A thorough going over: evidence for health assessments for older persons

Estimating the effect of health assessments on mortality, physical functioning and health care utilisation for women aged 75 years and older

Health assessments have potential to improve health of older people. This study compares long-term health care utilisation, physical functioning, and mortality for women aged 75 years or over who have had a health assessment and those who have not. Prospective data on health service use, physical functioning, and deaths among a large cohort of women born 1921–26 were analysed. Propensity score matching was used to produce comparable groups of women according to whether they had a health assessment or not. The study population included 6128 (67.3%) women who had an assessment, and 2971 (32.7%) women who had no assessment. Propensity matching produced 2101 pairs. Women who had an assessment had more use of other health services, longer survival, and were more likely to survive with high physical functioning compared to women with no assessment. Among women who had good baseline physcial functioning scores, women who had an assessment had significantly lower odds of poor outcomes at 1000 days follow-up compared to women who had no assessment (OR: 0.67, 95%CI: 0.52, 0.85). This large observational study shows the real-world potential for assessments to improve health outcomes for older women. However, they also increased health service use. This increased healthcare is likely to be an important mechanism in improving the women’s health outcomes.

Utilisation of general practice health assessments around an aged care assessment is associated with lower mortality risk in older Australians

OBJECTIVE

(i) to describe the general practitioner utilisation of health assessments, management plans, coordination of team care arrangements and medication review item numbers within 6 months of an aged care eligibility assessment for home care packages (HCP) and (ii) investigate the impact of health assessments on the risk of mortality and entry into permanent residential aged care (PRAC) of individuals accessing HCP.

DESIGN AND SETTING

retrospective cohort study utilising data from the Registry of Senior Australians (ROSA) was conducted.

SUBJECTS

75,172 individuals aged ≥75 years who received HCP between 2011 and 2015.

OUTCOME MEASURE

for objective 1: the use of comprehensive assessments (Medicare Benefits Schedule (MBS) items 705 or 707), management plans (MBS 721), coordination of team care arrangements (MBS 723), and medication reviews (MBS 900). For objective 2: time to death and entry into PRAC.

RESULTS

of the 75,172 individuals, 28.2% (95% confidence interval (CI): 27.8-8.5%) had comprehensive assessments, 36.7% (95% CI: 36.3-37.0%) had management plans, 33.0% (95% CI: 32.7-33.3%) received coordination of team care arrangements and 5.4% (95% CI: 5.2-5.5%) had medication reviews. Individuals with a comprehensive assessment had a 5% lower risk of mortality (adjusted hazard ratio (aHR), 95% CI = 0.95, 0.92-0.98) but 5% higher risk of transition to PRAC (adjusted subdistribution HRs, 95% CI = 1.05, 1.02-1.08) compared to those who did not have these services.

CONCLUSION

the utilisation of health assessments was associated with a lower risk of mortality. There is an opportunity for increased use of item numbers in frailer individuals.

Patterns of geriatric health assessment use among community dwelling older Australian women over a 14-year period

OBJECTIVE

To assess which older Australian women had Medicare subsidized health assessments between 1999 and 2013.

METHODS

This study used prospective, longitudinal survey data from the 1921 to 1926 birth cohort of Australian Longitudinal Study on Women's Health (ALSWH) linked with Medicare Australia data on health services use. Over 11,000 Australian women were included in the study. Latent class analysis was used to identify assessment patterns over time, accounting for death, and based on three categories ('no assessment'; 'assessment; 'deceased') for each year between 1999 and 2013. Further analysis explored the impact of health and sociodemographic characteristics on class membership.

RESULTS

Of the women included in the latent class analysis, 37% never had any assessment and the remainder had had at least one assessment. After a steady uptake from 1999 to 2003, there was decline in uptake from 2003 onwards. A six-class model with sufficient homogeneity and reliable estimation was selected to represent assessment patterns and mortality risk, labelled as: 'high mortality' rate with little chance for assessment (12.4%), 'intermediate mortality, low assessment' (14.1%), 'later mortality/low assessment' (13.1%), 'later mortality, high assessment' (7.0%), 'low mortality, low assessment' (31.8%), 'low mortality, high assessment' (21.6%). Older women with certain conditions (such as diabetes, depression, heart disease) were more likely to be in the low assessment groups, and women with difficulty managing on income were more likely to be in low assessment groups.

CONCLUSION

Distinct assessment and mortality patterns were seen, with many women not having assessment, in particular those who had certain health conditions, were taking 3+ medications, had difficulty in managing on income, needed help or were in respite care, and had caring responsibilities. The findings point to a need to promote these assessments among older women, and to reduce financial barriers, even within the context of a heavily subsidized health care system.

