Evaluation of data quality of interRAI assessments in home and community care

Drug Burden Index Is a Modifiable Predictor of 30-Day Hospitalization in Community-Dwelling Older Adults With Complex Care Needs: Machine Learning Analysis of InterRAI Data

BACKGROUND

Older adults (≥65 years) account for a disproportionately high proportion of hospitalization and in-hospital mortality, some of which may be avoidable. Although machine learning (ML) models have already been built and validated for predicting hospitalization and mortality, there remains a significant need to optimize ML models further. Accurately predicting hospitalization may tremendously affect the clinical care of older adults as preventative measures can be implemented to improve clinical outcomes for the patient.

METHODS

In this retrospective cohort study, a data set of 14 198 community-dwelling older adults (≥65 years) with complex care needs from the International Resident Assessment Instrument-Home Care database was used to develop and optimize 3 ML models to predict 30-day hospitalization. The models developed and optimized were Random Forest (RF), XGBoost (XGB), and Logistic Regression (LR). Variable importance plots were generated for all 3 models to identify key predictors of 30-day hospitalization.

RESULTS

The area under the receiver-operating characteristics curve for the RF, XGB, and LR models were 0.97, 0.90, and 0.72, respectively. Variable importance plots identified the Drug Burden Index and alcohol consumption as important, immediately potentially modifiable variables in predicting 30-day hospitalization.

CONCLUSIONS

Identifying immediately potentially modifiable risk factors such as the Drug Burden Index and alcohol consumption is of high clinical relevance. If clinicians can influence these variables, they could proactively lower the risk of 30-day hospitalization. ML holds promise to improve the clinical care of older adults. It is crucial that these models undergo extensive validation through large-scale clinical studies before being utilized in the clinical setting.

Comparison of hospitalization events among residents of assisted living and nursing homes during COVID-19: Do settings respond differently during public health crises?

BACKGROUND

COVID-19 and resulting health system and policy decisions led to significant changes in healthcare use by nursing homes (NH) residents. It is unclear whether healthcare outcomes were similarly affected among older adults in assisted living (AL). This study compared hospitalization events in AL and NHs during COVID-19 pandemic waves 1 through 4, relative to historical periods.

METHODS

This was a population-based, repeated cross-sectional study using linked clinical and health administrative databases (January 2018 to December 2021) for residents of all publicly subsidized AL and NH settings in Alberta, Canada. Setting-specific monthly cohorts were derived for pandemic (starting March 1, 2020) and comparable historical (2018/2019 combined) periods. Monthly rates (per 100 person-days) of all-cause hospitalization, hospitalization with delayed discharge, and hospitalization with death were plotted and rate ratios (RR) estimated for period (pandemic wave vs historical comparison), setting (AL vs NH) and period-setting interactions, using Poisson regression with generalized estimating equations, adjusting for resident and home characteristics.

RESULTS

On March 1, 2020, there were 9,485 AL and 14,319 NH residents, comparable in age (mean 81 years), sex (>60% female) and dementia prevalence (58-62%). All-cause hospitalization rates declined in both settings during waves 1 (AL: adjusted RR 0.60, 95%CI 0.51-0.71; NH: 0.74, 0.64-0.85) and 4 (AL: 0.76, 0.66-0.88; NH: 0.65, 0.56-0.75) but unlike NHs, AL rates were not significantly lower during wave 2 (and increased 27% vs NH, January 2021). Hospitalization with delayed discharge increased in NHs only (during and immediately after wave 1). Both settings showed a significant increase in hospitalization with death in wave 2, this increase was larger and persisted longer for AL.

CONCLUSIONS

Pandemic-related changes in hospitalization events differed for AL and NH residents and by wave, suggesting unique system and setting factors driving healthcare use and outcomes in these settings in response to this external stress.

Functional recovery in older adults with schizophrenia: A national interRAI study

BACKGROUND

The concept of recovery for people with schizophrenia (PwS) is still a matter of debate. Growing numbers of PwS living to older age calls for examination of their disease trajectories with a focus on recovery.

