A population‐based cohort study of ambulatory care service utilization among older adults

Rationale, aims and objectives Age‐related effects on ambulatory care service utilization are not well understood. We aim to measure the utilization patterns of ambulatory health care services (i.e. family physician visits, specialist physician visits and emergency room visits) in the late life course (65 years and older). Methods A population‐based retrospective cohort study was conducted for the period 1 April 2005 to 31 March 2006. All Ontario, Canada, residents aged 65+ and eligible for government health insurance were included in the analysis. Results This population‐based cohort study demonstrates considerable increase in utilization rates and variability of ambulatory services as age increases. Variations in utilization were observed by gender as overall women were more likely to consult a family physician, and men more likely to visit specialists and the emergency room. A small group of high users, constituting 5.5% of the total population, accounted for 18.7% of total ambulatory visits. Finally, we report socio‐economic status (SES) based disparity for specialist services in which high users were more likely to have higher SES. Conclusions There is increasing utilization and variability in ambulatory service utilization with increase in age. Further research is required to explain the gender and SES differences reported in this study.     

The exhausting dilemmas faced by home-care service providers when enhancing participation among older adults receiving home care

Older adults wish to stay at home, participate in society and manage on their own as long as possible. Many older adults will, however, eventually become dependent on care and help to maintain their daily living. Thus, to enhance activity and participation also among older adults that receive home-based services, there is a strong need for development of knowledge-based practice regarding participation. The specific aim of this study is to explore how service providers perceive that their working conditions influence on their possibilities to promote participation among older adults, and more specifically, how they perceive the influence of their working conditions. A purposeful sampling strategy was applied, and six focus groups with professionals in two municipalities were conducted. The focus groups comprised four and six participants of varying ages, length of working experience and professions. A total of 30 service providers participated. The data were analysed by a constant comparative method following the guidelines from Grounded Theory. The analysis identified the categories 'encountering needs that cannot be met', 'expectations about participation', 'organisation of services' and 'professional standards' influencing the service delivery. During this analytical process, 'being on the verge' emerged as a core category that describes the service providers' experience of a stressful workday, i.e. when they had the feeling of working against their own professional standards and being pushed to their limits. The findings indicate how the professional standards of service providers on the whole are in line with health policy for in-home services. Policy objectives are, however, not always followed owing to different constraints at the level of service delivery. Along the path from political ideals to the practical execution of services, external circumstances related to the organisation of services are perceived as crucial.     

Impact of Physical Activities on Frailty in Community-Dwelling Older Women

Aims: The aim of the study was to determine whether increased physical activities (PA) affect frailty for old women, 75 years and older (OO), compared to 60–74 years old (YO). Methods: This cross-sectional study measured 19 frailty indicators (muscle strength and endurance, balance, gait characteristics, and function), using 46 community-dwelling women. PA were divided into three levels by caloric expenditure per week (<2,000 kcal/week, 2,000–3,999 kcal/week, >4,000 kcal/week). Results: As PA level increased, a gap (=difference) between OO and YO narrowed for step length and function, but for quadriceps strength and endurance, a gap widened. Conclusions: Frailty progresses with aging but older women who engage in a high level of physical activity (>4,000 kcal/week) can increase mobility and functional capacity, but not for muscle strength and endurance. Starting regular resistance training activities early in the aging process is critical to improve or maintain muscle quality to offset age-related frailty.     

Urinary incontinence in older adults receiving home care diagnosis and strategies

