Home Care Assessment Research Articles

Symptom trajectories of non-cancer patients in the last six months of life: Identifying needs in a population-based home care cohort.

The end-of-life symptom prevalence of non-cancer patients have been described mostly in hospital and institutional settings. This study aims to describe the average symptom trajectories among non-cancer patients who are community-dwelling and used home care services at the end of life. This is a retrospective, population-based cohort study of non-cancer patients who used home care services in the last 6 months of life in Ontario, Canada, between 2007 and 2014. We linked the Resident Assessment Instrument for Home Care (RAI-HC) (standardized home care assessment tool) and the Discharge Abstract Databases (for hospital deaths). Patients were grouped into four non-cancer disease groups: cardiovascular, neurological, respiratory, and renal (not mutually exclusive). Our outcomes were the average prevalence of these outcomes, each week, across the last 6 months of life: uncontrolled moderate-severe pain as per the Pain Scale, presence of shortness of breath, mild-severe cognitive impairment as per the Cognitive Performance Scale, and presence of caregiver distress. We conducted a multivariate logistic regression to identify factors associated with having each outcome respectively, in the last 6 months. A total of 20,773 non-cancer patient were included in our study, which were analyzed by disease groups: cardiovascular (n = 12,923); neurological (n = 6,935); respiratory (n = 6,357); and renal (n = 3,062). Roughly 80% of patients were > 75 years and half were female. In the last 6 months of life, moderate to severe pain was frequent in the cardiovascular (57.2%), neurological (42.7%), renal (61.0%) and respiratory (58.3%) patients. Patients with renal disease had significantly higher odds for reporting uncontrolled moderate to severe pain (odds ratio [OR] = 1.21; 95% CI: 1.08 to 1.34) than those who did not. Patients with respiratory disease reported significantly higher odds for shortness of breath (5.37; 95% CI, 5.00 to 5.80) versus those who did not. Patients with neurological disease compared to those without were 9.65 times more likely to experience impaired cognitive performance and had 56% higher odds of caregiver distress (OR = 1.56; 95% CI: 1.43 to 1.71). In our cohort of non-cancer patients dying in the community, pain, shortness of breath, impaired cognitive function and caregiver distress are important symptoms to manage near the end of life even in non-institutional settings.

Towards a standardized approach of assessing social context of persons receiving home care in Flanders, Belgium: the development and test of a social supplement to the interRAI instruments

BackgroundApart from a person’s physical functioning, the early identification of social context indicators which affect patient outcomes - such as environmental and psychosocial issues - is key for high quality and comprehensive care at home. During a home care assessment, a person’s biomedical and functional problems are typically considered. Harder to define concepts, such as psychosocial well-being or living arrangements, are not routinely documented, even though research shows they also affect functioning and health outcomes. The purpose of this study is to develop and test a concise, integrated assessment (BelRAI Social Supplement) that evaluates these social context indicators for persons receiving home care to complement existing interRAI- instruments.Methods The development of the BelRAI Social Supplement is a multi-stage process, based upon the revised MRC-framework, involving both qualitative and quantitative research with stakeholders such as; clients, informal caregivers, care professionals and policy makers. The developmental process encompasses four stages: (I) item generation based on multiple methods and content validation by a panel of stakeholders (II) assessing feasibility and piloting methods, (III) early evaluation, and (IV) final evaluation. Stage II and III are covered in this paper.ResultsDuring Stages I and II, a testable version of the BelRAI Social Supplement was developed in an iterative process. In Stage III, 100 care professionals assessed 743 individuals receiving home care in Flanders between December 2018 and December 2019. Using inter-item correlation matrixes, frequency distributions and regular feedback from the participants, the BelRAI Social Supplement was improved and prepared for Stage IV. The updated version of the instrument consists of four main sections: (1) environmental assessment; (2) civic engagement; (3) psychosocial well-being; and (4) informal care and support. In total, the BelRAI Social Supplement contains a maximum of 76 items.Conclusions The BelRAI Social Supplement was reviewed and shortened in close collaboration with care professionals and other experts in Flanders. This study resulted in an instrument that documents need-to-know social context determinants of home dwelling adults.