AIM

To compare two groups of PwS (good wellbeing; poor wellbeing) on several psychosocial variables associated with social wellbeing to identify interventions that support functional recovery.

METHOD

Data was drawn from participants from across New Zealand (NZ), who had received a formal diagnosis of Schizophrenia; were living independently in the community, and who had undergone their first International Resident Assessment Instrument (interRAI) assessment from 2012 to 2022. We compared two groups of PwS (good social wellbeing; poor social wellbeing) examining associations with demographic and psychosocial variables.

RESULTS

We compared interRAI assessments for: 'poor psychosocial wellbeing' (n = 1,378; 67%; 56% female; 70.5% 65 years and over; 36.1% never married); and 'good psychosocial wellbeing' (n = 693; 33%; 61.1% female; 78.1% 65 years and over; 29.8% never married; n = 549 did not have sufficient social wellbeing data to be included). We found significant associations between social wellbeing and depression, disruptive behaviour, decision making, self-expression, understanding verbal information, activity level, self-reported health and medication adherence. Logistical regression showed depression (β = .84, p < .001, Wald = 51.01, Exp(B) = 2.31) and mild disruptive behaviour (β = .63, p = .002, Wald = 9.26, Exp(B) = 0.53) were the only predictors of poor social wellbeing. Those who reported some degree of depressive symptoms were 2.31 (CI [1.84, 2.91]) more likely to be in the poor social wellbeing group.

CONCLUSIONS

A significant minority (33.5%) of older PwS enjoy positive social wellbeing. Several psychosocial variables are associated with wellbeing. By addressing the comorbidity of depressive symptoms, we may be able to improve wellbeing for older PwS.

Identifying Frailty in Older Adults Receiving Home Care Assessment Using Machine Learning: Longitudinal Observational Study on the Role of Classifier, Feature Selection, and Sample Size

BACKGROUND

Machine learning techniques are starting to be used in various health care data sets to identify frail persons who may benefit from interventions. However, evidence about the performance of machine learning techniques compared to conventional regression is mixed. It is also unclear what methodological and database factors are associated with performance.

OBJECTIVE

This study aimed to compare the mortality prediction accuracy of various machine learning classifiers for identifying frail older adults in different scenarios.

METHODS

We used deidentified data collected from older adults (65 years of age and older) assessed with interRAI-Home Care instrument in New Zealand between January 1, 2012, and December 31, 2016. A total of 138 interRAI assessment items were used to predict 6-month and 12-month mortality, using 3 machine learning classifiers (random forest [RF], extreme gradient boosting [XGBoost], and multilayer perceptron [MLP]) and regularized logistic regression. We conducted a simulation study comparing the performance of machine learning models with logistic regression and interRAI Home Care Frailty Scale and examined the effects of sample sizes, the number of features, and train-test split ratios.

RESULTS

A total of 95,042 older adults (median age 82.66 years, IQR 77.92-88.76; n=37,462, 39.42% male) receiving home care were analyzed. The average area under the curve (AUC) and sensitivities of 6-month mortality prediction showed that machine learning classifiers did not outperform regularized logistic regressions. In terms of AUC, regularized logistic regression had better performance than XGBoost, MLP, and RF when the number of features was ≤80 and the sample size ≤16,000; MLP outperformed regularized logistic regression in terms of sensitivities when the number of features was ≥40 and the sample size ≥4000. Conversely, RF and XGBoost demonstrated higher specificities than regularized logistic regression in all scenarios.

CONCLUSIONS

The study revealed that machine learning models exhibited significant variation in prediction performance when evaluated using different metrics. Regularized logistic regression was an effective model for identifying frail older adults receiving home care, as indicated by the AUC, particularly when the number of features and sample sizes were not excessively large. Conversely, MLP displayed superior sensitivity, while RF exhibited superior specificity when the number of features and sample sizes were large.

