpose of this study was to investigate the relationship between nurses and family caregivers and its impact on the actual care that is provided. Method: Eighty‐eight interviews with family caregivers (n = 57) and nurses (n = 31) were conducted in Germany and analysed according to the Grounded Theory methodology. Findings: The relationship between formal and informal care is an encounter of two quite different perspectives that is focused on a negotiation process about caregiving work and the helpfulness of the actions taken and the interventions used. For family caregivers, it is determined by the goal of facilitating work and care for their sick family member. The nurses’ work is characterised by a process of shaping different realities in different homes. The results reveal the processes that lead to the involvement of nurses into home care arrangements and offer a deeper understanding of the negotiation processes between formal and informal caregivers. Conclusions: To provide sufficient support in home care, nurses need the ability to engage in negotiation processes that take the whole home care arrangement into account. Developmental work is needed to design services that are helpful for family caregivers.     

Service Use and Costs of Support 12 Years after Leaving Hospital

Background There have been major changes in the provision and organization of services for people with intellectual disabilities in England over the last 30 years, particularly deinstitutionalization and the development of the mixed economy of care. The experiences of the people who participated in the Care in the Community Demonstration Programme in the mid‐1980s provide evidence of the immediate and longer‐term effects of the reprovision policy. Methods Cross‐sectional and longitudinal evidence was gathered on service use and costs for over 250 people 12 years after they left long‐stay hospitals for community living arrangements. Comparisons were made with the situation in hospital, and 1 and 5 years after leaving. Relationships between costs after 12 years and individual characteristics assessed before people left hospital were explored. Results Community care at the 12‐year follow‐up remained more expensive than hospital‐based support, although the average cost was lower than at either of the 1‐ or 5‐year community follow‐up points. Service users were living in a wide variety of accommodation settings. Management responsibility fell on National Health Service (NHS) trusts, local authorities, voluntary agencies, or to private organizations or individuals. After standardizing for users’ skills and abilities, costs in minimum support accommodation were significantly lower than those in residential and nursing homes, costs in staffed group homes significantly higher, and costs in hostels slightly lower. When looking at differences between individuals, no relationship was found between costs and outcomes although, overall, people were better off in the community than they had been when in hospital. Conclusions Reprovision planning for hospital and other institutional modes of care requires major and long‐term commitment of resources. Quality of life improvements can be achieved at a cost little different in the long‐run from that for hospital care. The link between needs and costs (reflecting the services intended to meet those needs) would be made stronger through the individualization of care.     

Nonpharmacological interventions for persistent,noncancer pain in elders residing in long‐term care facilities: An integrative review of the literature

Elders residing in long‐term care facilities experience ongoing moderate to severe pain, relief from and increased comfort remain relevant healthcare concerns. However, persistent, noncancer pain may not have been properly addressed due to insufficient attention to research that exists to support the utilization and efficacy of nonpharmacological intervention(s) for elders in long‐term care facilities. Our aim of this integrated review was to evaluate the current state of the science on nonpharmacological intervention(s) for pain that are currently utilized in elders who reside in long‐term care facilities. Exercise, massage, heat therapy, and relaxation/rest were identified as significant nonpharmacological interventions for persistent pain in elder residents living in long‐term care facilities.     

Becoming a caregiver: new family carers' experience during the transition from hospital to home

Aims and objectives. To explore and understand the experience of new informal caregivers in Italy during the transition from hospital to home. Background. Frequent patient discharge into the home environment has lead to a significant increase in postdischarge care being provided by family caregivers. The transition period in particular is seen as a period of great significance, as caregivers may be unprepared and concerned as to the amount of care required by the recipient. Design. A qualitative phenomenological approach was used to gain a deeper understanding of caregivers’ lived experiences. Methods. Data were collected at two points in time using different methodologies: in‐depth interviews were conducted to explore the caregivers’ perspective of the predischarge period; focus groups obtained data after the patients’ re‐entry into the home environment and aimed to validate interview findings. Results. Family caregivers reflected on three main themes during the transition period: (1) their newly acquired role; (2) the recipient’s condition; and (3) the support they required. The core concept of ‘being responsible for everything’ seemed to be a recurring theme running through these three subject matters. Fulfilling numerous commitments and different social roles besides the caring activity itself seemed to weigh heavily on caregivers. Carers were referring particularly to their need for hope, confidence and safety during the transition from hospital to home. Conclusions. It cannot be assumed a priori that families can cope with the demands of care‐giving. Therefore, healthcare professionals should come to recognise caregivers as persons in need of emotional and practical support. Relevance to clinical practice. The findings of this study can stimulate healthcare professionals to acquire effective communication skills and display an empathic attitude when assessing caregivers’ needs in the particularly challenging phase of transition from hospital to home.     

