Assessing the needs of the elderly using unsolicited visits by health visitors

Home-based assessment for family carers: a preventative strategy to identify and meet service needs

OBJECTIVE

To identify unmet need for services among family carers and their frail or disabled relatives and to facilitate links to services.

DESIGN

Intervention study with a subgroup of carer dyads from a random statewide survey of family carers, followed by telephone 2 months post intervention.

SETTING

Carer dyads in general community; urban and rural Victoria.

PARTICIPANTS

All 186 identified carers were approached. One-third of the dyads were ineligible; of the remainder, 67 (53%) participated, matching refusals on sociodemographic characteristics. Carers were typically married, middle-aged women looking after parents or spouses. Almost half of the care recipients were aged > or = 80; most had multiple disorders and impairments. Follow-up rate was 94%.

INTERVENTION

One off, multidisciplinary home-based assessment of dyad by research team and regional aged care assessment service (ACAT).

MAIN OUTCOME MEASURES

"Unmet need': % dyads recommended new services; number services per dyad via ACAT; increases in service range; extension of pre-existing services. Service linkage: % dyads linked to new services; perceived usefulness of linkages.

MAIN RESULTS

Dyads recommended a new service (93%); increased range (73%); extensions (41%). Average two services requiring ACAT implementation; commonly respite care, aids and paramedical services. Recommendations related to impairment severity and carer stress. ACAT implemented recommendations (90% relevant dyads); links rated useful (75% relevant dyads). Three-quarters of the carers rated intervention as helpful.

CONCLUSION

A preventative programme of needs assessment for carer dyads has considerable potential; (a) identifying needs and engaging new services; (b) providing emotional support.

Case management: a randomized controlled study comparing a neighborhood team and a centralized individual model

This randomized controlled study compared two types of case management for skilled nursing level patients living at home: the centralized individual model and the neighborhood team model. The team model differed from the individual model in that team case managers performed client assessments, care planning, some direct services, and reassessments; they also had much smaller caseloads and were assigned a specific catchment area. While patients in both groups incurred very high estimated health services costs, the average annual cost during 1983-85 for team cases was 13.6 percent less than that of individual model cases. While the team cases were 18.3 percent less expensive among "old" patients (patients who entered the study from the existing ACCESS caseload), they were only 2.7 percent less costly among "new" cases. The lower costs were due to reductions in hospital days and home care. Team cases averaged 26 percent fewer hospital days per year and 17 percent fewer home health aide hours. Nursing home use was 48 percent higher for the team group than for the individual model group. Mortality was almost exactly the same for both groups during the first year (about 30 percent), but was lower for team patients during the second year (11 percent as compared to 16 percent). Probable mechanisms for the observed results are discussed.

The yield of a home visit in the assessment of geriatric patients

Elderly patients often have problems not easily detected during an office visit. We investigated the yield of a home visit by a geriatric nurse specialist as part of an interdisciplinary assessment process. Compared with the findings of an office-based assessment by a general internist, the home visit resulted in up to four new problems (median = 2, mean = 1.7, 95% confidence interval = 1.5-1.8) and one to eight new recommendations (median = 4, mean = 3.6, 95% confidence interval = 3.4-3.9). Twenty-three percent of the problems could have resulted in death or significant morbidity. The most frequent problems related to psychobehavioral difficulties (23.1% of problems involving 38.3% of patients), safety (21.6% of problems involving 35.7% of patients), and caregiver related problems (20.4% of problems involving 33.8% of patients). The most common recommendations related to safety (30.7% of recommendations involving 81.8% of patients), caregiver well-being (19.8% of recommendations involving 52.6% of patients), and social issues (12.7% involving 33.8% of patients). Baseline clinical information did not predict the yield of the home visit in this sample. We conclude that an in-home assessment contributes unique and meaningful information to the geriatric assessment process.