Psychotropic, Anticonvulsant, and Opioid Use in Assisted Living Residents Before and During the COVID-19 Pandemic

OBJECTIVES

To examine the associations between COVID-19 pandemic waves (1-4) and prevalent antipsychotic, antidepressant, benzodiazepine, anticonvulsant, and opioid use among assisted living (AL) residents, by setting (dementia care vs other).

DESIGN

Population-based, repeated cross-sectional study.

SETTING AND PARTICIPANTS

Linked clinical and health administrative databases for residents of all publicly subsidized AL homes (N = 256) in Alberta, Canada, examined from January 2018 to December 2021. Setting-specific quarterly cohorts of residents were derived for pandemic (starting March 1, 2020) and comparable historical (2018/2019 combined) periods.

METHODS

The quarterly proportion of residents dispensed an antipsychotic, antidepressant, benzodiazepine, anticonvulsant, or opioid was examined for each setting and period. Log-binomial generalized estimating equations models estimated prevalence ratios (PR) for period (pandemic vs historical quarterly periods), setting (dementia care vs other AL), and period-setting interactions.

RESULTS

On March 1, 2020, there were 2874 dementia care and 6611 other AL residents (mean age 82.4 vs 79.9 years, 68.2% vs 66.1% female, 93.5% vs 42.6% with dementia, respectively). Antipsychotic use increased during waves 2 to 4 for residents of both settings, but this increase was significantly greater for dementia care than other AL residents during waves 3 and 4 (eg, wave 3, PR 1.21, 95% CI 1.14-1.27 vs PR 1.12, 95% CI 1.07-1.17, interaction term P = .029). In both settings, there was a significant but modest increase in antidepressant use and a significant decrease in benzodiazepine use during several pandemic waves. For other AL residents only, there was a small statistically significant increase in anticonvulsant use during waves 2 to 4. No significant pandemic effect was observed for prevalent opioid use in either setting.

CONCLUSIONS AND IMPLICATIONS

The persistence of the pandemic-associated increase in antipsychotic, antidepressant, and anticonvulsant use in AL residents, and greater increase in antipsychotic use for dementia care settings, raises concerns about the attendant risks for residents, especially those with dementia.

Mapping a comprehensive assessment tool to a holistic definition of health for person-centred care planning in home care: a modified eDelphi study

BACKGROUND

Researchers in the Netherlands proposed the Pillars for Positive Health (PPH) as a broadly encompassing health definition to support more realistic and meaningful care planning for people living with chronic disease and other life-long health conditions. The PPH was subsequently converted to the My Positive Health (MPH) spider web visualization tool. This study sought to identify opportunities for more person-centred care planning at the point of care in home care, using the MPH tool as a framework to link comprehensive assessment and dialogue-based goal-setting.

METHODS

A modified eDelphi method was used to conduct domain mapping with a purposively sampled expert panel (n = 25). The panel consisted of researchers, health care providers, older adults and caregivers. A two-stage eDelphi process was conducted, with each stage consisting of three survey rounds. In the first stage, participants were asked to map 201 elements of the interRAI Home Care (interRAI HC) comprehensive assessment tool to the six MPH domains or "No pillar of best fit". The second stage focused on identifying opportunities to adapt or expand comprehensive assessment as it relates to the MPH domains.

RESULTS

In Stage 1, 189 of 201 elements reached consensus in domain mapping. These included: 80 elements for Bodily Functions, 32 for Daily Functioning, 32 for Mental Wellbeing, 24 for Quality of Life, 10 for Participation, and 1 for Meaningfulness. Ten elements were identified to have no pillar of best fit. The 12 elements that did not reach consensus in Stage 1 formed the basis for Stage 2, where expert panel participants proposed four new assessment elements in Meaningfulness and Participation and 11 additional descriptors across the six MPH domains. Of these, two elements and nine of the 11 descriptors reached consensus.

