A model for integrated home care of frail older patients: the Silver Network project. SILVERNET-HC Study Group

Care models for individuals with chronic multimorbidity: lessons for low- and middle-income countries

BACKGROUND

Patients with multiple long-term conditions requires understanding the existing care models to address their complex and multifaceted health needs. However, current literature lacks a comprehensive overview of the essential components, impacts, challenges, and facilitators of these care models, prompting this scoping review.

METHODS

A scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Extension for Scoping Reviews guideline. Our search encompassed articles from PubMed, Web of Science, EMBASE, SCOPUS, and Google Scholar. The World Health Organization's health system framework was utilized to synthesis the findings. This framework comprises six building blocks (service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance) and eight key characteristics of good service delivery models (access, coverage, quality, safety, improved health, responsiveness, social and financial risk protection, and improved efficiency). Findings were synthesized qualitatively to identify components, impacts, barriers, and facilitators of care models.

RESULTS

A care model represents various collective interventions in the healthcare delivery aimed at achieving desired outcomes. The names of these care models are derived from core activities or major responsibilities, involved healthcare teams, diseases conditions, eligible clients, purposes, and care settings. Notable care models include the Integrated, Collaborative, Integrated-Collaborative, Guided, Nurse-led, Geriatric, and Chronic care models, as well as All-inclusive Care Model for the Elderly, IMPACT clinic, and Geriatric Patient-Aligned Care Teams (GeriPACT). Other care models (include Care Management Plus, Value Stream Mapping, Preventive Home Visits, Transition Care, Self-Management, and Care Coordination) have supplemented the main ones. Care models improved quality of care (such as access, patient-centeredness, timeliness, safety, efficiency), cost of care, and quality of life for patients that were facilitated by presence of shared mission, system and function integration, availability of resources, and supportive tools.

CONCLUSIONS

Care models were implemented for the purpose of enhancing quality of care, health outcomes, cost efficiency, and patient satisfaction by considering careful recruitment of eligible clients, appropriate selection of service delivery settings, and robust organizational arrangements involving leadership roles, healthcare teams, financial support, and health information systems. The distinct team compositions and their roles in service provision processes differentiate care models.

<p>An Evidence-Informed and Key Informants-Appraised Conceptual Framework for an Integrated Elderly Health Care Governance in Iran (IEHCG-IR)</p>

Purpose

Population ageing has been steadily rising in Iran and in the over 60-year-old population, the ratio increased from 5.4% in 1986 to 8.6% in 2016 which represents an increase of 4.3 million over the past three decades. The inevitable impacts of a growing elderly population on the demand-side of the health care provision (HCP) equilibrium call for an urgent revision of the current arrangements of the Iran’s National health care system (INHS). The main aim of this study was to scrutinize the best available scientific evidence on the international integrated elderly health care governance (HCG) models to revamp health care practice and policy-making processes in Iran.

Materials and Methods

This multiphasic study consists of a scoping review of existent HCP modalities for the elderly population worldwide, and the disposition of an optimal HCP scheme for the elderly population and its application for the detection of the gaps in Iran. The final stage includes a Delphi-based consultation and consensus process which was reciprocated in three rounds and the key subjects were requested to give their judgment on the eventuated HCP layout designed to serve the ageing Iranian population.

Results

The yielded model (IEHCG-IR) included four dimensions consistent with the four levels of prevention along with social support services. The structure and feasibility of the preliminary framework were approved by 83.6% of the study participants.

Conclusion

The study findings could have important implications for future policy making in the INHS and the suggested healthcare framework for the elderly Iranian population could be a preliminary model for health system re-engineering.

Assessment of nursing home residents in Europe: the Services and Health for Elderly in Long TERm care (SHELTER) study

BACKGROUND

Aims of the present study are the following: 1. to describe the rationale and methodology of the Services and Health for Elderly in Long TERm care (SHELTER) study, a project funded by the European Union, aimed at implementing the interRAI instrument for Long Term Care Facilities (interRAI LTCF) as a tool to assess and gather uniform information about nursing home (NH) residents across different health systems in European countries; 2. to present the results about the test-retest and inter-rater reliability of the interRAI LTCF instrument translated into the languages of participating countries; 3 to illustrate the characteristics of NH residents at study entry.

METHODS

A 12 months prospective cohort study was conducted in 57 NH in 7 EU countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands) and 1 non EU country (Israel). Weighted kappa coefficients were used to evaluate the reliability of interRAI LTCF items.

RESULTS

Mean age of 4156 residents entering the study was 83.4 ± 9.4 years, 73% were female. ADL disability and cognitive impairment was observed in 81.3% and 68.0% of residents, respectively. Clinical complexity of residents was confirmed by a high prevalence of behavioral symptoms (27.5% of residents), falls (18.6%), pressure ulcers (10.4%), pain (36.0%) and urinary incontinence (73.5%). Overall, 197 of the 198 the items tested met or exceeded standard cut-offs for acceptable test-retest and inter-rater reliability after translation into the target languages.

CONCLUSION

The interRAI LTCF appears to be a reliable instrument. It enables the creation of databases that can be used to govern the provision of long-term care across different health systems in Europe, to answer relevant research and policy questions and to compare characteristics of NH residents across countries, languages and cultures.

Effects of anorexia on mortality among older adults receiving home care: an observation study

PURPOSE

We describe the prevalence of secondary anorexia in a population of older people living in community and receiving home care. In addition, we examined the relationship between secondary anorexia and mortality.