Caregiving burnout of community-dwelling people with dementia in Hong Kong and New Zealand: a cross-sectional study

BackgroundInformal caregiving for people with dementia can negatively impact caregivers’ health. In Asia-Pacific regions, growing dementia incidence has made caregiver burnout a pressing public health issue. A cross-sectional study with a representative sample helps to understand how caregivers experience burnout throughout this region. We explored the prevalence and contributing factors of burnout of caregivers of community-dwelling older people with dementia in Hong Kong (HK), China, and New Zealand (NZ) in this study.MethodsAnalysis of interRAI Home Care Assessment data for care-recipients (aged ≥65 with Alzheimer’s disease/other dementia) who had applied for government-funded community services and their caregivers was conducted. The sample comprised 9976 predominately Chinese in HK and 16,725 predominantly European in NZ from 2013 to 2016. Caregiver burnout rates for HK and NZ were calculated. Logistic regression was used to determine the adjusted odds ratio (AOR) of the significant factors associated with caregiver burnout in both regions.ResultsCaregiver burnout was present in 15.5 and 13.9% of the sample in HK and NZ respectively. Cross-regional differences in contributing factors to burnout were found. Care-recipients’ ADL dependency, fall history, and cohabitation with primary caregiver were significant contributing factors in NZ, while primary caregiver being child was found to be significant in HK. Some common contributing factors were observed in both regions, including care-recipients having behavioural problem, primary caregiver being spouse, providing activities-of-daily-living (ADL) care, and delivering more than 21 h of care every week. In HK, allied-health services (physiotherapy, occupational therapy and speech therapy) protected caregiver from burnout. Interaction analysis showed that allied-health service attenuates the risk of burnout contributed by care-recipient’s older age (85+), cohabitation with child, ADL dependency, mood problem, and ADL care provision by caregivers.ConclusionsThis study highlights differences in service delivery models, family structures and cultural values that may explain the cross-regional differences in dementia caregiving experience in NZ and HK. Characteristics of caregiving dyads and their allied-health service utilization are important contributing factors to caregiver burnout. A standardized needs assessment for caregivers could help policymakers and healthcare practitioners to identify caregiving dyads who are at risk of burnout and provide early intervention.

Assessment of home care aides’ respiratory exposure to total volatile organic compounds and chlorine during simulated bathroom cleaning: An experimental design with conventional and “green” products

Home care (HC) aide visits to clients’ homes often involve cleaning and disinfecting (C&D) bathrooms. Some ingredients in C&D household products are associated with respiratory illness, including sodium hypochlorite (bleach) and quaternary ammonium compounds (quats). “Green” products may be safer for the environment, however there are limited quantitative evaluations of their respiratory risks. This study assessed airborne concentrations and time profiles of total volatile organic compounds (TVOC) and chlorine generated during typical bathroom cleaning performed by aides using conventional and green products. Aides performed cleaning tasks in a simulated residential bathroom constructed in an environmental air sampling laboratory. A balanced experimental design involved each aide coming to the lab for four visits during which she performed two 20-min cleaning sessions using one of three C&D products (bleach-based, 1–5% sodium hypochlorite by weight; quats-based, 0.1–1% by weight quaternary ammonium compounds; and “green,” 0.05% by weight thymol, a component of botanical thyme oil) or distilled water as a control. TVOC and chlorine direct reading instruments were attached to aides with sample inlets located in the breathing zone. Ten-second averages of TVOC and chlorine gas concentrations and instantaneous peak concentrations were recorded for the sessions’ duration. TVOC concentrations by methods of C&D application (spraying, streaming, wiping) also were evaluated. The study completed 169 air sampling sessions with 22 aides. The quats-based product generated more than twice the average TVOC concentrations (mean = 1,210 ppb) than the bleach-based (mean = 593 ppb) or green (mean = 498 ppb) products. Each product generated TVOC concentrations that rose rapidly within the first few minutes of application. Spraying produced the highest TVOC exposures, wiping the lowest. Thirteen aides (65%) experienced peak chlorine exposures above the OSHA PEL ceiling limit (1 ppm) when using the bleach-based product. HC aides may experience respiratory hazards from use of conventional or green C&D products formulated with bleach or other respiratory irritants and sprayed in small, poorly ventilated spaces typical of bathrooms. Spraying should be avoided.

