interRAI Home Care Instrument Research Articles

The prevalence of non-pharmacological interventions in older homecare recipients: an overview from six European countries

Key summary pointsAimTo investigate the prevalence of non-pharmacological interventions (NPIs) in older homecare recipients in six European countries.FindingsThe prevalence of NPIs varied considerably between homecare users in different European countries. Interventions with a potential positive impact on health outcomes show a relatively low prevalence.MessageFurther research into better implementation of potentially beneficial interventions in treatment guidelines might be needed, in order to optimize functioning and quality of life of older homecare recipients.

Can the interRAI home care instrument be applied to the definition criteria of the Global Leadership Initiative on Malnutrition (GLIM)? A longitudinal study.

As malnutrition is an important modifiable risk factor for poor clinical outcomes, it is important to target malnourished older people and older people at risk of malnourishment. The Global Leadership Initiative on Malnutrition (GLIM) recently reached a consensus for a global definition of malnutrition. The primary aim of this study was to apply the interRAI Home Care (interRAI HC) instrument to fit the GLIM definition criteria of malnutrition to the closest. A second goal was to identify potential risk factors associated with malnutrition using this comprehensive assessment and to quantify their association. This is a case control study, which retrospectively determines the exposure to the risk of malnutrition and estimates its potential risk factors. The longitudinal data came from a larger study called Protocol 3. Eligibility criteria were a minimum age of 65 years old, a minimum score of 6 on the Edmonton Frail Scale or at least a moderate level of functional impairment measured by a Belgian version of the Katz scale. Older people with an official dementia diagnosis were also eligible. Bivariate analysis was performed and logistic regression models were developed in order to identify significant determinants of malnutrition. The data consisted of 6334 frail older people (mean age: 80.6±6.9, 70.6% female). About 2.4% became malnourished within a follow-up period of one year after baseline. The adjusted logistic regression yielded significant odds ratios for dysphagia (OR 2.2), loss of appetite (OR 1.8), bladder incontinence (OR 1.5) and low fluid intake (OR 1.5). Diabetes (OR 0.5) and visits to the physician (OR 0.5) had both a significant reverse effect. This study was the first large longitudinal research to explore the risk factors of malnutrition with a comprehensive assessment instrument as the interRAI HC, applying it to the recent GLIM definition criteria. The worldwide use of the interRAI instruments makes these findings relevant for global clinical practice and research. Adapting the interRAI instruments to the GLIM definition improves accurate detection, prevention and early treatment of malnourishment, avoiding further health deterioration in older people.

The Prevalence and Persistence of Dizziness in Older European Home Care Recipients: A Prospective Cohort Study

ObjectivesThe prevalence of different geriatric syndromes in older home care (HC) recipients is yet to be determined. Dizziness is often regarded as a geriatric syndrome. The natural course of dizziness in older people is still unknown, because of a lack of longitudinal studies. The objective of this study was to investigate the prevalence and persistence of dizziness in HC recipients. DesignProspective cohort study. SettingHome care organizations in 6 European countries participating in the EU-funded Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of community care (IBenC) project. Participants2616 community-dwelling long-term HC recipients aged 65 years or older. MethodsData were collected at baseline and 6 and 12 months by using the interRAI Home Care instrument (interRAI-HC). Dizziness status was assessed by the number of days people experienced dizziness in the last 3 days (0-3) and later dichotomized for analyses (present or not in the last 3 days). Dizziness persistence was defined as the odds for dizzy people at baseline to also report dizziness at subsequent follow-up moments, compared with people who were not dizzy at baseline. The pattern of dizziness was descriptively analyzed in recipients who completed all measurements. Generalized estimating equations analysis was used to determine the persistence of dizziness symptoms. ResultsThe prevalence of dizziness of 2616 eligible HC recipients at baseline was 25.1%, ranging from 16.2% (Belgium) to 39.7% (Italy). The majority of dizzy recipients at baseline also experienced dizziness after 6 and 12 months (79.1%). Dizziness persistence was high at 6 months [odds ratio (OR) 57.8, 95% confidence interval (CI) 43.1-77.5] and at 12 months (OR 30.2, 95% CI 22.3-41.1). Conclusions and ImplicationsDizziness in older HC recipients in Europe is common, and dizziness persistence is high. This warrants a more active approach in treating dizziness in older HC recipients.

