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.     

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.     

A non-randomised controlled trial of the Home Independence Program (HIP): an Australian restorative programme for older home-care clients

The Home Independence Program (HIP) is a short-term restorative programme targeted at older home-care clients, who do not have a diagnosis of dementia, when they are first referred for assistance or when they are referred for additional services because their needs have increased. This study compared the outcomes for individuals who participated in HIP with those of individuals who received 'usual' home-care services. The study was conducted in metropolitan Perth, Western Australia, between 2001 and 2003, when HIP was being trialled as a service in just one region. One hundred clients were recruited into each group and were visited at home on three occasions – service start and at 3 months and 1 year. Standardised outcome measures were used to measure functional dependency, morale, confidence in performing everyday activities without falling and functional mobility. Service outcomes were also examined at 3 months and 1 year. The HIP group showed improvements on all personal outcome measures compared with the control group. These improvements were, except for the morale scale, significantly associated with group assignment even when baseline differences between the groups were adjusted for. As regards service outcomes, the odds of the individuals who received HIP still requiring services was 0.07 (95% CI = 0.03–0.15, P  < 0.001) times those for the individuals in the control group at 3 months and 0.14 times at 12 months (95% CI = 0.07–0.29, P  < 0.001). The results of this study supported the hypothesis that older individuals referred for home care who participated in a programme to promote their independence had better individual and service outcomes than individuals who received usual home care.     

Home-based health promotion for chronically ill older persons: results of a randomized controlled trial of a critical reflection approach

The purpose of this study was to test a health promotion interventionfor people over 65 years of age discharged from hospital tocare at home for chronic medical conditions. Researchers hypothesizedthat chronically ill older people who received the interventionwould have a significantly more positive mindset (or attitudetoward their life, self, health, and health care), would usesignificantly less hospital and home care services, and wouldhave a significantly better quality of life. At the time ofdischarge from hospital, 298 seniors were randomized to receivethe usual home care plus the intervention, or to an attentioncontrol group receiving the usual home care. The interventionwas comprised of approximately 10 weekly hour-long sessionsin which a nurse facilitated critical reflection on life andhealth. Data collected by personal interview at baseline, 22weeks, and 1 year later were analyzed using ANOVA and logisticregression, controlling for age, gender, living arrangements,accommodation, number of chronic medical problems and baselinedifferences, as appropriate. Results: Those who received theintervention had significantly greater independence (p = 0.008)and perceived ability to manage their own health (p = 0.014)and significantly less desire for information (p = 0.021) immediatelypost-intervention. At the 1-year follow-up, the pattern persisted,although significant differences were limited to independence(p = 0.007) and desire for information (p = 0.035). As well,at 1-year the intervention group had higher yet more significantlydeclined self-care agency (p = 0.025) and locus of authority(p = 0.017). Comparison of changes in health resource utilizationby the two groups did not differ significantly. However, theintervention group had a significantly greater (p = 0.006) chanceof having higher quality of life immediately post-intervention.This trend persisted at 1 year, although differences were non-significant.Results suggest the clinical potential of critical reflectionto enhance the health of chronically ill older persons. Furtherinvestigation with less frail populations is needed.     

Perception, satisfaction and utilization of the VALUE home telehealth service

We conducted a randomized controlled trial to evaluate the perception, satisfaction and utilization of a home telehealth service for frail elderly people living independently in their home communities. Control group subjects continued with their usual care and intervention group subjects were able to supplement their usual care with the use of a web portal. The web portal allowed videoconferencing and electronic messaging between home care nurses and clients, ordering health-related and home care services, access to health-related information and general access to the Internet. A total of 99 eligible people (59 female, 40 male) from one urban and one rural study site agreed to participate in the study. Eighty-four subjects were active participants for nine months. There were no significant differences in perception of technology between the two groups at baseline. At 60-day follow-up, the intervention group was significantly more positive towards technology compared to their own baseline (P < 0.001) and compared to the 60-day scores for the controls (P < 0.001). The intervention group indicated that overall the telehealth service met their expectations (mean score 9 out of 10) and they would recommend it to others (mean score 9.5 out of 10). All subjects were able to use the portal without difficulty after brief instructions from the nurses. A total of 1054 videoconferences were conducted with the intervention subjects. Fifty-six of these (5%) had to be discontinued after successful connection because of technical problems. Intervention subjects made fewer emergency department visits than control subjects, more visits to the eye doctor, fewer visits in all categories of home care utilization, and lower use of transportation services. Frail elderly people are able to adopt home telehealth technologies which may enable them to maintain independent living arrangements.     

The impact of a decade of policy on home health care utilization

The Medicare home health care eligibility changes, which occurred during the 1980s, were designed to make home health care more accessible to older adults. Ideally, by the 1990s, older adults in need of home health care services should no longer have encountered barriers to accessing this benefit. Therefore, an individual's need for home health care services should have been the primary determinant of service utilization. This paper examined whether need was predictive of home health care use. Client-level data on the case mix of home health care agencies in San Francisco and Philadelphia, as well as agency administrator interview data, were analyzed to determine which characteristics were the best predictors of home health care use. The regression analyses results revealed that, although client characteristics were important predictors of the amount and type of home health care services received during an episode of care, client characteristics alone did not adequately predict the amount and type of home health care services received by older adults.     

