A realist review of the home care literature and its blind spots

Differentiating Between Home Care Types to Identify Older Adults at Risk of Adverse Health Outcomes in the Community

OBJECTIVES

Acute hospitalization, recurrent admissions, institutionalization, and death are important adverse health outcomes. Older adults receiving home care are especially at risk of these outcomes, yet it remains unclear if this risk differs between older adults receiving different types of home care and older adults not receiving home care.

DESIGN

Retrospective cohort study using national claims data from 2019.

SETTING AND PARTICIPANTS

Community-dwelling Dutch individuals aged ≥ 65 years (N = 3,174,953).

METHODS

Participants were categorized: no home care, household help, personal care, household help combined with personal care, or nursing home care at home. The primary outcomes were the number of people experiencing acute hospitalization, recurrent admissions, institutionalization, or death. Logistic regression models were applied.

RESULTS

In total, 2,758,093 adults were included in the no home care group, 131,260 in the household help group, 154,462 in the personal care group, 96,526 in the household help combined with personal care group, and 34,612 in the nursing home care at home group. The risk of adverse outcomes differed between home care groups, with all showing higher odds compared with the no home care group. Individuals receiving household help combined with personal care had the highest odds for acute hospitalization (odds ratio [OR], 2.60; 95% CI, 2.55-2.64) and recurrent admissions (OR, 2.60; 95% CI, 2.55-2.65), while those receiving nursing home care at home had the highest odds for death (OR, 7.59; 95% CI, 7.35-7.85) and institutionalization (OR, 63.22; 95% CI, 60.94-65.58).

CONCLUSIONS AND IMPLICATIONS

Differentiating between the type of home care older adults receive identifies subpopulations with different risks for adverse health outcomes compared with older adults not receiving home care. Older adults receiving personal care (nurse based) are at high risk for these outcomes and represent a substantial population with prevention potential. Future research should focus on developing effective interventions for this group.

Exploring Norwegian homecare healthcare professionals' perceptions of risk and the link to high-quality care: a qualitative multiple case study

OBJECTIVES

Homecare is a critical component of the ongoing restructuring of healthcare worldwide, given the shift from institution- to home-based care. The homecare evidence base still contains significant gaps: There is a lack of knowledge regarding quality and safety work and interventions. This study explores how home healthcare professionals perceive and use the concept of risk to guide them in providing high-quality healthcare while maintaining resilience.

DESIGN

The study design is a qualitative multiple case study. The phenomena explored were risk perception, sensemaking and adaptations of care delivered to patients in their homes. Inductive content analysis was conducted.

SETTING

The study was conducted in three Norwegian municipalities. Each municipality was defined as a single case.

PARTICIPANTS

Interviews with healthcare professionals were performed both individually and in focus groups of three to five persons. 19 interviews with 35 informants were conducted: 11 individual semistructured interviews and 8 focus groups.

RESULTS

Four themes were identified: 'professionalism is constantly prioritising and aligning care based on here-and-now observations' 'teamwork feels safe and enhances quality' 'taking responsibility for system risk' and 'reluctantly accepting the extended expectations from society'.

CONCLUSIONS

To make sense of risk when aspiring for high-quality care in everyday work, the healthcare professionals in this sample mainly used their clinical gaze, gut feeling and experience to detect subtle changes in the patients' condition. Assessing risk information, not only individually but also as a team, was reportedly crucial for high-quality care. Healthcare professionals emphasised the well-being, safety and soundness of the patients when acting on risk information. They felt obliged to act on their gut feeling, moral compass and clinical understanding of quality.

Tensions experienced by case managers working in home care for older adults in Quebec: first level analysis of an institutional ethnography

BACKGROUND

Case managers play a vital role in integrating the necessary services to optimise health-related goals and outcomes. Studies suggest that in home care, case managers encounter tensions in their day-to-day work, that is, disjuncture between what they should do, in theory, and what they actually do, in practice. However, direct exploration of these tensions is lacking. As such, this study aimed to describe the tensions encountered by case managers in public home care for older adults in Quebec and their influence on day-to-day work.

