Projecting Long-Term Care Costs for Home and Community-Based Services in China from 2005 to 2050

ObjectivesThe aim of this study was to estimate and project the trend in long-term care (LTC) costs for home and community-based services as a percentage of gross domestic product in China between 2005 and 2050.DesignLongitudinal.Setting and ParticipantsWe used 61,249 observations from 37,702 adults age ≥65 years from waves 2005, 2008, 2011, 2014, and 2018 of the Chinese Longitudinal Healthy Longevity Surveys.MethodsLTC costs for home and community-based services consisted of the monetary value of time spent on LTC and the direct LTC cost. We used the age-sex-residence-specific weights provided by the Chinese Longitudinal Healthy Longevity Surveys to estimate the LTC costs from 2005 to 2018. We used a component-based model to project LTC costs, in which the 2-part model was used to estimate the average LTC costs and the multi-state Markov model approach was used to project the future population by age, sex, and disability state.ResultsThe percentage of older adults with disabilities was projected to increase from 6.1% in 2005 to 7.5% in 2020 and 9.6% in 2050. The total LTC cost for home and community-based services were projected to increase from 0.3% of gross domestic product in 2005 to 0.7% in 2020 and to 6.4% in 2050.Conclusions and ImplicationsPolicymakers in China should take urgent actions to delay the onset of disabilities among older adults, which would curb the increasing LTC costs and maintain the sustainability of the LTC policies.     

Rushing Care by Care Aides Associated With Experiences of Responsive Behaviors From Residents in Nursing Homes

ObjectivesResidents with cognitive impairment favor “slow care,” so rushed care may cause additional responsive behaviors (eg, verbal threats, hitting) among residents. We assessed the association of rushed care (physical and social) by care aides with their experiences of responsive behaviors from residents.DesignCross-sectional analysis of survey data.Setting and ParticipantsA total of 3547 care aides (response rate: 69.97%) in 282 care units in a stratified random sample (health region, nursing home size, owner-operator model) of 87 urban nursing homes in Western Canada.MethodsData collection occurred between September 2019 and February 2020. The dependent variables were care aide self-report of 4 types of verbal and physical responsive behavior (yes/no). The independent variables were care aide self-report of rushed physical care (count, range = 0-6) and rushed social care (yes/no). We conducted a 2-level random-intercept logistic regression with each dependent variable, controlling for care aide, care unit, and nursing home characteristics.ResultsIn their most recent shift, 2182 (61.5%) care aides reported having rushed at least 1 physical care task and 1782 (50.2%) reported having rushed talking with residents (social care task). When care aides rushed an additional physical care task, they had 8% higher odds of reporting having experienced yelling and screaming [odds ratio (OR) 1.08, 95% CI 1.01-1.15; P = .019]. When care aides rushed social care (talking with residents), they had 70% higher odds of reporting having experienced yelling and screaming (OR 1.70, 95% CI 1.28-2.25; P < .001). We observed the same pattern for the other types of responsive behaviors.Conclusions and ImplicationsRushing of physical or social care tasks by care aides was associated with increased likelihood of responsive behaviors from residents. One approach to reducing both rushed care and resident responsive behaviors may be to improve the care environment for care aides and residents.     

The Impact of Home-Based Primary Care on Outcomes Among Older Adults in South Korea