METHODS

We analyzed data from a large collaborative observational study group, the Italian Silver Network Home Care project, that collected data on patients admitted to home care programs. A total of twelve Home Health Agencies participated in such project evaluating the implementation of the Minimum Data Set for Home Care (MDS-HC) instrument. A total of 2757 patients were enrolled in the present study. The main outcome measures were the prevalence of anorexia, weight loss and survival.

RESULTS

More than 25% (744 subjects) of the study sample suffered from anorexia. During a mean follow-up of 10 months from initial MDS-HC assessment, 468 patients (17%) died. There was uneven distribution of the risk. After adjusting for age, gender and for all other possible risk factors for death (living alone, physical and cognitive disability, behavior problems, urinary incontinence, pressure ulcer, hearing impairment, congestive heart failure, hypertension, depression, diabetes, renal failure, cancer), subjects with anorexia were more likely to die relative to patients without anorexia (RR, 1.83; 95% CI 1.45-2.31). Even though the risk of mortality was higher among subjects suffering from anorexia and weight loss, the anorexia per se was associated with higher risk compared with subjects without anorexia (RR, 1.45; 95% CI 1.01-2.19).

CONCLUSIONS

Anorexia is associated with a significant higher risk of all-cause mortality. The present findings support the possibility that anorexia has an independent effect on survival even among old people receiving home care.

Home care in Europe: a systematic literature review

BACKGROUND

Health and social services provided at home are becoming increasingly important. Hence, there is a need for information on home care in Europe. The objective of this literature review was to respond to this need by systematically describing what has been reported on home care in Europe in the scientific literature over the past decade.

METHODS

A systematic literature search was performed for papers on home care published in English, using the following data bases: Cinahl, the Cochrane Library, Embase, Medline, PsycINFO, Sociological Abstracts, Social Services Abstracts, and Social Care Online. Studies were only included if they complied with the definition of home care, were published between January 1998 and October 2009, and dealt with at least one of the 31 specified countries. Clinical interventions, instrument developments, local projects and reviews were excluded. The data extracted included: the characteristics of the study and aspects of home care 'policy & regulation', 'financing', 'organisation & service delivery', and 'clients & informal carers'.

RESULTS

Seventy-four out of 5,133 potentially relevant studies met the inclusion criteria, providing information on 18 countries. Many focused on the characteristics of home care recipients and on the organisation of home care. Geographical inequalities, market forces, quality and integration of services were also among the issues frequently discussed.

CONCLUSIONS

Home care systems appeared to differ both between and within countries. The papers included, however, provided only a limited picture of home care. Many studies only focused on one aspect of the home care system and international comparative studies were rare. Furthermore, little information emerged on home care financing and on home care in general in Eastern Europe. This review clearly shows the need for more scientific publications on home care, especially studies comparing countries. A comprehensive and more complete insight into the state of home care in Europe requires the gathering of information using a uniform framework and methodology.

A novel model of integrated care for the elderly: COPA, Coordination of Professional Care for the Elderly

Despite strong evidence for the efficacy of integrated systems, securing the participation of health professionals, particularly primary care physicians (PCPs), has proven difficult. Novel approaches are needed to resolve these problems. We developed a model - COPA - that is based on scientific evidence and an original design process in which health professionals, including PCPs, and managers participated actively. COPA targets very frail community-dwelling elders recruited through their PCP. It was designed to provide a better fit between the services provided and the needs of the elderly in order to reduce excess healthcare use, including unnecessary emergency room (ER) visits and hospitalizations, and prevent inappropriate long-term nursing home placements. The model's originality lies in: 1) having reinforced the role played by the PCP, which includes patient recruitment and care plan development; 2) having integrated health professionals into a multidisciplinary primary care team that includes case managers who collaborate closely with the PCP to perform a geriatric assessment (InterRAI MDS-HC) and implement care management programs; and 3) having integrated primary medical care and specialized care by introducing geriatricians into the community to see patients in their homes and organize direct hospitalizations while maintaining the PCP responsibility for medical decisions. Since COPA is currently the subject of both a quasi-experimental study and a qualitative study, we are also providing preliminary findings. These findings suggest that the model is feasible and well accepted by PCPs and patients. Moreover, our results indicate that the level of service utilization in COPA was less than what is reported at the national level, without any compromises in quality of care.

Case management for long-term conditions: implementation and processes

This paper presents a structured literature review that focused on comprehensive case management by nurses for adults with long-term conditions living in the community. The emphases of the review are the implementation of case-management approaches, including its roles, core tasks and components, and the coverage and quality of the reported implementation data. Twenty-nine studies were included: the majority were concerned with case management for frail older people, and others focused on people with multiple chronic diseases, high-cost patients, or those at high risk of hospital admissions. All the studies reported that case managers undertook the core tasks of assessment, care planning and the implementation of the care plan, but there was more variation in who carried out case finding, monitoring, review and case closure. Few studies provided adequate implementation information. On the basis of the reviewed evidence, three issues were identified as key to the coherent and sustainable implementation of case management for people with long-term conditions: fidelity to the core elements of case management; size of caseload; and case-management practice, incorporating matters relating to the continuity of care, the intensity and breadth of involvement, and control over resources. It is recommended that future evaluations of case-management interventions include a comprehensive process component or, at the very least, that interventions should be more fully described.

