Therapy-based allied health delivery in residential aged care, trends, factors, and outcomes: a systematic review

Risk factors for older people re-presenting to the emergency department with falls: A case-control analysis

OBJECTIVE

Falls are a leading cause for ED presentations among older adults. Existing secondary falls prevention interventions have not been shown to decrease fall-related ED re-presentation, indicating a need to better understand contributing factors. Our aim was to evaluate risk factors for fall re-presentations among the older patient population presenting to the ED.

METHODS

This is a single-centre case-control study. Cases were patients aged ≥65 years with two falls-related ED presentations within 6 months. Age- and sex-matched controls had a corresponding index, but no subsequent ED fall presentation. Data collected included falls risk factors and clinical features of the index presentation. Univariate and multivariate analyses were conducted to assess the relationship between potential exposures and fall re-presentation.

RESULTS

A total of 300 patients (mean age 83.8 years) were studied. On univariate analysis, factors significantly associated with ED fall re-presentation included increasing multimorbidity (P < 0.0001), increasing number of medications (P < 0.0001) and residing in residential aged care facility (RACF) (odds ratio [OR] 3.06, P < 0.001). No factors remained significant on multivariate analysis. Post-hoc analyses for the RACF subgroup showed that psychotropic medication use (OR 1.65, P = 0.04) and prior fall within 12 months (OR 2.68, P < 0.001) were significantly associated with re-presentation. Initial presentation with serious musculoskeletal injury was a significant protective factor (OR 0.21, P = 0.02).

CONCLUSION

The present study failed to identify factors independently associated with ED fall re-presentation, suggesting that the factors are complex and inter-related. Two high-risk populations were identified - those from RACF and those initially presenting with falls not resulting in serious injury.

Reform and reverberation: Australian aged care policy changes and the unintended consequences for allied health

INTRODUCTION

Allied health has a valuable role in providing services to people living in residential aged care. The recent Royal Commission into Aged Care Quality and Safety included several important recommendations relating to the nursing, personal care, and allied health workforce and the care that they provide. The purpose of this paper is to review these recommendations and the Australian Government's policy responses and explore the emerging changes in allied health service provision in residential aged care.

METHODS

Data from the four available Quarterly Financial Reports from the 2022-2023 financial year were extracted and analysed in relation to staff costs and time per person per day across personal care, nursing, and allied health workers. Supplementary data sources including the 2020 Aged Care Workforce Census were accessed to provide contextual data relating to individual allied health professions, including occupational therapy.

RESULTS

The analysis shows a modest increase in median registered nurse minutes per person per day, and cost per person per day, from the first to second quarter, and again in the third and fourth. By contrast, median time and cost for allied health declined. From 5.6 minutes per person per day in the first quarter, reported allied health minutes fell to 4.6 minutes per person per day in the second quarter, an 18% decrease, and by the fourth quarter was 4.3 minutes per person per day. This is just over half the Australian average of 8 minutes reported to the RCACQS in 2019.

CONCLUSION

Under recent residential aged care reforms, aged care providers have regulatory incentives to concentrate their financial resources on meeting the mandated care hours for registered nurses, enrolled nurses, personal care workers, and assistants in nursing. These same reforms do not mandate minutes of allied health services. Although providers of residential aged care in Australia continue to employ and value allied health, we argue that mandating care minutes for personal and nursing care without mandating the provision of allied health creates a perverse incentive whereby access to allied health services is unintentionally reduced.

Comparison of medical care needs and actual care in German and Dutch nursing home residents: A cross-sectional study conducted in neighboring European countries

OBJECTIVE

Assessing and comparing characteristics of German and Dutch nursing homes, their residents as well as residents' medical care needs and the actual provision of care.

METHODS

Two surveys were conducted among 600 randomly selected nursing homes each from Germany and the Netherlands. Questionnaires were mailed in May 2022. Responses were compared between German and Dutch respondents.

RESULTS

We received 199 German (response: 33.2%) and 102 Dutch questionnaires (response: 17.0%). Residents' characteristics were comparable in both countries. While German nursing homes rated residents' general medical care needs higher than Dutch facilities (87.9% vs. 78.4%), the reverse was true for dental care needs (81.4% vs. 71.1%). For all 4 medical specialties surveyed, German nursing homes saw a need for treatment more frequently than Dutch facilities, e.g., 48.3% vs. 11.7% for neurology. In addition, Dutch nursing homes significantly more often considered general practitioners/elder care physicians (GPs/ECPs) to be able to cover these needs. The number of GP/ECP contacts per resident per year was similar in both countries (Germany: 26.5; Netherlands: 28.7). Almost all Dutch facilities had permanently employed allied health professionals (e.g. physiotherapists), whereas this was rarely the case in Germany.

CONCLUSIONS

We observed large differences in nursing home residents' medical care. It appears that GPs/ECPs in the Netherlands cover needs deemed to require specialist consultations in Germany. Some differences between countries can possibly be explained by system-cultural differences. Future studies should therefore look closely at the process of medical care provision and its quality in nursing homes in both countries.

