Development of a Care Delivery Model for High-Need Older Adults in the Community

SOURCE, a learned resourcefulness program to reduce caregiver burden and improve quality of life for older family caregivers

BACKGROUND

Family members often undertake caregiving responsibilities over long periods of time, which could lead to caregiving burden. A theory-based and culturally sensitive learned resourcefulness program may help family caregivers mitigate stress by learning and using self-help strategies.

OBJECTIVES

This study's aim is to use rigorous methods to investigate the effects of a learned resourcefulness program called SOURCE (Chen et al., Geriatric Nursing, 2021, 45, 1129) to reduce caregiver burden and improve quality of life (QOL) for family caregivers. SOURCE is an acronym for the six self-help behaviors at the core of this theory-based learned resourcefulness program, developed by the Principal Investigator (PI) in collaboration with other researchers (Chen et al., Geriatric Nursing, 2021, 45, 1129). These behaviors are: seeking problem-solving strategies, organizing daily actions, using self-regulation, reframing positive situations, changing negative self-thinking, and exploring new thinking and skills.

METHODS

We used a quasi-experimental design with repeated measures for this study. The potential subjects were family caregivers whose family member was receiving home care. PI recruited 94 family caregivers (60 years old or older) who were caring for disabled and/or ill family members who also were 60 years old or older and living at home at the time of the study. The PI recruited these caregivers through the home care services department of a hospital and two community healthcare centers in Taiwan. The experimental group (n = 46) received the four-week in-person SOURCE while their family member continued to receive home care services, whereas the control group (n = 48) did not receive the SOURCE program while their family member received home care services. We collected data from the participants using the Caregiver Burden Scale, EuroQol-5 Dimension, and Rosenbaum's Self-Control Scale at baseline (T0, Week 1), after the intervention (T1, Week 5), and at follow-up (T2, Week 9). We analyzed the data using paired-sample t-tests and used the generalized estimating equation method to compare paired data between the baseline and follow-up.

RESULTS

Of the 94 recruited family caregivers, 90.4% (n = 85) completed the study. We found no significant differences between the experimental and control groups in terms of demographic, caregiver burden, and QOL variables at baseline. Compared to the control group, the experimental group had significantly improved caregiver burden scores (indicating a reduction in caregiver burden) at the end of the intervention and at follow-up. The experimental group had significantly improved QOL scores at follow-up only. The experimental group also showed high levels of adherence to and satisfaction with the intervention. The paired-sample t-test results show significantly improved learned resourcefulness between T0 and T1 and between T0 and T2 (t = -5.84, p < 0.001; t = -6.77, p < 0.001) for the experimental group.

CONCLUSION

The SOURCE program helped family caregivers develop and use self-help behaviors during their daily caregiving tasks. The family caregivers reported satisfaction with the program as well as reduced caregiver burden and improved QOL after the program ended.

IMPLICATIONS FOR PRACTICE

The SOURCE program can be implemented to improve family caregivers' caregiver burden and QOL. Community health nurses can improve self-help abilities of family caregivers by helping them to acquire abilities and skills that allow them to effectively handle stress and reduce their caregiver burden.

Improving patient well-being in the United States through care coordination interventions informed by social determinants of health

Health and well-being are promoted when primary care teams partner with patients and provide care coordination to mitigate risks and promote optimal health. Identification of patients for care coordination is typically based on claim-driven risk assessments. Evidence shows that social determinants of health (SDOH) drive risk for adverse health outcomes but are omitted from existing risk tools. Missed opportunities for care coordination contribute to increased healthcare costs, poorer health outcomes and reduced patient well-being. To address the gap of risk-informed care coordination that includes SDOH, the aim of this project was to implement process improvement of a system's care coordination program through refined patient selection and customised engagement in intensive care coordination. A non-randomised care coordination quality improvement project was conducted at a community health centre in 2020. Inclusion criteria (i.e. presence of risk attribution score, SDOH questionnaire completed) resulted in 540 patients being offered care coordination services; Patients having at least one month of care coordination were included in the analysis (N = 216). Analysis included the 216 patients that chose participation and the 324 patients that maintained usual care. Descriptive statistics were generated to distinguish patient demographics, frequency of care coordination contact, and specific SDOH insecurities for both the study and comparison groups. Paired t-tests were incorporated to evaluate statistical significance of the intervention group. Impact on well-being, SDOH barriers, appointment adherence and health outcomes were assessed in both conditions. Intervention condition patients reported improvement in well-being [feeling anxious (t = 4.051; p < 0.000)] and reduced SDOH barriers [food access (t = 4.662; p < 0.000); housing (t = 2.203; p = 0.008)] that were significantly different from the usual care condition in the expected directions. Care coordination based on factors including SDOH risks shows promise in improving patient well-being. Future research should refine this approach for comprehensive risk assessment to intervene and support patient health and well-being.