Uptake, prevalence and predictors of first-time use for the 75+ Health Assessment Scheme

In 1999, the Australian Federal Government introduced Medicare items for Health Assessments for people aged 75 years and older (75+ health assessments). This research examined uptake of these assessments and identified predictors of use by women from the Australian Longitudinal Study on Women's Health (ALSWH). Assessments were identified for each year from 1999 to 2013 using linked Medicare data. Time to first assessment was examined, as well as social and health factors associated with having an assessment. From 1999 to 2013, 61.8% of women had at least one assessment. Almost one-third had an assessment within 2 years of their introduction, 25% of women died before having an assessment and 13% survived but did not have an assessment. Factors associated with assessment included being widowed, private health insurance, marital status, education, having arthritis and urinary incontinence, and less difficulty managing on income. Many women never received an assessment, and many only received one. Promotion of the 75+ health assessments is necessary among older women to increase uptake.

Changes in vulnerability among older patients with cardiovascular disease in the first 90 days after hospital discharge: A secondary analysis of a cohort study

OBJECTIVES

(1) To compare changes in vulnerability after hospital discharge among older patients with cardiovascular disease who were discharged home with self-care versus a home healthcare (HHC) referral and (2) to examine factors associated with changes in vulnerability in this period.

DESIGN

Secondary analysis of longitudinal data from a cohort study.

PARTICIPANTS AND SETTING

834 older (≥65 years) patients hospitalised for acute coronary syndromes and/or acute decompensated heart failure who were discharged home with self-care (n=713) or an HHC referral (n=121).

OUTCOME

Vulnerability was measured using Vulnerable Elders Survey 13 (VES-13) at baseline (prior to hospital admission) and 30 days and/or 90 days after hospital discharge. Effects of HHC referral on postdischarge change in vulnerability were examined using three linear regression approaches, with potential confounding on HHC referral adjusted by propensity score matching.

RESULTS

Overall, 44.4% of the participants were vulnerable at prehospitalisation baseline and 34.4% were vulnerable at 90 days after hospital discharge. Compared with self-care patients, HHC-referred patients were more vulnerable at baseline (66.9% vs 40.3%), had more increase (worsening) in VES-13 score change (B=-1.34(-2.07, -0.61), p<0.001) in the initial 30 days and more decrease (improvement) in VES-13 score change (B=0.83(0.20, 1.45), p=0.01) from 30 to 90 days after hospital discharge. Baseline vulnerability and the HHC referral attributed to 14%-16% of the variance in vulnerability change during the 90 postdischarge days, and 6% was attributed by patient age, race (African-American), depressive symptoms, and outpatient visits and hospitalisations in the past year.

CONCLUSION

After adjusting for preceding vulnerability and covariates, older hospitalised patients with cardiovascular disease referred to HHC had delayed recovery in vulnerability in first initial 30 days after hospital discharge and greater improvement in vulnerability from 30 to 90 days after hospital discharge. HHC seemed to facilitate improvement in vulnerability among older patients with cardiovascular disease from 30 to 90 days after hospital discharge.

The Effectiveness and Efficiency of Home-Based Nursing Health Promotion for Older People: A Review of the Literature

Despite the large potential role that community nurses have in providing individualized health promotion to older people, there is a lack of consensus in the literature regarding this role's effectiveness and efficiency. This article presents a literature review and synthesis of 12 randomized controlled trials selected from 344 published studies on preventive home visitation programs for older people. The findings suggest that a diversity of home visiting interventions carried out by nurses can favorably affect health and functional status, mortality rates, use of hospitalization and nursing homes, and costs. Further research is needed that focuses on the outcomes of quality of life, mental health, social support, caregiver burden, the acceptability of intervention, and specific subgroups of clients who benefit most. Findings also indicate the need for a theoretical foundation, increased emphasis on health-promotion strategies, and more research using a more complete economic evaluation to establish efficiency.

The Australian 75+ Health Assessment: could it detect early functional decline better?

OBJECTIVE

The aim of the present study was to identify opportunities to improve the reach and impact of the Australian Medicare 75+ Health Assessment (75+HA) to detect early functional decline (FD).

METHODS

A comparison of two published review articles produced two outputs: (1) assessments identified in the systematic review that underpinned the 75+HA items were ranked for evidence of effectiveness and compared with the volume of research into assessment areas identified by a recent review on indicators of early FD; and (2) items in the 75+HA were compared with those in the recent review.

RESULTS

The review underpinning the 75+HA found 19 assessment areas, with strongest evidence of effectiveness for vision/hearing, teeth/oral, balance/gait, cognitive and service use. The more recent review reported on six domains (eight subdomains) of FD assessment: physical and cognitive elements of the performance capacity domain were the least well assessed, whereas the most comprehensively assessed domains were health service use, performance capacity (mental subdomain), participation (motivation/volition subdomain) and demographics. The 75+HA addresses only some items related to early FD as identified by the recent literature.