ObjectivesAlthough Korea issued a law and developed benefits of National Health Insurance (NHI) to enable the provision of home-based primary care (HBPC) along with implementation of a pilot project for community care for older adults in August 2019, the outcomes of HBPC services were not surveyed in Korea. This study aimed to assess the outcomes of HBPC among older adults.DesignAnalyses were conducted using data from the National Health Insurance Service in connection with administrative survey data. Difference-in-differences analysis was performed using a generalized estimating equation and Cox proportional hazards model.Setting and ParticipantsOverall, 538 older adults who used HBPC services in a pilot project for community care and 2059 propensity score–matched older individuals who did not use HBPC services in Korea were included.MethodsThe length of home stay, total costs of NHI, hospitalizations, and admission to long-term care (LTC) facilities were measured as outcomes, and the outcomes of the participants were compared to those of the control group.ResultsThe findings indicated an increase of 8.3 days (95% CI 2.1-14.5) in the length of home stay and a reduction of US$1241 (95% CI −2342 to −139) in total costs of NHI among older adults who used HBPC services compared to the control group. The odds ratio for rates of hospitalization among older adults who utilized HBPC services was 0.77 (95% CI 0.60-0.98) and the hazard ratio for the admission of LTC facilities was 0.12 (95% CI 0.04-0.32) in comparison to the control group.Conclusions and ImplicationsThe HBPC intervention has resulted in an increased length of home stay and reduced total costs, hospitalizations, and admission to LTC facilities among Korean older adults. In the future, new HBPC models must be developed to provide interprofessional team–based HBPC services with a standardized protocol of service provision.     

Feasibility of Routine Quality of Life Measurement for People Living With Dementia in Long-Term Care

ObjectivesMaximizing quality of life (QoL) is the ultimate goal of long-term dementia care. However, routine QoL measurement is rare in nursing home (NH) and assisted living (AL) facilities. Routine QoL measurement might lead to improvements in resident QoL. Our objective was to assess the feasibility of using DEMQOL-CH, completed by long-term care staff in video calls with researchers, to assess health-related quality of life (HrQoL) of NH and AL residents with dementia or other cognitive impairment.DesignCross-sectional study.Setting and ParticipantsWe included a convenience sample of 5 NHs and 5 AL facilities in the Canadian province of Alberta. Forty-two care staff who had worked in the facility for ≥3 months completed DEMQOL-CH assessments of 183 residents who had lived in the facility for 3 months or more and were aged ≥65 years. Sixteen residents were assessed independently by 2 care staff to assess inter-rater reliability.MethodsWe assessed HrQoL in people with dementia or other cognitive impairment using DEMQOL-CH, and assessed time to complete, inter-rater reliability, internal consistency reliability, and care staff ratings of feasibility of completing the DEMQOL-CH.ResultsAverage time to complete DEMQOL-CH was <5 minutes. Staff characteristics were not associated with time to complete or DEMQOL-CH scores. Inter-rater reliability [0.735, 95% confidence interval (CI): 0.712-0.780] and internal consistency reliability (0.834, 95% CI: 0.779-0.864) were high. The DEMQOL-CH score varied across residents (mean = 84.8, standard deviation = 11.20, 95% CI: 83.2-86.4). Care aides and managers rated use of the DEMQOL-CH as highly feasible, acceptable, and valuable.Conclusions and ImplicationsThis study provides a proof of concept that DEMQOL-CH can be used to assess HrQoL in NH and AL residents and provides initial indications of feasibility and resources required. DEMQOL-CH may be used to support actions to improve the QoL of residents.     

Long-Term Care Use During the Last 2 Years of Life in Sweden: Implications for Policy to Address Increased Population Aging

ObjectivesTo map out the total use of long-term care (LTC; ie, home care or institutional care) during the last 2 years of life and to investigate to what extent gender differences in LTC use were explained by cohabitation status and age at death.DesignThe National Cause of Death Register was used to identify decedents. Use of LTC was based on the Social Services Register (SSR) and sociodemographic factors were provided by Statistics Sweden.Setting and ParticipantsAll persons living in Sweden who died in November 2015 aged ≥67 years (n = 5948).MethodsZero inflated negative binomial regression was used to estimate the relative impact of age, gender, and cohabitation status on the use of LTC.ResultsWomen used LTC to a larger extent [odds ratio (OR) 2.17, 95% confidence interval (CI) 1.92-2.50] and for a longer period [risk ratio (RR) 1.14, 95% CI 1.11-1.18] than men. When controlling for age at death and cohabitation status, gender differences in LTC attenuated (OR 1.47, 95% CI 1.28-1.72) and vanished in regard to the duration. In the controlled model, women used LTC for 15.6 months (95% CI 15.2-16.0) and men for 14.1 months (95% CI 13.7-14.5) out of 24 months. The length of stay in institutional care was 7.2 (95% CI 6.8-7.5) and 6.2 months (95% CI 5.8-6.6), respectively.Conclusions and ImplicationsA substantial part of women's greater use of LTC was due to their higher age at death and because they more often lived alone. Given that survival continues to increase, the association between older age at death and LTC use suggests that policy makers will have to deal with an increased pressure on the LTC sector. Yet, increased survival among men could imply that more women will have access to spousal caregivers, although very old couples may have limited capacity for extensive caregiving at the end of life.     