Introduction:  Urinary incontinence (UI) is a major health problem mostly affecting older people. With the shift toward healthcare delivery in the home setting, it is necessary for home healthcare workers to know how to manage UI in the elderly. Little is known about the care for patients receiving home care suffering from UI. The aim of this study was to assess the prevalence of UI in older adults receiving home care and to gain insight into caring for patients with UI.
Method:  A cross-sectional survey using data from the Dutch National Prevalence Measurement of Health Care Problems was conducted.
Results:  Of the 2866 patients, 46% were suffering from UI. In 49% of these patients the type of UI was diagnosed. Patients with a diagnosis suffered more from their UI and were offered more strategies when compared with patients without a diagnosis. Most patients used pads. Relatively few patients were offered bladder training or pelvic floor muscle exercises (PFME).
Discussion:  Urinary incontinence is a highly prevalent condition in older patients receiving home care. In half of the patients with UI no diagnosis regarding the type of incontinence was made. However, to treat or manage UI it is essential to assess the type of UI, as UI is treatable even in older people. As this study had a cross-sectional design, only strategies being offered at a fixed point in time are documented.
Conclusion:  Despite studies reporting the success of behavioural interventions for adults suffering from UI, most patients use pads. With the aging of the population and the increasing number of older adults suffering from UI, home care agencies need to acquire the knowledge and skills to address UI.     

Restraint use in older adults in home care: A systematic review

ObjectivesTo get insight into restraint use in older adults receiving home care and, more specifically, into the definition, prevalence and types of restraint, as well as the reasons for restraint use and the people involved in the decision-making process.DesignSystematic review.Data sourcesFour databases (i.e. Pubmed, CINAHL, Embase, Cochrane Library) were systematically searched from inception to end of April 2017.Review methodsThe study encompassed qualitative and quantitative research on restraint use in older adults receiving home care that reported definitions of restraint, prevalence of use, types of restraint, reasons for use or the people involved. We considered publications written in English, French, Dutch and German. One reviewer performed the search and made the initial selection based on titles and abstracts. The final selection was made by two reviewers working independently; they also assessed study quality. We used an integrated design to synthesise the findings.ResultsEight studies were reviewed (one qualitative, seven quantitative) ranging in quality from moderate to high. The review indicated there was no single, clear definition of restraint. The prevalence of restraint use ranged from 5% to 24.7%, with various types of restraint being used. Families played an important role in the decision-making process and application of restraints; general practitioners were less involved. Specific reasons, other than safety for using restraints in home care were noted (e.g. delay to nursing home admission; to provide respite for an informal caregiver).ConclusionsContrary to the current socio demographical evolutions resulting in an increasing demand of restraint use in home care, research on this subject is still scarce and recent. The limited evidence however points to the challenging complexity and specificity of home care regarding restraint use. Given these serious challenges for clinical practice, more research about restraint use in home care is urgently needed.     

Engaging the consumer in disinvestment in public healthcare: Concerns,perspectives and attitudes of older adults

Rationale

Low-value care in public health can be addressed via disinvestment with the support of disinvestment research generated evidence. Consumers' views of disinvestment have rarely been explored despite the potential effects of this process on the care they will receive and the importance of consumer participation in decision-making in public healthcare.

Aims and Objectives

This study aimed to understand consumer concerns, perceptions and attitudes towards disinvestment processes, with the goal of providing recommendations to health service researchers and managers to more effectively engage consumers in shared decision-making in public healthcare.

Method

We conducted semistructured interviews using four scenarios describing the principles of disinvestment, how and why it could be undertaken, and a fifth scenario that described a real-life application of these principles. These scenarios were presented to participants in a written word document or a digital story during semistructured interviews. Participants were 18 community-dwelling older adults who were recruited via convenience sampling. Questions were addressed to the participants regarding their feelings and concerns towards disinvestment, their participation as consumers in disinvestment processes, as well as their preference for communicating information about disinvestment to patients and families.

Results

Four major themes emerged around the negative perception of disinvestment and positive perception of research. Participants were concerned that the removal of a clinical activity was mainly the result of financial constraints in hospital systems. At times, participants indicated that disinvestment and its justifications were not easily understood. Participants expressed a need for consumer advocacy not always through themselves, but via others with more expertize; a single consumer is insufficient in representing the broader consumer perspective. Participants stressed the importance of transparency in relation to research evidence and decision-making outcomes. Face-to-face dissemination of information by expert staff was preferred, which could be supplemented with clear and concise written materials.