CONCLUSION

Reassessment of the 75+HA with a view to including current evidence-based assessments for early FD is recommended. Updating the 75+HA items with ways to detect FD earlier may increase its relevance to Australia's ageing population.

Nurse-led health promotion interventions improve quality of life in frail older home care clients: lessons learned from three randomized trials in Ontario, Canada

OBJECTIVE

This paper explores the lessons learned from a series of three randomized controlled trials that included 498 community-living frail older adults (≥65 years) using home care services in Southern Ontario, Canada. Each study was designed to evaluate the effectiveness of different multi-component nurse-led health promotion and disease prevention (HPDP) interventions.

METHODS

The nurse-led HPDP interventions were 6- or 12-month multi-component and evidence-based strategies targeting known risk factors for functional decline and frailty. Across the three studies, a common approach was used to measure the change in health-related quality of life (HRQOL) (SF-36) and the costs of use of health services (Health and Social Services Utilization Inventory) from baseline to the end of the intervention.

RESULTS

The main lesson learned from the three studies is that nurse-led HPDP interventions for frail older home care clients provide greater improvements in HRQOL compared with usual home care. Such approaches are highly acceptable to this population and can be implemented using existing home care resources. Nurse-led HPDP interventions should include multiple home visits, multidimensional screening and assessment, multi-component evidence-based HPDP strategies, intensive case management, inter-professional collaboration, providers with geriatric training and experience, referral to and coordination of community services, and theory use.

CONCLUSION

The results of the three trials underscore the need to reinvest in nurse-led HPDP interventions in home care to optimize HRQOL and promote ageing in place in the target population of frail older adults. More studies are needed to evaluate the effectiveness of additional nurse-led HPDP interventions in other contexts and settings.

Nurse home visits with or without alert buttons versus usual care in the frail elderly: a randomized controlled trial

OBJECTIVE

To assess whether an intervention based on nurse home visits including alert buttons (NV+AB) is effective in reducing frailty compared to nurse home visits alone (NV-only) and usual care (control group) for older adults.

DESIGN

Unblinded, randomized, controlled trial.

SETTING

Insured population covered by the Mexican Social Security Institute living in the city of Ensenada, Baja California, Mexico.

PARTICIPANTS

Patients were aged over 60 years with a frailty index score higher than 0.14.

INTERVENTION

After screening and informed consent, participants were allocated randomly to the control, NV+AB, or NV-only groups.

MEASUREMENTS

The primary outcome was the frailty score 9 months later. Quality of life, depression, comorbidities, health status, and health service utilization were also considered.

RESULTS

The framing sample included 819 patients. Of those, 591 were not located because they did not have a landline/telephone (341 patients), they had died (107), they were ill (50), or they were not currently living in the city (28). A screening interview was applied to 228 participants, and 57 had a score ≤0.14, 171 had ≥0.14, and 16 refused to complete the baseline questionnaire. A home visit was scheduled for 155 patients. However, 22 did not complete the baseline questionnaire. The final 133 subjects were randomized into the NV+AB (n = 45), NV-only (n = 44), and control (n = 44) groups. There were no statistically significant differences in the baseline characteristics of the groups. The mean age overall was 76.3 years (standard deviation 4.7) and 45% were men. At the baseline, 61.65% were classified as frail. At end of follow-up the adjusted prevalence of frailty in NV+AB group was 23.3% versus 58.3% in the control group.

CONCLUSION

An intervention based on NV+AB seems to have a positive effect on frailty scores.

Home visits for frail older people: a qualitative study on the needs and preferences of frail older people and their informal caregivers

BACKGROUND

A number of studies have examined the effects of home visits and showed inconsistent results on physical functioning, institutionalisation, and mortality. Despite continuing interest from professionals in home visits for older people, reports on older people's needs and preferences for such visits are scarce.

AIM

This qualitative study aims to explore the views and needs of community-dwelling frail older people concerning home visits.

DESIGN AND SETTING

A qualitative study including interviews with frail older persons and their informal caregivers living in the area of Nijmegen, the Netherlands.

METHOD

Semi-structured interviews were conducted with frail older people and informal caregivers. A grounded theory approach was used for data-analysis.

RESULTS

Eleven frail older people and 11 informal caregivers were included. Most participants emphasised the importance of home visits for frail older people. They felt that it would give older people the personal attention they used to receive from GPs but miss nowadays. Most stated that this would give them more trust in GPs. Participants stated that trust is one of the most important factors in a good patient-professional relationship. Further, participants preferred home visits to focus on the psychosocial context of the patient. They stated that more knowledge of the psychosocial context and a good patient-professional relationship would enable the professional to provide better and more patient-centred care.