Sex Differences in Home Care Performance: A Population-Based Study

BackgroundHome care services play an integral role in promoting independence, reducing hospital admission and readmission rates, and preventing or delaying nursing home admission among older adults. Despite important sex differences in functional status and use of services by recipients of home care, differences in home care performance measures by sex have not been examined.ObjectiveTo assess sex differences in the quality of publicly funded home care services in Ontario, Canada.MethodsValidated, publicly reported home care quality indicators derived from the Resident Assessment Instrument for Home Care using the 2009 and 2010 Home Care Reporting System database were assessed for 119,795 Ontario home care clients aged 65 years and older. Unadjusted and risk-adjusted sex differences in performance were examined provincially and by health region.ResultsIn unadjusted analyses, there were sex differences in health outcomes on all indicators examined (decline or failure to improve in activities of daily living, cognitive decline, depressive symptoms, and pain control). After risk adjustment, differences were minimal. For example, in unadjusted analyses, 23.1% of women and 18.7% of men reported poorly controlled pain. After risk adjustment, 21.2% of women and 21.6% of men reported poorly controlled pain, with a difference of −0.4% (95% CI, −0.4% to −0.3%). Across health regions risk adjustment eliminated sex differences. There was 1.3-fold to 2.6-fold variation in performance on indicators across health regions.ConclusionsAfter risk adjustment, no important sex differences in home care quality indicators were identified. Sizable regional variations observed indicate potential to improve home care outcomes for both women and men. Sex differences in unadjusted analyses demonstrate the value of examining both unadjusted and adjusted outcomes and suggest sex-specific strategies will likely be needed to improve home care quality.     

The Association of Long-Term Opioid Use With Health Care and Home Care Service Use Among Aged Home Care Clients

ObjectivesTo compare health care and home care service utilization, mortality, and long-term care admissions between long-term opioid users and nonusers among aged home care clients.DesignA retrospective cohort study based on the Resident Assessment Instrument–Home Care (RAI-HC) assessments and electronic medical records.Setting and ParticipantsThe study sample included all regular home care clients aged ≥65 years (n = 2475), of whom 220 were long-term opioid users, in one city in Finland (population base 222,000 inhabitants).MethodsHealth care utilization, mortality, and long-term care admissions over a 1-year follow-up were recorded from electronic medical records, and home care service use from the RAI-HC. Negative binomial and multivariable logistic regression, adjusted for several socioeconomic and health characteristics, were used to analyze the associations between opioid use and health and home care service use.ResultsCompared with nonusers, long-term opioid users had more outpatient consultations (incidence rate ratio 1.26; 95% CI 1.08−1.48), home visits (1.23; 1.01−1.49), phone contacts (1.38; 1.13−1.68), and consultations without a patient attending a practice (1.22; 1.04−1.43) after adjustments. A greater proportion of long-term opioid users than nonusers had at least 1 hospitalization (49% vs 41%) but the number of inpatient days did not differ after adjustments. The home care nurses’ median work hours per week were 4.3 (Q₁-Q₃ 1.5−7.7) among opioid users and 2.8 (1.0−6.1) among nonusers. Mortality and long-term care admissions were not associated with opioid use.Conclusions and ImplicationsLong-term opioid use in home care clients is associated with increased health care utilization regardless of the severity of pain and other sociodemographic and health characteristics. This may indicate the inability of health care organizations to produce alternative treatment strategies for pain management when opioids do not meet patients’ needs. The exact reasons for opioid users’ greater health care utilization should be examined in future.     