Development and testing of the Geriatric Care Assessment Practices (G-CAP) survey

BackgroundWhile the Resident Assessment Instrument-Home Care (RAI-HC) tool was designed to support comprehensive geriatric assessment in home care, it is more often used for service allocation and little is known about how point-of-care providers collect the information they need to plan and provide care. The purpose of this pilot study was to develop and test a survey to explore the geriatric care assessment practices of nurses, occupational therapists (OTs) and physiotherapists (PTs) in home care.MethodsLiterature review and expert consultation informed the development of the Geriatric Care Assessment Practices (G-CAP) survey—a 33 question, online, self-report tool exploring assessment and information-sharing methods, attitudes, knowledge, experience and demographic information. The survey was pilot tested at a single home care agency in Ontario, Canada (N = 27). Test-retest reliability (N = 20) and construct validity were explored.ResultsThe subscales of the G-CAP survey showed fair to good test-retest reliability within a population of interdisciplinary home care providers [ICC2 (A,1) (M ICC = 0.58) for continuous items; weighted kappa (M kappa = 0.63) for categorical items]. Statistically significant differences between OT, PT and nurse responses [M t = 3.0; M p = 0.01] and moderate correlations between predicted related items [M r = |0.39|] provide preliminary support for our hypotheses around survey construct validity in this population. Pilot participants indicated that they use their clinical judgment far more often than standardized assessment tools. Client input was indicated to be the most important source of information for goal-setting. Most pilot participants had heard of the RAI-HC; however, few used it. Pilot participants agreed they could use assessment information from others but also said they must conduct their own assessments and only sometimes share and rarely receive information from other providers.ConclusionsThe G-CAP survey shows promise as a measure of the geriatric care assessment practices of interdisciplinary home care providers. Findings from the survey have the potential to inform improvements to integrated care planning. Next steps include making adaptations to the G-CAP survey to further improve the reliability and validity of the tool and a broad administration of the survey in Ontario home care.

Adverse Life Events: Do Home Care Clients Have Resources for Mastering Them?

Objectives: Research on life stressors and adverse life events has a long tradition. Few studies have addressed this topic in connection to very old people. Life stressors, especially major life stressors (MLSs) experienced by clients of home care services in the community have rarely been the subject of studies. Considering this gap, we investigated the prevalence of MLSs in home care clients. We examined the effects that MLSs have on their mood and health status as well as the impact of clients' social resources on MLSs and their outcomes.Method: We used assessment data from 2,884 home care clients in six European countries. The methodological basis was the comprehensive and standardized interRAI Home Care Assessment (interRAI HC).Results: Fifteen point four percent of the sample—that consisted of women and men with an average age of 82.89 years–experienced an MLS in the last 6 months before the assessment. They were more depressed than persons without these experiences, and their health status indicated a higher level of instability and deterioration. At reassessment after 6 months, the situation changed. Despite the fact that both outcomes of the MLSs, depression and health status became worse in the reassessment-sample, home care clients without MLS were more affected by the worsening, especially that of depression. The expected buffering impact of social resources was low.Discussion: Although this study worked with limited information on MLSs, it could contribute to closing various knowledge gaps. The study shows that the MLSs represent a prevalent problem in a population of home care clients and that this problem has negative consequences for their mood and the stability of their health status. Furthermore, this research took up the situation of very old and vulnerable adults, who have previously rarely been considered in studies on major critical life events and stressors.Conclusion and Research Perspective: Future research on MLSs has to take up the issue of the time passage between the MLS and the impact on health and well-being of individuals dependent on care. It has to determine immediate as well as later consequences and identify those factors that are appropriate to reduce the MLS-effects on very old people dependent on care.

