Home care for older couples: "it feels like a security blanket . . ."

Which features of ambulatory healthcare are preferred by people aged 80 and over? Findings from a systematic review of qualitative studies and appraisal of confidence using GRADE-CERQual

Background

Despite healthcare providers’ goal of patient-centeredness, current models for the ambulatory (i.e., outpatient) care of older people have not as yet systematically incorporated their views. Moreover, there is no systematic overview of the preferable features of ambulatory care from the perspective of people aged 80 and over. Therefore, the aim of this study was to summarize their specific wishes and preferences regarding ambulatory care from qualitative studies.

Methods

The study was based on qualitative studies identified in a prior systematic review. Firstly, the findings of the qualitative studies were meta-summarized, following Sandelowski and Barroso. Secondly, a list of preferred features of care from the perspective of older people was derived from the included studies’ findings through inductive coding. Thirdly, the review findings were appraised using the GRADE-CERQual tool to determine the level of confidence in the qualitative evidence. The appraisal comprised four domains: methodological limitations, coherence, data adequacy, and data relevance. Two reviewers independently evaluated every review finding in each domain. The final appraisals were discussed and ultimately summarized for the respective review finding (high, moderate, low, or very low confidence).

Results

The 22 qualitative studies included in the systematic review were mainly conducted in Northern and Western Europe (n = 15). In total, the studies comprised a sample of 330 participants (n = 5 to n = 42) with a mean or median age of 80 and over. From the studies’ findings, 23 preferred features of ambulatory care were identified. Eight features concerned care relationships (e.g., “Older people wish to receive personal attention”), and 15 features concerned healthcare structures (e.g., “Older want more time for their care”). The findings emphasized that older people wish to build strong relationships with their care providers. The majority of the review findings reached a moderate or high confidence appraisal.

Conclusions

While the listed features of healthcare structures are common elements of care models for older people (e.g., Geriatric Care Model), aspects of care relationships are somewhat underrepresented or are not addressed explicitly at all. Future research should further explore the identified preferred features and their impact on patient and care outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03006-6.

Association Between New-Onset Medicaid Home Care and Family Caregivers' Health

Importance

More than 17 million people in the US provide uncompensated care for adults with physical or cognitive limitations. Such caregiving is associated with worse mental and physical health, yet little research has investigated how publicly funded home care might ameliorate these harms.

Objective

To investigate the association between Medicaid home care services and family caregivers' health.

Design Setting and Participants

This longitudinal cohort study used data from the 1996 to 2017 Medical Expenditures Panel Survey. Data on all household members were collected in 5 interviews over 2 years. Person-level difference-in-difference models were used to isolate within-person changes associated with new onset of Medicaid home care. The Medical Expenditures Panel Survey longitudinal data sets included 331 202 individuals (approximately 10% excluded owing to loss to follow-up). Adult (age ≥21 years) members of households that contained at least 1 person with limited activities of daily living were included in our study. The analysis itself was performed from March to August of 2020.

Exposures

New onset of regular (≥1 time per month) Medicaid home care in the household.

Main Outcomes and Measures

Self-rated mental and physical health (planned prior to beginning the study).

Results

The study population was 14 013 adults; 7232 were "likely caregivers," or nondisabled adult coresidents of someone with activities of daily living limitations. Overall, 962 likely caregivers were ever exposed to Medicaid home care in the household; for 563, we observed the onset. Of likely caregivers exposed to Medicaid home care, 479 (50%) were women; 296 (31%) were White non-Hispanic, 309 (31%) were Hispanic or Latinx, and 279 (29%) were Black non-Hispanic individuals, respectively; 326 (34%) had less than a high school education; and 300 (31%) were in or near poverty. Median age of participants was 51 (interquartile range, 39-62) years. New-onset Medicaid home care was associated with a 0.08 standard deviation improvement in likely caregivers' self-rated mental health (95% CI, 0.01-0.14; P = .02) measured 1 to 6 months after onset, equivalent to a 3.39% improvement (95% CI, 0.05%-6.33%) over their average preonset mental health. No association with self-rated physical health was found (<0.001 standard deviations; 95% CI, -0.06 to 0.06; P = .99).

