Article

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

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Abstract

Objective: To examine home care service-related and person-based factors associated with time to entry into permanent residential aged care. Design: Longitudinal cohort study using routinely collected client management data. Setting: A large aged care service provider in New South Wales and the Australian Capital Territory, Australia. Participants: A total of 1116 people aged 60 years and older who commenced home care services for higher-level needs between July 1, 2015 and June 30, 2016. Methods: Survival analysis methods were used to examine service-related and person-based factors that were associated with time between first home care service and entry into permanent residential aged care. Predictors included service hours per week, combination of service types, demographics, needs, hospital leave, and change in care level. Cluster analysis was used to determine patterns of types of services used. Results: By December 31, 2016, 21.1% of people using home care services had entered into permanent residential care (n = 235). After adjusting for significant factors such as age and care needs, each hour of service received per week was associated with a 6% lower risk of entry into residential care (hazard ratio = 0.94, 95% confidence interval 0.90-0.98). People who were predominant users of social support services, those with an identified carer, and those born in a non-main English-speaking country also remained in their own homes for longer. Conclusions: Greater volume of home care services was associated with significantly delayed entry into permanent residential care. This study provides much-needed evidence about service outcomes that could be used to inform older adults' care choices.

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... With aged care providers increasingly using electronic care management systems, there is potential to utilise their routinely collected data to gain insights into the impact of policy reforms. 10 The aim of this study was to examine changes in service uptake, use and cessation following HCP allocation reforms for a large provider in New South Wales (NSW) and Australian Capital Territory (ACT). ...
... This study forms part of a larger program of research examining the care and outcomes of community aged care clients. 10 Routinely collected data were extracted from the centralised information system of a large non-profit organisation which provides community aged care services to over 7500 clients each year across metropolitan, regional and rural areas of NSW/ACT. Extracted data included information on reasons for referral, care needs, 11 demographic characteristics, services provided and service cessation. ...
... Importantly, home care also has potential to delay more costly forms of care. 10 Phasing out limits on the maximum number of HCPs has long been recommended; 21 however, progress towards this has not been made. National aged care data sets should be utilised not just to examine the impact of past reforms, but also to model the effect of current policy capping the number of HCPs on the outcomes of the 119,524 older Australians waiting for care. ...
Article
Objective: To utilise routinely collected data to examine changes in the client profile of a large aged care provider before and after commencement of the 2017 policy reforms, whereby home care packages were allocated to individuals rather than providers. Methods: Interrupted time series analysis was used to measure changes in service uptake and cessation. Chi-square and t tests were used to compare client profiles in the 12 months before and after policy changes. Results: A total of 4132 people used home care services with the provider between March 2016 and March 2018. Fewer people commenced services post-reforms, and they were more likely to be younger and have a partner. There was no change in the number choosing to terminate services post-reforms. Conclusion: Vulnerable older Australians may experience greater difficulty accessing services under the new system, suggesting greater scrutiny of the reforms in achieving policy objectives is required. Analyses of routinely collected data sets can support this evaluation process.
... Besides the individuals' factors, greater volume of home-and community-based care use are associated with a reduced risk of subsequent nursing home admission in the USA [14][15][16]. A recent Australian study has demonstrated that each hour per week of HCP service use is associated with a 6% decreased risk of entering RAC [17]. Although this study provides significant insights into service outcomes of HCP, the participants were from only one HCP provider in New South Wales and Canberra, and were studied for a relatively small observation period. ...
... The aim of the current study was to examine whether patterns of HACC use and person-based characteristics are associated with the cumulative incidence of RAC admission across later life. Based on earlier research, we hypothesize that high/complex use of HACC is associated with delayed transition to RAC [16][17][18]. ...
... Several US-based regional studies reported that increased home-and community-based care use is associated with a reduced risk of transitioning to a nursing home [14][15][16]. A recent region-based Australian study demonstrated that one hour per week of HCP service use is associated with a 6% decrease in risk of time to entering RAC over the 18-month period [17]. ...
Article
Objective: To examine whether patterns of home and community care (HACC) use and person-based characteristics were associated with time to enter permanent residential aged care (RAC). Study design: A prospective cohort study. The sample consisted of 8062 participants of the Australian Longitudinal Study on Women's Health who used HACC services between 2001 and 2014. Main outcome measures: Time from first HACC use to enter permanent RAC. The median follow-up time was 63 months. Factors associated with time to enter RAC were identified using competing risk regression models. Results: Of the 8062 participants, 60% belonged to the 'basic HACC' group, who used few services minimally; 16% belonged to the 'moderate HACC' group, who predominantly used domestic assistance with moderate use of other services; and 24% belonged to the 'complex HACC' group, who used many services frequently. Being a member of the complex HACC group was associated with a lower cumulative incidence of RAC than basic or moderate HACC (chances 15% versus 30% by the median observation period, p < 0.01). Living in a remote/outer region (sub-distributional hazard ratio (sdHR) = 0.83, 95%CI: 0.74 - 0.93) was associated with delayed admission to RAC. Meanwhile, earlier admission was associated with living in an apartment (sdHR = 1.29, 95%CI: 1.20-1.40) or a retirement village (sdHR = 1.54, 95%CI = 1.38-1.72), having a physical functioning score <40 (sdHR = 1.16, 95%CI = 1.05-1.25), and falls with injury (sdHR = 1.15, 95%CI = 1.05-1.25). Conclusions: Our findings highlight the importance of providing more community care services, age-friendly housing, falls prevention and physical activity programs to reduce inappropriate admission to RAC.
... 2,3 However, according to the most recent estimates (2009/2010) only 75% of individuals with approvals accessed these services. 3 While there is significant literature on factors that lead to use of long-term care, [4][5][6][7][8][9] less is understood about factors that lead to use of home, respite and transition care. Even less is understood about individuals who obtained approvals for support and did not access these services. ...
... These similarities are due to the overlap in the population accessing these services. 5,6 However, we also identified factors associated with the use of respite approvals only, including having a DVA card, living outside major cities and having hypertension, arthritis, diabetes, eye diseases and fractures. The differences in the effect of certain diseases could be related to the demanding nature of certain conditions (ie, fractures). ...
Article
Full-text available
Objective: To evaluate access to approved aged care services and factors associated with accessing these services. Methods: A retrospective cohort study was conducted (1/7/2003-30/6/2013). The incidence of accessing permanent residential, home and respite care services within one year, or transition care within 28 days of approval, was evaluated. The association of participants' socio-demographic characteristics, limitations, health conditions and assessment characteristics with service use was evaluated. Results: In 799 750 older Australians, the incidence of accessing approved permanent residential care within one year was 70.9% (95% confidence interval [CI] 70.8%-71.0%), home care 49.5% (95% CI 49.3%-49.7%) and respite care 41.8% (95% CI 41.7%-41.9%). The incidence of accessing transition care within 28 days was 78.5% (95% CI 78.2%-78.7%). Aged care seekers', assessments' and assessors' characteristics are associated with service access. Conclusion: Monitoring the use of aged care service approvals to identify service access barriers can support ongoing evidence-based policy changes.
... People often have to access private community and in-home services to remain at home while waiting (Day et al., 2017). Another Australian study has shown that people who use care services in Australia live at home longer, with greater service use equating to better outcomes (Jorgensen et al., 2018). These Australian studies provide relevant knowledge about the issues with and benefits of service use; however, study samples do not specifically include people with dementia. ...
... The finding that a lack of family or social support was an impetus for entry to residential care supports Brodaty et al's. (2014) finding that living alone was likely to be linked to entering residential care earlier. Additionally, the finding that service assistance supports people with dementia to remain living at home longer is consistent with Jorgensen et al's. (2018) study, which identified that Australian care service users live at home longer. However, barriers exist to accessing timely support, with recent findings by the Aged Care Royal Commission that wait times to access a home care package range from three to more than 12 months (Royal Commission into Aged Care Quality and Safety, 2019). A su ...
Article
Background People with dementia usually prefer to live in the community. Research is needed to identify the ‘tipping point’ for residential care entry and to highlight how people with dementia can be supported to remain at home as long as possible. Few previous studies have examined caregivers’ perceptions and explanations for the reasons people with dementia need to enter residential care in Australia. Aim To explore the factors contributing to people with dementia entering residential care in Perth, Western Australia, from the perspectives of informal carers and care staff. Method This phenomenological study used purposive sampling to recruit informal and formal caregivers of people with dementia. Semi-structured in-depth interviews were conducted with 13 family carers and 11 home care staff. Data were thematically analysed to identify individual, carer and contextual factors that impact on residential care entry. Findings The majority of participants identified a combination of factors as the ‘tipping point’ to residential care entry; a few also identified the cause as a sudden event or specific issue. Factors identified included deterioration related to worsening cognition, changed behaviours and a decline in the performance of activities of daily living; co-occurring health conditions; safety concerns; carer no longer able to meet care needs; impact of providing support becoming too much for the informal carer; lack of family or social support and needing assistance from services that were unavailable or inaccessible. Factors assisting people with dementia to remain living at home longer were family and social support, formal services and dog ownership. Conclusion This study identified individual, carer and contextual factors that contribute to people with dementia entering residential care in Australia. The ‘tipping point’ was recognised as when the needs of a person with dementia outweigh the capacity of their informal and formal carers, services and supports to care for them.