CONCLUSION

Patients' expectations of home visits are quite different from the actual purpose of home visiting programmes; that is, care and wellbeing versus cure and prevention. This difference may partly explain why the effectiveness of home visits remains controversial. Future studies on home visits should involve patients in the development of home visiting programmes.

First Steps towards Evidence-Based Preventive Home Visits: Experiences Gathered in a Swedish Municipality

The purpose of preventive home visits is to promote overall health and wellbeing in old age. The aim of this paper was to describe the process of the development of evidence-based preventive home visits, targeting independent community-living older persons. The evidence base was generated from published studies and practical experiences. The results demonstrate that preventive home visits should be directed to persons 80 years old and older and involve various professional competences. The visits should be personalized, lead to concrete interventions, and be followed up. The health areas assessed should derive from a broad perspective and include social, psychological, and medical aspects. Core components in the protocol developed in this study captured physical, medical, psychosocial, and environmental aspects. Results of a pilot study showed that the protocol validly identified health risks among older people with different levels of ADL dependence.

Barriers and facilitators to optimize function and prevent disability worsening: a content analysis of a nurse home visit intervention

AIMS

This paper is a report of an analysis of how to better understand the results of the nurse home visit intervention in the Medicare Primary and Consumer-Directed Care Demonstration in terms of facilitators and barriers to disability improvement/maintenance as compared with disability worsening.

BACKGROUND

There is a lack of literature describing how nurse home visit interventions are able to maintain/improve disability among older persons with disability. The present study is one of only six reporting beneficial disability outcomes.

METHODS

Cases were purposefully sampled to represent change in the disability construct leading to selection of ten cases each of disability maintenance/improvement (no change or decrease in total Activities of Daily Living score from baseline) and worsening (an increase in total Activities of Daily Living score from baseline). Data from nurses' progress notes and case studies (collected in March 1998-June 2002) were analysed using qualitative descriptive analysis (May 2009). These results remain relevant because the present study is one of the few studies to identify select nurse activities instrumental in postponing/minimizing disability worsening.

RESULTS/FINDINGS

Three primary themes captured the facilitators and barriers to effective disability maintenance/improvement: (1) building and maintaining patient-centred working relationships, (2) negotiating delivery of intervention components and (3) establishing balance between patients' acute and chronic care needs. Sub-themes illustrate nurse, patient and system factors associated with effective disability maintenance/improvement (e.g. nurse caring, communicating, facilitating interdisciplinary communication) and barriers associated with disability worsening (e.g. dementia, depression and recurring acute illnesses).

CONCLUSION

This study provides new insights about the facilitators and barriers to effective disability maintenance/improvement experienced by patients receiving home visits. Potential opportunities exist to integrate these insights into best-practice models of nurse home visiting.

Comprehensive assessment of older people with complex care needs: the multi-disciplinarity of the Single Assessment Process in England

The quality of assessment of older people with health and social care needs has for some time been a concern of policy makers, practitioners, older people and carers in the United Kingdom and internationally. This article seeks to address a key aspect of these concerns, namely whether sufficient expertise is deployed when, as a basis for a care plan and service allocation, an older person's eligibility for local authority adult social-care services requires a comprehensive needs assessment of their usually complex and multiple problems. Is an adequate range of professionals engaged, and is a multi-disciplinary approach applied? The Single Assessment Process (SAP) was introduced in England in 2004 to promote a multi-disciplinary model of service delivery. After its introduction, a survey in 2005–06 was conducted to establish the prevalence and patterns of comprehensive assessment practice across England. The reported arrangements for multi-disciplinary working among local authority areas in England were categorised and reviewed. The findings suggest, first, that the provision of comprehensive assessments of older people that require the expertise of multiple professionals is limited, except where the possibility arose of placement in a care-home-with-nursing, and second that by and large a systematic multi-disciplinary approach was absent. Policy initiatives to address the difficulties in assessment need to be more prescriptive if they are to produce the intended outcomes.

Effect of preventive primary care outreach on health related quality of life among older adults at risk of functional decline: randomised controlled trial

OBJECTIVE

To evaluate the impact of a provider initiated primary care outreach intervention compared with usual care among older adults at risk of functional decline.

DESIGN

Randomised controlled trial.

SETTING

Patients enrolled with 35 family physicians in five primary care networks in Hamilton, Ontario, Canada.

PARTICIPANTS

Patients were eligible if they were 75 years of age or older and were not receiving home care services. Of 3166 potentially eligible patients, 2662 (84%) completed the validated postal questionnaire used to determine risk of functional decline. Of 1724 patients who met the risk criteria, 769 (45%) agreed to participate and 719 were randomised.