Pressure ulcer and mortality in frail elderly people living in community

Pressure ulcer is one of the most common, disruptive and often disabling conditions affecting frail older people. Purposes of the present study are to ascertain the prevalence of pressure ulcer and to explore the relationship between pressure ulcer and the risk of 1-year all-cause mortality in a large population of frail and very old people living in community. This was an observational cohort study. We analyzed data from the Italian Silver Network Home Care project that collected data on patients admitted to home care programs. A total of twelve home health agencies participated in such project evaluating the implementation of the minimum data set for home care (MDS-HC) instrument. A total of 3,103 patients were enrolled in the present study. The prevalence of patients with pressure ulcer was about 18%. During a follow-up of 12 months from the initial MDS-HC assessment, 160 subjects (29%) died in the pressure ulcer group compared to 368 subjects (14%) in the group of patient without pressure ulcer (p<0.001). After adjusting for age, gender and for all the significantly different variables between subjects with and without pressure ulcer at baseline, subjects with pressure ulcer were more likely to die compared to those without pressure ulcer (RR=1.92; 95% Cl 1.52-2.43).

Physical activity prevented functional decline among frail community-living elderly subjects in an international observational study

OBJECTIVES

The aims of the study were to describe the prevalence of physical activity in a sample of older adults in home care in Europe and to examine the relationship between physical activity and incident disability.

STUDY DESIGN AND SETTING

Study population consisted of a random sample of 2,005 subjects aged 65 or older admitted to home care programs in 11 European Home Health Agencies who participated in AgeD in HOme Care project. Participants who reported spending 2 or more hours of physical activities in last 3 days were defined physically active. Disability performing activities of daily living was defined as the need of assistance in one or more of the following ADL: eating, dressing, transferring, mobility in bed, personal hygiene, and toileting.

RESULTS

More than 50% of participants were physically active. During a median follow-up of 12 months, 370 subjects (15%) became disabled. After adjusting for age, gender, and other possible confounding variables, active subjects were significantly less likely to become disabled compared to those reporting no or very low-intensity physical activity (OR, 0.67; 95% CI 0.53-0.84).

CONCLUSIONS

These findings support the possibility that physical activity has an independent effect on functional autonomy among frail and old people.

Cross-sectional association between behavioral symptoms and potential elder abuse among subjects in home care in Italy: results from the Silvernet Study

OBJECTIVES

The objectives of this study were to evaluate the prevalence of potential elder abuse among older adults receiving home care and to assess the association between behavioral symptoms and potential abuse.

METHODS

Data on 4,630 subjects aged 65 or older receiving home care in Italy were collected using the Minimum Data Set for Home Care assessment. Potential abuse included signs of physical or emotional abuse and neglect. Behavioral symptoms were present if the participant exhibited one or more of the following symptoms in the 3 days before the assessment: wandering, verbally abusive, physically abusive, socially inappropriate behavior, and active resistance to care.

RESULTS

Mean age of participants was 80.5 years (standard deviation: 7.7) and 2,761 (60%) were female. Signs of potential abuse were identified in 336 of 3,869 (9%) participants without behavioral symptoms and 126 of 761 (17%) with behavioral symptoms. After adjustment for potential confounders, presence of behavioral symptoms was significantly associated with potential abuse (odds ratio [OR]: 1.56; 95% confidence interval [CI]: 1.21-2.00). Examining behavioral symptoms separately, wandering was negatively associated with potential abuse (OR: 0.58; 95% CI: 0.36-0.97), whereas other symptoms were positively associated with this outcome (verbally abusive behavior OR: 1.69, 95% CI: 1.24-2.31; physically abusive behavior OR: 1.42, 95% CI: 1.00-2.03; socially inappropriate behavior OR: 1.78, 95% CI: 1.26-2.53; active resistance of care OR: 1.69, 95% CI: 1.20-2.38).

CONCLUSION

Signs of potential abuse are common among older adults in home care in Italy and they are associated with the presence of behavioral symptoms.

In a prospective observational study, influenza vaccination prevented hospitalization among older home care patients

OBJECTIVE

The aim of the study is (1) to describe the prevalence of vaccination against influenza in older home care patients and (2) to investigate the protective effect of influenza vaccination for hospitalization events.

STUDY DESIGN AND SETTING

This is an observational study conducted in four large cohorts of elderly patients in home care during the 1998-1999, 1999-2000, 2000-2001, and 2001-2002 influenza seasons. We analyzed data from the Italian Silver Network Home Care project. A total of 2,201 patients were enrolled in the present study. The main outcome measures were prevalence of vaccination against influenza and the rate of hospitalization according to vaccination status and influenza season.

RESULTS

The rate of influenza vaccination was around 48% of the studied sample. During the follow-up including the peak of influenza and the total influenza season, 412 subjects (40%) were hospitalized among vaccinated compared to 610 subjects (59%) among not vaccinated (P<0.001). After adjusting for age, gender, location of home care program, and all the variables significantly different between vaccinated and not-vaccinated subjects, vaccinated subjects were less likely to be hospitalized compared to not-vaccinated subjects (OR, 0.73; 95% CI 0.60-0.90).

CONCLUSIONS

Vaccination against influenza has an important prognostic implication for frail geriatric patients living in the community.

Proposal of a service delivery integration index of home care for older persons: application in several European cities

PURPOSE

To propose an integration index of home care delivery to older persons, to study its validity and to apply it to home care services of European cities.

THEORY

Home care delivery integration was based on two dimensions referring to process-centred integration and organisational structure approach.