... Use of home care services is associated with delayed entry into permanent residential aged care. 2 This has resulted in residents being older, frailer and having more complex care needs at the time of entry to RACS. 3 When prescribed appropriately, international literature suggest medications improve quality of life and reduce the risk of hospitalization. 4 However, inappropriate and unnecessary medication use can contribute to medication-related harm and preventable hospitalizations. ...
Article
Background: There is increasing international interest in initiatives to reduce medication-related harm and preventable hospitalizations in residential aged care services (RACS). The Australian Government recommends that RACS establish multidisciplinary Medication Advisory Committees (MACs). No previous research has specifically investigated the structures and functioning of MACs. Objectives: To explore the current structures and functioning of MACs, and identify opportunities for MACs to better promote safe and effective medication use. Methods: Semi-structured interviews and focus groups were conducted with a maximum variation sample of health professionals (n = 44) across four health services operating across 27 RACS in rural and regional Victoria, Australia. Qualitative data were analyzed using deductive and inductive content analyses. Results were presented to a multidisciplinary expert panel (n = 13) to identify opportunities for improvement. Results: Deductively coded themes included composition and functioning of the MAC, education and information needs and support to better manage polypharmacy. Emergent inductively coded themes included general medical practitioner (GP) and pharmacist engagement, collaboration and effectiveness. Participation by GPs and pharmacists was variable, while no MACs involved residents or family carers. Aged care specific and multidisciplinary MACs were generally more proactive in addressing potential medication-related harm. Education to identify and report adverse drug events with high risk medications was identified as a priority. The multidisciplinary panel made 12 recommendations to promote safe and effective medication use. Conclusion: Despite all MACs having a strong commitment to medication safety, opportunities exist to improve the composition and structure, proactive identification and response to emerging issues, and systems for staff, resident and family carer training.
... 39,40 A recent study in Australia found that HCP service use is significantly associated with decreased odds of entering RAC. 41 In a US-based study, nearly one-fifth of residents in nursing homes were found to be high functioning and could potentially be supported in community-based care. 12 The recent growth in HCP services in Australia may reduce the care trajectory in RAC as an increasing number of older people prefer to stay at home for longer and enter RAC with a higher care trajectory than before. ...
Article
Objective: Older women are more likely than men to enter residential aged care (RAC) and generally stay longer. We aimed to identify and examine their trajectories of care needs over time in RAC across 3 fundamental care needs domains, including activities of daily living (ADL), behavior, and complex health care. Design: Population-based longitudinal cohort study. Setting: RAC facilities in Australia. Participants: A total of 3519 participants from the 1921-1926 birth cohort of the Australian Longitudinal Study on Women's Health (ALSWH), who used permanent RAC between 2008 and 2014. Methods: We used data from the Aged Care Funding Instrument, National Death Index, and linked ALSWH survey. Participants' care needs in the 3 domains were followed every 6 months up to 60 months from the date of admission to RAC. Trajectories of care needs over time were identified using group-based multitrajectory modeling. Results: Five distinct trajectory groups were identified, with large variation in the combinations of levels of care needs over time. Approximately 28% of residents belonged to the "high dependent-behavioral and complex need" group, which had high care needs in all 3 domains over time, whereas around one-third of residents (31%) were included in 2 trajectory groups ("less dependent-low need" and "less dependent-increasing need"), which had low or low to medium care needs over time. More than two-fifths of residents (41%) comprised 2 trajectory groups ("high dependent-complex need" and "high dependent-behavioral need"), which had medium to high care needs in 2 domains. Higher age at admission to RAC and multiple morbidities were associated with increased odds of being a member of the high dependent-complex need group than the less dependent-increasing need group. Conclusions and implications: Identification of the differential trajectories of care needs among older women in RAC will help to better understand the circumstances of their changing care needs over time. This will facilitate appropriate care planning and service delivery for RAC residents, who are mostly older women.
... 6 Home-and community-based aged care services provide vital support for basic health and care needs (such as meals, social support, and personal hygiene), support health service provision (e.g., transport to medical appointments), and can contribute to the prevention of falls, inappropriate hospital admissions, and premature entry to permanent residential aged care. [7][8][9] The quality of the HC system thus has the potential to alleviate, or increase, pressures on other parts of the health and aged care systems. ...
Article
Full-text available
Objectives: Australia is lagging behind other countries in implementing quality indicators (QIs) in home- and community-based aged care. This research aimed to identify and appraise home care QI sets used internationally for older adults, to inform the future development and utilisation of QIs in the Australian context. Methods: A systematic search of eligible studies outlining the development and validation of home care QI sets for older adults was undertaken. QIs were categorised using the Donabedian model to identify potential gaps in coverage of key areas of care quality. Each QI was classified as potentially "derivable" or not from existing national routinely collected datasets. Methodological quality was determined using the Appraisal of Indicators through Research and Evaluation instrument. Results: Three sets of home care QIs developed and used internationally for older adults were identified. Two of the QI sets focused predominantly on clinical and functional aspects of care. Of 45 unique QIs, the majority were outcome measures (93%), with only three QIs measuring care processes (7%), and zero indicators measuring quality in terms of the structure of care (e.g., waiting time to access services). Nearly half of the individual indicators identified would require Australian home care providers to undertake additional data collection. There were significant methodological limitations in the development of QI sets, particularly in the scientific evidence domain. Conclusions: This review identified important gaps in existing QI sets, which should be considered by policymakers, researchers, and other stakeholders when developing and applying QIs in the Australian setting.
... 7 In line with global preferences, 8 older Australians desire care services that enable them to age in their own homes, a trend that continues to grow. 9 Home care services can significantly delay entry to residential aged care, 10,11 with the risk of entry into residential care also lower in home care services with a case management approach. 12 Case management aims to support populations with long-term vulnerabilities, such as older people, and includes care coordination, client education, negotiation of care options, client advocacy, liaison with service providers, client care and support and assistance with managing budgets. ...
Article
Objective The aim of this study was to quantify the work activities of community aged care case managers and assess changes following consumer-directed policy reforms. MethodsA longitudinal, time and motion study was performed, with direct observation (n=339h) of case managers undertaking work in the office or in the community. We compared the distribution of proportions of time spent across seven broad work task categories during May–August 2014 (P1) and May–October 2016 (P2). ResultsOffice time was primarily consumed by communication (43.7%) and documentation (33.3%) tasks. Documentation increased substantially from P1 to P2 (29.4% vs 37.0% respectively; P<0.001), with more time spent on the subtask of recording information (18.0% vs 24.5% respectively; P=0.039). Travel (45.9%) and communication (41.0%) accounted for most community time. Time in communication increased from P1 to P2 (37.3% vs 48.4% respectively; P=0.047), with more time allocated to client communication (14.6% vs 31.7%; P<0.001). Case managers spent 33.6% of community time in clients’ homes (median 25.2min per client; 22.8 vs 30.1min in P1 and P2 respectively) and visited a median of two clients per day (3 vs 1 visits per day in P1 and P2 respectively). Conclusions This study provides the first quantification of task–time distribution among this workforce and how work patterns have changed during a time of significant policy reform and operational changes within the community aged care sector. What is known about the topic?Early qualitative studies gauging case managers’ perceptions of the effect of consumer-directed care reforms on their work activities indicate an increase in time spent working directly with aged care clients. However, there is no existing quantitative evidence examining changes to case managers’ work activities. What does this paper add?By capturing timed, multidimensional data, this study provides new quantitative evidence of how case managers distribute their time on work activities in office and community settings. Further, the results provide an indication of changes in work task–time distribution over a 2-year period when significant policy reforms and operational changes occurred. Amid a changing aged care landscape, how and with whom case managers spend their time was found to shift, with an increase in time spent recording information and communicating with clients identified. What are the implications for practitioners?This study demonstrates that direct observational studies provide important evidence of the ways in which policy and organisational changes affect community aged care case managers’ work activities in practice. Triangulating this quantitative evidence with existing qualitative accounts of policy impact can further allow assessment of how complex reforms may affect everyday work. For policy makers and aged care organisations, such evidence can help discern whether policies and changes are having their desired effects, as well as providing insights as to why or why not.