Frailty Index Status of Canadian Home Care Clients Improves With Exercise Therapy and Declines in the Presence of Polypharmacy

ObjectiveThis study aimed to investigate if exercise therapy and polypharmacy was associated with frailty state transitions for home care service recipients.DesignLongitudinal cohort-study using client-level health information collected using interRAI home care (RAI-HC) assessments.SettingPopulation-based study with Canadian home care clients in Alberta, British Columbia, Ontario and the Yukon.ParticipantsHome care clients aged 65 years and older.MethodsA Markov chain multistate transition logistic regression model was used to calculate ORs for state transitions with exercise therapy and polypharmacy as independent variables.ResultsIn total, 250,428 home care clients experiencing 402,005 frailty state transitions were included in the analyses. At baseline, 39.4% of clients were categorized as nonfrail, 30.2% were categorized as prefrail, and 30.4% were categorized as frail. Nonfrail clients using polypharmacy were more likely to become prefrail (OR 1.16) and frail (OR 1.11). Pre-frail clients using polypharmacy were more likely to become frail (OR 1.06), and they were less likely to become nonfrail (OR 0.80). Frail clients using polypharmacy were significantly less likely to become prefrail (OR 0.82) or nonfrail (OR 0.62). Nonfrail clients who participated in exercise therapy were more likely to become prefrail (OR 1.05). Prefrail clients who participated in exercise therapy were more likely to become nonfrail (OR 1.26). Frail clients who participated in exercise therapy were more likely to become nonfrail (OR 1.27) and prefrail (OR 1.12).Conclusions and ImplicationsThis study suggests that frailty among home care clients can be reversed. Frailty state improvement occurred significantly more often among home care clients receiving exercise therapy and significantly less often among clients with polypharmacy.     

Clinical Comorbidities and Transitions Between Care Settings Among Residents of Assisted Living Facilities: A Repeated Cross-Sectional Study

ObjectiveWe investigate the changes in the sociodemographic characteristics, clinical comorbidities, and transitions between care settings among residents of assisted living facilities.DesignRepeated cross-sectional study.Setting and ParticipantsLinked, individual-level health system administrative data on residents of assisted living facilities in Ontario, Canada, from January 1, 2013, to December 31, 2019.MethodsCounts and proportions were calculated to describe the sociodemographic characteristics and clinical comorbidities. Relative changes and trend tests were calculated to quantify the longitudinal changes in the characteristics of residents of assisted living facilities between 2013 and 2019. A Sankey plot was graphed to display transitions between different care settings (ie, hospital admission, nursing home admission, died, or remained in the assisted living facility) each year from 2013 to 2019.ResultsThere was a 34% relative increase in the resident population size of assisted living facilities (56,975₂₀₁₉ vs 42,600₂₀₁₃). These older adults had a mean age of 87 years, and women accounted for nearly two-thirds of the population across all years. The 5 clinical comorbidities that had the highest relative increases were renal disease (24.3%), other mental health conditions (16.8%), cardiac arrhythmias (9.6%), diabetes (8.5%), and cancer (6.9%). Nearly 20% of the original cohort from 2013 remained in an assisted living facility at the end of 2019, and approximately 10% of that cohort transitioned to a nursing home in any year from 2013 to 2019.Conclusions and ImplicationsResidents of assisted living facilities are an important older adult population that has progressively increased in clinical complexity within less than a decade. Clinicians and policy makers should advocate for the implementation of on-site medical care that is aligned with the needs of these older adults.     