METHOD

Items considered as part of both dimensions according to an expert consensus (face validity) were extracted from a standardised questionnaire used in "Aged in Home care" (AdHoc) study to capture basic characteristics of home care services. Their summation leads to a services' delivery integration index. This index was applied to AdHoc services. A factor analysis was computed in order to empirically test the validity of the theoretical constructs. The plot of the settings was performed.

RESULTS

Application of the index ranks home care services in four groups according to their score. Factor analysis identifies a first factor which opposes working arrangement within service to organisational structure bringing together provisions for social care. A second factor corresponds to basic nursing care and therapies. Internal consistency for those three domains ranges from 0.78 to 0.93. When plotting the different settings different models of service delivery appear.

CONCLUSION

The proposed index shows that behind a total score several models of care delivery are hidden. Comparison of service delivery integration should take into account this heterogeneity.

Functional decline in frail community-dwelling stroke patients

Patients who suffer a stroke event are at high risk of functional decline after the post-acute rehabilitation period. The aim of the present study was the evaluation of factors associated with functional decline in a large sample of older patients with stroke living in the community. The study population consisted of all patients admitted to home care programs after a post-acute rehabilitation program--with at least 1 year of follow-up--in twenty-two Italian Home Health Agencies from 2000 to 2002 (n=1338). For the present study we selected 355 (26%) patients with diagnosis of stroke. After 1 year of in-home care program, 149 out of 355 stroke survivors (42%) had presented a worsening in the activities of daily living (ADL) scale score. In the final adjusted model, patients with cognitive impairment (OR 2.59, 95% CI, 1.45-4.64), pressure ulcer (OR 2.74, 95% CI, 1.45-5.18), urinary incontinence (OR 1.64, 95% CI, 1.01-3.29), or hearing impairment (OR 1.83, 95% CI, 1.02-3.29) were more likely to significantly decline in physical functioning after a period of 1 year in-home care program. Our study documents that functional decline of stroke patients was largely dependent on specific subjects' clinical characteristics. Three of four concomitant disabling conditions associated in our sample with functional decline--pressure ulcer, urinary incontinence, hearing--can be prevented and eventually treated or modified. Appropriate post-acute rehabilitation programs and adequate home care interventions focused on the prevention and treatment of these conditions might be correlated to better outcomes in older post-stroke patients.

Psychotropic medications and risk for falls among community-dwelling frail older people: an observational study

BACKGROUND

Injuries due to falls are one of the most important public health concerns for all ages, but especially for frail elderly people. Although a small number of falls have a single cause, the majority have many different causes resulting from the interactions between intrinsic or extrinsic risk factors.

METHODS

We conducted an observational study on data from a large population of community-dwelling elderly people to tests the hypothesis that the current use of different classes of psychotropic medications, including antipsychotic agents, benzodiazepines, nonbenzodiazepine sedative-hypnotics, and antidepressants, increases the risk for falls. We analyzed data from a large collaborative observational study group, the Italian Silver Network Home Care project, that collected data on patients admitted to home care programs (n = 2854).

RESULTS

After adjusting for all potential confounders, users of any psychotropic drugs had an increased risk of fall of nearly 47% (adjusted odds ratio [OR], 1.47; 95% confidence interval [CI], 1.24-1.74). Similarly, compared with nonusers, users of atypical antipsychotic drugs also had an increased risk of falling at least once (OR, 1.45; 95% CI, 1.00-2.11). Among benzodiazepine users, patients taking agents with long elimination half-life (OR, 1.45; 95% CI, 1.00-2.19) and patients taking benzodiazepines with short elimination half-life (OR, 1.32; 95% CI, 1.02-1.72) had an increased risk of falls. Patients taking antidepressants did not show a higher risk of falling compared to nonusers (OR, 0.92; 95% CI, 0.83-1.41).

CONCLUSIONS

Our data suggest that, among psychotropic medications, antipsychotic agents and benzodiazepines are associated with an increased risk of falls. Our findings do not support the hypothesis that preferential prescribing of short-acting benzodiazepines instead of long-acting agents or atypical antipsychotic medications instead of typical agents will substantially decrease fall risk associated with the use of these classes of drugs.

Prevalence and predictors of influenza vaccination among frail, community-living elderly patients: an international observational study

The annual winter outbreak of influenza is one of the major cause of morbidity and mortality among frail elderly people. The aim of the present study was to identify prevalence and predictors of influenza vaccination in a large European population of frail and old people living in community. This was an observational study conducted in 11 European countries. We enrolled 3878 people 65 years and older already receiving home care services within the urban areas. All participants were assessed with the Minimum Data Set-Home Care (MDS-HC) instrument containing over 300 items, including socio-demographic, physical and cognitive characteristics of patients as well as medical diagnoses and medications received. A single question about the influenza vaccination status was used. The rate of influenza vaccination was around 59% of the studied sample. Significant geographical variations were evident in the prevalence of vaccination ranging from 31% of Prague (Czech Republic) to 88% of Rotterdam (The Netherlands). Overall, persons living alone were less likely to receive influenza vaccine as compared with those living with an informal caregiver (OR, 0.78; 95% CI 0.67-0.90). Similarly, cognitive impairment and presence of economic problems were associated with a lower likelihood of being vaccinated (OR: 0.69, 95% CI 0.59-0.80 and OR, 0.58; 95% CI 0.45-0.74, respectively). On the other hand, old age and comorbidity were associated with an higher probability of being vaccinated. In conclusion, more than 40% of subjects in this sample of home care patients in Europe did not receive influenza vaccination. Recommendations for influenza vaccination have not been adequately implemented.