A staged management diabetes foot program versus standard care: a 1-year cost and utilization comparison in a state public hospital system

OBJECTIVE: To determine whether staged management of foot ulcers reduces health care costs and utilization. DESIGN: Nonrandomized retrospective study using data from 1998-1999 in the Louisiana public hospital system. SETTING: Louisiana public hospital system. PARTICIPANTS: Forty-five patients with diabetes foot ulcer who received staged management foot care and 169 patients with diabetes foot ulcer who received standard foot care. INTERVENTIONS: Staged management of foot ulcers consisting of devices to offload pressure; self-care education; and, after healing, custom-fabricated orthoses and footwear, and monitored progressive ambulation. MAIN OUTCOME MEASURES: One-year levels of the number of foot-related inpatient hospitalizations, number of amputation-related hospitalizations, total number of foot-related inpatient days, total charges for foot-related inpatient hospitalizations, all-cause outpatient visits, total charges for all-cause outpatient visits, and combined outpatient and foot-related inpatient charges. RESULTS: Over the 12-month study period, the staged management group had a lower foot-related hospitalization rate than did the comparison group (.09 admissions per person vs.50 admissions per person, P=.0002); lower foot-related inpatient days (.91d per person vs 3.97d per person, P=.0289); lower foot-related inpatient charges ($1321 per person vs $5411 per person, P=.0151); fewer amputation-related hospitalizations (.04 per person vs.19 per person, P=.0351); fewer emergency department visits (.60 visits per person vs 1.22 visits per person, P=.0043); lower emergency department charges ($104 per person vs $208 per person, P=.0057); and lower total charges ($4776 per person vs $9402 per person, P=.0141). The staged management group had a higher number of outpatient visits (24.91 per person vs 8.04 per person, P<.0001) and higher outpatient charges ($2169 per person vs $1471 per person, P<.0001). CONCLUSIONS: A staged management diabetes foot program significantly reduced emergency department and hospital utilization and charges in a statewide public hospital system.     

Health and social care management for older adults with multimorbidity: a multiperspective approach

Multimorbidity, a condition common among older adults, may be regarded as a failure of a complex system. The aim of this study was to describe the core components in health and social care management for older adults with multimorbidity. A cross‐sectional design included two methods: individual interviews and group discussions. A total of 105 participants included older adults with multimorbidity and their relatives, care staff and healthcare policymakers. Data were analysed using content analysis. The results show that seven core components comprise a multiperspective view of health and social care management for older adults with multimorbidity: political steering, leadership, cooperation, competence, support for relatives, availability and continuity. Steps should be taken to ensure that every older adult with multimorbidity has a treatment plan according to a multiperspective view to prevent fragmentation of their health care. This study provides relevant evidence developing a multiperspective model of health and social care management for older adults with multimorbidity.     

Treatment of a high healthcare utilizer with sepsis in a virtual hybrid hospital‐at‐home program

High healthcare utilizers are often chronically ill patients who require aggressive hospital and outpatient care. We describe a patient with septic shock who was stabilized in the intensive care unit, then transitioned to a virtual hybrid hospital‐at‐home to complete both inpatient care as well as outpatient wound and rehabilitation therapy.     