Development of a novel benchmark method to identify and characterize best practices in home care across six European countries: design, baseline, and rationale of the IBenC project

BackgroundEurope’s ageing society leads to an increased demand for long-term care, thereby putting a strain on the sustainability of health care systems. The ‘Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of Community Care’ (IBenC) project aims to develop a new benchmark methodology based on quality of care and cost of care utilization to identify best practices in home care. The study’s baseline data, methodology, and rationale are reported.MethodsHome care organizations in Belgium, Finland, Germany, Iceland, Italy, and the Netherlands, home care clients of 65 years and over receiving home care, and professionals working in these organizations were included. Client data were collected according to a prospective longitudinal design with the interRAI Home Care instrument. Assessments were performed at baseline, after six and 12 months by trained (research) nurses. Characteristics of home care organizations and professionals were collected cross-sectionally with online surveys.ResultsThirty-eight home care organizations, 2884 home care clients, and 1067 professionals were enrolled. Home care clients were mainly female (66.9%), on average 82.9 years (± 7.3). Extensive support in activities of daily living was needed for 41.6% of the sample, and 17.6% suffered cognitive decline. Care professionals were mainly female (93.4%), and over 45 years (52.8%). Considerable country differences were found.ConclusionA unique, international, comprehensive database is established, containing in-depth information on home care organizations, their clients and staff members. The variety of data enables the development of a novel cost-quality benchmark method, based on interRAI-HC data. This benchmark can be used to explore relevant links between organizational efficiency and organizational and staff characteristics.

A Systematic Review Evaluating the Use of the interRAI Home Care Instrument in Research for Older People

ABSTRACTObjective: To summarize studies that used the international Resident Assessment home care instrument (interRAI HC) to examine study outcomes for older people.Methods: A comprehensive systematic search was performed to identify relevant studies, using five databases from 1990 until October 2016. The Cochrane Risk-Bias assessment tool and Newcastle-Ottawa Scale was used to assess the quality of RCTs and non-RCTs, respectively.Results: Based on the full-text analysis, 40 studies met the inclusion criteria out of 506 total records. The review included 6 RCTs, 2 quasi-experimental, 17 prospective and retrospective studies, 13 cross-sectional and 2 longitudinal studies. A series of interventions and/or applications were identified from this review that employed the use of interRAI HC instrument: (a) in health services, (b) as a new integrated care model and for implementing machine learning algorithm, (c) as a comprehensive geriatric assessment tool, (d) in case management, (e) for care planning and screening, (f) in drug therapy assessment, (g) to assess caregiver burden, and (h) for various risk assessments. Studies that employed the interRAI HC instrument reported an array of health-outcome measures mostly related to functional, cognition, hospitalization and mortality.Conclusions: Application of the interRAI HC tool varied markedly across all studies, and the outcomes measures were heterogeneous. Future research directions are discussed.Clinical Implications: The results from this study facilitate the use of interRAI HC as a tool to measure an intervention's effect that leads to improvements in specific geriatric-related health outcome measures emphasizes on functional status and quality of life and ascertain its utility as a quality indicator for the care of older individuals.