Pain and its relation to depressive symptoms in frail older people living in the community: an observational study

The association of pain and depression represents an important health problem that is correlated with high rates of disability, morbidity, greater consumption of health care resources, and socioeconomic difficulties. Understanding the interaction between pain and depression is an important issue in light of the fact that physicians frequently fail to accurately assess and diagnose pain symptoms, and that elderly patients suffering from pain are particularly likely to receive inaccurate treatments. The aim of the present study was to describe the prevalence of pain and to investigate the association between pain and depressive symptoms in a representative sample of frail elderly people living in the community (n=5,372). The results show that more than 15% and 40% of elderly patients experienced pain less than daily and daily, respectively. The average score on the depression scale was significantly lower in patients without pain (2.5+/-2.5) than patients with less than daily and daily pain (3.2+/-2.5 and 3.6+/-2.5, respectively) (P<0.001). Without substantial differences between men and women, the rate of each depressive symptom was significantly and progressively higher among patients suffering less than daily and daily pain compared to those without pain. In conclusion, this study provides evidence from a large sample of frail elderly people that individuals suffering pain present an elevated risk to experience depressive symptoms. Treatment models that put together the assessment and the treatment of both pain and depression are indispensable for better outcomes.

Comorbidity and social factors predicted hospitalization in frail elderly patients

OBJECTIVE

Studies on factors predicting the hospital admission of geriatric patients have reported different findings. The present study was undertaken to examine the rate of hospitalization among a large sample of frail elderly people living in the community and to identify the most important clinical and patient-centered factors associated with the hospital admission.

STUDY DESIGN AND SETTING

This is an observational cohort study. All patients (n = 1,291) in six Italian home health care agencies were assessed by a trained staff who collected data on the Minimum Data Set for Home Care (MDS-HC) form. We constructed a longitudinal database including MDS-HC data and information on hospital utilization by each patient.

RESULTS

During the follow-up of 12 months, the rate of hospitalization was about 26% of the studied sample. Persons living alone were more likely to have a hospital admission than those living with an informal caregiver (odds ratio OR = 2.59, 95% confidence interval CI = 1.82-3.69). Similarly, persons with economic hardship were more frequently hospitalized than those without these problems(OR = 3.01, 95% CI = 1.75-5.18). Comorbidity and previous hospital admission were associated with a higher risk to be hospitalized, too.

CONCLUSION

Our results support the hypothesis that a mix of social and health problems are independent predictors of hospitalization. Identification of those factors that best predict hospital admissions and readmissions gives direction for potential interventions and further research toward reducing unnecessary hospitalizations.

Physical activity and mortality in frail, community-living elderly patients

BACKGROUND

The authors describe the prevalence of moderate-intensity physical activity in a population of older persons living in the community. In addition, they explore the relationship between physical activity and mortality.

METHODS

In this longitudinal observational study, the authors analyzed data from patients admitted to home care programs collected as part of the Italian Silver Network Home Care project. Twelve home health agencies participated in the project, which evaluated the implementation of the Minimum Data Set for Home Care (MDS-HC) instrument. A total of 2757 patients were enrolled in the current study. The primary outcome measures were the prevalence of 2 or more hours per week of physical activity and survival.

RESULTS

Fewer than 20% of patients had regular physical activity. During a median follow-up period of 10 months from the initial MDS-HC assessment, 442 (16%) patients died. After adjusting for sex, physical and cognitive disability, and all potential risk factors for death, active patients were less likely to die compared with those with no or very low-intensity physical activity (relative risk ratio [RR], 0.51; 95% confidence interval [CI], 0.35-0.73). This inverse relationship was also significant in patients aged 80 years and older (RR 0.55; 95% CI, 0.32-0.95).

CONCLUSIONS

Physical activity is associated with a significantly lower risk of all-cause mortality. The current findings support the possibility that moderate-intensity physical activity has an independent effect on survival even among frail and old persons.

Community care in Europe. The Aged in Home Care project (AdHOC)

BACKGROUND AND AIMS

Community care for older people is increasing dramatically in most European countries as the preferred option to hospital and long-term care. While there has been a rapid expansion in Evidence-Based Medicine, apart from studies of specific interventions such as home visiting and hospital at home (specialist visits or hospital services provided to people in their own homes in the community), there is little evidence of characteristics of the recipients of community care services or the organisation of services that produce the best outcomes for them and their informal carers. The AdHOC Study was designed to compare outcomes of different models of community care using a structured comparison of services and a comprehensive standardised assessment instrument across 11 European countries. This paper describes the study and baseline data.

METHODS

4,500 people 65 years and older already receiving home care services within the urban areas selected in each country were randomly sampled. They were assessed with the MDS-HC (Minimum Data Set-Home Care) instrument, containing over 300 items, including socio-demographic, physical and cognitive characteristics of patients as well as medical diagnoses and medications received. These data were linked to information on the setting, services structures and services utilization, including use of hospital and long-term care. After baseline assessment, patients were re-evaluated at 6 months with an abbreviated version of the instrument, and then at the end of one year. Data collection was performed by specially-trained personnel. In this paper, socio-demographics, physical and cognitive function and provision of hours of formal care are compared between countries at baseline.

RESULTS

The final study sample comprised 3,785 patients; mean age was 82+/-7.2 years, 74.2% were females. Marital and living status reflected close family relationships in southern Europe relative to Nordic countries, where 5 times as many patients live alone. Recipients of community care in France and Italy are characterised by very high physical and cognitive impairment compared with those in northern Europe, who have comparatively little impairment in Activities of Daily Living and cognitive function. The provision of formal care to people with similar dependency varies extremely widely with very little formal care in Italy and more than double the average across all levels of dependency in the UK.