Conclusion

Consumers' main perception of disinvestment processes was that the removal of a clinical care activity depended on financial imperatives from hospital administration and political agendas. This tended to cause suspicion about reasons behind the removal of care, which overshadowed comprehension of the ineffective/inconclusive evidence that were key to disinvestment.     

Errors in completion of referrals among older urban adults in ambulatory care

Rationale, aims and objectives  Clinical care often requires referrals, but many referrals never result in completed evaluations. We determined the extent to which referral-based consultations were completed in a US medical institution. Factors associated with completion were identified.
Method  In a cross-sectional analysis, we analysed billing records and electronic and paper-based medical records for patients aged 65 years or older receiving health care between July 2000 and June 2002 in an integrated, urban, tax-supported medical institution on an academic campus. All referrals in ambulatory care, scheduling of consultation within 180 days, and completion were assessed. We conducted a multivariate survival analysis to identify factors associated with completion.
Results  We identified 6785 patients with encounters. Mean age was 72 years, and, of the participants, 66% were women, 55% were African-American and 32% were Medicaid eligible. Of the 81% with at least one primary-care visit in ambulatory care, 63% had at least one referral. About 8% of referrals required multiple orders before an appointment was scheduled. Among 7819 orders for specialty consultation in ambulatory care, 71% led to appointments, and 70% of appointments were kept (completed = 0.71*0.70 or 50%). Scheduling of consultations varied (12% to 90%) by specialty. Medicare, singular orders, location of referral and lack of hospitalization were independently significantly associated with scheduling of appointments.
Conclusions  Among older adults studied, half of medical specialty referrals were not completed. Multiple process errors, including missing information, misguided referrals and faulty communications, likely contribute to these results. Information systems offer important opportunities to improve the referrals process.     

Pillars for the care of older persons in the Caribbean

Pillars for the Care of Older Persons in the Caribbean: A Comprehensive Community-Based Framework (Pillars) is a hybrid of multiple public health frameworks developed through community-based participatory research processes. Health and social service professionals, governmental organizations, elderly persons, and others from across the English-speaking Caribbean countries developed the Pillars framework to address the growing elderly population and with an aim to increase the number of healthy and active years of life. The Pillars framework consists of four interrelated pillars organized across multiple sectors of society: primary care with care management; integrated services coordination; population-based health promotion and disease prevention; and planning and accountability. Pillars is enabled by an envisioned integrated system of information technology that will increase community-based services delivery, interprofessional communication and coordination, and will aggregate data with all identifiers removed for surveillance, planning, forecasting, policy making, evaluation, and research.     

The effect of disability on personal quality of primary care received by older adults

Purpose.?To quantify the association between disability and patient-rated personal quality of primary care among older adults.

Methods.?Participants were community-dwelling Medicare beneficiaries aged ≥65 enrolled in traditional Medicare or a Medicare health maintenance organisations. Functional status was evaluated twice (1998 and 1999) using nine activities of daily living (ADLs) and instrumental ADLs. Respondents were classified as having no, persistent, incident or previous disability based on the combination of their functional statuses at the two measurements. Self-reported personal quality of primary care was assessed using the Primary Care Assessment Survey in five domains.

Results.?Compared to those with no disability, respondents with previous disability reported lower quality of care by 0.497 (p = 0.001) of a standard deviation, whereas persistent or incident disability was not associated with a difference in personal quality of care.

Conclusions.?Previous disability appears to have a negative effect on the personal quality of care while incident and persistent disability do not. Findings for previous and incident disability may suggest a lag in the perception of quality of care. A ‘response shift’ phenomenon may explain the lack of an observed association between persistent disability and personal quality of care.     