... In addition to these broader social benefits, high quality aged care services also save costs within the health and aged care systems. Research has found that access to home care services delays entry into more expensive residential care (Jorgensen et al. 2018), while high quality residential care can reduce the likelihood that an older person will be transferred to a more expensive acute care hospital (Feng et al. 2018;Rantz et al. 2017). ...
Technical Report
Full-text available
Aged care services touch the lives of substantial – and increasing – numbers of people. Yet the capacity of service systems to meet older people’s needs, and to do so at standards acceptable to the community, remains under question, subject to several major inquiries in recent years including Australia's current Royal Commission into Aged Care Quality and Safety. Recognising that the community expects aged care services to deliver supports which go beyond basic physical care, this project explored the ways current aged care arrangements and processes of care work attend to older people’s social and emotional needs; and the policy, regulatory and organisational arrangements which would more effectively ensure provision of quality, whole-of-person care.
... Current aged care reforms in Australia include a focus on providing home and community-based care services to support older people to remain in their own homes (Jorgensen & Haddock, 2018). The provision of these services recognizes the importance of maintaining social engagement for older adults and supporting socially isolated individuals through a range of social care services (Cherry et al., 2013;Jorgensen, Siette, Georgiou, Warland & Westbrook, 2018). Despite efforts to increase social engagement, aged care providers have found that 41% of older adults initially accessing services are lonely (The Benevolent Society & Social Policy Research Centre, 2009). ...
Article
Full-text available
Aged care services have the potential to support social participation for the growing number of adults aging at home, but little is known about the types of social activities older adults in community care are engaged in. We used cluster analysis to examine the current profiles of social participation across seven domains in 1,114 older Australians, and chi-square analyses to explore between-group differences in social participation and sociodemographic and community care service use. Two distinct participation profiles were identified: (a) connected, capable, older rural women and (b) isolated, high-needs, urban-dwelling men. The first group had higher levels of engagement across six social participation domains compared with the second group. Social participation among older adults receiving community care services varies by gender, age, individual care needs, and geographical location. More targeted service provision at both the individual and community levels may assist older adults to access social participation opportunities.
... Several systematic reviews have demonstrated the effectiveness of different community care and interventional programs in improving cognition, quality of life, and the physical and mental health of vulnerable older adults [4,[12][13][14]. Recent work has further identified the value of community-based social support services in delaying entry into residential aged care [15]. Communitybased care services that can improve social connections in isolated older adults mostly focus on Adult Day Services (ADSs). ...
Article
Full-text available
Background Social isolation is an increasing concern for older adults who live in the community. Despite some availability of social support programs to address social isolation, their effectiveness is not routinely measured. This study aimed to evaluate an innovative excursion-based program offering unique social experiences to older adults receiving aged care services. Methods This six-month before and after mixed-methods study evaluated the outcomes of an Australian excursion-based program which offered social and physical outings to bring older adults receiving aged care services into the wider community. The study combined two parts: Part 1 was a pre-post survey assessing the quality of life of older adults who received the excursion-based program for 6 months ( n = 56; two time-points, analysed using signed rank test) and Part 2 involved qualitative in-depth, semi-structured interviews ( n = 24 aged care staff, older adults and carers; analysed using thematic analysis). Results Older adults experienced a significant increase in quality of life scores ( p < 0.001) between baseline and 6 months. Interviews confirmed these observations and suggested that benefits of participation included increased opportunities for social participation, psychological wellbeing, physical function, and carer respite. Interviews also revealed being in a group setting, having tailored, convenient and accessible activities, alongside supportive staff were key drivers in improving the wellbeing of participants. Conclusions Participating in an excursion-based community program may improve wellbeing in older adults. Aging policy should focus on prioritizing initiatives that promote social connectivity with the wider community and assist in improving outcomes for older adults.
... We and Jorgensen et al. have found that community care can delay the need for RAC. However, our other analyses show that use of services is low and often delayed, and largely independent of housing type except that women living in a house were less likely to have ACAP assessment or be admitted to RAC (38). ...
Article
Full-text available
Background: Housing is essential for healthy ageing, being a source of shelter, purpose, and identity. As people age, and with diminishing physical and mental capacity, they become increasingly dependent on external supports from others and from their environment. In this paper we look at changes in housing across later life, with a focus on the relationship between housing and women's care needs. Methods: Data from 12,432 women in the 1921–26 cohort of the Australian Longitudinal Study on Women's Health were used to examine the interaction between housing and aged care service use across later life. Results: We found that there were no differences in access to home and community care according to housing type, but women living in an apartment and those in a retirement village/hostel were more likely to have an aged care assessment and had a faster rate of admission to institutional residential aged care than women living in a house. The odds of having an aged care assessment were also higher if women were older at baseline, required help with daily activities, reported a fall, were admitted to hospital in the last 12 months, had been diagnosed or treated for a stroke in the last 3 years, or had multiple comorbidities. On average, women received few services in the 24 months prior to admission to institutional residential aged care, indicating a potential need to improve the reach of these services. Discussion: We find that coincident with changes in functional capacities and abilities, women make changes to their housing, sometimes moving from a house to an apartment, or to a village. For some, increasing needs in later life are associated with the need to move from the community into institutional residential aged care. However, before moving into care, many women will use community services and these may in turn delay the need to leave their homes and move to an institutional setting. We identify a need to increase the use of community services to delay the admission to institutional residential aged care.
... Very old individuals are the ones who need supportive care services as they are nearing the end of life and this is also at a time of life when spousal death and the death of others who could be their first line of care [23]. We also found that a lower proportion of people entering PRAC were born in non-English speaking countries (< 20%) and had a preferred language (< 12%) other than English (Culturally And Linguistically Diverse, CALD), which had been reported by AIHW for the national cohort and studies by Petrov et al. and Jorgensen et al. [4,11,24]. When compared to Australian general population (about 21% spoke a language other than English), the proportion of older CALD people using PRAC was low [25]. ...
Article
Full-text available
Background: Aged care support services in Australia are delivered through home care packages, permanent residential care, respite care and transition care. This study aimed to determine age and gender specific incidence rates of aged care service utilisation in Australia between 2008-09 and 2015-16. Methods: This is a population-based epidmiological study of people accessing aged care services in Australia. The trends and characteristics of people (over the age of 65 years old) accessing aged care services in Australia were evaluated, using data (2008-09 and 2015-16) from the Australian Institute of Health and Welfare and Australian Bureau of Statistics. The yearly utilisation incidence rates (per 1000 people) per service type were calculated and changes in incidence rate ratios (IRR) of service utilisation for the study period were estimated using Poisson regression models. Results: The proportion of older Australians aged ≥65 years who used aged care services remained similar between 2008-09 (5.4%, N = 208,247) and 2015-16 (5.6%, N = 248,669). However, the incidence use of specific services changed during the study period. Specifically, admissions into permanent residential care decreased (from 23.8/1000 people in 2008-09 to 19.6/1000 in 2015-16, at a IRR of 0.84/year, p < 0.001) but increased for transition care (from 4.3/1000 in 2008-09 to 6.6/1000 in 2015-16, at a IRR of 1.57/year, p < 0.001) and home care packages (from 8.04/1000 in 2008-09 to 12.0/1000 per 1000 in 2015-16, at a IRR of 1.52/year, p < 0.001). Between 2008-09 and 2015-16, the greatest changes in IRR were observed in males aged 80-89 years accessing transition care (IRR = 1.68/year, p < 0.001). A higher proportion of people aged between 80-89 years (≥45%), females (≥60%), Australia born (≥ 60%) and English speakers (≥80%) used all the service types. Conclusions: Patterns of service utilisation for aged care services changed over the study period with a decrease in incidence of individuals accessing permanent residential care but increased for other service types. This finding reflects changes in attitudes regarding ageing in place and policies. These findings are helpful to inform key stakeholders on service planning to further improve quality of the aged-care services in Australia.
... The concept of aging in public can be used to understand the narrative that PCHs are intended to accommodate a subset of frail older adults who have extraordinary care needs, as reflected by the idea of PCHs as a last resort option in the continuum of care. Recent research highlights a predominant focus on keeping older adults out of LTRC and reducing what are considered to be inappropriate admissions (Jorgensen, Siette, Georgiou, Warland, & Westbrooks, 2018;Rahman & Byles, 2020). Indeed, the texts examined in our study tended to suggest that there is no "good" public place to care for frail older adults, and PCHs were largely characterized as an imperfect or problematic solution to the problem of public aging. ...