Evaluation of the effectiveness of complex health care interventions: the example of case management

Introduction: The aim is to present the evaluation of effectiveness of case management interventions, designed from the bottom-up, which have been implemented in Belgium since 2010 to support dependent elderly people at home. This type of intervention is an integrated care process which combines prevention, evaluation, custom designed multidisciplinary care plan, coordination of services and follow-up. Mixed methods are necessary for covering the indispensable steps of the analysis of effectiveness which includes the specific description of the interventions, the identification of the target populations, the building of a control group, the tracking of pertinent indicators, and the choice of a quantitative approach bearing in mind the implementation process of the interventions. Methods: The quantitative analysis of effectiveness has been guided by the results of the implementation analysis, a qualitative approach which provides the description of essential components of the interventions. Two quantitative databases are available for the beneficiaries and the control group (not benefiting from interventions and recruited by home care organisations, thus reflecting “usual care”): (1) a prospective data collection through a validated comprehensive geriatric instrument (the interRAI Home Care instrument) including clinical variables and data related to the informal caregivers, and (2) the administrative database of the reimbursed health care consumption (routinely recorded by the health care insurance). The different types of dependency are defined through a clustering analysis grouping beneficiaries according to functional and cognitive limitations. Thereafter, each P3 beneficiary is matched by using a propensity score method with one individual of the control group having similar health characteristics and similar levels of presence of informal caregiver (without, non-cohabitant, cohabitant). Finally, the different variables for assessing effectiveness are tested between beneficiaries and the control group. Results: Case management interventions are grouped according to three criteria: (1) the feedback to a general practitioner, (2) the psychological support, and (3) the intensity of the intervention. Beneficiaries are divided into five dependency types (low limitations; important IADL limitations; important ADL and IADL limitations; significant cognitive and functional deficiencies; and people cumulating significant cognitive, functional and behavioural problems). The results are presented for each of the above subgroups in the form of a “dashboard” including the different essential indicators for the evaluation of the impact of the intervention: indicators of health care consumption (i.e. nursing care at home, visits to a medical specialist), indicators identifying the stress on the health system (i.e. unexpected hospitalisation, visits to emergency service) and clinical outcomes (i.e. functional, cognitive, and depressive status, quality of life, informal caregiver’s perceived burden). Discussion: The analysis of the data collected through the questionnaires filled out by both the care recipients and their main informal caregivers linked to the administrative database of health care consumption provides a comprehensive evaluation of the effectiveness of a complex intervention. Both clinical and use of resources outcomes are analyzed for the dyads of care recipients/informal caregivers and allow for comprehensively and accurately describing the consequences of case management interventions according to various types of situations at home.

The determinants of informal caregivers' burden in the care of frail older persons: a dynamic and role-related perspective

ABSTRACTResearch into informal caregivers’ burden does not distinguish between different stages of impairment. This study explored the determinants of burden from an in-depth perspective in order to identify which determinants apply to which phases of impairment.Methods: This was a cross-sectional study including frail older persons aged 65 and above. Instruments used were the interRAI Home Care, the Zarit-12 interview and an ad hoc economic questionnaire. A combination of variables from the Stress Process Model and Role Theory and a sub-group analysis enabled refined multivariate logistic analyses.Results: The study population consisted of 4175 older persons (average age: 81.4 ± 6.8, 67.8% female) and their informal caregivers. About 57% of them perceived burden. Depressive symptoms, behavioral problems, IADL impairment, previous admissions to nursing homes and risk of falls yielded significant odds ratios in relation to informal caregivers’ burden for the whole sample. These determinants were taken from the Stress Process Model. When the population was stratified according to impairment, some factors were only significant for the population with severe impairment (behavioral problems OR:2.50; previous admissions to nursing homes OR:2.02) and not for the population with mild or moderate impairment. The informal caregiver being an adult child, which is a determinant from Role Theory, and cohabitation showed significant associations with burden in all strata.Conclusion: Determinants of informal caregivers’ burden varied according to stages of impairment. The results of this study can help professional caregivers gain a greater insight into which informal caregivers are most susceptible to perceive burden.Abbreviations: NIHDI: National Institute for Health and Disability Insurance; ZBI12: Zarit Burden Interview - 12 items; InterRAI HC: interRAI Home Care instrument; ADL: Activities of Daily Living; ADLH: interRAI Activities of Daily Living Hierarchy scale; IADL: Instrumental Activities of Daily Living; IADLP: InterRAI Instrumental Activities of Daily Living Performance scale; CPS2: InterRAI Cognitive Performance scale 2; DRS: InterRAI Depression Rating scale

Quality of care in European home care programs using the second generation interRAI Home Care Quality Indicators (HCQIs).