The Impact of a Decade of Policy on Home Health Care Utilization

ABSTRACT

The Medicare home health care eligibility changes, which occurred during the 1980s, were designed to make home health care more accessible to older adults. Ideally, by the 1990s, older adults in need of home health care services should no longer have encountered barriers to accessing this benefit Therefore, an individual's need for home health care services should have been the primary determinant of service utilization. This paper examined whether need was predictive of home health care use. Client-level data on the case mix of home health care agencies in San Francisco and Philadelphia, as well as agency administrator interview data, were analyzed to determine which characteristics were the best predictors of home health care use. The regression analyses results revealed that, although client characteristics were important predictors of the amount and type of home health care services received during an episode of care, client characteristics alone did not adequately predict the amount and type of home health care services received by older adults.     

Home Health Care With Telemonitoring Improves Health Status for Older Adults With Heart Failure

Home telemonitoring can augment home health care services during a patient's transition from hospital to home. Home health care agencies commonly use telemonitors for patients with heart failure although studies have shown mixed results in the use of telemonitors to reduce rehospitalizations. This randomized trial investigated if older patients with heart failure admitted to home health care following a hospitalization would have a reduction in rehospitalizations and improved health status if they received telemonitoring. Patients were followed up to 180 days post-discharge from home health care services. Results showed no difference in the time to rehospitalization or emergency visit between those who received telemonitoring versus usual care. Older heart failure patients who received telemonitoring had better health status by home health care discharge than those who received usual care. Therefore, for older adults with heart failure, telemonitoring may be an important adjunct to home health care services to improve health status.     

Developing and utilising a new funding model for home‐care services in New Zealand

Worldwide increases in the numbers of older people alongside an accompanying international policy incentive to support ageing‐in‐place have focussed the importance of home‐care services as an alternative to institutionalisation. Despite this, funding models that facilitate a responsive, flexible approach are lacking. Casemix provides one solution, but the transition from the well‐established hospital system to community has been problematic. This research seeks to develop a Casemix funding solution for home‐care services through meaningful client profile groups and supporting pathways. Unique assessments from 3,135 older people were collected from two health board regions in 2012. Of these, 1,009 arose from older people with non‐complex needs using the interRAI‐Contact Assessment (CA) and 2,126 from the interRAI‐Home‐Care (HC) from older people with complex needs. Home‐care service hours were collected for 3 months following each assessment and the mean weekly hours were calculated. Data were analysed using a decision tree analysis, whereby mean hours of weekly home‐care was the dependent variable with responses from the assessment tools, the independent variables. A total of three main groups were developed from the interRAI‐CA, each one further classified into “stable” or “flexible.” The classification explained 16% of formal home‐care service hour variability. Analysis of the interRAI‐HC generated 33 clusters, organised through eight disability “sub” groups and five “lead” groups. The groupings explained 24% of formal home‐care services hour variance. Adopting a Casemix system within home‐care services can facilitate a more appropriate response to the changing needs of older people.     

Modeling the Association Between Home Care Service Use and Entry Into Residential Aged Care: A Cohort Study Using Routinely Collected Data

Objective

To examine home care service-related and person-based factors associated with time to entry into permanent residential aged care.

High-Tech Home Health Care

This study examines staff perspectives and personnel issues related to the delivery of high-tech home health care services to older adults. Data were collected from a national sample of 154 agency directors and 92 local agency staff. Agency staff and directors consistently report an increase in high-tech service delivery over the past five years. Both agency directors and local staff agree that a variety of staff may be involved in the delivery of high-tech services, including both professional and paraprofessional staff. Although agency directors report providing training to at least one or more type of direct care staff, agency staff are less likely to report being required to participate in training programs. The provision of high-tech services impacts the agency, the staff, and the patient in various ways. Most staff feel that high-tech care enhances the quality of life of older patients, although high-tech care may be somewhat difficult to define and even more difficult to deliver. Challenges related to the provision of high-tech care, including providing adequate staff training, and developing appropriate quality assurance measures, are discussed.     

居家不出老年人居家养老服务需求影响因素分析

目的 探讨居家不出老年人居家养老服务需求的现状及其影响因素,为更好的开展居家养老服务和提高老年人的生活质量提供理论依据。方法 采取随机整群抽样方法在河北省唐山市路北区抽取2个社区860名≥60岁老年人进行居家不出状况筛查,对筛查出的居家不出老年人进行问卷调查。结果 860名老年人中共筛查出居家不出老年人149人,居家不出发生率为17.4%;对于养老服务的需求,有70.5%和77.2%的居家不出老年人选择日常生活照料养老服务和医疗保健养老服务,仅有11.4%的居家不出老年人选择精神慰藉养老服务;多因素非条件 logistic 回归分析结果显示,女性、患≥2种慢性病、不能自理是居家不出老年人日常生活照料养老服务需求的影响因素;患≥2种慢性病是居家不出老年人医疗保健养老服务需求的影响因素。结论 居家不出老年人更愿意选择日常生活照料和医疗保健养老服务;性别、患慢性病数量、自理能力是日常生活照料和医疗保健养老服务需求的影响因素。     

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.     