How does the delivery of paid home care compare to the care plan for clients living with dementia?

Many people living with dementia choose to remain in their own homes, supported by home-care workers, who provide care that is specified in care plans. We explored how care plans of clients living with dementia, compared with ethnographic observations of home care they received. In a secondary, reflexive thematic analysis, we reviewed care plans for 17 clients living with dementia and transcripts from 100 h of observations with 16 home-care workers delivering care to them. Our overarching theme was: Care plans as a starting point but incomplete repository. Clients' care plans provided useful background information but did not reflect a wealth of knowledge home-care workers built through practice. Two sub-themes described: (a) Person-centred care planning: whether and how the care plan supported tailoring of care to clients' needs and (b) Filling in the gaps: home-care workers often worked beyond the scope of vague, incomplete or out-of-date care plans. We found considerable inconsistencies between care plans and the care that was delivered. Care plans that were comprehensive about care needs, and rich in person-specific information aided the delivery of person-centred care. Lack of documentation was sometimes associated with observed failures in person-centred care, as helpful information and strategies were not shared. Including information in care plans about how, as well as what care tasks, should be completed, and frequently discussing and updating care plans can create more person-centred plans that reflect changing needs. Electronic care planning systems may support this.

Psychometric Properties of the High-Need Community-Dwelling Older Adults Screening Scale

This study aimed to verify the factorial structure, internal consistency, test-retest reliability, and discriminant validity of the High-need Community-dwelling Older Adults Screening Scale (HCOASS). A 20-item HCOASS covering five domains was used with a systematic random sample of 818 community-dwelling older adults. After the analyses, the Exploratory Factor Analysis suggested a removal of two items, resulting in 5 domains with 18 items, and the Confirmatory Factor Analysis yielded satisfactory results with Goodness of Fit Index of .98. The HCOASS demonstrated acceptable internal consistency (Kuder-Richardson Formula 20 α = .75) and excellent test-retest reliability (0.94; 95% CI [0.91, 0.97]). The area under the Receiver Operating Characteristic (ROC) curve was 0.90 (95% CI [0.84, 0.95]) and the optimal cut-off score was 4/5. The HCOASS is a valid and reliable screening tool. It has the potential for consistent and efficient administration to be used by non-healthcare professionals in the community.

Factors related to complex care needs of older adults in community-based integrated care centers in Japan: A cross-sectional study

AIM

This study aimed to identify the factors related to complex care needs of older adults in community-based integrated care centers.

METHODS

We sent 936 self-reported questionnaires to community-based integrated care center directors in the Kinki region of Japan. These questionnaires included questions not only about the directors' demographic data, but also regarding the sociodemographic, psychosocial, and family-related dimensions of the older adults in the community centers. The directors divided their cases into two categories: "Complex cases" and "Straightforward cases." We compared the intergroup differences and examined the factors related to complex care needs in older adults.

RESULTS

A total of 232 directors responded. Complex cases were significantly associated with younger age, poor health conditions, and having a family member who needs care, as compared to straightforward cases where these associations were not present. Logistic regression showed that in older adults, factors of refusing support or social services, social isolation, and trouble with neighbors were associated with their complexities. Additionally, family members with a high likelihood of refusing social services, older adults without a key family member, and difficulties in forming their consensus regarding care were associated with older adults' complexities.

CONCLUSION

Older adults with complex care needs could have the risk of self-neglect, and their families faced difficulties in supporting them as family members. Healthcare professions should carefully assess these factors and develop needs-oriented services for them without their family support as an upstream intervention.