Technology-dependent children and their families: a review

Background. Advances in medical technology and nursing care have enabled children who rely on long‐term medical and technical support to reunite with their families and community. The impact of discharging these children into the community involves a number of unprecedented social implications that warrant policy consideration. To begin with, an effort must be made to understand the phenomenon of caring for technology‐dependent children living at home. Aim. The aim of this paper is to provide a comprehensive literature review on caring for technology‐dependent children living at home. Methods. The review was conducted via keyword searches using various electronic databases. These included CINAHL, MEDLINE, Social Science Index, Sociological Abstracts, Australian Family and Society Abstracts, and the Australian Bureau of Statistics. The articles and books found were examined for commonality and difference, significant themes were extracted, and the strength of the research methods and subsequent evidence were critiqued. Findings. In this paper, themes relating to home care for technology‐dependent children and their families are elucidated and summarized. These are: chronic illness and children; the impact of paediatric home care on children; the uniqueness of technology‐dependent children and their families; and parents’ experience of paediatric home care. Discussion. Contentious issues, relevant to the social life of these children and their families, are raised and are discussed with the intention of extending awareness and provoking further debate among key stakeholders. These issues include: the changed meaning of home; family dynamics; social isolation; saving costs for whom?; shifts in responsibility; and parent–professional relationships. Conclusion. More research is needed in the arena of paediatric home care, to facilitate relevant policy formation and implementation.     

Warfarin management after discharge from hospital: a qualitative analysis

What is Known and Objective: Warfarin is recognized as a high‐risk medication for adverse events, and the risks are particularly heightened in the period immediately following a patient’s discharge from hospital. This qualitative study aimed to explore the experiences of Australian patients and healthcare professionals of warfarin management in the post‐discharge period and identify the benefits and deficiencies of existing systems, to inform the development of a model for a new collaborative post‐discharge warfarin management service. Methods: Healthcare professionals, professional organization representatives and patients recently discharged from hospital taking warfarin (consumers) were recruited via purposive, criterion‐based sampling within two Australian states. Semi‐structured telephone interviews were conducted between August and October 2008 using standard discussion guides. Data were manually analyzed to identify emergent themes using a phenomenological approach. Results: Forty‐seven participants were involved in the telephone interviews. Three major themes emerged: (i) appropriate warfarin education is integral to effective warfarin management, (ii) problems occur in communication along the continuum of care and (iii) home‐delivered services are valuable to both patients and healthcare professionals. Discussion: Although high‐quality warfarin education and effective communication at the hospital–community interface were identified as important in post‐discharge warfarin management, deficiencies were perceived within current systems. The role of home‐delivered services in ensuring timely follow‐up and promoting continuity of care was recognized. Previous studies exploring anticoagulation management in other settings have identified similar themes. Post‐discharge management should therefore focus on providing patients with a solid foundation to minimize future problems. What is New and Conclusion: Addressing the three identified facets of care within a new, collaborative post‐discharge warfarin management service may address the perceived deficiencies in existing systems. Improvements may result in the short‐ and longer‐term health outcomes of patients discharged from hospital taking warfarin, including a reduction in their risk of adverse events.     

Predictors of elders' and family caregivers' use of formal home services

The purposes of this study were to examine the characteristics of care recipients, caregivers, and their relationship to predict the use of formal services in the home by functionally impaired elders, and to explore the effect of informal care on formal service use in the home. A secondary analysis of data from the informal caregiver questionnaire and the community survey of the 1989 National Long-Term Care Survey was performed using logistic regression analysis. Results showed that the utilization of formal services was less frequent as the hours of informal care increased. Care recipient characteristics that emerged as important predictors included residence in elder housing, recent hospitalization, gender, limitations in activities of daily living, recipient of Medicaid, age, quantity of informal care, and number of household members. Important caregiver characteristics included difficulty getting around outside, rearrangement of work hours, and bowel and bladder care performed by female caregivers. The findings from this study support the consideration of both care recipient and caregiver characteristics when predicting the utilization of formal service use in the home. Data also support the development of interventions to promote the caregiving process. © 1998 John Wiley & Sons, Inc. Res Nurs Health 21:533–543, 1998