Loneliness and social isolation is associated with sleep problems among older community dwelling women and men with complex needs

Sleep problems, loneliness and social isolation often increase with age, significantly impacting older adults’ health and wellbeing. Yet general population health empirical evidence is surprisingly scant. Using the largest national database to date, cross-sectional and longitudinal analyses was undertaken on 140,423 assessments from 95,045 (women: 61.0%) community living older adults aged ≥ 65 years having standardised home care assessments between 1 July 2012 and 31 May 2018 to establish the prevalence and relationships between insufficient sleep, excessive sleep, loneliness and social isolation. At first assessment, insufficient sleep (women: 12.4%, men: 12.7%) was more commonly reported than excessive sleep (women: 4.7%, men: 7.6%). Overall, 23.6% of women and 18.9% of men reported feeling lonely, while 53.8% women and 33.8% men were living alone. In adjusted longitudinal analyses, those who were lonely and socially isolated were more likely to experience insufficient sleep. Respondents with excessive sleep were more likely to live with others. Both loneliness and social isolation contributed to insufficient sleep, synergistically. Loneliness, social isolation and health-concerns may affect the restorative properties of sleep over and above the effects of ageing. Further research is warranted.

End-of-life outcomes with or without early palliative care: a propensity score matched, population-based cancer cohort study

ObjectivesTo investigate whether cancer decedents who received palliative care early (ie, >6 months before death) and not-early had different risk of using hospital care and supportive home care in the...

Do premorbid characteristics of home care clients predict delayed discharges in acute care hospitals: a retrospective cohort study in Ontario and British Columbia, Canada

BackgroundImproved identification of patients with complex needs early during hospitalisation may help target individuals at risk of delayed discharge with interventions to prevent iatrogenic complications, reduce length of stay and...

Using Big Data to Estimate Dementia Prevalence in New Zealand: Protocol for an Observational Study.

BackgroundDementia describes a cluster of symptoms that includes memory loss; difficulties with thinking, problem solving, or language; and functional impairment. Dementia can be caused by a number of neurodegenerative diseases, such as Alzheimer disease and cerebrovascular disease. Currently in New Zealand, most of the systematically collected and detailed information on dementia is obtained through a suite of International Residential Assessment Instrument (interRAI) assessments, including the home care, contact assessment, and long-term care facility versions. These versions of interRAI are standardized comprehensive geriatric assessments. Patients are referred to have an interRAI assessment by the Needs Assessment and Service Coordination (NASC) services after a series of screening processes. Previous estimates of the prevalence and costs of dementia in New Zealand have been based on international studies with different populations and health and social care systems. This new local knowledge will have implications for estimating the demographic distribution and socioeconomic impact of dementia in New Zealand.ObjectiveThis study investigates the prevalence of dementia, risk factors for dementia, and drivers of the informal cost of dementia among people registered in the NASC database in New Zealand.MethodsThis study aims to analyze secondary data routinely collected by the NASC and interRAI (home care and contact assessment versions) databases between July 1, 2014, and July 1, 2019, in New Zealand. The databases will be linked to produce an integrated data set, which will be used to (1) investigate the sociodemographic and clinical risk factors associated with dementia and other neurological conditions, (2) estimate the prevalence of dementia using weighting methods for complex samples, and (3) identify the cost of informal care per client (in number of hours of care provided by unpaid carers) and the drivers of such costs. We will use design-based survey methods for the estimation of prevalence and generalized estimating equations for regression models and correlated and longitudinal data.ResultsThe results will provide much needed statistics regarding dementia prevalence and risk factors and the cost of informal care for people living with dementia in New Zealand. Potential health inequities for different ethnic groups will be highlighted, which can then be used by decision makers to inform the development of policy and practice.ConclusionsAs of November 2020, there were no dementia prevalence studies or studies on informal care costs of dementia using national data from New Zealand. All existing studies have used data from other populations with substantially different demographic distributions. This study will give insight into the actual prevalence, risk factors, and informal care costs of dementia for the population with support needs in New Zealand. It will provide valuable information to improve health outcomes and better inform policy and planning.International Registered Report Identifier (IRRID)DERR1-10.2196/20225

Development and validation of multivariable mortality risk-prediction models in older people undergoing an interRAI home-care assessment (RiskOP).