CONCLUSION

Findings show that elements of the interRAI HC are oriented toward the physical, functional, and mental health domains. Consequently, complementary assessment elements and/or tools may be needed to support comprehensive assessment of 'Meaningfulness' and 'Participation' in person-centred home and community care. Additional descriptors may also be needed to aid communication regarding the understanding and application of MPH domains.

Inter-provincial variation in older home care clients and their pathways: a population-based retrospective cohort study in Canada

BACKGROUND

In Canada, publicly-funded home care programs enable older adults to remain and be cared for in their home for as long as possible but they often differ in types of services offered, and the way services are delivered. This paper examines whether these differing approaches to care shape the pathway that home care clients will take. Older adult client pathways refer to trajectories within, and out of, the home care system (e.g., improvement, long term care (LTC) placement, death).

METHODS

A retrospective analysis of home care assessment data (RAI-HC was linked with health administrative data, long-term care admissions and vital statistics in Nova Scotia Health (NSH) and Winnipeg Regional Health Authority (WRHA). The study cohort consists of clients age 60 + years, admitted to home care between January 1, 2011 to December 31, 2013 and up to four years from baseline. Differences in home care service use, client characteristics and their pathways were tested across the two jurisdictions overall, and among the four discharge streams within jurisdictions using t-tests and chi-square tests of significance.

RESULTS

NS and WHRA clients were similar in age, sex, and marital status. NS clients had higher levels of need (ADL, cognitive impairment, CHESS) at base line and were more likely discharged to LTC (43% compared to 38% in WRHA). Caregiver distress was a factor correlated with being discharged to LTC. While a third remained as home care clients after 4 years; more than half were no longer in the community - either discharged to LTC placement or death. Such discharges occurred on average at around two years, a relatively short time period.

CONCLUSIONS

By following older clients over 4 years, we provide enhanced evidence of client pathways, the characteristics that influence these paths, as well as the length of time to the outcomes. This evidence is central to identification of clients at risk in the community and aids in planning for future home care servicing needs that will allow more older adults to remain living in the community.

Prognostic Association Between Frailty and Post-Arrest Health Outcomes in Patients Receiving Home Care: A Population-Based Retrospective Cohort Study

AIM

To evaluate the association between frailty and post-cardiac arrest survival, functional decline, and cognitive decline, among patients receiving home care METHODS: Frailty was measured using the Clinical Frailty Scale (CFS) and a valid frailty index. We used multivariable logistic regression to measure the association between frailty and post-arrest outcomes after adjusting for age, sex, and arrest setting. Functional independence and cognitive performance were measured using the interRAI ADL Long-Form and Cognitive Performance Scale, respectively. We conducted sub-group analytics of in-hospital and out-of-hospital arrests RESULTS: Our cohort consisted of 7,901 home care clients; most patients arrested out-of-hospital (55.4%) and were 75 years or older (66.3%). Most of the cohort was classified as frail (94.2%), with a CFS score of 5 or greater. The 30-day survival rate was higher for in-hospital (26.6%) than out-of-hospital cardiac arrests (5.2%). Most patients who survived to discharge had declines in post-arrest functional independence (65.8%) and cognitive performance (46.5%). A one-point increase in the CFS decreased the odds of 30-day survival by 8% (aOR=0.92; 95%CI = 0.87-0.97). A 0.1 unit increase in the frailty index reduced 30-day survival odds by 9% (aOR = 0.91; 95%CI = 0.86-0.96). The frailty index was associated with declines in functional independence (OR = 1.16; 95%CI = 1.02-1.31) and cognitive performance (OR = 1.24; 95%CI = 1.09-1.42), while the CFS was not.

CONCLUSION

Frailty is associated with cardiac arrest survival and post-arrest cognitive and functional status in patients receiving home care. Post-cardiac arrest cognitive and functional status are best predicted using more comprehensive frailty indices.

Analysing Realistic effects of modifiable risk factors for dementia in a large National Dataset

BACKGROUND

Modifiable risk factors affect 40% of dementia risk thus creating an opportunity for prevention or delay. The risk factor life-course model of dementia prevention by the Lancet Commission has yet to be tested in the general populations. We aimed to assess the model's assumptions in a large national dataset of older adults assessed for support services.