Article
Public representations of long-term residential care (LTRC) facilities have received limited focus in Canada, although literature from other countries indicates that public perceptions of LTRC tend to be negative, particularly in contexts that prioritize aging and dying in place. Using Manitoba as the study context, we investigate a question of broad relevance to the Canadian perspective; specifically, what are current public perceptions of the role and function of long-term care in the context of a changing health care system? Through critical discourse analysis, we identify four overarching discourses dominating public perceptions of LTRC: the problem of public aging, LTRC as an imperfect solution to the problem, LTRC as ambiguous social spaces, and LTRC as a last resort option. Building on prior theoretical work, we suggest that public perceptions of LTRC are informed by neoliberal discourses that privilege individual responsibility and problematize public care.
... Increasingly, policies have acknowledged the importance of supporting the dignity and social lives of older adults, as opposed to merely keeping older adults physically well enough to remain at home (e.g., see Aged Care Quality and Safety Commission (2019)). Although research on the outcomes of community care is relatively sparse, available evidence indicates community aged care services can improve the social, psychological and physical health of recipients (Ellen et al., 2017;Milligan et al., 2016) and delay entry into residential care (Jorgensen et al., 2018). Adult day services (ADS) are a principal form of community care that provides older adults routine opportunities for social engagement (Aged & Community Services Australia, 2015). ...
Article
Social participation is critical to the health and well‐being of older adults, however, participation often declines with age. Research has identified that personal and environmental factors such as high socioeconomic status and accessible transportation are associated with higher levels of social participation. However, the barriers and facilitators to social participation experienced by older adults receiving community aged care services remains largely unexplored. This qualitative study aimed to generate context‐rich data and identify the barriers and facilitators to effective community care services that can support older adults’ participation in the community and contribute to individual well‐being. Semi‐structured focus groups were conducted with 40 community aged care clients and 21 staff members between January to July 2018 and thematic analysis was undertaken. Environmental factors, such as availability and accessibility of transportation services emerged as the most important factors influencing participation. Older age, self‐attitude towards one's own functional ability and limited social networks were important personal factors affecting participation. Proactive aged care services (e.g., engaged staff, tailored activities) were reported to assist with continual engagement in aged care services. In contrast, the type, location and accessibility of the activity, associated costs and limited options for accessible transportation were key barriers to older adults’ social participation. Pathways contributing to positive engagement were complex and variable, but personal well‐being and local community resources emerged as important factors encouraging higher social participation. These findings are discussed in the context of the ongoing pandemic and implications for future aged care services are provided.
... Within the community care setting, older adults are often provided with no opportunity to articulate their social situation (e.g., feelings of loneliness) and quality of life (e.g., independence and wellbeing) during their assessments (Gill et al., 2017). There is growing evidence to suggest that providing access to social engagement opportunities and services to improve social participation can enhance older adults' quality of life (Berry, 2009;Berry, Rodgers, & Dear, 2007), generate societal benefits by increasing community involvement (Kendig et al., 2012;Kim, Auh, Lee, & Ahn, 2013;Murayama et al., 2013), and potentially delay entry into residential aged care (Jorgensen, Siette, Georgiou, Warland, & Westbrook, 2018). ...
Article
Rich social relationships contribute to improved well-being and health outcomes, yet aged care client assessments tend to focus almost exclusively on physical issues. We aim to explore the experiences of aged care staff following their use of social engagement and well-being instruments as part of routine assessments for home-care clients. The social engagement (Australian Community Participation Questionnaire, ACPQ) and well-being (ICEpop CAPability Measure for Older Adults, ICECAP-O) instruments were embedded into the centralised information system of an Australian aged care provider. Staff administered these instruments during routine client assessments across a 9-month period involving 289 assessments. Semistructured interviews with 12 staff members were conducted and themes explored using qualitative content analysis. Key factors related to the acceptability of instrument adoption were found. Staff reported the instruments were convenient to use and were valuable in eliciting information for care plan development. Staff found that the instruments complemented their standard assessment procedures and did not disrupt their routine workload. They emphasised that the information gained greatly assisted their discussions with clients, identified social needs, and enhanced client involvement in decisions about desired services. There were also some challenging elements, including staff concerns regarding their ability to deal with emotional responses from clients evoked by the survey questions. ACPQ and ICECAP-O are useful tools for identifying psychosocial client needs, are feasible for use by large-scale aged care organisations and provide valuable information to guide decision-making about services. Future research should identify the long-term effects on improving social participation and client outcomes.
... International datasets have allowed exploration of the role of social care services [32,33] an area which has been underresearched in the UK context. This article provides an overview of Scotland's two key Social Care datasets -the Social Care Survey and Care Home Census. ...
Article
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IntroductionLinked health care datasets have been used effectively in Scotland for some time. Use of social care data has been much more limited, partly because responsibility for these services is distributed across multiple local authorities. However, there are substantial interactions between health and social care (also known internationally as long-term care) services, and keen policy interest in better understanding these. We introduce two social care resources that can now be linked to health datasets at a population level across Scotland to study these interdependencies. These data emerge from the Scottish Government’s centralised collation of data from mandatory returns provided by local authorities and care homes. Methods Deterministic and Probabilistic methods were used to match the Social Care Survey (SCS) and Scottish Care Home Census (SCHC) to the Community Health Index (CHI) number via the National Records of Scotland (NRS) Research Indexing Spine. ResultsFor the years 2010/11 to 2015/16, an overall match rate of 91.2% was achieved for the SCS to CHI from 31 of Scotland’s 32 local authority areas. This rate varied from 76.7% to 98.5% for local authority areas. A match rate of 89.8% to CHI was achieved for the SCHC in years 2012/13 to 2015/16 but only 52.5% for the years 2010/11 to 2011/12. Conclusion Indexing of the SCS and SCHC to CHI offers a new and rich resource of data for health and social care research.
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Many middle aged and older people will need to adapt or modify their home in order to age in place. Arming older people and their families with the knowledge and tools to assess their home and plan simple modifications ahead of time will decrease reliance on professional assessment. The objective of this project was to co-design a tool which enables people to assess their own home environment and make future plans for ageing in the home. We recruited members of the public who were aged 60 or older to attend a series of two co-design workshops. Thirteen participants worked through a series of discussions and activities including appraising different types of tools available and mapping what a digital health tool might look like. Participants had a good understanding of the main types of home hazards in their own homes and the types of modifications which may be useful. Participants believed the concept of the tool would be worthwhile and identified a number of features which were important including a checklist, examples of good design which was both accessible and aesthetically pleasing and links to other resources such as websites which provide advice about to make basic home improvements. Some also wanted to share the results of their assessment with family or friends. Participants highlighted that features of the neighbourhood, such as safety and proximity to shops and cafes, were also important when considering the suitability of their home for ageing in place. Findings will be used to develop a prototype for usability testing.
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Objective: To explore the policy and program implications of the Australian aged care reforms for low-income older renters. Method: Interviews and focus groups with low-income older renters and service providers of both housing and in-home aged care were undertaken. Result: Analysis of the findings emphasised the complex world of aged care service provision, particularly for low-income renters and their service providers. Conclusions: Societal, systemic and systematic change is required to ensure easier access to services. Policy and programming must be driven from both the bottom up and the top down, and not take a "market-making by government" approach.
Article
Objectives: To assess the impact of home care on length-of-stay within residential care. Design: A retrospective observational data-linkage study. Setting and participants: In total there were 3151 participants from the 45 and Up Study in New South Wales, Australia with dementia who entered residential care between 2010 and 2014. Methods: Survey data collected from 2006‒2009 were linked to administrative data for 2006‒2016. The highest level of home care a person accessed prior to residential care was defined as no home care, home support, low-level home care, and high-level home care. Multinomial logistic regression and Cox proportional hazards were used to investigate differences in activities of daily living, behavioral, and complex healthcare scales at entering residential care; and length-of-stay in residential care. Results: People with prior high-level home care entered residential care needing higher assistance compared with the no home care group: activities of daily living [odds ratio (OR) 3.41, 95% confidence interval (CI) 2.14‒5.44], behavior (OR 2.61, 95% CI 1.69‒4.03), and complex healthcare (OR 2.02, 95% CI 1.06‒3.84). They had a higher death rate, meaning shorter length-of-stay in residential care (<2 years after entry: hazard ratio 1.12; 95% CI 0.89‒1.42; 2-4 years: hazard ratio 1.49; 95% CI 1.01‒2.21). Those using low-level home care were less likely to enter residential care needing high assistance compared to the no home care group (activities of daily living: OR 0.61, 95% CI 0.45‒0.81; behavioral: OR 0.72, 95% CI 0.54‒0.95; complex healthcare: OR 0.51, 95% CI 0.33‒0.77). There was no difference between the home support and no home care groups. Conclusions: High-level home care prior to residential care may help those with dementia stay at home for longer, but the low-level care group entered residential care at low assistance levels, possibly signaling lack of informal care and barriers in accessing higher-level home care. Implications: Better transition options from low-level home care, including more timely availability of high-level care packages, may help people with dementia remain at home longer.