Conclusions and Relevance

In this cohort study, Medicaid home care was associated with improvement in caregiver self-rated mental health, but not with any short-term change in self-rated physical health. When evaluating the social value of home care programs, policy makers should consider spillover benefits to caregivers.

What matters to people aged 80 and over regarding ambulatory care? A systematic review and meta-synthesis of qualitative studies

The growing percentage of the population aged 80 and over is challenging for healthcare systems, as frailty and other complex health issues are common in this age group. In order to provide patient-centered ambulatory healthcare, their preferences and expectations need to be explored. Therefore, the aim of this study was to systematically search for and synthesize qualitative evidence on how people aged 80 and over believe ambulatory healthcare (medical and nursing care) should be delivered to them. Medline, PsycINFO, CINAHL, Web of Science Core Collection and Google Scholar were searched for full research reports of qualitative studies focusing on the preferences, wishes, needs, expectations and experiences of people aged 80 and over regarding ambulatory medical and nursing care. The results were screened by two independent reviewers using a two-step approach. The included studies were meta-synthesized using Thomas and Harden’s ‘thematic synthesis’ approach in order to gain a new, second-order interpretation of the findings of the primary studies. In the intermediate synthesis step, 14 aspects of healthcare structures and care relationships were identified as relevant. Based on these, three underlying wishes were found: feeling safe, feeling like a meaningful human being, and maintaining control and independence. The results of this review are in line with other research, such as reviews focusing on the preferences of the younger age group (65–80). However, the importance of aspects of care relationships as an integral part of favorable ambulatory healthcare and the wish to be strengthened as a meaningful human being are emphasized more strongly.

Maneuvering the care puzzle: Experiences of participation in care by frail older persons with significant care needs living at home

PURPOSE

Despite evidence that older persons want to be involved in care, little is known about how frail older people with significant care needs living at home experience participation in care provided by different stakeholders. This study investigates the experiences of participation in care by older people following their involvement in an intervention of a health care model called Focused Primary care (FPC).

METHODS

Individual semi-structured interviews were conducted with 20 older persons in five municipalities in Sweden.

RESULTS

The results show that older persons highlighted opportunities and limitations for participation on a personal level i.e., conditions for being involved in direct care and in relation to independence. Experiences of participation on organizational levels were reported to a lesser degree. This included being able to understand the organizational system underpinning care. The relational dimensions of caregiving were emphasized by the older persons as the most central aspects of caregiving in relation to participation.

CONCLUSIONS

Primary care should involve older persons more directly in planning and execution of care on all levels. An ongoing connection with one specialized elderly team and a coordinating person in Primary care who safeguards relationships is important for providing participation in care for frail older persons with significant care needs living at home.

An integrative counselling program to promote active ageing for older people in Thai nursing homes: an intervention mixed methods design

BACKGROUND

Active ageing has been a rapidly developing field of study in light of the growing population of older people. Acknowledgement of the lack of a counselling program to promote active ageing for the older people in nursing homes led to the development of this study which aims to investigate active ageing of the Thai elderly in a nursing home in addition to promoting active ageing for them through integrative counselling.

METHODS

The study was conducted in a nursing home in Samut Prakan province, Thailand. The integrative counselling program referred to appropriate literature along with implementation of the Satir Model and Motivational Interviewing techniques. An intervention mixed methods design was applied in the study, which consisted of two phases. Phase 1 involved an investigation of the concept of active ageing, based on the context of older people in nursing homes by way of in-depth interviews, involving 5 participants. Phase 2 comprised of an investigation of the effects of an integrative counselling program to promote active ageing for older people in the same nursing home. There was a total of 16 participants in phase 2 which were divided equally into experimental and control groups respectively.

RESULTS

Phase 1 of the study showcased qualitative results of the progress of active ageing development in older people that resulted in 4 sub-themes (Health development, spiritual development, active engagement and psychosocial support). Two parameters were used to analyze the results in phase 2. The quantitative results showed that the active ageing score of participants in the experimental arm increased significantly after enrollment (p < 0.05). Furthermore, the experimental group had a higher overall active ageing score in comparison to the control group. Qualitative results of phase 2 elicited factors promoting active ageing in the elderly which included activities, group facilitator and group atmosphere. Both quantitative and qualitative results of phase 2 proved to be significant, showing that the program managed to develop active ageing in participants.

