Non-use of community health-care services – an exploratory cross-sectional study among family care-givers for older, home-dwelling persons with dementia

Unspoken expectations and situational participation: a qualitative study exploring the instantiation of next of kin involvement within the trust model

BACKGROUND

Demographic changes, such as an increase in older adults, present a challenge to the healthcare service's current capacity. Moreover, the need for healthcare personnel is rising, while the availability of labour is dwindling, leading to a potential workforce shortage. To address some of these challenges, enhanced collaboration between home-based healthcare frontline workers, service users, and next of kin is a necessity. The trust model is an organisational model where home-based healthcare services are organised into smaller interdisciplinary teams aiming to tailor the services in collaboration with service-users and their next of kin'. This study explores how the next of kin and frontline workers perceive and perform involvement in making decisions regarding tailoring the services for the users of home-based healthcare services organised after the trust model.

METHODS

Four in-depth interviews and 32 observations were conducted, and thematic analysis was employed to identify meaningful patterns across the datasets.

RESULTS

The results are presented as two themes: (i) unspoken expectations and (ii) situational participation. The results highlight the complex nature of next-of-kin involvement and shared decision making, raising questions about meeting expectations, evaluating available resources, and developing sustainable involvement processes.

CONCLUSION

This study indicates that despite of an interdisciplinary organisational model aiming for shared decision making as the trust model, the involvement of next of kin continues to be a challenge for frontline workers in home-based healthcare services. It also points to the importance of transparent communication and how it is deemed essential for clarifying implicit expectations.

Rural-urban differences in use of health services before and after dementia diagnosis: a retrospective cohort study

BACKGROUND

Rural-urban differences in health service use among persons with prevalent dementia are known. However, the extent of geographic differences in health service use over a long observation period, and prior to diagnosis, have not been sufficiently examined. The purpose of this study was to examine yearly rural-urban differences in the proportion of patients using health services, and the mean number of services, in the 5-year period before and 5-year period after a first diagnosis of dementia.

METHODS

This population-based retrospective cohort study used linked administrative health data from the Canadian province of Saskatchewan to investigate the use of five health services [family physician (FP), specialist physician, hospital admission, all-type prescription drug dispensations, and short-term institutional care admission] each year from April 2008 to March 2019. Persons with dementia included 2,024 adults aged 65 years and older diagnosed from 1 April 2013 to 31 March 2014 (617 rural; 1,407 urban). Matching was performed 1:1 to persons without dementia on age group, sex, rural versus urban residence, geographic region, and comorbidity. Differences between rural and urban persons within the dementia and control cohorts were separately identified using the Z-score test for proportions (p < 0.05) and independent samples t-test for means (p < 0.05).

RESULTS

Rural compared to urban persons with dementia had a lower average number of FP visits during 1-year and 2-year preindex and between 2-year and 4-year postindex (p < 0.05), a lower likelihood of at least one specialist visit and a lower average number of specialist visits during each year (p < 0.05), and a lower average number of all-type prescription drug dispensations for most of the 10-year study period (p < 0.05). Rural-urban differences were not observed in admission to hospital or short-term institutional care (p > 0.05 each year).

CONCLUSIONS

This study identified important geographic differences in physician services and all-type prescription drugs before and after dementia diagnosis. Health system planners and educators must determine how to use existing resources and technological advances to support care for rural persons living with dementia.

Qualitative Analysis of Implementation Factors of an Embedded Caregiver Support Intervention into Adult Day Services

Background

Adult day services (ADS) are an important and often underutilized support resource for older adults. For persons living with dementia (PLWD), ADS is an optimal access point to not only receive therapeutic and rehabilitative activities, but as a vehicle for respite/relief for dementia caregivers. Yet, there is currently a lack of research on integrating caregiver interventions into home and community-based services such as ADS.

Objective

This paper reports on qualitative findings from the Improving Outcomes for Family Caregivers of Older Adults with Complex Conditions: The Adult Day Plus (ADS Plus) Program Trial.

Methods

Drawing from semi-structured interviews conducted with family caregivers and ADS site staff, we conducted a thematic analysis to examine the implementation process of ADS Plus.

Results

Themes address the relational nature of the intervention, learning, influence of the administrative infrastructure, and receptivity of ADS Plus.

Conclusions

Our analysis determined that implementation of ADS Plus was feasible and accepted by site staff and dementia caregivers but also calls for additional evaluation of embedded caregiver support interventions across different contexts (e.g., staff size, limited technology environments) to further identify and test implementation mechanisms across settings.

Health service use before and after dementia diagnosis: a retrospective matched case-control study

OBJECTIVES

This study investigated patterns in health service usage among older adults with dementia and matched controls over a 10-year span from 5 years before until 5 years after diagnosis.

DESIGN

Population-based retrospective matched case-control study.

SETTING

Administrative health data of individuals in Saskatchewan, Canada from 1 April 2008 to 31 March 2019.

PARTICIPANTS

The study included 2024 adults aged 65 years and older living in the community at the time of dementia diagnosis from 1 April 2013 to 31 March 2014, matched 1:1 to individuals without a dementia diagnosis on age group, sex, rural versus urban residence, geographical region and comorbidity.