CONCLUSIONS

The AdHOC study, by virtue of the use of a common comprehensive standardised assessment instrument, is a unique tool in examining older recipients of community care services in European countries and their widely varied organisation. The extreme differences seen in dependency and hours of care illustrate the probable contribution the study will make to developing an evidence based on the structure, quantity and targeting of community care, which will have major policy implications.

Effect of preventive home visits for ambulatory housebound elders in Japan: a pilot study

BACKGROUND AND AIMS

Programs of preventive home visits for ambulatory housebound elders have not yet become established in Japan. The aim of this randomized pilot study was to investigate effects of such visits by public health nurses in Japan.

METHODS

A randomized controlled study with 18-month follow-up was conducted in a small Japanese agricultural town. Participants (n=119) were ambulatory housebound elders aged 65 and over, who were able to walk but who went outdoors less than three times a week at baseline survey. They were randomly assigned to intervention (n=59) or control group (n=60). Intervention group subjects received preventive home visits by public health nurses over 18 months (mean home visits=4.3). Control group subjects received usual primary and community care. Activities of daily living (ADLs), functional capacity, self-efficacy for daily activities, self-efficacy for health promotion, depression, and social support were collected via questionnaire at baseline and at the 18-month follow-up point.

RESULTS

At follow-up, 81.4% of intervention group subjects were still living at home vs 73.3% of control group subjects (NS). Simple group comparisons following repeated measures (ANCOVA) showed that the intervention group had higher ADL scores than the control group at follow-up (p=0.044).

CONCLUSIONS

These pilot results suggest that home visits by public health nurses may be effective in helping to reduce ADL decline among ambulatory housebound elders.

Indwelling urethral catheter and mortality in frail elderly women living in community

AIM

Urinary incontinence is one of the most common, disruptive and often disabling conditions affecting frail older people living in community. The aims of present study were to describe the prevalence of bladder catheter in a population of older women living in community and to examine the relationship between urinary catheter and mortality.

METHODS

This was an observational cohort study. We analyzed data from the Italian Silver Network Home Care project that collected data on patients admitted to Home Care programs. A total of twelve Home Health Agencies participated in such project evaluating the implementation of the Minimum Data Set for Home Care (MDS-HC) instrument. A total of 1,004 women were enrolled in the present study. The main outcome measures were prevalence of bladder catheter and 1-year survival according to catheterization.

RESULTS

The prevalence of incontinent patients with bladder catheter was 38.1%. Incontinent patients with indwelling bladder catheter did not show significant difference for age and comorbidity while they showed a significant higher level of physical and functional impairment, as expressed by higher score in activities of daily living (ADL) scale (6.5 +/- 1.3 vs. 5.5 +/- 2.2, P < 0.001) and higher prevalence of sensory impairment, pressure ulcers (44% vs. 12%, P < 0.001), and urinary tract infections (21% vs. 10%, P < 0.001). After adjusting for age and for all the variables significantly different between catheterized and not-catheterized subjects at baseline, subjects with indwelling bladder catheter were more likely to die compared to those without catheter (RR, 1.44; 95% CI 1.01-2.07).

CONCLUSIONS

Catheterization has an important prognostic implication for frail old women living in the community, independent of age and other clinical and functional variables. A failure in decreasing the unnecessary bladder catheter use and the duration of catheterization among frail incontinent women should be considered an indicator of poor quality of care.

Antithrombotic drugs in secondary stroke prevention among a community dwelling older population

BACKGROUND

Patients who suffer a cerebrovascular event are at high risk of a recurrence. Secondary prevention is crucial in reducing the burden of cerebrovascular disease.

OBJECTIVE

To estimate the percentage of stroke survivors receiving antiplatelet or anticoagulant drugs and to identify factors associated with such treatment.

DESIGN

Cross sectional retrospective cohort study.

METHODS

Data were analysed from a large collaborative observational study, the Italian "silver network" home care project, which collected data (from 1997 to 2001) on patients admitted to home care programmes (n = 5372). Twenty two home health agencies participated in evaluating the implementation of the minimum dataset for home care (MDS-HC) instrument. For the present study, 648 individuals with a diagnosis of stroke were selected and the initial MDS-HC assessment reported.

RESULTS

70% of stroke survivors did not receive any antiplatelet or anticoagulant drugs (95% confidence interval (CI), 66.5 to 73.5). Among all age categories, aspirin and ticlopidine were the two most commonly prescribed drugs. Living alone (odds ratio (OR), 0.49 (95% CI, 0.24 to 0.89)), dependency in activities of daily living (0.66 (0.40 to 0.99)), cognitive impairment (0.58 (0.38 to 0.86)), and low educational level (0.58 (0.34 to 0.98)) were associated with a reduced likelihood of receiving secondary stroke prevention treatment. Cardiac arrhythmias, coronary artery disease, heart failure, and peripheral vascular disease were associated with the use of antiplatelet or anticoagulant treatment.

CONCLUSIONS

Negative attitudes among physicians with respect to secondary stroke prevention are prevalent and reinforce the need for increased awareness of existing data on the risks and benefits for elderly individuals. Social problems and functional impairment may be issues concerning physicians when deciding whether or not the risks of treatment exceed the benefit.