BackgroundEvaluating the quality of care provided to older individuals is a key step to ensure that needs are being met and to target interventions to improve care. To this aim, interRAI’s second-generation home care quality indicators (HCQIs) were developed in 2013. This study assesses the quality of home care services in six European countries using these HCQIs as well as the two derived summary scales.MethodsData for this study were derived from the Aged in Home Care (AdHOC) study - a cohort study that examined different models of community care in European countries. The current study selected a sub-sample of the AdHOC cohort from six countries whose follow-up data were complete (Czech Republic, Denmark, Finland, Germany, Italy and the Netherlands). Data were collected from the interRAI Home Care instrument (RAI-HC) between 2000 and 2002. The 23 HCQIs of interest were determined according to previously established methodology, including risk adjustment. Two summary measures, the Clinical Balance Scale and Independence Quality Scale were also determined using established methodology.ResultsA total of 1,354 individuals from the AdHOC study were included in these analyses. Of the 23 HCQIs that were measured, the highest proportion of individuals experienced declines in Instrumental Activities of Daily Living (IADLs) (48.4 %). Of the clinical quality indicators, mood decline was the most prevalent (30.0 %), while no flu vaccination and being alone and distressed were the most prevalent procedural and social quality indicators, respectively (33.4 and 12.8 %). Scores on the two summary scales varied by country, but were concentrated around the median mark.ConclusionsThe interRAI HCQIs can be used to determine the quality of home care services in Europe and identify areas for improvement. Our results suggest functional declines may prove the most beneficial targets for interventions.

Incomplete assessments: towards a better understanding of causes and solutions. The case of the interRAI home care instrument in Belgium.

The chronic diseases, comorbidities and rapidly changing needs of frail older persons increase the complexity of caregiving. A comprehensive, systematic and structured collection of data on the status of the frail older person is presumed to be essential in facilitating decision-making and thus improving the quality of care provided. However, the way in which an assessment is completed has a substantial impact on the quality and value of the results. This study examines the online completion of interRAI Home Care assessments, the possible causes for incomplete assessments and the consequences of these factors with respect to the quality of care received. Our findings indicate high nurse engagement and poor physician participation. We also observed the poor completion of items in predominantly medically- oriented sections characterized by, first, the fact that the assessors felt incapable of answering certain questions, second, the absence of required data or of a competent person to fill out the data, and third, the lack of tools necessary for essential measurements. The incompleteness of assessments has a clear negative influence on outcome generation. Moreover, without the added value of support outcomes, the improvement of care quality can be impeded and information technology can easily be seen as burdensome by the assessors. We have observed that multidisciplinary cooperation is an important prerequisite to establishing high-quality assessments aimed at improving the quality of care.

Outcomes of cognitively impaired older people in Transition Care.

The benefits of Transition Care Programs (TCPs) for patients with cognitive impairment are not well established. This study aimed to investigate the impact of TCP on patients according to their cognitive status. In this prospective cohort study, 351 patients were comprehensively assessed at TCP admission using the interRAI Home Care instrument and divided into two groups based on scores on the Cognitive Performance Scale. Of 346 patients assessed for cognition, 242 (69.9%) were considered cognitively intact, and 104 (30.1%) were classified as cognitively impaired (Cognitive Performance Scale ≥ 2). There were no significant differences in TCP outcomes between the two groups, including community living at six months (P = 0.1), hospital readmission rates (P = 0.6), or achievement of TCP goals (P = 0.3). Cognitively intact and cognitively impaired patients have similar outcomes post-TCP. Older patients should not be refused Transition Care based on the presence of cognitive impairment.