The association among knowledge of and confidence in home health care services,acculturation, and family caregivers' relationships to older adults of Mexican descent

The purposes of this study were to examine the relationships among knowledge of and confidence in health care services (HHCS), acculturation, characteristics of family caregivers of Mexican descent, and differences by caregivers' relationship (spouse or adult child). A sample of Mexican-descent older adults and their caregivers was recruited (n?=?74 dyads) in Arizona. Each participant completed questionnaires on knowledge, confidence, and acculturation. There were moderate but significant associations among higher Anglo Orientation with Knowledge and with Confidence. Fear of HHCS was positively associated with higher Anglo Orientation and English Language Preference; and negatively associated with Mexican Orientation and Spanish Language Preference. For Spouse caregivers, Fear of HHCS was positively correlated with higher Anglo Orientation and English Language Preference; for Offspring caregivers, Fear of HHCS was negatively correlated with Mexican Orientation and Spanish Language Preference. Results support assessing caregiver cohort and socio-cultural context to decrease HHCS use disparities by Mexican-descent caregiving families.     

Prevalence of urinary incontinence among community-dwelling adults receiving home care

We conducted a cross-sectional survey in 2005 to determine the prevalence of and factors associated with urinary incontinence (UI) in adults receiving home care. Of the 2,866 patients surveyed, 46% suffered from UI; 6.5% had stress, 16.6% had urge, 9% had mixed, and 17.6% had functional incontinence. No diagnosis regarding type of UI had been established in 50.2%. Factors associated with UI were advanced age, higher body mass index, and impaired mobility. UI is prevalent in older persons receiving home care, but the lack of diagnosis of type of UI in half of the participants surveyed impedes management of UI.     

A concept analysis of home and its meaning in the lives of three older adults

gillsjö c. & schwartz‐barcott d. (2010) A concept analysis of home and its meaning in the lives of three older adults. International Journal of Older People Nursing 6 , 4–12
doi: 10.1111/j.1748‐3743.2010.00207.x Aim. To identify and define the concept of home and its meaning in the lives of three older women. Background. For many older adults home is the centre of daily life and increasingly important as a place where health care is delivered. Yet, as a concept, home remains theoretically and empirically underdeveloped. Methods. The Hybrid Model of Concept Development was used to interface theoretical analysis and empirical observation with a focus on definition. A comprehensive, interdisciplinary literature review, semi‐structured interviews with three older women and case and cross‐case analysis were completed. Results. Interviewees spoke of childhood, community, residential, church and heavenly homes. Feelings of comfort and security were associated with residential homes, peace and quiet with church homes, safety and pleasure with heavenly homes. The experience of home as being taken for granted, unselfconscious and unrecognized, became obvious when one woman tried to consciously establish a sense of being at home in her new residence. Conclusion. No single comprehensive and measurable definition was found. However, three major components were identified (place, relationship and experience) and used to define home as a place to which one is attached, feels comfortable and secure and has the experience of dwelling. Relevance to clinical practice. Every day assumptions about the meaning of home and home as just another place where health care is provided are called into question. Increased awareness and dialogue is needed among health‐care providers working with older adults in their homes. Future research needs to explore the impact of home care on the older adult’s meaning of home and its potential impact on recovery.     

The crisis nature of health care transitions for rural older adults

The complex health, socioeconomic, and environmental problems experienced by many American elders often place them at high risk for disease and disability. Over time, acutely or chronically ill older persons experience numerous transitions across various health care settings. Although availability of health services is improving in rural areas, barriers such as distance, geography, and poor distribution often limit access to health care. In a longitudinal rural ethnography, the health care transition experiences of older adults, families, and health care providers were examined. A major ethnographic theme emerged from analysis data from interviews, participant observations, and photographs: the crisis nature of health care transitions experienced by rural older adults and their families and observed by rural nurses and other health care providers. Several patterns were observed including the crisis was compounded by surprise; limited knowledge of local resources exacerbated the crisis; inconsistent discharge planning disrupted transitions; changing family support necessitated admission to nursing homes; continuity of care in nursing home discharge lessened transition crisis; and rural home health care was identified as a strength. Recommendations were made for community-based interventions to improve the transition experience. Comprehensive care management services provided by public health nurses (PHNs) in the local rural community were recommended.