Probable Delirium and Associated Patient Characteristics in Long-Term Care and Complex Continuing Care: A Population-Based Observational Study

ObjectivesTo estimate the prevalence of probable delirium in long-term care (LTC) and complex continuing care (CCC) settings and to describe the resident characteristics associated with probable delirium.DesignPopulation-based cross-sectional study using routinely collected administrative health data.Setting and ParticipantsAll LTC and CCC residents in Ontario, Canada, assessed with the Resident Assessment Instrument–Minimum Dataset (RAI-MDS) assessment between July 1, 2016, and December 31, 2016 (LTC n=86,454, CCC n=10,217).MethodsProbable delirium was identified via the delirium Clinical Assessment Protocol on the RAI-MDS assessment, which is triggered when individuals display at least 1 of 6 delirium symptoms that are of recent onset and different from their usual functioning. RAI-MDS assessments were linked to demographic and health services utilization databases to ascertain resident demographics and health status. Multivariable logistic regression was used to identify characteristics associated with probable delirium, with adjusted odds ratios (ORs) and 95% confidence intervals (CIs) reported.ResultsDelirium was probable in 3.6% of LTC residents and 16.5% of CCC patients. LTC patients displayed fewer delirium symptoms than CCC patients. The most common delirium symptom in LTC was periods of lethargy (44.6% of delirium cases); in CCC, it was mental function varying over the course of the day (63.5% of delirium cases). The odds of probable delirium varied across individual demographics and health characteristics, with increased health instability having the strongest association with the outcome in both care settings (LTC: OR 30.4, 95% CI 26.2-35.3; CCC: OR 21.0, 95% CI 16.7-26.5 for high vs low instability).Conclusions and ImplicationsThere were differences in the presentation and burden of delirium symptoms between LTC and CCC, potentially reflecting differences in delirium severity or symptom identification. Several risk factors for probable delirium in LTC and CCC were identified that may be amenable to interventions to prevent this highly distressing condition.     

COVID-19 Recommendations for Assisted Living: Implications for the Future

ObjectivesAssisted living (AL) emerged over 2 decades ago as a preferred residential care option for older adults who require supportive care; however, as resident acuity increased, concern has been expressed whether AL sufficiently addresses health care needs. COVID-19 amplified those concerns, and an examination of recommendations to manage COVID-19 may shed light on the future of AL. This review summarizes recommendations from 6 key organizations related to preparation for and response to COVID-19 in AL in relation to resident health and quality of life; compares recommendations for AL with those for nursing homes (NHs); and assesses implications for the future of AL.DesignNonsystematic review involving search of gray literature.Setting and ParticipantsRecommendations from key governmental bodies and professional societies regarding COVID-19 in AL, long-term care facilities (LTCFs) in general, and NHs.MeasuresWe collected, categorized, and summarized these recommendations as they pertained to quality of life and health care.ResultsMany recommendations for AL and NHs were similar, but differences provided insight into ways the pandemic was recognized and challenged AL communities in particular: recommending more flexible visitation and group activities for AL, providing screening by AL staff or an outside provider, and suggesting that AL staff access resources to facilitate advance care planning discussions. Recommendations were that AL integrate health care into offered services, including working with consulting clinicians who know both the residents and the LTC community.Conclusions and ImplicationsLong-term care providers and policy makers have recognized the need to modify current long-term care options. Because COVID-19 recommendations suggest AL communities would benefit from the services and expertise of social workers, licensed nurses, and physicians, it may accelerate the integration and closer coordination of psychosocial and medical care into AL. Future research should investigate different models of integrated, interdisciplinary health care in AL.     