Gait speed as a predictor of outcomes in post-acute transitional care for older people

Gait speed has been advocated as a marker of vulnerability, but its discriminatory utility and predictive ability in frail older people in a post-acute community-based rehabilitation program has not been extensively investigated. The aims of this research were to examine whether there was a meaningful improvement in gait speed in post-acute care patients, and to determine whether gait speed predicted outcomes at 6-month follow up. In a prospective cohort study, 351 older persons admitted to a transition care program were comprehensively assessed using the interRAI Home Care instrument. This included a timed 4-m walk at admission and discharge. A telephone interview 6 months after admission determined functional independence, living status and readmissions to hospital. Mean (SD) gait speed was 0.34 m/s (0.21 m/s) at admission and 0.54 m/s (0.33 m/s) at discharge. The improvement in gait speed over the program was significant (P<0.001), and represents a clinically meaningful change. At 6 months postadmission to transition care, a majority of patients (86.9%) were living in the community and 40.5% had at least one readmission to hospital. Higher gait speed at admission was associated with increased likelihood of living in the community (OR 1.34, P=0.015) and being functionally independent (OR 1.19 P=0.017) at follow up, as well as a reduced risk of hospital readmissions (OR 1.18, P=0.006). Gait speed is an inexpensive, feasible and objective measure of physical performance in frail older people. It could be a useful tool in community-based transition care settings to predict outcomes.

Impact of Post-Acute Transition Care for Frail Older People: A Prospective Study.

To describe the characteristics and outcomes of frail older people in a post-acute transitional care program and to compare the recovery trajectories of patients with high and low care needs to determine who benefits from transition care. Prospective observational cohort. 351 patients admitted to community-based transition care in two Australian states during an 11 month recruitment period. Transition care provides a package of services including personal care, physiotherapy and occupational therapy, nursing care and case management post discharge from hospital. It is targeted at frail older people who, in the absence of an alternative, would otherwise be eligible for admission to residential aged care. A comprehensive geriatric assessment using the interRAI Home Care instrument was conducted at transition care admission and discharge. Primary outcomes included changes in functional ability during transition care, living status at discharge and six months follow-up, and hospital re-admissions over the follow-up period. For comparison of outcomes, the cohort was divided into two groups based on risk factors for admission to high or low-level residential aged care. There were no significant differences between groups on outcomes, with over 85% of the cohort living in the community at follow-up. More than 80% of the cohort showed functional improvement or maintenance of independence during transition care, with no significant differences between the groups. Post-acute programs should not be targeted solely at fitter older people: those who are frail also have the potential to gain from community-based rehabilitation.

Interventions to delay institutionalization of frail older persons: design of a longitudinal study in the home care setting

BackgroundOlder people usually prefer staying at home rather than going into residential care. The Belgian National Institute for Health and Disability Insurance wishes to invest in home care by financing innovative projects that effectively help older people to stay at home longer. In this study protocol we describe the evaluation of 34 home care projects. These projects are clustered according to the type of their main intervention such as case management, night care, occupational therapy at home and psychological/psychosocial support. The main goal of this study is to identify which types of projects have the most effect in delaying institutionalization of frail older persons.Methods/designThis is a longitudinal intervention study based on a quasi-experimental design. Researchers use three comparison strategies to evaluate intervention - comparison among different types of projects, comparisons between older persons in the projects and older persons not benefiting from a project but who are still at home and between older persons in the projects and older persons who are already institutionalized. Projects are asked to include clients who are frail and at risk of institutionalization. In the study we use internationally validated instruments such as the interRAI Home Care instrument, the WHO-QOL-8 and the Zarit Burden Interview-12. These instruments are filled out at baseline, at exit from the project and 6 months after baseline. Additionally, caregivers have to do a follow-up every 6 months until exit from the project. Criteria to exit the cohort will be institutionalization longer than 3 months and death. The main analysis in the study consists of the calculation of incidence rates, cumulative incidence rates and hazard rates of definitive institutionalization through survival analyses for each type of project.DiscussionThis research will provide knowledge on the functional status of frail older persons who are still living at home. This is important information to identify determinants of risk for institutionalization. The identification of effective home care projects in delaying institutionalization will be useful to inform and empower home care providers, policy and related decision makers to manage and improve home care services.