METHODS

The interRAI assessment is a comprehensive evidence-based tool encompassing 236 items that is mandatory in New Zealand (NZ) for older adults providing a standardized national dataset. We tested the Lancet model of dementia prevention in a sample of 66,638 participants who underwent an interRAI assessment during the period 2013-2018. There were 59% female interviewees; mean age was 82 years (range: 65-107). Our cross-sectional dataset analysis was performed in using a logistic regression model with diagnosis of dementia as the primary outcome.

RESULTS

The Lancet prevention model was supported in part. Hypertension, Hearing Impairment and past or present Depression increase risk of dementia. Age - increased risk demonstrated until 85 years; Gender - females at increased risk; BMI - initial effect of high BMI increases risk of dementia. However, exercise, diabetes, vision impairment and smoking as modifiable factors were not associated with dementia risk as predicted by the Lancet model.

CONCLUSIONS

Limitations of the dataset analysed may have affected our findings. Nevertheless, important modifiable factors are herein confirmed as increasing dementia risk. BMI, hypertension, hearing impairment and depression are risks confirmed in the older NZ population lending credibility to prevention efforts targeted at these variables.

Factors associated with informal caregiver's ability to continue care: a subgroup analysis

BACKGROUND/OBJECTIVE

maintaining informal caregiver's ability to continue care can prevent early institutionalisation and decrease health care costs, contributing to sustainable health care. This study aims to identify factors associated with informal caregiver's ability to continue care across several degrees of cognitive decline and risk of burden.

METHODS

this is a cross-sectional study that collected nationwide data on frail older people and their informal caregivers living in the community. Instruments used were InterRAI Home Care, Zarit Burden Interview and questionnaire for the informal caregiver. Multivariate logistic regression analyses and a stratification of the population were performed.

RESULTS

a total of 8,309 people had at least one primary caregiver, and a majority of them were able to continue care (68.2%). Cognitive impairment was a risk factor for being able to continue care, even the borderline (odds ratios (ORs): 0.72; 95% CI: 0.61-0.85) or mild condition (OR: 0.52; 95% CI: 0.43-0.61). Protective factors like social participation of older people, strong family support and availability of a secondary caregiver showed the highest association in subgroups with mild cognitive impairment (ORs: 2.20, 2.08, 1.64) and in subgroups at low risk of burden (ORs: 1.91, 2.77, 1.64).

CONCLUSION

factors associated with informal caregiver's ability to continue care vary across several degrees of cognitive decline and risk of burden. Interventions related to family and social support resources are recommended, and informal caregivers at a lower level of risk may benefit most. Supportive counselling should be proactively provided to informal caregivers, considering the changes of associated factors with the ongoing caregiving situation.

Use of the interRAI PEDS HC in children receiving home care in Ontario, Canada

BACKGROUND

There is no standard assessment tool for pediatric home care recipients in Canada, limiting the availability of comparable, population-based data. The objective of this study was to describe pediatric home care recipients who were part of a pilot implementation of the interRAI Pediatric Home Care Assessment Form (PEDS-HC) among medically complex children referred to home care agencies in three regions in Ontario, Canada.

METHODS

All 14 agencies providing home care to children in Ontario were invited to participate in the pilot project, and 9 participated in an education session. Three of these agencies used the PEDS-HC during the pilot implementation between February 2018 and March 2020. We used de-identified data to describe the demographics, home care needs, and diagnoses of pediatric home care recipients.

RESULTS

The sample of 474 assessments was predominantly male (60.34%), with an average age at assessment of 12.36 years (SD 4.56). Most (78.48%) reported English as their primary language. Most children assessed had between two and eight medical diagnoses. Diagnoses reported varied: gastrointestinal, musculoskeletal, respiratory and neurological conditions were most common. The prevalence of urinary incontinence (40.1%) and bowel incontinence (70.9%) were high. Over 60% of children were rarely or only sometimes understood. A majority of children had adequate hearing (83.5%) and vision (68.6%). Extensive services were being provided in 10% of children assessed. Most children received care both at school and at home (70.89%), with 20.89% receiving home care only.