Association of Living in Evacuation Areas With Long-Term Care Need After the Fukushima Accident

ObjectivesA previous report indicated that evacuation owing to the government order after the Fukushima disaster impacted the health status of older people; however, the association between living in evacuation areas and independence in their daily lives was unclear. This study examined the hypothesis that people who were forced to evacuate their homes were more likely to need long-term care (LTC).DesignHistorical cohort study.Setting and ParticipantsOlder individuals (n = 13,934) in Minamisoma, Fukushima Prefecture, Japan, part of which was designated as an evacuation area.MethodsBackground and certification data from April 2012 to December 2016 were extracted. Logistic regression analysis with sex stratification was performed to examine the association between certification of care levels 1-5 and living in evacuation areas.ResultsIn total, 18,178 Minamisoma residents aged ≥65 years who had not received LTC certification as of March 11, 2011, were eligible for follow-up. Of these, 4244 residents without a certificate of residence by June 1, 2016, were excluded. Of 13,934 residents followed up, 1553 (11.1%) were newly certified as care levels 1-5. Certification of care levels 1-5 was associated with living in evacuation areas [odds ratio (OR) 1.61, 95% confidence interval (CI) 1.20-2.18] and living alone at the time of the disaster (OR 2.58, 95% CI 1.92-3.47) in men and living alone at the time of the disaster (OR 1.35, 95% CI 1.15-1.59) in women.Conclusions and ImplicationsLiving in evacuation areas and living alone were associated with LTC certification. In evacuation areas, individuals with family members were more likely to be certified compared with those in nonevacuation areas. Among residents in evacuation areas, several individuals with family members experiencing family structure changes might need LTC. Preventive measures (including group relocation) may be beneficial for those being evacuated following a disaster.     

Effects of Copayment in Long-Term Care Insurance on Long-Term Care and Medical Care Expenditure

ObjectiveThis study aimed to clarify the difference in (1) long-term care (LTC) usage and expenditure and (2) medical care service usage and expenditure before and after the change in the copayment limit for qualifying individuals from 10% to 20%.Setting and ParticipantsThis quasi-experimental longitudinal design used the database from 1 prefecture of Japan that included 570,434 person-month records of 23,879 insured individuals (in August 2014) who used LTC services between August 2014 and July 2015 and were aged 65 years and older on August 1, 2014.MethodsWe conducted difference-in-difference estimations to compare “before” and “after” outcome differences between insured individuals whose LTC copayment increased to 20% and those whose copayment remained at 10%. Sex, age, Care Needs Level, subsidy, and public assistance were adjusted in the models, along with robustness checks.ResultsDifferences in both insurer's payment and insured's copayment indicated statistical significance between those whose copayment increased and those whose copayment did not increase. We found no significant difference in the number of minutes of home care service use, days of facility care service use, and LTC expenditures among those with copayment increases as well as those with no increase in copayment following the insured's copayment increase policy implementation. In contrast, the policy implementation caused significant differences in the number of days of hospitalization, medical care expenditures, and total expenditures.Conclusions and ImplicationsThe increase in insured individuals' copayment decreased LTC insurer's payment. However, total LTC expenditure increased over time although the increase trend slowed down in the treatment group after the copayment increase policy implemented. Besides, medical care expenditure increased consistently among insured individuals whose copayment increased. As there appears to be a “balloon effect” between LTC and medical care services, it is important to discuss the medical care system while considering the LTC insurance system comprehensively.     

Impact of the COVID-19 Pandemic on Home Care Services Among Community-Dwelling Adults With Dementia

ObjectiveTo examine how the COVID-19 pandemic impacted use of home care services for individuals with dementia across service types and sociodemographic strata.DesignPopulation-based time series analysis.Setting and ParticipantsCommunity-dwelling adults with dementia in Ontario, Canada, from January 2019 to September 2020.MethodsWe used health administrative databases (Ontario Registered Persons Database and Home Care Database) to measure home care services used by participants. Poisson regression models were fit to compare weekly rates of home care services during the pandemic to historical trends with rate ratios (RRs) and 95% confidence intervals (CIs) stratified by service type (nursing, personal care, therapy), sex, rurality, and neighborhood income quintile.ResultsDuring the first wave of the pandemic, personal care fell by 16% compared to historical levels (RR 0.84, 95% CI 0.84, 0.85) and therapies fell by 50% (RR 0.50, 95% CI 0.48, 0.52), whereas nursing did not significantly decline (RR 1.02, 95% CI 1.00, 1.04). All rates had recovered by September 2020, with nursing and therapies higher than historical levels. Changes in services were largely consistent across sociodemographic strata, although the rural population experienced a larger decline in personal care and smaller rebound in nursing.Conclusions and ImplicationsPersonal care and therapies for individuals with dementia were interrupted during the early months of the pandemic, whereas nursing was only minimally impacted. Pandemic responses with the potential to disrupt home care for individuals living with dementia must balance the impacts on individuals with dementia, caregivers, and providers.     