Article
Background This study had two aims: (a) to identify the different patterns of use of home- and community-based services (HCBS) among older adults in Taiwan, and (b) to examine the effects of the different use patterns on HCBS recipients’ use of institutional long-term care services. Methods The study analyzed cohort data from Taiwan’s first National 10-Year Long-Term Care Plan database and from National Health Insurance Claim Data. We extracted baseline information on older adults who were first evaluated for and prescribed HCBS from 2010 through 2013 (N = 71,260). We used latent class analysis to specify the underlying subgroups of recipients with similar patterns of HCBS use. We used hierarchical multinomial logistic regression to examine the effect of the different use patterns on the risk of institutional (e.g., nursing home) placement from 4 to 15 months after initial HCBS evaluation. Results Four subgroups of HCBS recipients were identified, with patterns of home-based personal care (PC), home-based personal care and medical care (PC/MC), home-based medical care (MC), and community care services. Compared to the home-based PC/MC group, people in the home-based MC group had lower risk (OR = 0.54) and people in the community care group had higher risk (OR = 1.76) of admission to a nursing home. Conclusions Study findings may provide insights for policy makers regarding the usefulness of integrating medical care and other types of long-term care services into adult day care.
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Most people prefer to age in place. However, there is a growing body of literature to suggest a reluctance to accept supportive services in the home due to concerns about trust, privacy, cost, and fear of being a burden. The purpose of this study was to examine potential facilitators and barriers to accepting home care services in the website content of Licensed Home Care Service Agencies (LHSCA). In this linguistic analysis study, the written content from 88 randomly selected LHCSA websites was examined. We used LIWC2015 and Microsoft ® Word software to analyze websites for relevant word categories that reflect older adult identified facilitators and barriers to the acceptance of home care services. Results revealed that the summary score for clout (i.e., confidence and leadership reflected in the writing) was high. Some of the most commonly used word categories were positive emotions, present focused, and affiliation. The word category money was included, but to a lesser degree. However, Burden and related words were highly prevalent in the writing sample. In summary, LHCSA website content contains both facilitators and barriers to the acceptance of home care services. Given the importance of home care services in promoting the ability of older adults to age in place, greater attention may be needed regarding the way services are presented and advertised to consumers.
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Objective This paper tests the hypothesis that increases in recorded dependency levels of permanent residential aged care clients are associated with reduced length of stay and higher turnover. A secondary objective is to compare the Aged Care Funding Instrument with its predecessor, the Resident Classification Scale, on a common schema.Methods Administrative data for all Commonwealth-subsidised residential aged care services in Australia from 2008-09 to 2018-19 were obtained from the National Aged Care Data Clearinghouse. More than 750000 episodes of permanent residential aged care were analysed. The categories from the two rating systems were mapped to a six-level schema, primarily based on the dollar value of the categories at the time of transition.ResultsThere was a strong trend towards higher dependency ratings across admissions, residents, and separations. However, contrary to expectation, measures of system activity showed a slowing of the system: length of stay increased and turnover decreased.Conclusions The mapping of dependency rating schemes to a common rating enables the analysis of long-term trends in residential care dynamics. There is no evidence that the marked increases in reported dependency ratings led to accelerated system activity, consistent with an earlier study. This analysis forms a solid base for ongoing analysis of care appraisals in the context of a possible new rating scheme. It highlights the interplay between policy changes and provider behaviour, and the need for robust data to monitor care appraisals and system dynamics.What is known about the topic?Residential aged care subsidies are determined by care needs in relation to assessed dependency levels, using the Aged Care Funding Instrument since 2008, and before that, the Resident Classification Scale. Between 2008-09 and 2018-19, there was considerable growth in residents classified at more dependent levels, and this would be expected to result in greater turnover in the system.What does this paper add?This paper maps the rating schemes to a simplified, common rating that enables the analysis of long-term trends in residential care dynamics. It shows that the system is slowing, contrary to the trends expected if residents were more frail as the reported ratings imply. The paper examines possible explanations of these trends, and addresses policy implications.What are the implications for practitioners?In the context of a potential new client-dependency classification, this study shows the importance of robust measures of the dynamics of the system-and the underlying data-vis-à-vis the means by which client dependency is assessed.
Article
Electronic information systems are becoming increasingly common in residential aged care in Australia. These systems contain valuable data generated during day‐to‐day care delivery for older adults. These data (termed ‘routinely collected residential aged care provider data’) are currently underutilised, however have potential significant benefits for both care delivery and research purposes. Routinely collected residential aged care provider data are more readily accessible, contain up‐to‐date information and can be linked to existing national or state‐based administrative data sets, while providing more granular details about care delivered at the coalface. The aim of this paper is to provide clinicians, researchers, policymakers and providers with an understanding of the strengths of these types of data, as well as identifying areas that require future development to maximise their potential to drive improvements in resident care and outcomes. These considerations include data quality, data standardisation and models for data governance, consent and consumer involvement.
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Purpose Aging in place has been a crucial goal of long-term care policies, yet little is known about regional differences in older adults’ perceptions of aging in place. This study examined the factors associated with the intention to age in place while receiving home care services among older adults in urban and rural areas in South Korea. Methods Data were obtained from the 2020 National Survey of Older Koreans conducted in South Korea. The study population comprised 10,097 adults aged ≥ 65 years. Multivariate logistic regression analysis was performed separately for residential areas. Results Among urban residents, being married, having higher satisfaction with the distance to healthcare facilities, and owning a house were associated with higher odds of the intention to age in place, whereas higher educational level, higher income, having interaction with friends and neighbors, and having perceived control over death preparation issues were associated with lower odds of the outcome. Among rural residents, only homeownership was associated with higher odds of aging in place, while female gender, higher income, not wanting to burden family and friends, and knowledge of formal care services were associated with lower odds of the outcome. Conclusions By applying the expanded Andersen model, the study showed that enabling and psychosocial factors significantly affect older adults’ intention to age in place. The results also revealed urban and rural differences in the factors associated with the intention to age in place. The study suggests that home-and community-based services, considering urban-rural differences, are needed to support successful aging in place.
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Introduction: There is limited evidence of the benefits of information and communication technology (ICT) to support integrated aged care services. Objectives: We undertook a case study to describe carelink+, a centralised client service management ICT system implemented by a large aged and community care service provider, Uniting. We sought to explicate the care-related information exchange processes associated with carelink+ and identify lessons for organisations attempting to use ICT to support service integration. Methods: Our case study included seventeen interviews and eleven observation sessions with a purposive sample of staff within the organisation. Inductive analysis was used to develop a model of ICT-supported information exchange. Results: Management staff described the integrated care model designed to underpin carelink+. Frontline staff described complex information exchange processes supporting coordination of client services. Mismatches between the data quality and the functions carelink+ was designed to support necessitated the evolution of new work processes associated with the system. Conclusions: There is value in explicitly modelling the work processes that emerge as a consequence of ICT. Continuous evaluation of the match between ICT and work processes will help aged care organisations to achieve higher levels of ICT maturity that support their efforts to provide integrated care to clients.
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Background: Information management systems and processes have an impact on quality and safety of care in any setting and particularly in the complex care setting of aged care. Few studies have comprehensively examined information management in the Australian aged care setting. Objective: To (i) critically analyse and synthesize evidence related to information management in aged care, (ii) identify aged care data collection frameworks and (iii) identify factors impacting information management. Methods: An integrative review of Australian literature published between March 2008 and August 2014 and data collection frameworks concerning information management in aged care were carried out. Results: There is limited research investigating the information-rich setting of aged care in Australia. Electronic systems featured strongly in the review. Existing research focuses on residential settings with community aged care largely absent. Information systems and processes in the setting of aged care in Australia are underdeveloped and poorly integrated. Conclusions: Data quality and access are more problematic within community aged care than residential care settings. The results of this review represent an argument for a national approach to information management in aged care to address multiple stakeholder information needs and more effectively support client care.
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Competing risks occur frequently in the analysis of survival data. A competing risk is an event whose occurrence precludes the occurrence of the primary event of interest. In a study examining time to death attributable to cardiovascular causes, death attributable to noncardiovascular causes is a competing risk. When estimating the crude incidence of outcomes, analysts should use the cumulative incidence function, rather than the complement of the Kaplan-Meier survival function. The use of the Kaplan-Meier survival function results in estimates of incidence that are biased upward, regardless of whether the competing events are independent of one another. When fitting regression models in the presence of competing risks, researchers can choose from 2 different families of models: modeling the effect of covariates on the cause-specific hazard of the outcome or modeling the effect of covariates on the cumulative incidence function. The former allows one to estimate the effect of the covariates on the rate of occurrence of the outcome in those subjects who are currently event free. The latter allows one to estimate the effect of covariates on the absolute risk of the outcome over time. The former family of models may be better suited for addressing etiologic questions, whereas the latter model may be better suited for estimating a patient's clinical prognosis. We illustrate the application of these methods by examining cause-specific mortality in patients hospitalized with heart failure. Statistical software code in both R and SAS is provided.