CONCLUSIONS

The PEDS-HC provides a detailed, standardised descriptive profile of medically complex children receiving home care. Expanding use of PEDS-HC would promote consistency in care planning and delivery on the patient level, enable cross-jurisdictional comparisons, and inform utilization tracking and health care funding decisions on the organization and provincial levels.

Developing an evidence-informed model of long-term life care at home for older adults with medical, functional and/or social care needs in Ontario, Canada: a mixed methods study protocol

INTRODUCTION

The COVID-19 pandemic exacerbated existing challenges within the Canadian healthcare system and reinforced the need for long-term care (LTC) reform to prioritise building an integrated continuum of services to meet the needs of older adults. Almost all Canadians want to live, age and receive care at home, yet funding for home and community-based care and support services is limited and integration with primary care and specialised geriatric services is sparse. Optimisation of existing home and community care services would equip the healthcare system to proactively meet the needs of older Canadians and enhance capacity within the hospital and residential care sectors to facilitate access and reduce wait times for those whose needs are best served in these settings. The aim of this study is to design a model of long-term 'life care' at home (LTlifeC model) to sustainably meet the needs of a greater number of community-dwelling older adults.

METHODS AND ANALYSIS

An explanatory sequential mixed methods design will be applied across three phases. In the quantitative phase, secondary data analysis will be applied to historical Ontario Home Care data to develop unique groupings of patient needs according to known predictors of residential LTC home admission, and to define unique patient vignettes using dominant care needs. In the qualitative phase, a modified eDelphi process and focus groups will engage community-based clinicians, older adults and family caregivers in the development of needs-based home care packages. The third phase involves triangulation to determine initial model feasibility.

ETHICS AND DISSEMINATION

This study has received ethics clearance from the University of Waterloo Research Ethics Board (ORE #42182). Results of this study will be disseminated through peer-reviewed publications and local, national and international conferences. Other forms of knowledge mobilisation will include webinars, policy briefs and lay summaries to elicit support for implementation and pilot testing phases.

Changes in Urinary Continence After Admission to a Complex Care Setting: A Multistate Transition Model

OBJECTIVES

To examine changes in urinary continence for post-acute, Complex Continuing Care hospital patients from time of admission to short-term follow-up, either in hospital or after discharge to long-term care or home with services.

DESIGN

Retrospective cohort study of patients in Complex Continuing Care hospitals using clinical data collected with interRAI Minimum Data Set 2.0 and interRAI Resident Assessment Instrument Home Care.

SETTING AND PARTICIPANTS

Adults aged 18 years and older, admitted to Complex Continuing Care hospitals in Ontario, Canada, between 2009 and 2015 (n = 78,913).

METHODS

A multistate transition model was used to characterize the association between patient characteristics measured at admission and changes in urinary continence state transitions (continent, sometimes continent, and incontinent) between admission and follow-up.

RESULTS

The cohort included 27,896 patients. At admission, 9583 (34.3%) patients belonged to the continent state, 6441 (23.09%) patients belonged to the sometimes incontinent state, and the remaining 11,872 (42.6%) patients belonged to the incontinent state. For patients who were continent at admission, the majority (62.7%) remained continent at follow-up. However, nearly a quarter (23.9%) transitioned to the sometimes continent state, and an additional 13.4% became incontinent at follow-up. Several factors were associated with continence state transitions, including cognitive impairment, rehabilitation potential, stroke, Parkinson's disease, Alzheimer's disease and related dementias, and hip fracture.

CONCLUSIONS AND IMPLICATIONS

This study suggests that urinary incontinence is a prevalent problem for Complex Continuing Care hospital patients and multiple factors are associated with continence state transitions. Standardized assessment of urinary incontinence is helpful in this setting to identify patients in need of further assessment and patient-centered intervention and as a quality improvement metric to examine changes in continence from admission to discharge.