Buying time II: an economic evaluation of a joint NHS/Social Services residential rehabilitation unit for older people on discharge from hospital

The study's aim was to investigate the cost-effectiveness of an NHS/Social Services short-term residential rehabilitation unit (a form of intermediate care) for older people on discharge from community hospital compared with 'usual' community services. An economic evaluation was conducted alongside a prospective controlled trial, which explored the effectiveness of a rehabilitation unit in a practice setting. The aim of the unit was to help individuals regain independence. A matched control group went home from hospital with the health/social care services they would ordinarily receive. The research was conducted in two matched geographical areas in Devon: one with a rehabilitation unit, one without. Participants were recruited from January 1999 to October 2000 in 10 community hospitals and their eligibility determined using the unit's strict inclusion/exclusion criteria, including 55 years or older and likely to benefit from a short-term rehabilitation programme: potential to improve, realistic, achievable goals, motivation to participate. Ninety-four people were recruited to the intervention and 112 to the control group. Details were collated of the NHS and Social Services resources participants used over a 12-month follow-up. The cost of the resource use was compared between those who went to the unit and those who went straight home. Overall, costs were very similar between the two groups. Aggregated mean NHS/Social Services costs for the 12 months of follow-up were pound 8542.28 for the intervention group and pound 8510.68 for the control. However, there was a clear 'seesaw' effect between the NHS and Social Services: the cost of the unit option fell more heavily on Social Services (pound 5011.56, whereas pound 3530.72 to the NHS), the community option more so on the NHS (pound 5146.74, whereas pound 3363.94 to Social Services). This suggests that residential rehabilitation for older people is no more cost-effective over a year after discharge from community hospital than usual community services. The variability in cost burden between the NHS and Social Services has implications for 'who pays' and being sure that agencies share both pain and gain.     

Prioritization and resource allocation in health care. The views of older people receiving continuous public care and service

OBJECTIVE: To describe the views of people, 65 years and over, receiving continuous public care and service, on prioritization and resource allocation in health care, in relation to gender, age, housing, health-related quality of life (QoL) and degree of activities of daily living (ADL) dependency. BACKGROUND: How older people receiving continuous public care and service view prioritization and resource allocation in health care is sparsely investigated, although this group most certainly has the experience and also often is the target in discussions concerning prioritization. It is necessary, for democracy and for the development of new models of service delivery, to find out how people receiving long-term care and service view these issues. DESIGN: 146 persons, 34 men (23%) and 112 women (77%), aged 66-100 years were interviewed face to face, following a structured questionnaire. RESULTS: The respondents thought that the patients' well-being, way of living and family situation should affect prioritization, not age per se. Resourcing of several health-care services were considered to be below what is required by a majority of the respondents. The respondents wanted doctors to decide on prioritization at an individual level and wanted higher taxes to finance increasing health-care costs. Although the respondents wanted publicly financed health care, a relatively high number were willing to pay for treatment. CONCLUSIONS: Knowledge of how older people receiving care and services, view prioritization and resource allocation has not previously been available. It seems that their views are in line with the Swedish Parliamentary Priority Commission which suggested that no account should be taken of age when allocating resources within the health-care system. Respondents' age, gender, housing, health-related QoL and degree of dependency in ADL had limited influence on their views of resource allocation.     

A systematic narrative review of consumer‐directed care for older people: implications for model development

Consumer‐directed care is increasingly becoming a mainstream option in community‐based aged care. However, a systematic review describing how the current evaluation research translates into practise has not been published to date. This review aimed to systematically establish an evidence base of user preferences for and satisfaction with services associated with consumer‐directed care programmes for older people. Twelve databases were searched, including MedLine, BioMed Central, Cinahl, Expanded Academic ASAP, PsychInfo, ProQuest, Age Line, Science Direct, Social Citation Index, Sociological Abstracts, Web of Science and the Cochrane Library. Google Scholar and Google were also searched. Eligible studies were those reporting on choice, user preferences and service satisfaction outcomes regarding a programme or model of home‐based care in the United States or United Kingdom. This systematic narrative review retrieved literature published from January 1992 to August 2011. A total of 277 references were identified. Of these 17 met the selection criteria and were reviewed. Findings indicate that older people report varying preferences for consumer‐directed care with some demonstrating limited interest. Clients and carers reported good service satisfaction. However, research comparing user preferences across countries or investigating how ecological factors shape user preferences has received limited attention. Policy‐makers and practitioners need to carefully consider the diverse contexts, needs and preferences of older adults in adopting consumer‐directed care approaches in community aged care. The review calls for the development of consumer‐directed care programmes offering a broad range of options that allow for personalisation and greater control over services without necessarily transferring the responsibility for administrative responsibilities to service users. Review findings suggest that consumer‐directed care approaches have the potential to empower older people.