BackgroundCurrently, one-year survival of older people with complex co-morbidities is unpredictable. Identifying older adults with a reduced life expectancy will lead to more targeted care and better healthcare resource allocation.MethodsDevelopment and validation of one-year and three-month mortality risks in people aged ≥65 years who had completed an International Resident Assessment Instrument-Home Care (interRAI-HC) assessment between July 2012 and March 2018. Data was split into development (90%) and validation data sets (10%). A multivariable logistic regression model using data from 108 interRAI questions across multiple domains was developed and validated using discrimination metrics and calibration curves. Variables each explaining at least 1% of the model were then used to develop and validate a parsimonious model. Subgroups by sex, age, ethnicity, and comorbidities were evaluated.FindingsThere were 104,436 persons (60.2% female; mean age 82.1 years) in the study cohort of whom 20,972 (20.1%) died within one year. The full multivariable model had area under the curves (AUCs) of 0.778 to 0.795 in the 5 validation datasets and was well calibrated. After variable reduction a parsimonious model consisted of 16 variables and was well calibrated and the AUC remained high: 0.773 (0.769 to 0.777). The three-month parsimonious model comprised 22 variables and was well calibrated with an AUC of 0.843 (95%CI: 0.839 to 0.848).InterpretationThese community-based risk prediction models accurately predict mortality in older people with complex co-morbidities. They may contribute to both forecasting for policy making and clinical decision making regarding an individual's needs.FundingThe New Zealand Health Research Council.

External validation of the detection of indicators and vulnerabilities for emergency room trips (DIVERT) scale: a retrospective cohort study

BackgroundThe Detection of Indicators and Vulnerabilities of Emergency Room Trips (DIVERT) scale was developed to classify and estimate the risk of emergency department (ED) use among home care clients. The objective of this study was to externally validate the DIVERT scale in a secondary population of home care clients.MethodsWe conducted a retrospective cohort study, linking data from the Home Care Reporting System and the National Ambulatory Care Reporting System. Data were collected on older long-stay home care clients who received a RAI Home Care (RAI-HC) assessment. Data were collected for home care clients in the Canadian provinces of Ontario and Alberta, as well as in the cities of Winnipeg, Manitoba and Whitehorse, Yukon Territories between April 1, 2011 and September 30, 2014. The DIVERT scale was originally derived from the items of the RAI-HC through the use of recursive partitioning informed by a multinational clinical panel. This scale is currently implemented alongside the RAI-HC in provinces across Canada. The primary outcome of this study was ED visitation within 6 months of a RAI-HC assessment.ResultsThe cohort contained 1,001,133 home care clients. The vast majority of cases received services in Ontario (88%), followed by Alberta (8%), Winnipeg (4%), and Whitehorse (< 1%). Across the four cohorts, the DIVERT scale demonstrated similar discriminative ability to the original validation work for all outcomes during the six-month follow-up: ED visitation (AUC = 0.617–0.647), two or more ED visits (AUC = 0.628–0.634) and hospital admission (AUC = 0.617–0.664).ConclusionsThe findings of this study support the external validity of the DIVERT scale. More specifically, the predictive accuracy of the DIVERT scale from the original work was similar to the accuracy demonstrated within a new cohort, created from different geographical regions and time periods.

Frailty of Māori, Pasifika, and Non-Māori/Non-Pasifika Older People in New Zealand: A National Population Study of Older People Referred for Home Care Services.