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Background Dementia is the most common cause of functional decline among elderly people and is associated with high costs of national healthcare in European countries. With increasing functional and cognitive decline, it is likely that many people suffering from dementia will receive institutional care in their lifetime. To delay entry to institutional care, many European countries invest in home and community based care services. Objectives This study aimed to compare costs for people with dementia (PwD) at risk for institutionalization receiving professional home care (HC) with cost for PwD recently admitted to institutional long-term nursing care (ILTC) in eight European countries. Special emphasis was placed on differences in cost patterns across settings and countries, on the main predictors of costs and on a comprehensive assessment of costs from a societal perspective. Methods Interviews using structured questionnaires were conducted with 2,014 people with dementia and their primary informal caregivers living at home or in an ILTC facility. Costs of care were assessed with the resource utilization in dementia instrument. Dementia severity was measured with the standardized mini mental state examination. ADL dependence was assessed using the Katz index, neuropsychiatric symptoms using the neuropsychiatric inventory (NPI) and comorbidities using the Charlson. Descriptive analysis and multivariate regression models were used to estimate mean costs in both settings. A log link generalized linear model assuming gamma distributed costs was applied to identify the most important cost drivers of dementia care. Results In all countries costs for PwD in the HC setting were significantly lower in comparison to ILTC costs. On average ILTC costs amounted to 4,491 Euro per month and were 1.8 fold higher than HC costs (2,491 Euro). The relation of costs between settings ranged from 2.4 (Sweden) to 1.4 (UK). Costs in the ILTC setting were dominated by nursing home costs (on average 94 %). In the HC setting, informal care giving was the most important cost contributor (on average 52 %). In all countries costs in the HC setting increased strongly with disease severity. The most important predictor of cost was ADL independence in all countries, except Spain and France where NPI severity was the most important cost driver. A standard deviation increase in ADL independence translated on average into a cost decrease of about 22 %. Conclusion Transition into ILTC seems to increase total costs of dementia care from a societal perspective. The prevention of long-term care placement might be cost reducing for European health systems. However, this conclusion depends on the country, on the valuation method for informal caregiving and on the degree of impairment.
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The purpose of this study was to determine whether the volume of Home- and Community-Based Services (HCBS) that target Activities of Daily Living disabilities, such as attendant care, homemaking services, and home-delivered meals, increases recipients' risk of transitioning from long-term care provided through HCBS to long-term care provided in a nursing home. Data are from the Indiana Medicaid enrollment, claims, and Insite databases. Insite is the software system that was developed for collecting and reporting data for In-Home Service Programs. Enrollees in Indiana Medicaid's Aged and Disabled Waiver program were followed forward from time of enrollment to assess the association between the volume of attendant care, homemaking services, home-delivered meals, and related covariates, and the risk for nursing-home placement. An extension of the Cox proportional hazard model was computed to determine the cumulative hazard of nursing-home placement in the presence of death as a competing risk. Of the 1354 Medicaid HCBS recipients followed in this study, 17% did not receive any attendant care, homemaking services, or home-delivered meals. Among recipients who survived through 24 months after enrollment, one in five transitioned from HCBS to a nursing-home. Risk for nursing-home placement was significantly lower for each five-hour increment in personal care (HR=0.95, 95% CI=0.92-0.98) and homemaking services (HR=0.87, 95% CI=0.77-0.99). Future policies and practices that are focused on optimizing long-term care outcomes should consider that a greater volume of HCBS for an individual is associated with reduced risk of nursing-home placement.
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Several residential aged-care facilities have replaced the institutional model of care to one that accepts person-centered care as the guiding standard of practice. This culture change is impacting the provision of aged-care services around the world. This systematic review evaluates the evidence for an impact of person-centered interventions on aged-care residents and nursing staff. We searched Medline, Cinahl, Academic Search Premier, Scopus, Proquest, and Expanded Academic ASAP databases for studies published between January 1995 and October 2012, using subject headings and free-text search terms (in UK and US English spelling) including person-centered care, patient-centered care, resident-oriented care, Eden Alternative, Green House model, Wellspring model, long-term care, and nursing homes. The search identified 323 potentially relevant articles. Once duplicates were removed, 146 were screened for inclusion in this review; 21 were assessed for methodological quality, resulting in nine articles (seven studies) that met our inclusion criteria. There was only one randomized, controlled trial. The majority of studies were quasi-experimental pre-post test designs, with a control group (n = 4). The studies in this review incorporated a range of different outcome measures (ie, dependent variables) to evaluate the impact of person-centered interventions on aged-care residents and staff. One person-centered intervention, ie, the Eden Alternative, was associated with significant improvements in residents' levels of boredom and helplessness. In contrast, facility-specific person-centered interventions were found to impact nurses' sense of job satisfaction and their capacity to meet the individual needs of residents in a positive way. Two studies found that person-centered care was actually associated with an increased risk of falls. The findings from this review need to be interpreted cautiously due to limitations in study designs and the potential for confounding bias. Typically, person-centered interventions are multifactorial, comprising: elements of environmental enhancement; opportunities for social stimulation and interaction; leadership and management changes; staffing models focused on staff empowerment; and assigning residents to the same care staff and an individualized philosophy of care. The complexity of the interventions and range of outcomes examined makes it difficult to form accurate conclusions about the impact of person-centered care interventions adopted and implemented in aged-care facilities. The few negative consequences of the introduction of person-centered care models suggest that the introduction of person-centered care is not always incorporated within a wider "hierarchy of needs" structure, where safety and physiological need are met before moving onto higher level needs. Further research is necessary to establish the effectiveness of these elements of person-centered care, either singly or in combination.
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As Home-and Community-Based Services (HCBS), such as skilled nursing services or personal care services, have become increasingly available, it has become clear that older adults transit through different residential statuses over time. Older adults may transit through different residential statuses as the various services meet their needs. The purpose of this exploratory study was to better understand the interplay between community-dwelling older adults' use of home- and community-based services and their residential transitions. The study compared HCBS service-use patterns and residential transitions of 3,085 older adults from the Second Longitudinal Study of Aging. Based on older adults' residential status at the three follow-up interviews, four residential transitions were tracked: (1) Community-Community-Community (CCC: Resided in community during the entire study period); (2) Community-Institution-Community (CIC: Resided in community at T1, had lived in an institution at some time between T1 and T2, then had returned to community by T3); (3) Community-Community-Institution (CCI: Resided in community between at T1, and betweenT1 and T2, including at T2, but had used institutional services between T2 and T3); (4) Community-Institution-Institution (CII: Resided in community at T1 but in an institution at some time between T1 and T2, and at some time between T2 and T3.). Older adults' use of nondiscretionary and discretionary services differed significantly among the four groups, and the patterns of HCBS use among these groups were also different. Older adults' use of nondiscretionary services, such as skilled nursing care, may help them to return to communities from institutions. Personal care services (PCS) and senior center services may be the key to either support elders to stay in communities longer or help elders to return to their communities from institutions. Different combinations of PCS with other services, such as senior center services or meal services, were associated with different directions in residential transition, such as CIC and CII respectively. Older adults' differing HCBS use patterns may be the key to explaining older adults' transitions. Attention to older adults' HCBS use patterns is recommended for future practice. However, this was an exploratory study and the analyses cannot establish causal relationships.
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This population-based retrospective cohort study aimed to clarify the impact of home and community-based services on the hospitalisation and institutionalisation of individuals certified as eligible for long-term care insurance (LTCI) benefits. Health insurance data and LTCI data were combined into a database of 1,020 individuals in two farming communities in Hokkaido who were enrolled in Citizen's Health Insurance. They had not received long-term care services prior to April 1, 2000 and were newly certified as eligible for Long-Term Care Insurance benefits between April 1, 2000 and February 29, 2008. The analysis covered 565 subjects who had not been hospitalised or institutionalised at the time of first certification of LTCI benefits. The adjusted hazard ratios (HRs) of hospitalisation or institutionalisation or death after the initial certification were calculated using the Cox proportional hazard model. The predictors were age, sex, eligibility level, area of residence, income, year of initial certification and average monthly outpatient medical expenditures, in addition to average monthly total home and community-based services expenditures (analysis 1), the use or no use of each type of service (analysis 2), and average monthly expenditures for home-visit and day-care types of services, the use or no use of respite care, and the use or no use of rental services for assistive devices (analysis 3). Users of home and community-based services were less likely than non-users to be hospitalised or institutionalised. Among the types of services, users of respite care (HR: 0.71, 95% confidence interval [CI]: 0.55-0.93) and rental services for assistive devices (HR: 0.70, 95% CI: 0.54-0.92) were less likely to be hospitalised or institutionalised than non-users. For those with relatively light needs, users of day care were also less likely to be hospitalised or institutionalized than non-users (HR: 0.77, 95% CI: 0.61-0.98). Respite care, rental services for assistive devices and day care are effective in preventing hospitalisation and institutionalisation. Our results suggest that home and community-based services contribute to the goal of the LTCI system of encouraging individuals certified as needing long-term care to live independently at home for as long as possible.