INTERVENTION

The 12 month intervention, provided by experienced home care nurses in 2004-6, consisted of a comprehensive initial assessment using the resident assessment instrument for home care; collaborative care planning with patients, their families, and family physicians; health promotion; and referral to community health and social support services.

MAIN OUTCOME MEASURES

Quality adjusted life years (QALYs), use and costs of health and social services, functional status, self rated health, and mortality.

RESULTS

The mean difference in QALYs between intervention and control patients during the study period was not statistically significant (0.017, 95% confidence interval -0.022 to 0.056; P=0.388). The mean difference in overall cost of prescription drugs and services between the intervention and control groups was not statistically significant, (-$C165 ( pound107; euro118; $162), 95% confidence interval -$C16 545 to $C16 214; P=0.984). Changes over 12 months in functional status and self rated health were not significantly different between the intervention and control groups. Ten patients died in each group.

CONCLUSIONS

The results of this study do not support adoption of this preventive primary care intervention for this target population of high risk older adults. Trial registration Clinical trials NCT00134836.

Feasibility and effects of preventive home visits for at-risk older people: design of a randomized controlled trial

BACKGROUND

The search for preventive methods to mitigate functional decline and unwanted relocation by older adults living in the community is important. Preventive home visit (PHV) models use infrequent but regular visits to older adults by trained practitioners with the goal of maintaining function and quality of life. Evidence about PHV efficacy is mixed but generally supportive. Yet interventions have rarely combined a comprehensive (biopsychosocial) occupational therapy intervention protocol with a home visit to older adults. There is a particular need in the USA to create and examine such a protocol.

METHODS/DESIGN

The study is a single-blind randomized controlled pilot trial designed to assess the feasibility, and to obtain preliminary efficacy estimates, of an intervention consisting of preventive home visits to community-dwelling older adults. An occupational therapy-based preventive home visit (PHV) intervention was developed and is being implemented and evaluated using a repeated measures design. We recruited a sample of 110 from a population of older adults (75+) who were screened and found to be at-risk for functional decline. Participants are currently living in the community (not in assisted living or a skilled nursing facility) in one of three central North Carolina counties. After consent, participants were randomly assigned into experimental and comparison groups. The experimental group receives the intervention 4 times over a 12 month follow-up period while the comparison group receives a minimal intervention of mailed printed materials. Pre- and post-intervention measures are being gathered by questionnaires administered face-to-face by a treatment-blinded research associate. Key outcome measures include functional ability, participation, life satisfaction, self-rated health, and depression. Additional information is collected from participants in the experimental group during the intervention to assess the feasibility of the intervention and potential modifiers. Fidelity is being addressed and measured across several domains.

DISCUSSION

Feasibility indications to date are positive. Although the protocol has some limitations, we expect to learn enough about the intervention, delivery and effects to support a larger trial with a more stringent design and enhanced statistical power.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT00985283.

On the effectiveness of care co-ordination services aimed at preventing hospital admissions and emergency attendances

Finding alternatives to hospital admissions for older people and helping them to live for as long as possible in their own homes is a key objective of UK health and social policy. However, there is a lack of proof as to whether such alternatives actually work and are cost-effective. The research reported in this paper is based on an evaluation of a care co-ordination service with the aim helping people to remain at home and preventing unnecessary hospital admissions and A&E attendances. An initial evaluation found that the effectiveness of the service was at best marginal. The new method of evaluation described in this paper tracks patient attendance at A&E departments and hospital stays 12 months before they are accepted into the care co-ordination service and evaluates the resultant savings in health care activity. It finds that the service results in between 14 and 29 saved hospital bed days per client per year and between three and eight A&E attendances. Whilst the service does not arrest functional decline in individuals, the incidence of falls is significantly reduced, and that the effect on quality of life is neutral to broadly favourable. It finds that mortality levels are higher than in the general population of similar age but this is probably due to selection effects because clients are unhealthier from the outset, and that in the 90+ age group there is no significant difference. Without the benefit of a control group it is not possible to confirm the results with certainty, but corroborating independent evidence is provided that supports the conclusions reached.

Multidimensional preventive home visit programs for community-dwelling older adults: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Multidimensional preventive home visit programs aim at maintaining health and autonomy of older adults and preventing disability and subsequent nursing home admission, but results of randomized controlled trials (RCTs) have been inconsistent. Our objective was to systematically review RCTs examining the effect of home visit programs on mortality, nursing home admissions, and functional status decline.

METHODS

Data sources were MEDLINE, EMBASE, Cochrane CENTRAL database, and references. Studies were reviewed to identify RCTs that compared outcome data of older participants in preventive home visit programs with control group outcome data. Publications reporting 21 trials were included. Data on study population, intervention characteristics, outcomes, and trial quality were double-extracted. We conducted random effects meta-analyses.