The individualized supervision strategy and effectiveness under the strength perspective: a pilot study for the case management model of the high-care elderly in communities

Background

This study tried to improve the operational efficiency and service quality of the community case management model for the High-Care Elderly in Communities in Taiwan. This study tried to assistant social workers in community care sites to establish individualized treatment planning, to empower them with flexibility to discover and utilize their own unique strengths, to reach the goal of developing community care capacity.

Methods

A case consulting model was employed in this study by providing case by case supervision service. We collected all supervision meeting records and related data as our qualitative research materials, analyzed these materials and tried to define intervention effectiveness of the individualized supervision strategy under the strength perspective applied to the case management model of the high-care elderly in communities. To find out what helps these social workers the most, and how these social workers realize and recognize their process and key to improve their service quality and work efficiency, in the way of qualitative interpretation.

Results

A supervision model under the perspective of strength was developed in this study, and was applied to clinical community care sites to help their social workers. The results proved that our supervision model provided an opportunity to empower and re-know themselves, re-establish their professional confidence and meaning of existence for their organization, and eventually produced positive effect to quality of service and service receiver’s satisfaction improvement. The key feature that made this supervision model of the strength perspective work was to let social workers have the autonomy to interpret the challenges they face and to think possible alternative solutions creatively.

Conclusions

This study showed that create a supervisee-friendly psycho-socio environment empowered these workers by increasing their resource network and taking advantage of what they still have and what they were good at, this could help these workers upgrade their level on ladders of empowerment, become an active and independent professional worker that have power and confidence to make treatment and intervention.

Prevalence and demographic characteristics of high-need community-dwelling older adults in Taiwan

By early screening, the high-need older adults who require multiple care needs and resources can be identified and the necessary assistance can then be provided. However, a precise definition of and related research on high-need older adults are limited. Identifying older adults with high needs is of practical urgency. This study aimed to investigate the prevalence of high-need community-dwelling older adults and to identify the characteristic differences between high-need older adults and those without high needs. This cross-sectional descriptive survey research was conducted between July and December 2018 and used a simple random sampling to select older adults aged 65 and older who had lived in the community for at least 3 months. The High-need Community-dwelling Older Adults Screening Scale was used to identify high-need older adults in the community. A total of 818 community-dwelling older adults were surveyed and the prevalence of high-need older adults was 24.1%. Those screened as high-need older adults (n = 197) were 78.58 (SD = 7.60) years old in average, mostly female, widowed or single but living with someone, had chronic illnesses (M = 2.11, SD = 1.41), an elementary school level of education and religious beliefs. Furthermore, differences were found between older adults with high needs (n = 197) and those without high needs (n = 621) where there is a significantly higher proportion of high-need older adults who were 85 years and older, being male, widowed or single, illiterate, living alone, had chronic illnesses and no religious belief. The high prevalence of high-need community-dwelling older adults highlighted the importance of screening. If community care centres are provided with a comprehensive screening tool for finding high-need older adults during home visits, this would lead to timely identification of older adults with potential needs and enhance the preventive nature of home visits.

Development of a Screening Scale for Community-dwelling Older Adults with Multiple Care Needs

Objectives: To develop a screening scale for community-dwelling older adults with multiple care needs.Methods: A modified Delphi was employed; 10 experts were invited to evaluate the relevancy, clarity, and suitability of the scale. A descriptive evaluation survey was tested on the screening scale users who were community volunteers to evaluate the clarity, relevance, and usefulness of the scale using a 10-point rating system. Confirmatory factor analysis was applied to determine the suitability of the factorial structure of the HCOASS. The internal consistency was examined using Kuder-Richardson Formula 20. A suitable cutoff point was developed using receiver operating characteristic analysis.Results: In the first round of the modified Delphi, the item-level content validity index (I-CVI) on the content relevance, item clarity, and suitability of the scale were all higher than .90, .80, and .80, respectively. In the second round, the scores for content relevancy, item clarity, and suitability were all 1.0. Community volunteers rated highly on the scale. The result of the confirmatory factor analysis indicated a good fit. The internal consistency reliability was satisfactory. The area under curve (AUC), sensitivity, and specificity for cutoff score of 6/7 were .91, 88%, and 81%, respectively.Conclusions: The screening scale demonstrated adequate reliability, content validity, and discriminant validity.Clinical Implications: The screening scale would serve as a reference for community volunteers in the identification of community-dwelling older adults with multiple care needs.