CONCLUSION

Psychologists and multidisciplinary teams looking after older people in nursing homes are able to use this integrative counselling program for development of active ageing in the elderly population.

Psychometric evaluation of the German version of a social support scale of FAFHES (Family Functioning, Family Health and Social Support)

BACKGROUND

Family members often need to be supported in informal care of the elderly and desire to be involved into care planning and decision-making. Valid and reliable instruments are needed to measure how family members perceive the care and support they receive from nurses for older family members living at home.

AIM

The purpose of this study was to translate the 20-item social support scale of the Family Functioning, Family Health and Social Support (FAFHES) questionnaire from English to German and test the validity and reliability of the scale among Swiss-German-speaking family caregivers of home-dwelling elderly people who receive home healthcare services.

METHODS

A cross-sectional study was conducted to test the empirical and psychometric properties of the translated and culturally adapted version of the social support questionnaire. A factor analysis with the principal component analysis PCA was used to test construct validity. The internal consistency of items was measured with the Cronbach`s alpha coefficient.

RESULTS

After a rigorous translation process the original 20-item questionnaire was adapted into a 19-item version and tested with family caregivers (n = 207) of home-dwelling elderly. Psychometric testing of the German version of the social support questionnaire revealed that the three factors - affirmation, affect and concrete aid - were congruent with the original questionnaire. The accounted variance was 79.5% and the internal consistency determined by the Cronbach's alpha was 0.973.

CONCLUSION

The German version of the social support scale of the FAFHES questionnaire is a valid and reliable instrument to assess family perceived support on three dimensions - affirmation, affect and concrete aid - received from nursing professionals. The questionnaire should be tested further in other German-speaking populations.

Safety of older people at home: An integrative literature review

AIM

The aim of this review was to examine the relevant health literature, to describe safety in the homes of older and older people's perceptions and understanding of their safety at home based on current literature.

BACKGROUND

Safety is a multifaceted, basic need of older people living at home. Many studies are hospital focused and few focus on safety at home. Research on the safety of older people at home appears to be under-researched.

METHODS

MEDLINE, CINAHL, Scopus and Web of Science databases from the earliest to August 2017 were investigated. The integrative literature review was conducted in December 2017. The full text of the remaining n = 93 papers was then screened for relevance by inclusion and exclusion criteria which reduced the number by 59 to n = 34.

RESULTS

Four dimensions of safety at home were discovered, namely physical, social, emotional and mental, and cognitive safety. Safety dimensions had both positive and negative components. Older people's main wish was to be able to live in their own home for as long as possible. Their perceptions of safety at home was categorised as active living, coping at home, managed living and the knowledge of the existence of disease.

CONCLUSIONS

The safety of older people at home is a worldwide concern. Identification of safety issues can assist in developing measures to help people stay at home for longer as they age. The management of this would need to take account of all four dimensions of safety, in ways that promote ageing at home.

IMPLICATIONS FOR PRACTICE

Learning, understanding and developing new strategies about safety affect everyone who visits the home of older people, and stakeholders have an important role to identify safety risks.

Engagement and experience of older people with socially assistive robots in home care

Social isolation is one of the most common consequences of older people with dementia, especially for those who live at their own dwellings alone due to limited access to social activities. Research relating to the use of social robots in aged care has increasing attention to facilitating the support to care services for older people with dementia. Particularly less attention has focused on the applicability of social robots in home care services. This paper aims to study the engagement and robot experience of older people with dementia while interacting with a social robot named Betty in the context of home-based care. This paper contributes to the research relating to care service embedded robots by expanding the knowledge regarding longitudinal research in home based care, while there is limited long-term study in this context. The results show that social robots are evident to be able to engage with older people with dementia at home. Consequently, designing social robots in a social context is desirable. While the robots enabled service for the human partner within the social context is possible, there is a need to underpin the concept of personhood to realize personalization of services and its contents to suit individual preferences.