Reforming allied health service provision in residential aged care to improve the rehabilitation reach: a feasibility study

Objective My Therapy is an allied health guided, co-designed rehabilitation self-management program for residents of aged care facilities. This study aimed to determine the feasibility of implementing My Therapy in a residential aged care setting. Methods This observational study was conducted on a 30-bed wing, within a 90-bed metropolitan residential aged care facility, attached to a public health service, in Victoria, Australia. Staff and resident data were collected prospectively over 6 weeks (staff focus groups, patient surveys, and audits) to evaluate the feasibility domains of acceptability , reach and demand , practicality , integration , limited efficacy testing and adaptations . Results Twenty-six residents and five allied health staff (physiotherapy and occupational therapy) participated. My Therapy was acceptable to residents (survey) and staff (focus groups). Via initial My Therapy discussions between the resident and the therapists, to determine goals and resident preferences, My Therapy reached 26 residents (n  = 26/26, 100% program reach ), with 15 residents subsequently receiving a rehabilitation program (n  = 15/26, 58% program demand ). The remaining 11 residents did not participate due to resident preference or safety issues (n  = 11/26, 42%). Collecting physical function outcome measures for limited efficacy testing was practical , and the cost of My Therapy was AUD$6 per resident per day, suggesting financial integration may be possible. Several adaptations were required, due to limited allied health staff, complex resident goal setting and program co-design. Conclusion My Therapy has the potential to improve the rehabilitation reach of allied health services in residential aged care. While introducing this low-cost intervention is feasible, adaptations were required for successful implementation.

The relationship between nursing home staffing and resident safety outcomes: A systematic review of reviews

BACKGROUND

Resident safety is an important topic for nursing home practice with up to 33 % of residents subjected to an adverse event. In spite of a large evidence base examining the relationship between nursing home staffing and resident outcomes, the findings of several systematic reviews remain inconclusive and contradicting, possibly due to methodological shortcomings.

OBJECTIVE

The main aim of this review was to provide a comprehensive overview of the literature on nursing home staffing and its relationship with resident safety outcomes.

DESIGN

We undertook a systematic review of reviews. We searched Medline, CINAHL and Embase by the end of November 2022. Reviews were included if they assessed the relationship between nursing home staffing and resident safety outcomes using objective measures and data at resident level. Quality appraisal was conducted using the SIGN-checklist, but we did not exclude any reviews based on quality assessment. We used a narrative approach, tables and figures to summarize the findings.

RESULTS

We included 13 systematic reviews published between 2006 and 2022 building on primary evidence from 1977 to 2022. Twelve reviews investigated the relationship between nurse staffing and resident safety outcomes (187 unique primary studies), and one review focused on allied health professionals (28 primary studies). Five reviews originated as work to inform governmental recommendations on staffing. We found diverse approaches used to investigate the staffing-outcome relationship with regard to design, timeframe, operationalization, data-source and theoretical rationales guiding the studies. The most prominently reported resident safety outcomes were pressure ulcers and urinary tract infections. Commonly reported staffing measures included number and level of education of nursing home staff. Based on narrative summaries, staffing seems to have a favorable relationship with resident safety outcomes, but logic models explaining the mechanisms of this relationship were sparsely reported.

CONCLUSIONS

The existing literature shows methodological limitations that demand a change in research on the staffing-outcome relationship in the nursing home setting. Our work highlights the need for carefully designed primary studies that address the pertinent shortcomings by design, timeframe, operationalization, data-source and theoretical rationales. These future studies will allow to carefully examine the causal relationship between selected staffing measures and resident safety outcomes in further detail and serve as legitimate evidence bases to inform action plans for clinical practice and to evaluate staffing policies.

Primary health care service utilisation before and after entry into long-term care in Australia

OBJECTIVES

To examine utilisation of primary health care services (subsidised by the Australian Government, Medicare Benefits Schedule, MBS) before and after entry into long-term care (LTC) in Australia.

METHODS

A retrospective cohort study of older people (aged ≥65 years) who entered LTC in Australia between 2012 and 2016 using the Historical Cohort of the Registry of Senior Australians. MBS-subsidised general attendances (general practitioner (GP), medical and nurse practitioners), health assessment and management plans, allied health, mental health services and selected specialist attendances accessed in 91-day periods 12 months before and after LTC entry were examined. Adjusted relative changes in utilisation 0-3 months before and after LTC entry were estimated using risk ratios (RR) calculated using Generalised Estimating Equation Poisson models.

RESULTS

235,217 residents were included in the study with a median age of 84 years (interquartile range 79-89) and 61.1% female. In the first 3 months following LTC entry, GP / medical practitioner attendances increased from 86.6% to 95.6% (aRR 1.10 95%CI 1.10-1.11), GP / medical practitioner urgent after hours (from 12.3% to 21.1%; aRR 1.72, 95%CI 1.70-1.74) and after-hours attendances (from 18.5% to 33.8%; aRR 1.83, 95%CI 1.81-1.84) increased almost two-fold. Pain, palliative and geriatric specialist medicine attendances were low in the 3 months prior (<3%) and decreased further following LTC admission.