Association Between Dementia Care Programs in Assisted Living Facilities and Transitions to Nursing Homes in Ontario,Canada: A Population-Based Cohort Study

ObjectiveWe investigate whether older adults who were newly diagnosed with dementia (severity unspecified) and resided in an assisted living facility that offered a dementia care program had a lower rate of transition to a nursing home, compared to those who resided in an assisted living facility without such a program.DesignPopulation-based retrospective cohort study.Setting and ParticipantsLinked, person-level health system administrative data on older adults who were newly diagnosed with dementia and resided in an assisted living facility in Ontario, Canada, from 2014 to 2019 (n = 977).MethodsAccess to a dementia care program in an assisted living facility (n = 57) was examined. Multivariable Cox proportional hazards regression with robust standard errors clustered on the assisted living facility was used to model the time to transition to a nursing home from the new dementia diagnosis.ResultsThere were 11.8 transitions to a nursing home per 100 person-years among older adults who resided in an assisted living facility with a dementia care program, compared with 20.5 transitions to a nursing home per 100 person-years among older adults who resided in an assisted living facility without a dementia care program. After adjustment for relevant characteristics at baseline, older adults who resided in an assisted living facility with a dementia care program had a 40% lower rate of transition to a nursing home (hazard ratio 0.60, 95% confidence interval 0.44, 0.81), compared with those in an assisted living facility without such a program at any point during the follow-up period.Conclusions and ImplicationsThe rate of transition to a nursing home was significantly lower among older adults who resided in an assisted living facility that offered a dementia care program. These findings support the expansion of dementia care programs in assisted living facilities.     

Impact of Prior Home Care on Length of Stay in Residential Care for Australians With Dementia

ObjectivesTo assess the impact of home care on length-of-stay within residential care.DesignA retrospective observational data-linkage study.Setting and ParticipantsIn total there were 3151 participants from the 45 and Up Study in New South Wales, Australia with dementia who entered residential care between 2010 and 2014.MethodsSurvey data collected from 2006‒2009 were linked to administrative data for 2006‒2016. The highest level of home care a person accessed prior to residential care was defined as no home care, home support, low-level home care, and high-level home care. Multinomial logistic regression and Cox proportional hazards were used to investigate differences in activities of daily living, behavioral, and complex healthcare scales at entering residential care; and length-of-stay in residential care.ResultsPeople with prior high-level home care entered residential care needing higher assistance compared with the no home care group: activities of daily living [odds ratio (OR) 3.41, 95% confidence interval (CI) 2.14‒5.44], behavior (OR 2.61, 95% CI 1.69‒4.03), and complex healthcare (OR 2.02, 95% CI 1.06‒3.84). They had a higher death rate, meaning shorter length-of-stay in residential care (<2 years after entry: hazard ratio 1.12; 95% CI 0.89‒1.42; 2-4 years: hazard ratio 1.49; 95% CI 1.01‒2.21). Those using low-level home care were less likely to enter residential care needing high assistance compared to the no home care group (activities of daily living: OR 0.61, 95% CI 0.45‒0.81; behavioral: OR 0.72, 95% CI 0.54‒0.95; complex healthcare: OR 0.51, 95% CI 0.33‒0.77). There was no difference between the home support and no home care groups.ConclusionsHigh-level home care prior to residential care may help those with dementia stay at home for longer, but the low-level care group entered residential care at low assistance levels, possibly signaling lack of informal care and barriers in accessing higher-level home care.ImplicationsBetter transition options from low-level home care, including more timely availability of high-level care packages, may help people with dementia remain at home longer.     