METHODS

An institutional ethnography was conducted through observations of work, interviews and a survey with case managers working in home care in Quebec. Data were analysed using institutional ethnography first-level analysis procedures. This included mapping the work sequences as well as identifying the tensions experienced by case managers through the words they used.

RESULTS

Three main tensions were identified. First, case managers perceive that, despite working to return hospitalised older adults at home safely, their work also aims to help free up hospital beds. Thus, they often find themselves needing to respond quickly to hospital-related inquiries or expedite requests for home care services. Second, they are supposed to delegate the care to "partners" (e.g., private organisations). However, they feel that they are in effect managing the quality of the services provided by the "partners." Consequently, they go to great lengths to ensure that good care will be provided. Finally, they must choose between meeting organisational requirements (e.g., reporting statistics about the work, documenting information in the older adults' file, doing mandatory assessments) and spending time providing direct care. This often leads to prioritising direct care provision over administrative tasks, resulting in minimal reporting of essential information.

CONCLUSION

The results are discussed using the three lenses of professional practice context analyses (i.e., accountability, ethics, and professional-as-worker) to formulate recommendations for practice and research. They suggest that, despite their important role, case managers have limited power in home care (e.g., with partners, with the hospital).

Individual goal-setting in municipal homecare: A participatory appreciative action and reflection study

Background

There is a need for structural change in municipal homecare to shift power to older persons and to center the individuals in need. To make this change, the individual older persons should have enough self-determination to formulate their own individual homecare goals. Our aim was to explore how stakeholders reason about individual goal-setting in homecare.

Design and methods

We theoretically and methodologically used a participatory appreciative action and reflection (PAAR) design. The stakeholders, that is, the older persons, the older persons' relatives, and the multi-professional team, were seen as co-researchers. Data were collected between 2019 and 2020 through in depth-interviews, focus group discussions, and reference groups. The data were analyzed using thematic analysis.

Results

We learned from the stakeholders that it was a struggle to sustain the individual's goal to continue life as usual, that is, being an ordinary human being with an ordinary everyday life and maintaining individual roles. The individual wants to improve health, be active, and enjoying life. The individuals were struggling against the homecare organization, which tended to overshadow the individual's goals. The individual's goals fall under several legal jurisdictions and come to be overshadowed by the professionals' dominant goal. The organization is rigid, with finances and resources creating the framework.

Conclusion

We learned that older persons receiving homecare must have the same rights as other citizens in society, which is in line with public health goals.

Research priorities for homecare for older people: A UK multi-stakeholder consultation

Homecare is generally understood to refer to services that support people to continue living in their own homes. Older people are the primary users and many countries report an increase in the number using homecare services and greater spending on such provision, driven in part by investment in 'ageing in place' policies. Despite this, and reflecting social care more generally, homecare is relatively under-researched. However, in the UK at least, there is growing interest and investment in social care research. In order that this investment is not wasted, it is essential that research addresses what stakeholders identify as research priorities. This study reports work undertaken in the UK during 2021/22 to identify research priorities for homecare for older people, and a broad scoping of existing evidence. A two-stage consultation process was used. First, topic areas for research were identified through consultations with stakeholders. Second, a survey ascertained agreement and differences between groups regarding the relative importance of topic areas as research priorities. Over 50 people participated including older people (n = 7), family members (n = 11), homecare workers (n = 16), homecare providers (n = 9) and national policy, evidence and advocacy leads (n = 13). Twenty discrete research topic areas were identified. Only one topic area (Joint working between homecare and health services) was a 'Top 5' research priority for all stakeholder groups. Timely engagement with homecare and Workforce: recruitment and retention were 'Top 5' priorities for three stakeholder groups. Scoping of existing research indicates that topic areas receiving the most research attention to date are not among those identified as being of high priority for research. To our knowledge, this is the first time research priorities for homecare have been generated. Findings will be of value to research funders, organisations using research evidence and the research community.