CONCLUSION

There is an opportunity to improve the utilisation of primary health care services following LTC entry to ensure that residents' increasingly complex care needs are adequately met.

Occupation-Based Interventions to Improve Occupational Performance Among Older Adults Living in Long-Term Care: A Systematic Review

IMPORTANCE

Evidence for the positive effects of occupation-based interventions on occupational performance is increasing; however, little is known about the impacts of occupation-based interventions on older adults living in long-term care.

OBJECTIVE

To consolidate the evidence on the effectiveness of occupation-based interventions for improving occupational performance among older adults living in long-term care.

DATA SOURCES

MEDLINE, CINAHL, PsycINFO, SCOPUS, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from journal-database inception to February 2023.

STUDY SELECTION AND DATA COLLECTION

This systematic review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included articles were peer-reviewed studies published in English that evaluated occupation-based interventions for older adults living in long-term care and used validated tools to measure occupational performance.

FINDINGS

Seventeen articles, with 2,974 participants, were identified. The reviewed studies included 6 Level 1b randomized controlled trials, 5 Level 2b studies of various study designs, and 5 Level 3b studies with quasi-experimental designs. Across studies, heterogeneous measures were used to assess occupational performance. All studies implemented client-centered, occupation-based interventions designed and/or delivered by occupational therapists. Interventions were tailored to residents' goals, interests, or abilities to improve occupational performance and participation, and inconsistent effects were reported.

CONCLUSIONS AND RELEVANCE

Moderate evidence supports the use of occupation-based interventions tailored to individual residents and incorporation of physical activities for improving the occupational performance of older adults living in long-term care. Currently, evidence for care partner involvement and multilevel occupation-based interventions is limited. Plain-Language Summary: This study adds to the evidence base indicating that occupation-based interventions have the potential to promote the occupational performance of older adults living in long-term care. High-quality randomized controlled trials with longer term follow-up and assessment of clinically meaningful outcomes are critical for developing the evidence base in this practice setting.

Allied health service delivery in residential aged care and the impact of the coronavirus (COVID-19) pandemic: a survey of the allied health workforce

Objectives Industry reports suggest that routine and essential care in Australian residential aged care (RAC), including allied health (AH) services, were disrupted during the coronavirus diseas 2019 (COVID-19) pandemic. This study aimed to explore whether AH services in RAC were paused during the pandemic, factors associated with a pause in care delivery, and qualitative details on how COVID-19 impacted AH service delivery. Methods A 26-question survey was distributed via social media, health service providers, and AH networks between February and April 2022. Participation was restricted to AH professionals and assistants with experience in RAC during the pandemic. A mix of closed and open-ended response questions was used to collect demographic data and experiences of delivering care during the pandemic. Quantitative responses were analysed with descriptive statistics and a probit model. Content analysis was performed on open-ended questions. Results One hundred and four AH professionals and assistants responded to the survey. Fifty-five percent of participants (n  = 51) were contractually or casually employed. AH services were negatively impacted by the pandemic with 52% of respondents experiencing a pause in service delivery and 78% reporting poorer AH care quality. In a probit model, contracted/casually employed respondents were more likely to experience a pause in care delivery (1.03, P  < 0.05) compared to permanently employed AH professionals. Conclusion Insecure work arrangements may have exacerbated inconsistent care during the pandemic (impacting residents) and may have negative implications on the RAC AH workforce. In the future, an AH inclusive workforce policy including data collection and research is required to monitor and plan the RAC workforce.

Caregiver Involvement and Concerns with Care of Residents of Assisted Living before and during the COVID-19 Pandemic

INTRODUCTION

Family/friend caregivers play an essential role in promoting the physical and mental health of older adults in need of care - especially during the COVID-19 pandemic and especially in assisted living (AL) homes, where resident care needs are similarly complex as in long-term care homes but fewer staffing resources and services are available. However, little research is available on caregiver involvement and concerns with care of AL residents prior to and during waves 1 and 2 of the COVID-19 pandemic. This study addressed this important knowledge gap.

METHODS

This prospective cohort study used baseline and follow-up online surveys with primary caregivers to AL residents in Western Canada who were 65 years or older and had lived in the AL home for at least 3 months before Mar 1, 2020. Surveys assessed the following outcomes in the 3 months prior to and during waves 1 and 2 of the pandemic: sociodemographics, 5 ways of visiting or communicating with residents, involvement in 16 care tasks, concerns with 9 resident physical/mental health conditions, perceived lack of resident access to 7 care services, and whether caregivers felt well informed and involved with resident care.

RESULTS

Based on 386 caregiver responses, in-person visits dropped significantly in wave 1 of the pandemic and so did caregiver involvement in nearly all care tasks. While these rates increased in wave 2, most did not return to pre-pandemic levels. Correspondingly, caregiver concerns (already high before the pandemic) substantially increased in wave 1 and stayed high in wave 2. These were particularly elevated among caregivers who did not feel well informed/involved with resident care.

CONCLUSIONS

Restricted in-person visiting disrupted resident care and was associated with worse perceptions of resident health and well-being. Continued caregiver involvement in resident care and communication with caregivers even during lockdowns is key to mitigating these issues.