An integrative review on family caregivers' involvement in care of home-dwelling elderly

Often family members provide care-giving, which allows older adults to remain in their homes. With declining health and increasing frailty, care-giving of elderly people becomes a task of family caregivers (FC) in conjunction with home care nurses. It has been shown in both acute care settings and long-term care facilities that family members prefer to be involved in decision-making and care planning for their next of kin. Therefore, an integrative review was conducted to explore the body of knowledge of FCs' involvement in home-care settings from the FCs' perspective. CINAHL, PubMed, and Cochrane databases was searched with the terms family caregiver, involvement, home care, and community dwelling. Studies written in German or English between 1996 and 2017 focusing on FCs' caring for home-dwelling older adults together with home care nurses were included and critically appraised. The extracted findings were analysed with concept analysis method. Twenty-six studies were included and five themes were identified. Four themes formed the basis of assistance towards family caregivers by nurses and included "relationship building with professionals," "negotiating with professional care," "being professionally supported," and "managing role expectations and knowledge sharing". The fifth theme, "working together" described the mutual care for the care recipient. Although the first four themes were consistent with a pre-existing conceptual model by Sims-Gould and Marin-Matthews (2010), the fifth required an expansion of the model with an additional contribution "collaborative practice". The findings illustrate that involvement in care is an interactional process, which provides the basis for collaborative practices with the home care nurses for family caregivers. Family members often want to be part of the healthcare team, and nurses need contextual factors that allow providing their full range of skills and knowledge to involve family caregivers accordingly.

Utilization of Formal and Informal Home Care: How Do Older Canadians’ Experiences Vary by Care Arrangements?

This study investigates how the receipt of formal, informal, and/or a combination of both types of care at home relates to older adults’ perceived loneliness, life satisfaction, and day-to-day lives. Quantitative analyses using the Canadian Community Health Survey ( n = 3,928) reveal that older adults who only received formal care reported lower levels of loneliness and higher levels of life satisfaction when compared with respondents who received informal or a blend of home care. Qualitative analyses of persons aged 65+ years receiving formal and informal home care in Ontario ( n = 34) suggest that formal care bolstered care recipients’ autonomy and reduced their sense of being a burden on family. In turn, receiving formal care served to improve these older adults’ social connectedness and well-being. Findings underscore older adults’ symbolic, functional, and emotional attachment to formal care services, as well as the limitations of a reliance on informal support.

‘Independence’ among older people receiving support at home: the meaning of daily care practices

Later life care practices are closely entangled with the ideals of independence and dependence. Based on an interpretive analysis of qualitative interviews with 34 people aged 65–100 receiving home care in Ontario, Canada, this article explores older people's subjective interpretations of caring for themselves (i.e. independence) and receiving support from others (i.e. dependence). Findings suggest that individuals construct subjective meanings of independence in relation to their changing physical capacities, and in the context of their relationships with family members, friends and formal care providers. First, participants considered their care activities to be a way of maintaining independence when they undertook certain practices with the intention of staving off dependency and future decline. Second, when they accepted assistance, many engaged in care relations that allowed them to preserve an independent identity in the face of limits to physical self-sufficiency. Third, participants reached the limits of independence when they lacked adequate assistance, and were unable to care for themselves in desirable ways. Findings illustrate how objective circumstances related to social and financial resources as well as access to formal services shape subjective interpretations, allowing some older people to hold on to independent identities while exacerbating feelings of dependency among others.

Task shifting in the provision of home and social care in Ontario, Canada: implications for quality of care

Growing healthcare costs have caused home-care providers to look for more efficient use of healthcare resources. Task shifting is suggested as a strategy to reduce the costs of delivering home-care services. Task shifting refers to the delegation or transfer of tasks from regulated healthcare professionals to home-care workers (HCWs). The purpose of this paper is to explore the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers. This qualitative study was completed in collaboration with a large home and community care organisation in Ontario, Canada, in 2010-2011. Using a purposive sampling strategy, semi-structured telephone interviews were conducted with 46 home healthcare workers including HCWs, home-care worker supervisors, nurses and therapists. Study participants reported that the most common skills transferred or delegated to HCWs were transfers, simple wound care, exercises, catheterisation, colostomies, compression stockings, G-tube feeding and continence care. A thematic analysis of the data revealed mixed opinions on the impacts of task shifting on the quality of care. HCWs and their supervisors, more often than nurses and therapists, felt that task shifting improved the quality of care through the provision of more consistent care; the development of trust-based relationships with clients; and because task shifting reduced the number of care providers entering the client's home. Nurses followed by therapists, as well as some supervisors and HCWs, expressed concerns that task shifting might compromise the quality of care because HCWs lacked the knowledge, training and education necessary for more complex tasks, and that scheduling problems might leave clients with inconsistent care once tasks are delegated or transferred. Policy implications for regulating bodies, employers, unions and educators are discussed.