RESULTS

Pooled effects estimates revealed statistically nonsignificant favorable, and heterogeneous effects on mortality (odds ratio [OR] 0.92, 95% confidence interval [CI], 0.80-1.05), functional status decline (OR 0.89, 95% CI, 0.77-1.03), and nursing home admission (OR 0.86, 95% CI, 0.68-1.10). A beneficial effect on mortality was seen in younger study populations (OR 0.74, 95% CI, 0.58-0.94) but not in older populations (OR 1.14, 95% CI, 0.90-1.43). Functional decline was reduced in programs including a clinical examination in the initial assessment (OR 0.64, 95% CI, 0.48-0.87) but not in other trials (OR 1.00, 95% CI, 0.88-1.14). There was no single factor explaining the heterogenous effects of trials on nursing home admissions.

CONCLUSION

Multidimensional preventive home visits have the potential to reduce disability burden among older adults when based on multidimensional assessment with clinical examination. Effects on nursing home admissions are heterogeneous and likely depend on multiple factors including population factors, program characteristics, and health care setting.

Functional ability and health complaints among older people with a combination of public and informal care vs. public care only

The aim of the study was to investigate functional ability and health complaints of people, 65+, living in special accommodation (equivalent to nursing home) and their counterparts who live at home and receive municipal care or a combination of municipal and informal care. Persons (n = 1958) receiving municipal care were assessed in terms of functional ability, health complaints, and level of informal and municipal care and services. The results showed that more home care, services and help with Instrumental Activities of Daily Living (IADL) were provided to those receiving only municipal care at home, while more home care and services associated with Personal Activities of Daily Living (PADL) as well as nursing care were provided to those receiving informal care in addition to formal care. Cohabitation was a predictor of a combination of municipal and informal care in the home (OR: 5.935), while assistance with IADL provided by municipal home care and services predicted municipal care only (OR: 0.344). Care in special accommodation was predicted by advanced age (OR: 1.051), dependency in IADL (OR: 19.883) and PADL (OR: 2.695), and impaired cognitive ability (OR: 3.849) with receiving municipal care only as a reference. Living alone (OR: 0.106), dependency in IADL (OR: 11.348) and PADL (OR: 2.506), impaired cognitive ability (OR: 3.448), impaired vision or blindness (OR: 1.812) and the absence of slowly healing wounds (OR: 0.407) were predictors of special accommodation with a combination of informal and municipal care at home as a reference. The distribution of municipal care divided older people into three distinct groups. The most frail and elderly people who had no cohabitants received care in special accommodation, determined by their level of physical and cognitive dependency. The frailest individuals living at home were cohabiting and received a combination of municipal and informal care, while those who were less dependent mainly had help with IADL from municipal care only. The results indicate that there is a shift from the substitution to the complementary model and highlights that attention to the family carers is needed.

Annual health assessments for older Australian women: uptake and equity

OBJECTIVE

To measure utilisation of Enhanced Primary Care (EPC) health assessment items for women aged 75 years and over, and to describe health and socio-demographic characteristics of users and non-users.

METHOD

Analysis of longitudinal survey and Medicare claims data from women in the Australian Longitudinal Study on Women's Health (ALSWH) aged 75 to 78 years when EPC items were introduced and who provided permission to access their Medicare records for the period 1999-2003 (n = 4,646).

RESULTS

There was an increase in uptake of assessments over four years: from November 1999, 12% of eligible women had a health assessment during the following year; by October 2003, 49% had at least one health assessment ever. Few had repeat assessments. Women who visited a GP more often and who were satisfied with the number of GPs available were more likely to have an assessment in the first 12 months, and women who visited a GP more often, those taking more medications, and those caring for another were more likely to have at least one assessment in four years. Women in smaller rural and remote areas were less likely to have an assessment than women in urban areas.

CONCLUSIONS

Most women are not having annual assessments and there is some geographic inequity.

Health promotion for frail older home care clients

AIM

This paper reports a study evaluating the comparative effects and costs of a proactive nursing health promotion intervention in addition to usual home care for older people compared with usual home care services alone.

BACKGROUND

An ageing population, budget constraints and technological advances in many countries have increased the pressure on home care resources. The result is a shift in nursing services from health promotion to meet the more pressing need for postacute care. For frail older people with long-term needs, these changes combine to create a fragmented system of health service delivery, characterized by providing nursing on demand rather than proactively.

METHODS

A two-armed, single-blind, randomized controlled trial was carried out with older people > or =75 years and eligible for personal support services through a home care programme in Ontario, Canada. Participants were randomly allocated either to usual home care (control) or to a nursing (experimental) group. In addition to usual home care, the nursing group received a health assessment combined with regular home visits or telephone contacts, health education about management of illness, coordination of community services, and use of empowerment strategies to enhance independence. The data were collected in 2001-2002.