OUTCOME MEASURES

For each 5-year period before and after diagnosis, we examined usage of health services each year including family physician (FP) visits, specialist visits, hospital admissions, all-type prescription drug dispensations and short-term care admissions. We used negative binomial regression to estimate the effect of dementia on yearly average health service utilisation adjusting for sex, age group, rural versus urban residence, geographical region, 1 year prior health service use and comorbidity.

RESULTS

Adjusted findings demonstrated that 5 years before diagnosis, usage of all health services except hospitalisation was lower among persons with dementia than persons without dementia (all p<0.001). After this point, differences in higher health service usage among persons with dementia compared to without dementia were greatest in the year before and year after diagnosis. In the year before diagnosis, specialist visits were 59.7% higher (p<0.001) and hospitalisations 90.5% higher (p<0.001). In the year after diagnosis, FP visits were 70.0% higher (p<0.001) and all-type drug prescriptions 29.1% higher (p<0.001).

CONCLUSIONS

Findings suggest the year before and year after diagnosis offer multiple opportunities to implement quality supports. FPs are integral to dementia care and require effective resources to properly serve this population.

Barriers and facilitators of using dementia community support services provided by an Alzheimers organisation: Perceptions of informal caregivers receiving services

Known barriers prevent informal caregivers of a person with dementia using community services; however, there is a dearth of knowledge on how organisations can overcome these barriers. This study examined caregivers' perceptions of the barriers and facilitators of service use with regards to their membership to one Alzheimers organisation and their recommendations for improvements. In-depth interviews were conducted with 19 informal caregivers. Thematic analysis revealed personal and organisational barriers to service use, and associated recommendations. Six recommendations were made for dementia service organisations: (a) be proactive and arrange regular scheduled meetings with clients; (b) utilise consistent, trusting, empathic support personnel who can build strong relationships with clients; (c) provide support groups; (d) tailor support; (e) ensure expert knowledge and numerous channels of information delivery to clients, the general public and health professionals and (f) actively promote the organisation and services offered. This study provides novel insights into how a community organisation can overcome client barriers to service use. In addition, the study reveals caregivers perceived value of an Alzheimers organisation, argued to be an essential service, but until now clients' perceptions of the value received have not been explored.

Indigenous Sami Family Caregivers' Experiences With Accessing and Collaborating With Municipal Health and Care Services

Previous research has indicated that Indigenous Sami families in Norway use public home-based care services less often than their non-Sami peers. Based on qualitative interviews with Sami family caregivers, we explore what they experience as barriers to accessing public care services for older adults living with dementia, and how they experience collaborating with care services providers. Through a reflexive thematic approach, we identified that rather than a cultural norm of “taking care of one’s own,” the underuse of public care services among Sami families were related to several intertwined circumstances. The Sami family caregivers reported barriers to accessing public care, such as lack of familiarity with the services and cultural and language concerns and the legacy of history, and drivers for continuing family care, such as blurred distribution of responsibility, lack of continuity of care, and culturally unsafe caring environments and marginalizing practices.

How to stay motivated: A focus group study of Norwegian caregivers' experiences with community healthcare services to their parents with dementia

Motivation to provide care is a significant predictor of informal caregiving among family caregivers of persons with dementia. Adequate support is an important source of help and relief to caregivers, but fragmentation of dementia care services is common and better ways of supporting these caregivers are needed. Knowledge of adult-child caregivers' motivation and how this motivation is influenced by community healthcare services is lacking. The aim of this study is therefore to describe and explore adult children's experiences with community healthcare services for their home-dwelling parent with dementia and how these influence their caregiver motivation. The study applied a qualitative design based on three focus group interviews with 15 of these caregivers (40-69 years) in Norway in 2017. The study results indicate three categories supporting adult children's sustained motivation as caregivers: (a) caregivers prioritize their parent's need for healthcare services over their own need for support; (b) caregivers need acknowledgement through respect and involvement; and (c) caregivers need timely information and competence as the dementia progresses. To stimulate collaboration among adult-child caregivers, their parents with dementia, and community healthcare services, we claim that a relationship-centred care framework could be emphasised as a way of supporting sustained motivation among caregivers to parents with dementia as part of community healthcare services.

‘We're happy as we are’: the experience of living with possible undiagnosed dementia

It is estimated that a third of people in the United Kingdom with signs of dementia are living without a formal diagnosis. In Wales, the proportion is nearly half. Some explanations for the gap between prevalence of dementia and number of diagnoses include living with a long-term partner/spouse and systemic barriers to diagnosis. This study recruited participants from the Cognitive Function and Ageing Studies-Wales (CFAS-Wales) cohort, randomly selected from people aged over 65 living in two areas of Wales, who met study criteria for a diagnosis of dementia and did not have a record of a formal diagnosis in general practice records. We aimed to understand more about the contexts and circumstances of people who live with and cope with cognitive difficulties without having a formal diagnosis of dementia. We conducted qualitative interviews with six participants and their spouses, and additionally with four family members of three invited people who were unable to take part. Themes were generated using thematic analysis. We present the argument that there is an adaptive response to low service levels and a complex interaction between the expectations of levels of service, perceptions of the legitimacy of cognitive problems and the right to make demands on services. This paper concludes that more could be done to address barriers to diagnosis and treatment services for those living with symptoms of dementia, but that the value placed on diagnosis by some individuals might be lower than anticipated by government policy.