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The phrase "patient-centered care" is in vogue, but its meaning is poorly understood. This article describes patient-centered care, why it matters, and how policy makers can advance it in practice. Ultimately, patient-centered care is determined by the quality of interactions between patients and clinicians. The evidence shows that patient-centered care improves disease outcomes and quality of life, and that it is critical to addressing racial, ethnic, and socioeconomic disparities in health care and health outcomes. Policy makers need to look beyond such areas as health information technology to shape a coordinated and focused national policy in support of patient-centered care. This policy should help health professionals acquire and maintain skills related to patient-centered care, and it should encourage organizations to cultivate a culture of patient-centeredness.
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strategies to enable older people to remain in their own homes require information on potential intervention areas and target groups for health promotion and healthcare services. this study aimed to identify socioeconomic, health and lifestyle factors in entry to residential aged care facilities. a prospective cohort study was conducted from 1994 to 2005. the information source was the Melbourne Longitudinal Studies on Healthy Ageing Program. one thousand Australians aged 65 years and over living in the community were used as baseline sample. socio-medical data were gathered in face-to-face baseline interviews, and outcomes were identified in biennial follow-ups with respondents, informants and death registries over 12 years. Cox regression models identified baseline predictors of subsequent entry to residential aged care for men and women from among socio-demographic, health status and lifestyle factors. the most significant factors were older age, Instrumental Activities of Daily Living (IADL) dependence, cognitive impairment, underweight body mass index (BMI) and low social activity. For men only, the number of medical conditions and healthy nutrition score also emerged as significant. For women only, never having been married, IADL dependence and low BMI also were significant. For men, the risk of entry to residential aged care facilities was associated mainly with disease burden, whereas for women, social vulnerability and functional capacities were more important. Healthy lifestyles were important indirectly insofar as they influenced subjects' health status. to facilitate older people to stay in the community, it is important to treat or ameliorate medical conditions, promote healthy lifestyles and consider gender-specific risks.
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In Australia, many community service program data collections developed over the last decade, including several for aged care programs, contain a statistical linkage key (SLK) to enable derivation of client-level data. In addition, a common SLK is now used in many collections to facilitate the statistical examination of cross-program use. In 2005, the Pathways in Aged Care (PIAC) cohort study was funded to create a linked aged care database using the common SLK to enable analysis of pathways through aged care services. Linkage using an SLK is commonly deterministic. The purpose of this paper is to describe an extended deterministic record linkage strategy for situations where there is a general person identifier (e.g. an SLK) and several additional variables suitable for data linkage. This approach can allow for variation in client information recorded on different databases. A stepwise deterministic record linkage algorithm was developed to link datasets using an SLK and several other variables. Three measures of likely match accuracy were used: the discriminating power of match key values, an estimated false match rate, and an estimated step-specific trade-off between true and false matches. The method was validated through examining link properties and clerical review of three samples of links. The deterministic algorithm resulted in up to an 11% increase in links compared with simple deterministic matching using an SLK. The links identified are of high quality: validation samples showed that less than 0.5% of links were false positives, and very few matches were made using non-unique match information (0.01%). There was a high degree of consistency in the characteristics of linked events. The linkage strategy described in this paper has allowed the linking of multiple large aged care service datasets using a statistical linkage key while allowing for variation in its reporting. More widely, our deterministic algorithm, based on statistical properties of match keys, is a useful addition to the linker's toolkit. In particular, it may prove attractive when insufficient data are available for clerical review or follow-up, and the researcher has fewer options in relation to probabilistic linkage.
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This paper examines transitions in living arrangement decisions of the seniors using the first six cycles of the Canadian longitudinal National Population Health Survey microdata. Transitions from independent to intergenerational and institutional living arrangements are uniquely analyzed using a discrete-time hazard rate multinomial logit modelling framework and accounted for unobserved individual heterogeneity in the data. Our results show: a) provision of publicly-provided homecare reduces the likelihood of institutionalization, but it has no effect on intergenerational living arrangements; b) access to social support services reduces the probability of both institutional and intergenerational living arrangements; c) higher levels of functional health status, measured by Health Utility Index, reduce the probability of transitions from independent to intergenerational and institutional living arrangements; d) a decline in self-reported health status increases the probability of institutionalization, but its effect on intergenerational living arrangements is statistically insignificant; e) higher levels of household income tend to decrease the probability of institutionalization; and f) the likelihood of transitioning to both intergenerational and institutional living arrangements increases with the duration of survival. Our findings suggest that access to and availability of publicly-provided homecare, social support services and other programs designed to foster better functional health status would contribute positively towards independent or intergenerational living arrangements and reduce the probability of institutionalization.
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While existing reviews have identified significant predictors of nursing home admission, this meta-analysis attempted to provide more integrated empirical findings to identify predictors. The present study aimed to generate pooled empirical associations for sociodemographic, functional, cognitive, service use, and informal support indicators that predict nursing home admission among older adults in the U.S. Studies published in English were retrieved by searching the MEDLINE, PSYCINFO, CINAHL, and Digital Dissertations databases using the keywords: "nursing home placement," "nursing home entry," "nursing home admission," and "predictors/institutionalization." Any reports including these key words were retrieved. Bibliographies of retrieved articles were also searched. Selected studies included sampling frames that were nationally- or regionally-representative of the U.S. older population. Of 736 relevant reports identified, 77 reports across 12 data sources were included that used longitudinal designs and community-based samples. Information on number of nursing home admissions, length of follow-up, sample characteristics, analysis type, statistical adjustment, and potential risk factors were extracted with standardized protocols. Random effects models were used to separately pool the logistic and Cox regression model results from the individual data sources. Among the strongest predictors of nursing home admission were 3 or more activities of daily living dependencies (summary odds ratio [OR] = 3.25; 95% confidence interval [CI], 2.56-4.09), cognitive impairment (OR = 2.54; CI, 1.44-4.51), and prior nursing home use (OR = 3.47; CI, 1.89-6.37). The pooled associations provided detailed empirical information as to which variables emerged as the strongest predictors of NH admission (e.g., 3 or more ADL dependencies, cognitive impairment, prior NH use). These results could be utilized as weights in the construction and validation of prognostic tools to estimate risk for NH entry over a multi-year period.
Article
The study aimed to identify the shared issues and challenges being experienced by staff, their clients and informal carers, with the introduction of Consumer Directed Care (CDC). Secondary analysis was undertaken of data that had been initially collected, via semi‐structured in‐depth interviews, to inform the development of a discrete choice experiment. The raw staff and client/carer data were re‐examined using an iterative inductive process. The analysis focused on locating the shared themes and differences between the participant groups based on their CDC experience. The data were also assessed for difficulties or barriers that impacted on the service. Four broad shared themes were derived: culture, role change, operational systems and resourcing, but with a range of diverse and sometimes conflicting sub‐themes between the different participant groups. Differences can be linked to participant role in the service chain, with discordance emerging between what has been traditionally offered and what might be possible. This investigation occurred during the period in which services were transitioning from a traditional aged care service model to a new model of service provision requiring considerable industry change. We conclude that existing industry regulation, culture and practice supports an established service model in Australia that arguably makes translation of the objectives of CDC difficult.
Article
The study aimed to identify the shared issues and challenges being experienced by staff, their clients and informal carers, with the introduction of Consumer Directed Care (CDC). Secondary analysis was undertaken of data that had been initially collected, via semi-structured in-depth interviews, to inform the development of a discrete choice experiment. The raw staff and client/carer data were re-examined using an iterative inductive process. The analysis focused on locating the shared themes and differences between the participant groups based on their CDC experience. The data were also assessed for difficulties or barriers that impacted on the service. Four broad shared themes were derived: culture, role change, operational systems and resourcing, but with a range of diverse and sometimes conflicting sub-themes between the different participant groups. Differences can be linked to participant role in the service chain, with discordance emerging between what has been traditionally offered and what might be possible. This investigation occurred during the period in which services were transitioning from a traditional aged care service model to a new model of service provision requiring considerable industry change. We conclude that existing industry regulation, culture and practice supports an established service model in Australia that arguably makes translation of the objectives of CDC difficult.