Little is known about the prevalence of frailty in indigenous populations. We developed a frailty index (FI) for older New Zealand Māori and Pasifika who require publicly funded support services. An FI was developed for New Zealand adults aged 65 and older who had an interRAI Home Care assessment between June 1, 2012 and October 30, 2015. A frailty score for each participant was calculated by summing the number of deficits recorded and dividing by the total number of possible deficits. This created a FI with a potential range from 0 to 1. Linear regression models for FIs with ethnicity were adjusted for age and sex. Cox proportional hazards models were used to assess the association between the FI and mortality for Māori, Pasifika, and non-Māori/non-Pasifika. Of 54 345 participants, 3096 (5.7%) identified as Māori, 1846 (3.4%) were Pasifika, and 49 415 (86.7%) identified as neither Māori nor Pasifika. New Zealand Europeans (48 178, 97.5%) constituted most of the latter group. Within each sex, the mean FIs for Māori and Pasifika were greater than the mean FIs for non-Māori and non-Pasifika, with the difference being more pronounced in women. The FI was associated with mortality (Māori subhazard ratio [SHR] 2.53, 95% CI 1.63-3.95; Pasifika SHR 6.03, 95% CI 3.06-11.90; non-Māori and non-Pasifika SHR 2.86, 95% CI 2.53-3.25). This study demonstrated differences in FI between the ethnicities in this select cohort. After adjustment for age and sex, increases in FI were associated with increased mortality. This suggests that FI is predictive of poor outcomes in these ethnic groups.

Using Standardized Tools to Characterize Adult Day Program Populations: Implications for Future Research and Clinical Practice

ObjectivesTo demonstrate the usefulness of primary data collection using clinician-rated and self-rated standardized measures to describe adult day program (ADP) populations and address programming issues such as identifying members at risk of dropping out. Setting and ParticipantsOne ADP in London, Ontario, and 2 ADPs in Toronto, Ontario, Canada. A total of 223 community-dwelling older adults were recruited across the 3 different programs. MethodsThe interRAI Community Health or Home Care Assessment and self-rated psychosocial assessments were collected on program enrollment. Data analyses included descriptive statistics, comparison of the populations between ADPs, and multinomial regression models to assess reasons for program withdrawal. ResultsMean ages across the 3 programs ranged from 78.3 to 83.8 years and the proportion of women ranged from 49.3% to 56.6%. Compared with one of the ADPs, members from 2 other ADPs exhibited higher use of mobility aids (P < .001), higher levels of cognitive impairment (P < .05), increased risk for institutionalization (P < .001), lower levels of depression (P < .01), and greater need for supervision for basic and instrumental activities of daily living (P < .01). Members assessed to be at higher risk for institutionalization and have increased medical complexity showed possible association with program withdrawal at one ADP. Conclusions and ImplicationsThe tools were useful in identifying differences in physical and psychosocial characteristics of members across the 3 ADPs. Information collected from interRAI and self-rated psychosocial assessments may be helpful in the development of individualized care plans, program services, and recommendations that target transitional care. By understanding member profiles and reasons for withdrawal, ADPs may be able to develop strategies to help members stay in the program and live in the community longer.

Trajectory of psychosocial symptoms among home care patients with cancer at end-of-life.

Understanding the end-of-life psychosocial needs of cancer patients at home is a knowledge gap. This study describes the trajectory of psychosocial symptoms in the last 6 months of life among cancer decedents who were receiving home care. Observational population-based cohort study of cancer decedents who were receiving home care services between 2007 and 2014. Decedents had to have at least one home care assessment in the last 6 months of life for inclusion. Outcomes were the presence of psychosocial symptoms (i.e., anxiety, loneliness, depression, social decline, caregiver distress, and cognitive decline) at each week before death. Our cohort included 27,295 unique cancer decedents (30,368 assessments), of which 58% died in hospital. Fifty-six percent were older than 74, and 47% were female. The prevalence of all symptoms increased approaching death, except loneliness. Social decline (48%-78%) was the most prevalent psychosocial symptom, though loneliness was reported in less than 10% of the cohort. Caregiver distress rose over time from 15%-27%. A third of the cohort reported issues with cognitive impairment. Multivariate regression showed that physical symptoms such as uncontrolled pain, impairment in independent activities of daily living, and a high level of health instability all significantly worsened the odds of having a psychosocial symptom in the last 3 months of life. In this large home care cancer cohort, trajectories of psychosocial symptoms worsened close to death. Physical symptoms, such as uncontrolled pain, were associated with having worse psychosocial symptoms at end of life.

Effect of Capacity to Undertake Instrumental Activities of Daily Living on Entry to Aged Residential Care in Older People With Heart Failure.