Effects of influenza vaccination on mortality among frail, community-living elderly patients: an observational study

BACKGROUND AND AIMS

The annual winter outbreak of influenza is one of the major causes of morbidity and mortality among frail elderly people. The aims of the present study were to describe the prevalence of vaccination against influenza in a population of older people living in the community, and to examine the relationship between influenza vaccination and mortality.

METHODS

This was an observational cohort study. We analyzed data from the Italian Silver Network Home Care project, which collected data on patients admitted to home care programs. A total of twelve Home Health Agencies participated in this project, evaluating the implementation of the Minimum Data Set for Home Care (MDS-HC) instrument. A total of 2082 patients were enrolled in the present study. The main outcome measures were prevalence of vaccination against influenza and 1-year survival according to vaccination status.

RESULTS

Nearly half the subjects in our Italian sample did not receive influenza vaccination. During a mean follow-up period of 10 months from initial MDS-HC assessment, 167 vaccinated subjects (15%) died compared with 192 non-vaccinated subjects (19%) (p = 0.01). After adjusting for age, gender, and all variables significantly different between vaccinated and non-vaccinated subjects at baseline (functional and cognitive impairment, number of diseases, number of medications, depression, pressure ulcers), vaccinated subjects were less likely to die than non-vaccinated ones (RR 0.73; 95% CI 0.56-0.94).

CONCLUSIONS

Vaccination against influenza has important prognostic implications for frail geriatric patients living in the community, independent of age, gender, and other clinical and functional variables. Despite extensive scientific evidence, recommendations for annual vaccination against influenza among subjects at higher risk have never been adequately implemented.

Prevalence and risk factors for falls in an older community-dwelling population

BACKGROUND

Falls are responsible for considerable morbidity, immobility, and mortality among elderly people. The aim of this study was to determine the prevalence of falls and related intrinsic and extrinsic risk factors in a community-dwelling older population.

METHODS

An observational study was performed on all patients (N = 5570) admitted from 1997 to 2001 to home care programs in 19 home health agencies that participated in the National Silver Network project in Italy. Patient evaluation was performed through the Minimum Data Set-Home Care (MDS-HC) instrument.

RESULTS

A 35.9% falls prevalence was found within 90 days of the patient assessment through the MDS-HC instrument. After adjusting for all potential confounding factors, the logistic regression showed a high increase in risk of falling for those patients who wandered (odds ratio [OR] 2.38; 95% confidence interval [CI] 1.81-3.12) or suffered with gait problems (OR 2.13; 95% CI 1.81-2.51). Patients affected by depression were more likely to fall (OR 1.53; 95% CI 1.36-1.73). Those who lived in an unsafe place with environmental hazards had an increase in the risk of falling (OR 1.51; 95% CI 1.34-1.69). The associations of main risk factors for falls were also evaluated.

CONCLUSIONS

Rate of falls among frail elderly people living in the community is very high and frequently correlates with potentially reversible factors. To identify those with higher falling risk, home care staff and general practitioners could use the MDS-HC assessment tool.

Health care for older persons in Italy

The aging of the population, with the ensuing rise in the number of older "clients" of the Health Agencies (15.2% people aged 0-14 vs 16% of those aged 64+ already in 1993), the new prospective payment system and a corporate philosophy were the driving forces that led the local Health Agencies to redesign the long-term care system, shifting resources from the hospital to the community. This shift constitutes a present challenge to the entire National Health Service. Furthermore, the Italian Health Service is also becoming decentralized, reflecting closely the political and administrative division of Italy into twenty regions. Regional authorities assign the available resources according to local needs and often interpret the central government's directives for controlling their health care budgets at their own discretion. As a result, profound interregional differences in health care expenditure occur which may aggravate the pre-existing inequalities between the Italian regions. In the coming years, the main priorities to satisfy the needs of frail elderly people are the following: 1) to adapt the number of rehabilitation beds to the standard of 1 bed for 1000 inhabitants; 2) to guarantee in all Health Agencies the presence of Geriatric Evaluation Units in a position to: perform comprehensive geriatric assessment immediately upon request; design and implement individualized care plans in agreement with general practitioners; determine the services that patients are eligible for; and coordinate the delivery and facilitate the integration process between social and health care professionals; 3) to develop all possible alternatives to hospitalization, chiefly programs of integrated home health care or hospital at home; and 4) to realize the number of beds already funded in skilled nursing facilities (RSA) while decreasing acute beds to 4/1000.

Impact of a new assessment system, the MDS-HC, on function and hospitalization of homebound older people: a controlled clinical trial

OBJECTIVES

To evaluate the impact of a new assessment system, the Minimum Data Set for Home Care (MDS-HC), on the functional status and hospitalization rates of frail, community-dwelling older people.

DESIGN

Single-blind randomized trial with 1-year follow-up.

SETTING

Bergamo, Italy.

PARTICIPANTS

All 187 subjects who were eligible for home care services delivered by two Health Districts between September 1998 and April 1999.

INTERVENTION

Random allocation to an intervention group undergoing MDS-HC assessment or to a control group receiving conventional geriatric assessment with Barthel, Lawton and Brody, and Mini-Mental State Examination (MMSE) scales.

MEASUREMENTS

Hospitalization, health services use and costs, and variations in functional status.

RESULTS

Survival analysis indicated that the intervention group was admitted to the hospital later and less often than were controls (relative risk = 0.49, 95% confidence interval = 0.56-0.97). Health services were used to the same extent, but intervention subjects used more in-home help services. Total costs for the intervention group were 21% lower than for the control group. The adjusted mean scores of the activities of daily living index (51.7+/-36.1 vs 46.3+/-33.7; P = .05) and MMSE (19.9+/-8.9 vs 19.2+/-10.7; P = .03) were significantly improved in the intervention group as compared with the control group.