Article
With explanatory covariates, the standard analysis for competing risks data involves modeling the cause-specific hazard functions via a proportional hazards assumption. Unfortunately, the cause-specific hazard function does not have a direct interpretation in terms of survival probabilities for the particular failure type. In recent years many clinicians have begun using the cumulative incidence function, the marginal failure probabilities for a particular cause, which is intuitively appealing and more easily explained to the nonstatistician. The cumulative incidence is especially relevant in cost-effectiveness analyses in which the survival probabilities are needed to determine treatment utility. Previously, authors have considered methods for combining estimates of the cause-specific hazard functions under the proportional hazards formulation. However, these methods do not allow the analyst to directly assess the effect of a covariate on the marginal probability function. In this article we propose a novel semiparametric proportional hazards model for the subdistribution. Using the partial likelihood principle and weighting techniques, we derive estimation and inference procedures for the finite-dimensional regression parameter under a variety of censoring scenarios. We give a uniformly consistent estimator for the predicted cumulative incidence for an individual with certain covariates; confidence intervals and bands can be obtained analytically or with an easy-to-implement simulation technique. To contrast the two approaches, we analyze a dataset from a breast cancer clinical trial under both models.
Article
Background: Several states offer publicly funded-care management programs to prevent long-term care placement of high-risk Medicaid beneficiaries. Understanding participant risk factors and services that may prevent long-term care placement can facilitate efficient allocation of program resources. Objectives: To develop a practical prediction model to identify participants in a home- and community-based services program who are at highest risk for long-term nursing home placement, and to examine participant-level and program-level predictors of nursing home placement. Study design: In a retrospective observational study, we used deidentified data for participants in the Connecticut Home Care Program for Elders who completed an annual assessment survey between 2005 and 2010. Methods: We analyzed data on patient characteristics, use of program services, and short-term facility admissions in the previous year. We used logistic regression models with random effects to predict nursing home placement. The main outcome measures were long-term nursing home placement within 180 days or 1 year of assessment. Results: Among 10,975 study participants, 1249 (11.4%) had nursing home placement within 1 year of annual assessment. Risk factors included Alzheimer's disease (odds ratio [OR], 1.30; 95% CI, 1.18-1.43), money management dependency (OR, 1.33; 95% CI, 1.18-1.51), living alone (OR, 1.53; 95% CI, 1.31-1.80), and number of prior short-term skilled nursing facility stays (OR, 1.46; 95% CI, 1.31-1.62). Use of a personal care assistance service was associated with 46% lower odds of nursing home placement. The model C statistic was 0.76 in the validation cohort. Conclusions: A model using information from a home- and community-based service program had strong discrimination to predict risk of long-term nursing home placement and can be used to identify high-risk participants for targeted interventions.
Article
The first part of the paper argues that the care relationship is crucial to securing care quality, which has implications for the way in which quality is achieved and measured. However, for more than twenty years, governments have emphasised the part that increasing market competition and, more recently, user choice of services can play in driving up the quality of care. The second part of the paper analyses the development of social care services for older people, from the reform of 1990 to the changes following the general election of 2010. The paper goes on to examine whether competition and choice are in any case enough to result in ‘good care’, given the evidence of limitations both in the amount of choice available and in how far older people are able or willing to choose. It is argued that if ‘good care’ depends disproportionately on the quality of the care relationship, then more attention should be paid to the care workforce, which has received relatively little comment in recent government documents.
Article
This article critically examines recent changes in markets for home (domiciliary) care services in England. During the 1990s, the introduction of competition between private (for-profit and charitable) organizations and local authority providers of long-term care services aimed to create a ‘mixed economy’ of supply. More recently, care markets have undergone further reforms through the introduction of direct payments and personal budgets. Underpinned by discourses of user choice, these mechanisms aim to offer older people increased control over the public resources for their care, thereby introducing further competitive pressures within local care markets.The article presents early evidence of these changes on:The commissioning and contracting of home care services by local authorities and individual older people.The experiences and outcomes for individual older people using home care services.Drawing on evidence from two recent empirical studies, the article describes how the new emphasis on choice and competition is being operationalized within six local care markets. There are suggestions of small increases in user agency and in opportunities for older people to receive more personalized home care, in which the quality of care-giving relationships can also be optimized. However, the article also presents early evidence of increases in risk and costs associated with the expansion of competition and choice, both for organizations providing home care services and for individual older service users.
Article
In the second article in their series, Patrick Royston and colleagues describe different approaches to building clinical prognostic models
Article
An analysis of the impacts of channeling on the use of hospital, nursing home, and other medical services is described. Comprehensive data on hospital and nursing home use were obtained from Medicare and Medicaid claims and provider records; other medical service use was limited to that which is reimbursed by Medicare or Medicaid. The analysis showed that the population served was not at high risk of institutionalization, and that the reductions in nursing home use among the treatment group were neither large nor, generally, statistically significant. An exception was for the small group of persons who were in a nursing home at enrollment, for whom large reductions in nursing home use were found. The population showed a very high use of hospitals and other medical services, but the channeling program had no impact on the use of these services.
Article
Two long-term care settings not now covered by Medicare--adult day care and homemaker services--were studied in a randomized experiment to test the effects on patient outcomes and costs of using these new services. This article reports findings for day care. Patients' physical, psychosocial and health functions were assessed quarterly, and their Medicare bill files were obtained. Medicaid data were obtained on most patients, but few used many Medicaid-covered long-term care services. Multistage analysis was performed to mitigate effects of departures from the randomized design. Day-care patients showed no benefits in physical functioning ability at the end of the study, compared with the control group. Institutionalization in skilled nursing facilities was lower for the experimental group than the control group, but the factors other than the treatment variable appeared to explain most of the variance. There was a possibility that life was extended for some day-care patients. the new services averaged $52 per day or $3,235 per year. When costs for existing Medicare services used were added, the yearly cost of the experimental group was $6,501, compared with $3,809 for the control group--an increase of $2,692 or 71 per cent.
Article
The Behavioral Model of Health Services Use was initially developed over 25 years ago. In the interim it has been subject to considerable application, reprobation, and alteration. I review its development and assess its continued relevance.
Article
States vary greatly in their support for home- and community-based services (HCBS) that are intended to help disabled seniors live in the community. This article examines how states' generosity in providing HCBS affects the risk of nursing home admission among older Americans and how family availability moderates such effects. We conducted discrete time survival analysis of first long-term (90 or more days) nursing home admissions that occurred between 1995 and 2002, using Health and Retirement Study panel data from respondents born in 1923 or earlier. State HCBS effects were conditional on child availability among older Americans. Living in a state with higher HCBS expenditures was associated with lower risk of nursing home admission among childless seniors (p <.001). However, the association was not statistically significant among seniors with living children. Doubling state HCBS expenditures per person aged 65 or older would reduce the risk of nursing home admission among childless seniors by 35%. Results provided modest but important evidence supportive of increasing state investment in HCBS. Within-state allocation of HCBS resources, however, requires further research and careful consideration about fairness for individual seniors and their families as well as cost effectiveness.
Australia to 2050: Future challenges Commonwealth of Australia, Capital Hill, ACT. Available at: http://archive.treasury.gov
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Volume of home-and community-based services and time to nursing-home placement
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Sands LP, Xu H, Thomas J III, et al. Volume of home-and community-based services and time to nursing-home placement. Medicare Medicaid Res Rev 2011:2:E1eE21.
Issues facing aged care services in rural and remote Australia
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Baldwin R, Stephens M, Sharp D, Kelly J. Issues facing aged care services in rural and remote Australia. Aged and Community Services Australia. Available at: https://www.parliament.nsw.gov.au/committees/DBAssets/InquiryOther/Tran script/9768/Issues%20facing%20aged%20care%20services%20in%20rural%20an d%20remote%20Australia.pdf; 2013. Accessed September 8, 2017.
Carelinkþ Community Care Software and Solutions Available at: http://www.carelinkplus.com
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A note on quantifying follow-up in studies of failure time
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The Australian Community Care Needs Assessment (ACCNA): Towards a national standard
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Samsa P, Ramsay L, Owen A, et al. The Australian Community Care Needs Assessment (ACCNA): Towards a national standard. Wollongong: Centre for Health Service Development, University of Wollongong. Available at: https:// ahsri.uow.edu.au/content/groups/public/@web/@chsd/documents/doc/uow 082086.pdf; 2007. Accessed September 8, 2017.
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A proportional hazards model for the subdistribution of a competing risk
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