Frail older people’s use and experience of the Irish healthcare system: a mixed methods study to inform the design of integrated models of care

Abstract

Background: Frailty makes older people vulnerable to poor outcomes and in need of intensive management to remain living at home. An integrated package of services is suggested and the model of care recommended includes; comprehensive geriatric assessment, a single access point, case management, multidisciplinary input and financial incentives to promote downward substitution. Developing a model of care requires evidence of baseline patterns in service-use, however a scoping review revealed these were often not provided in the literature on new models of integrated care for frail older people. This study describes the community-living frail older Irish population, examines their patterns of service-use and their experiences of seeking, securing and managing services, to better inform the design of future care. Methods: A sequential explanatory mixed methods design was operationalised. Data was obtained from wave one of the Irish Longitudinal Study on Ageing (TILDA) for those aged ≥65 years (n=3,422). Multivariate regression techniques examined the impact of frailty, measured by the Frailty Index, on utilisation of various hospital and community services adjusting for need, predisposing and enabling factors. Next, latent class analysis identified profiles of service-use among the TILDA participants classified as frail (n=745). Finally, data from semi-structured interviews with a qualitative sample of frail older people (n=12) examined why service-use profiles occur. Results: 24% (95%CI: 23-26) of the Irish older population were classified as frail. Frailty was a significant predictor of utilisation across many types of services adjusting for other factors. However, patterns of service use by frail older people differed. The majority (52% ±0.2) were Non-Users of services, 26% (±0.2) were Community-Care Users, a fifth (20%±0.1) were Hospital-Care Users, while 2% (±0.0) were both Hospital-and-Community Care Users. Factors which impeded access to services included community services which were only activated upon hospital discharge following a severe health event; long waiting times for specialist hospital services and a lack of services to address psychosocial needs in a meaningful way. Factors which facilitated access to services included the Public Health Nurse service which provided navigation and referral to wider community services. Discussion: The findings together indicate a supply-constrained, hospital-centric healthcare system which fails to proactively manage the needs of the frail older population. Receiving community services is a rarity rather than the norm, and these are utilised mainly by the very-frail (FI >0.40). Rather, the majority of frail older people rely on hospital and General Practitioner services only. Financial constraints such as poorly-resourced community services, and structural constraints such as inflexible budgets, meant that the required intervention was not available at the right time. Conclusions: Since the frail older population comprises a diverse set of service users, new models of care should be designed to reflect that diversity. An evidence-based approach to service re-design is advised since healthcare systems function differently. Limitations: The qualitative sample had in general high frailty scores, which limited the scope of this study to explain diverse service use profiles. Suggestions for future research: We recommend investigating the impact of service-use profiles by examining longitudinal health outcomes.