CONCLUSIONS

The MDS-HC assessment instrument may provide a cost-saving approach to reducing institutionalization and functional decline in older people living in the community.

A new model of integrated home care for the elderly: impact on hospital use

The objective of the present study was to examine the effect of a home care program based on comprehensive geriatric assessment-Minimum Data Set for Home Care-and case management on hospital use/cost of frail elderly individuals. We determined all hospital admissions and days spent in hospital during the first year since the implementation of the home care program, and compared them to the rate of hospitalization that the same patients had experienced in the year preceding the implementation of such program. Following the implementation of this program, there was a significant reduction of the number of hospitalizations (pre 44% vs. post 26%, P < 0.001), associated with a reduction of hospital days, both at the individual patient level and for each admission. In conclusion, an integrated home care program based on the implementation of a comprehensive geriatric assessment instrument guided by a case manager has a significant impact on hospitalization and is cost-effective.

Functional status and clinical correlates in cognitively impaired community-living older people

We describe the prevalence of cognitive impairment in a population of community-living older people, its association with functional decline, and degree of comorbidity. In addition, we examined the relationship between different levels of cognitive impairment and mortality. We conducted an observational study of 1787 patients aged 65 years and above with any degree of cognitive impairment. Patient data were collected with the Minimum Data Set for Home Care. More than 50% of patients had some level of cognitive impairment, which correlates with the degree of physical frailty. On the contrary, patients with cognitive impairment appear to have fewer comorbid conditions and are less likely to receive medications than patients with normal cognitive status. In particular, hypertension, congestive heart failure, chronic obstructive pulmonary disease, cancer, diabetes mellitus, and osteoporosis are found more frequently among patients with normal mental status compared with those showing some level of cognitive defects. Yet, more severe cognitive impairment is associated with a higher mortality rate. Demented patients are characterized by a high prevalence of functional disability and by increased mortality. This increased morbidity and mortality rate is associated with a lower prevalence of comorbid clinical conditions and drug use, relative to patients with normal cognitive performance. The present findings support the possibility that severe cognitive impairment has an independent effect on survival.

Minimum data set for home care: a valid instrument to assess frail older people living in the community

BACKGROUND

Optimal care for frail elderly patients depends on comprehensive assessment. This is especially true in the complex setting of interdisciplinary home care programs. To facilitate comprehensive assessment, as well as to generate a useful, policy-relevant patient database, standardized, multidimensional, and validated instruments are very helpful.

OBJECTIVES

The aim of the present study was to demonstrate that the Minimum Data Set assessment instrument for Home Care (MDS-HC) can be used to detect functional and cognitive impairment as defined by analogous research instruments.

RESEARCH DESIGN

This was a cross-sectional correlation study.

SUBJECTS

We studied 95 patients admitted to home care services of the Health Care Agency of Bergamo (Italy).

MEASURES

The MDS-HC form was completed for all patients by well-trained nurses, independently of and with nurses blinded to the results from the research rating scales. The Barthel Activities of Daily Living (ADL) Index, the Instrumental Activities of Daily Living of Lawton (IADL), and the Mini Mental State Examination (MMSE) were considered the gold standard.

RESULTS

Agreement between the MDS-HC scales and the research rating scales was assessed with Pearson's correlation coefficient. This coefficient was 0.74 for MDS-ADL versus Barthel Index, 0.81 for MDS-IADL versus Lawton Index, and 0.81 for Cognitive Performance Scale versus MMSE, indicating an excellent agreement.

CONCLUSIONS

The MDS-HC scales, when performed by trained nurses using recommended protocols, provide a valid measure of function and cognitive status in frail home care patients. These findings point out the overall validity of the functional and clinical data contained in the MDS-HC assessment. Use of the MDS-HC gives the unique opportunity of setting up a database, a prerequisite for all epidemiological evidence-based medicine studies.

Impact of integrated home care services on hospital use

OBJECTIVE

To examine the effect of a home care program based on comprehensive geriatric assessment and case management on hospital use and costs among frail older individuals.

DESIGN

Quasi-experimental study with a 6-month follow-up.

SETTING

Vittorio Veneto, a town in northern Italy.

PARTICIPANTS

One hundred fifteen frail older people who applied for integrated home care services.

INTERVENTION

Each patient was assessed with the Minimum Data Set for Home Care, and, subsequently, a case manager and a multidisciplinary team delivered social and health care services as indicated.

MAIN OUTCOME MEASURES

We determined the hospital admissions and days spent in the hospital for all subjects during the first 6 months after the implementation of the home care program and compared them with the rate of hospitalization that the same patients had experienced in the 6 months preceding the implementation of the program.

RESULTS

After the implementation of the integrated home care program, there was a significant reduction in the number of hospitalizations compared with pre-implementation (56% vs 46%, respectively; P < .001), associated with a reduction in the number of hospital days, both at the individual patient level (28+/-23 days vs 18+/-15 days, respectively; P < .01) and for each admission (16+/-12 days vs 12+/-8 days, respectively; P < .01). This resulted in a 29% cost reduction with an estimated savings of $1260 per patient.

CONCLUSIONS

The implementation of an integrated home care program based on the use of a comprehensive geriatric assessment instrument guided by a case manager has a significant impact on hospitalization and is cost-effective.