RESULTS

Of the 288 older people who were randomly allocated at baseline, 242 (84%) completed the study (120 nursing group; 122 control group). Proactively providing older people with nursing health promotion, compared with providing nursing services on-demand, resulted in better mental health functioning (P = 0.009), a reduction in depression (P = 0.009), and enhanced perceptions of social support (P = 0.009) at no additional cost from a societal perspective.

CONCLUSIONS

Home based nursing health promotion, proactively provided to frail older people with chronic health needs, enhances quality of life while not increasing the overall costs of health care. The results underscore the need to re-invest in nursing services for health promotion for older clients receiving home care.

Older people in Sweden with various degrees of present quality of life: their health, social support, everyday activities and sense of coherence

Public health policies in most European countries are concerned with how to keep older people living independently with a qualitatively good life in the community as long as possible. However, knowledge about what may characterise those seemingly 'healthy' older people is sparse. The aim of the study was to investigate the characteristics of a sample of people (75+) reporting various degrees of Quality of Life (QoL) with respect to QoL in different areas, as well as self-rated health, health problems, social support, everyday activities and sense of coherence. A postal questionnaire was sent out in spring 2001 to a randomly selected population-based sample (n= 600) in the southern parts of Sweden. A two-step cluster analysis was performed (n= 385, mean age 84.6, SD = 5.7) with 'present QoL' as clustering attribute. Three groups were disclosed, classified as high, intermediate and low present QoL, of which 33.8% could be regarded being at risk of low QoL. Those with low present QoL (18.4%) were the oldest and most vulnerable, a majority were women with 'poor or bad' self-rated health, high frequencies of health problems, low total QoL, low social support and sense of coherence and less physically active. Those with high present QoL (47.8%) reported more 'excellent or good' self-rated health, physical activity, satisfactory social support and higher sense of coherence and total QoL than the other two groups. Those with intermediate present QoL (33.8%) had more of 'poor or bad' self-rated health, more health problems were less physically active, had lower total QoL and sense of coherence, and less social support than those with high present QoL. The sample seemed to reflect the ageing process in that the respondents were at different stages of ageing. However, the fact that the level of social support, sense of coherence and self-rated health followed the same curve as QoL may indicate that some are more vulnerable to low present QoL given the same health and these should be targeted in preventive programmes since they report low QoL.

Comparison of the uptake of health assessment items for Aboriginal and Torres Strait Islander people and other Australians: implications for policy

BACKGROUND

Health Assessment (HA) items were introduced in 1999 for Aboriginal and Torres Strait Islander people aged at least 55 years and all Australians aged over 75 years. In 2004 a new item was introduced for HAs among adult Aboriginal and Torres Strait Islander people aged 15-54 years. The new item has been applauded as a major policy innovation however this enthusiasm has been tempered with concern about potential barriers to its uptake. In this study we aim to determine whether there are disparities in uptake of HA items for Aboriginal and Torres Strait Islander people compared to other Australians.

METHOD

The analysis was based on Health Insurance Commission data. Indigenous status was ascertained based on the item number used. Logistic regression was used to compare uptake of HA items for older people among Aboriginal and Torres Strait Islander people compared to other Australians. Adjustments were made for dual eligibility. Uptake of the HA items for older people was compared to the uptake of the new item for Aboriginal and Torres Strait Islander people aged 15-44 years.

RESULTS

Our analyses suggest a significant and persistent disparity in the uptake of items for older patients among Aboriginal and Torres Strait Islander people compared to other Australians. A similar disparity appears to exist in the uptake of the new adult Aboriginal and Torres Strait Islander HA item.

CONCLUSION

Further engagement of primary care providers and the community around the uptake of the new HA items may be required to ensure that the anticipated health benefits eventuate.

Structured home visits to older people. Are they only of benefit for women? A randomised controlled trial

OBJECTIVE

To investigate whether education of primary care professionals improved functional ability in home-dwelling older people, with special focus on gender differences.

DESIGN

A prospective controlled three-year follow-up study (1999-2001) with randomisation and intervention at municipality level and outcomes measured at individual level. Intervention municipality visitors received regular education and GPs were introduced to a short assessment programme. Control municipalities received no education but conducted the preventive programme in their own way.

SETTING

Primary care, 34 municipalities.

SUBJECTS

5788 home-dwelling 75- and 80-year-olds were invited. 4060 (70.1%) participated: 2104 in 17 intervention- and 1956 in 17 matched control-municipalities. The main outcome measure was obtained from 3383 (95.6%) of 3540 surviving participants.