"I'm satisfied … but": clients' and families' contingent responses about home care

Home care service organizations need a means of gaining useful feedback about satisfaction with care from clients and their families. Interviews were conducted with 82 older adult clients and 52 family members about their satisfaction with home care. A subgroup of participants (n = 39) provided "contingent" satisfaction responses. Contingent responses reflect the duality of perceptions that clients and families convey about services. Three themes emerged as critical to understanding these types of responses: adept versus inept staff, predictable versus precarious scheduling, and responsive versus restrictive care plans. Understanding the reasons for contingent responses could help home care agencies to target quality improvement initiatives for individual clients and families.

Assessing Trustworthiness of Personal Aides

Background: Smaller family size has increased the need for assistance from personal aides. Respite care provided by personal aides reduces depressive symptoms and improves intergenerational relations and overall well-being of family members and patients. Yet, little is known about how family members evaluate personal aides prior to and during the employment period. Methods: Qualitative semistructured interviews were conducted face-to-face with 10 families providing home-based care. Family members’ ages ranged from 43 to 70 years. Patients’ ages ranged from 67 to 86 years. Interviews were audio-recorded and transcribed verbatim. Data were coded and themes were identified. Results: Family members emphasized the importance of personal aides. Other concerns included protection of their loved ones against risks from dishonest, unethical, or incompetent personal aides and unsafe, uncomfortable caregiving contexts. After family members hired a personal aide they presumed to be trustworthy, monitoring was a nearly endless task in seeking assurance that their initial assessment was accurate. Conclusions: Appropriate care, according to family members, went far beyond actions required to competently administer medicines, assist with activities of daily living, or maintain a watchful presence in the home. While positive experiences with personal aides added to the quality of life for both family members and patients when trustworthiness was established, quite the opposite was found when trust was violated. Personal relations, interpersonal communication skills, and affection between the aide and the patient were found to be much more important in determining trustworthiness than were standard caregiving skills.

Valuing the Older Person in the Context of Delivery and Receipt of Home Support

Client perspectives of home support (i.e., assistance with daily activities that help to maintain a safe and supportive home) have not been considered in relation to personhood: “a standing or status that is bestowed upon one human being, by others, in the context of relationship and social being.” Personhood and positive person work interactions conceptually guided our secondary analysis of data from a generic qualitative study including 82 semi-structured interviews with older adult home support clients in British Columbia, Canada. Findings revealed clients value a “focus on the person,” “preservation of autonomy,” and interactions characterized by recognition, validation, collaboration, and negotiation. Individuals involved in the delivery of home support services are in a key position to support the personhood of older adult clients.

We share the care: family caregivers' experiences of their older relative receiving home support services

Although both family care and home support are considered essential components of home-based health-care, the experiences of family caregivers who have a relative in receipt of home support services are not well understood. Little is known about what aspects of home support services assist family caregivers or hinder them in their caregiving. This study examines family member's experiences of the home support services received by their elderly relatives. Based on a previous Canadian study of contributions in family caregiving, we developed a conceptual model for understanding multiple contributions in caregiving. The present study used this conceptual model to guide the analysis of data from in-depth interviews with family caregivers (N = 52), completed August 2007-April 2008, who have or had an older relative in receipt of home support services in British Columbia, Canada, in the previous 12 months. Verbatim transcripts were read, re-read and independently coded by three members of the research team to identify common themes. Themes relating to direct care (care provided directly to the elderly person) and assistive care (care provided to one caregiver by another) were identified. In discussing the direct care provided by workers, family members emphasised dissatisfaction with instrumental assistance provided by home support workers while also stressing the importance of affective assistance. In commenting about assistive care there were three key themes: caring together, care management, and quality assurance and monitoring. In conclusion, the important role of home support in providing relief for caregivers is highlighted and implications for caregiver policy are discussed.