Formal and Informal Costs of Care for People With Dementia Who Experience a Transition to Hospital at the End of Life: A Secondary Data Analysis

ObjectivesTo explore formal and informal care costs in the last 3 months of life for people with dementia, and to evaluate the association between transitions to hospital and usual place of care with costs.DesignCross-sectional study using pooled data from 3 mortality follow-back surveys.Setting and ParticipantsPeople who died with dementia.MethodsThe Client Service Receipt Inventory survey was used to derive formal (health, social) and informal care costs in the last 3 months of life. Generalized linear models were used to explore the association between transitions to hospital and usual place of care with formal and informal care costs.ResultsA total of 146 people who died with dementia were included. The mean age was 88.1 years (SD 6.0), and 98 (67.1%) were female. The usual place of care was care home for 85 (58.2%). Sixty-five individuals (44.5%) died in a care home, and 85 (58.2%) experienced a transition to hospital in the last 3 months. The mean total costs of care in the last 3 months of life were £31,224.7 (SD 23,536.6). People with a transition to hospital had higher total costs (£33,239.2, 95% CI 28,301.8-39,037.8) than people without transition (£21,522.0, 95% CI 17,784.0-26,045.8), mainly explained by hospital costs. People whose usual place of care was care homes had lower total costs (£23,801.3, 95% CI 20,172.0-28,083.6) compared to home (£34,331.4, 95% CI 27,824.7-42,359.5), mainly explained by lower informal care costs.Conclusions and ImplicationsTotal care costs are high among people dying with dementia, and informal care costs represent an important component of end-of-life care costs. Transitions to hospital have a large impact on total costs; preventing these transitions might reduce costs from the health care perspective, but not from patients' and families' perspectives. Access to care homes could help reduce transitions to hospital as well as reduce formal and informal care costs.     

A Multicenter Study to Identify Clinician Barriers to Participating in Goals of Care Discussions in Long-Term Care

ObjectivesLong-term care (LTC) is an important setting for goals of care (GoC) discussions. Understanding clinician barriers to GoC discussions could identify opportunities for LTC-specific interventions to improve quantity and quality of GoC discussions in the context of serious illness.DesignA multicenter, cross-sectional survey study.Setting and Participants1184 LTC clinicians from 34 Ontario LTC homes were invited to participate.MeasuresThe questionnaire assessed (1) clinician barriers related to the LTC resident power of attorney (POA), the health care provider, and the health care system; (2) willingness to engage in GoC discussions; and (3) suggestions to address identified barriers. Responses were rated on a 7-point scale (1 = extremely unimportant/unwilling, 7 = extremely important/willing). A linear mixed-effects model determined significance between mean importance ratings for each barrier and the willingness to engage in GoC discussion between physicians and nurses. A simple content analysis was performed on written suggestions to address GoC discussion barriers.ResultsThe overall response rate was 49% (581/1184). The top 3 rated barriers were (1) POA's difficulty accepting their loved one's poor prognosis, (2) POA's difficulty understanding the limitations and complications of life-sustaining therapies, and (3) lack of adequate documentation of prior discussions with LTC resident or POA. Barriers related to the health care provider, and the health care system, were deemed statistically more important by nurses. LTC physicians were more willing to exchange information, be a decision coach, and participate in the final decision than nurses. Suggestions to improve GoC discussions include a dedicated team to have these conversations in LTC, and updating policies to mandate and standardize these conversations at all family meetings.Conclusions and ImplicationsThis study has identified key LTC clinician–identified barriers to GoC discussions. Developing targeted interventions to these barriers could be the foundation for developing new interventions that support high-quality GoC discussions.