MAIN OUTCOME MEASURE

Functional ability.

RESULTS

Municipality intervention in coordination with GPs was associated with better functional ability in women (OR: 1.26; CI95: 1.08-1.47, p=0.004), but not in men (OR: 1.04; CI95: 1.85-1.27). Accepting and receiving free preventive home visits was associated with better functional ability among women (OR: 1.36; CI95: 1.16-1.60, p=0.0002), but not among men (OR: 0.98; CI95: 0.80-1.21).

CONCLUSION

A brief, feasible educational intervention for primary care professionals and to accept and receive preventive home visits may have effect in older women, but not in older men.

Residential aged care and general practice: workforce demographic trends, 1984-2000

OBJECTIVE

To examine the demographic changes in the cohort of general practitioners servicing residential aged-care facilities (RACFs) from 1984 to 2000.

DESIGN

Quantitative analysis of Medicare datasets from 1984 to 2000.

PARTICIPANTS AND SETTING

All GPs who provided Medicare-claimed RACF services from 1984 to 2000.

MAIN OUTCOME MEASURES

Aggregate data on RACF GPs by age group and sex; total and average number of RACF services by GP age group and sex.

RESULTS

The proportion of RACF GPs younger than 35 years has declined from a peak of 30.2% in 1986 to 11.5% in 2000. GPs aged 45 years and older made up 58.1% of all RACF GPs in 2000, compared with 41.4% in 1984. In 2000, 28.4% of RACF GPs were female, compared with 13.5% in 1984. The proportion of RACF services provided by GPs younger than 35 years fell from 19.2% in 1984 to 4.5% in 2000, and the proportion provided by GPs aged 45 years and older increased from 54.7% to 72.4%. Female GPs' RACF services as a proportion of all RACF services increased from 8.9% to 15.9% between 1984 and 2000, but the average number of RACF services per female GP declined by 15.6 services per year. In contrast, the average number of RACF services per male GP increased by 11.2 per year. The increasing rate of RACF servicing by older GPs is independent of female GPs' declining involvement.

CONCLUSION

Our results suggest an increasing reliance on older, male GPs in the supply of RACF services. Although the proportion of female RACF GPs has increased, average services by these GPs, who are generally younger, has declined. The personal and work preferences of female GPs may have implications for future RACF services supply as older, generally male, GPs retire.

The experiences of non-medical health professionals undertaking community-based health assessments for people aged 75 years and over

Our objective was to explore the perceptions of allied health professionals who conducted over 3000 home-based health assessments within the general-practice-dominated Australian primary healthcare system. A series of semistructured qualitative interviews were carried out within the Department of Veterans' Affairs 'Preventive Care Trial', where health assessments are undertaken by health professionals in the homes of participating veterans and war widows. Health professionals were employed within the Preventive Care Trial to conduct assessments in 10 areas of New South Wales and Queensland. Subjects were mainly registered nurses, but also included a social worker, an occupational therapist, a physiotherapist and a psychologist. The health professionals described positive attitudes towards the health assessments, and showed that they have the broad range of necessary personal and professional skills to undertake them. Home visits were seen as an essential component and the most useful aspects included direct observation of home safety and medications. This study demonstrates that health assessments for older people can be acceptably and competently undertaken by suitably qualified allied health professionals, and that an effective collaborative approach to patient care can be achieved through such a system.

A randomised controlled trial of the outcome of health assessment of people aged 75 years and over

OBJECTIVES

To measure the outcomes of a health assessment, conducted by a nurse, of people aged 75 years and older (75+HA) living independently in their own homes.

DESIGN

Randomised controlled trial (RCT).

SETTING

A convenience sample of six general practices within the Adelaide Western Division of General Practice (AWDGP). A random sample of 100 participants was drawn from practice age-sex registers. Data were collected in initial visits between 1 August 1998 and February 1999, then in follow-up visits one year later.

PARTICIPANTS

Participants were aged 75 years and over on 1 August 1998 and living independently in the community. 145 eligible patients were invited to join the study, and 100 of these consented to enrol (69%).

INTERVENTION

A 75+HA conducted in the participant's home by a nurse and reported to their usual general practitioner.

MAIN OUTCOME MEASURES

Primary: number of problems in each group; number of participants with problems; and mortality. Secondary: physical function; psychological (including cognitive) function; falls; and admission to institution.

RESULTS

There were no significant differences between the control and intervention groups at follow-up in the number of problems, the number of participants with problems, or mortality. In the intervention group, there was significant improvement in self-rated health, geriatric depression score (GDS 15), and number of falls.

CONCLUSIONS

This RCT has not demonstrated improvement in health status of the intervention group which received a 75+HA compared with a control group left to usual care.