Background: Heart failure is a common condition in older people with complex medical needs. A key factor in resilience after heart failure is the capacity to perform the instrumental activities of daily living (IADLs). Knowing the association between capacity to perform IADLs and entry into aged residential care will help health professionals plan interventions that will allow older people to remain independent longer.Methods: We analyzed the association between the capacity to perform eight IADLs and entry into ARC. Participants included New Zealanders aged ≥65 years with a diagnosis of heart failure, and who had an InterRAI 9.1 Home Care assessment between July 2012 and June 2018. A multivariable competing risks regression model for entry to ARC with death as the competing risks was used to establish sub-hazard ratios (SHR) for IADL capacity. Co-variates included demographic variables, co-morbidities, living arrangements, cognitive performance, depression, timed walk, alcohol use, smoking, activities of daily living, recent hospitalization and history of falls.Results: There were 13,220 participants with heart failure who were followed for a median 1.69 (0.70–3.17) years. There were 3,177 (24.0%) participants who entered aged residential care and 5,714 (43.2%) who died without having first entered residential care. Overall capacity to perform specific IADLs was “very poor” for housework (85.5%), shopping (68.0%), stairs (61.7%), meal preparation (53.0%), and transportation (52.2%). In the multivariable model, compared to adequate capacity (the reference) poorer capacity for managing finance, managing medications, meal preparation and transport were all associated with increased risk of entering aged residential care, with SHR from 1.05 to 1.18. Overall, the IADL capacity explained ~10% of the risk of entering aged residential care.Conclusion: Capacity to perform IADL is a key factor in maintaining resilience in older people with heart failure. Capacity to manage finances, transport and medications, prepare meals, and transport oneself with minimal supervision could reduce the risk of entry into aged residential care. Developing early interventions and support for people with poor capacity to perform their IADL may help reduce admission into aged residential care.

Physician Home Visit Patterns and Hospital Use Among Older Adults with Functional Impairments.

Home-based primary care has been associated with reductions in hospital use among homebound older adults, but population-based studies on the general home visit patterns of primary care physicians are lacking. We examined the association between the provision of home visits by primary care physicians and subsequent use of hospital-based care among their older adult patients with extensive functional impairments. Population-based retrospective cohort study. The setting was Ontario, Canada, from October 2014 to September 2016. Older adults (aged ≥65 years) with extensive functional impairments receiving publicly funded home care. We measured the provision of home visits by a patient's most responsible primary care physician during the year before a comprehensive home care assessment. Physician home visit patterns were measured as the proportion of the total outpatient visits in a year that were home visits, categorized with quartiles. Multivariable, multilevel negative binomial regression models examined the associations between physician-level home visit provision and patient emergency department visits and hospital admissions over the 6 months following the home care assessment. There were 49,613 patients in the cohort who were linked to 8,096 unique primary care physicians. A total of 69.1% of physicians provided at least one home visit in a year, with the median proportion of home visits to total visits ranging from 0.057% to 3.19% across quartiles. Patients whose physicians were in the highest home visit provision quartile had lower rates of emergency department visits (incidence rate ratio [IRR] = 0.93; 95% confidence interval [CI] = 0.90-0.96) and hospital admissions (IRR = 0.89; 95% CI = 0.85-0.93) compared with patients whose physician did not do home visits. Home care patients with extensive functional impairments whose physicians provided higher levels of home visits had fewer emergency department visits and hospital admissions. Expanding home visits by primary care physicians could reduce hospital use by older adults living with functional impairments in the community.

Associations between continuity of primary and specialty physician care and use of hospital-based care among community-dwelling older adults with complex care needs.

While research suggests that higher continuity of primary and specialty physician care can improve patient outcomes, their effects have rarely been examined and compared concurrently. We investigated associations between continuity of primary and specialty physician care and emergency department visits and hospital admissions among community-dwelling older adults with complex care needs. We conducted a retrospective cohort study of home care patients in Ontario, Canada, from October 2014 to September 2016. We measured continuity of primary and specialty physician care over the two years prior to a home care assessment and categorized them into low, medium, and high groups using terciles of the distribution. We used Cox regression models to concurrently test the associations between continuity of primary and specialty care and risk of an emergency department visit and hospital admission within six months of assessment, controlling for potential confounders. We examined interactions between continuity of care and count of chronic conditions, count of physician specialties seen, functional impairment, and cognitive impairment. Of 178,686 participants, 49% had an emergency department visit during follow-up and 27% had a hospital admission. High vs. low continuity of primary care was associated with a reduced risk of an emergency department visit (HR = 0.90 (0.89-0.92)) as was continuity of specialty care (HR = 0.93 (0.91-0.95)). High vs. low continuity of primary care was associated also with a reduced risk of a hospital admission (HR = 0.94 (0.92-0.96)) as was continuity of specialty care (HR = 0.92 (0.90-0.94)). The effect of continuity of specialty care was moderately stronger among patients who saw four or more physician specialties. Higher continuity of primary physician and specialty physician care had independent, protective effects of similar magnitude against emergency department use and hospital admissions. Improving continuity of specialty care should be a priority alongside improving continuity of primary care in complex, older adult populations with significant specialist use.

Home care clients: a research protocol for studying their pathways

BackgroundEnhancing non-clinical home care supports and services for older adults to live well is a strategic priority in developed countries, including Canada. Underpinning these supports and services are structures of care that are reflected in home care policies, programs and practices within jurisdictions. These approaches to care exist at multiple levels and inform interactions, perceptions, and care assessment, planning and provision, ultimately shaping the supports that are delivered. Jurisdictional differences in approaches to care mean that pathways through home care systems may differ, depending on where one lives. The goal of this study is to understand how approaches to care shape the pathways of older adult home care clients with chronic and long term conditions in two Canadian health jurisdictions.MethodsThis longitudinal mixed-methods study has three interrelated research streams informed by aspects of the socio-ecological framework. We will examine client pathways using a retrospective analysis of home care assessment data (Resident Assessment Instrument- Home Care) in two health authorities (Client/Service Data Stream). We will analyze interview data from older adult home care clients and a cluster of each client’s family or friend caregiver(s), home support worker(s), care/case coordinator(s) and potentially other professionals at up to three points over 18 months using a prospective qualitative comparative case study design (Constellation Data Stream). We will review home care policies relevant to both health authorities and interview key informants regarding the creation and implementation of policies (Policy Stream). Our study will apply an integrated knowledge translation (iKT) approach that engages knowledge users in research design, analysis and interpretation to facilitate relevancy of results.DiscussionApplying a mixed-method research design to understand approaches to care within and between two jurisdictions will contribute to the evidence base on older adult home care client pathways. Study results will identify how potential differences are experienced by clients and their families. An understanding of the policies will help to contextualize these findings. The iKT model will ensure that findings are useful for strategic planning and decision-making, and supporting changes in care practice.

In-Hospital Patient Harm Across Linguistic Groups: A Retrospective Cohort Study of Home Care Recipients.

Research examining the impact of language barriers on patient safety is limited. We conducted a population-based study to determine whether patients whose primary language is not English are more likely to experience harm when admitted to hospitals in Ontario, Canada. We used linked administrative health records to establish a retrospective cohort of home care recipients (from 2010 to 2015) who were subsequently admitted to hospital. Patient language (obtained from home care assessments) was coded as English, French, or other. Harmful events were identified using the Hospital Harm Indicator developed by the Canadian Institute for Health Information. We included 190,724 patients (156,186 Anglophones, 5,110 Francophones, and 29,428 Allophones). There was no significant difference in the unadjusted risk of harm for Francophones compared with Anglophones (relative risk [RR], 0.94; 95% confidence interval [CI], 0.87-1.02). However, Allophones were more likely to experience harm when compared with Anglophones (RR, 1.14; 95% CI, 1.10-1.18). The risk of harm was even greater for Allophones with low English proficiency (RR, 1.18; 95% CI, 1.13-1.24). After adjusting for potential confounders, Anglophones and Allophones were equally likely to experience harm of any type, but Allophones more likely to experience harm from infections and procedures. Patients whose primary language was not English or French were more likely to experience harm after admission to hospital, especially if they had low English proficiency. For these patients, the risk of harm from infections and procedures persisted in the adjusted analysis, but the overall risk of harm did not.