Patterns of home care assessment and service provision before and during the COVID-19 pandemic in Ontario, Canada

OBJECTIVE

The objective was to compare home care episode, standardised assessment, and service patterns in Ontario's publicly funded home care system during the first wave of the COVID-19 pandemic (i.e., March to September 2020) using the previous year as reference.

STUDY DESIGN AND SETTING

We plotted monthly time series data from March 2019 to September 2020 for home care recipients in Ontario, Canada. Home care episodes were linked to interRAI Home Care assessments, interRAI Contact Assessments, and home care services. Health status measures from the patient's most recent interRAI assessment were used to stratify the receipt of personal support, nursing, and occupational or physical therapy services. Significant level and slope changes were detected using Poisson, beta, and linear regression models.

RESULTS

The March to September 2020 period was associated with significantly fewer home care admissions, discharges, and standardised assessments. Among those assessed with the interRAI Home Care assessment, significantly fewer patients received any personal support services. Among those assessed with either interRAI assessment and identified to have rehabilitation needs, significantly fewer patients received any therapy services. Among patients receiving services, patients received significantly fewer hours of personal support and fewer therapy visits per month. By September 2020, the rate of admissions and services had mostly returned to pre-pandemic levels, but completion of standardised assessments lagged behind.

CONCLUSION

The first wave of the COVID-19 pandemic was associated with substantial changes in Ontario's publicly funded home care system. Although it may have been necessary to prioritise service delivery during a crisis situation, standardised assessments are needed to support individualised patient care and system-level monitoring. Given the potential disruptions to home care services, future studies should examine the impact of the pandemic on the health and well-being of home care recipients and their caregiving networks.

A multi-stage process to develop quality indicators for community-based palliative care using interRAI data

Background

Individuals receiving palliative care (PC) are generally thought to prefer to receive care and die in their homes, yet little research has assessed the quality of home- and community-based PC. This project developed a set of valid and reliable quality indicators (QIs) that can be generated using data that are already gathered with interRAI assessments—an internationally validated set of tools commonly used in North America for home care clients. The QIs can serve as decision-support measures to assist providers and decision makers in delivering optimal care to individuals and their families.

Methods

The development efforts took part in multiple stages, between 2017–2021, including a workshop with clinicians and decision-makers working in PC, qualitative interviews with individuals receiving PC, families and decision makers and a modified Delphi panel, based on the RAND/ULCA appropriateness method.

Results

Based on the workshop results, and qualitative interviews, a set of 27 candidate QIs were defined. They capture issues such as caregiver burden, pain, breathlessness, falls, constipation, nausea/vomiting and loneliness. These QIs were further evaluated by clinicians/decision makers working in PC, through the modified Delphi panel, and five were removed from further consideration, resulting in 22 QIs.

Conclusions

Through in-depth and multiple-stakeholder consultations we developed a set of QIs generated with data already collected with interRAI assessments. These indicators provide a feasible basis for quality benchmarking and improvement systems for care providers aiming to optimize PC to individuals and their families.

Mood Disturbances Across the Continuum of Care Based on Self-Report and Clinician Rated Measures in the interRAI Suite of Assessment Instruments

BACKGROUND

Mood disturbance is a pervasive problem affecting persons of all ages in the general population and the subset of those receiving services from different health care providers. interRAI assessment instruments comprise an integrated health information system providing a common approach to comprehensive assessment of the strengths, preferences and needs of persons with complex needs across the continuum of care.

OBJECTIVE

Our objective was to create new mood scales for use with the full suite of interRAI assessments including a composite version with both clinician-rated and self-reported items as well as a self-report only version.

METHODS

We completed a cross-sectional analysis of 511,641 interRAI assessments of Canadian adults aged 18+ in community mental health, home care, community support services, nursing homes, palliative care, acute hospital, and general population surveys to develop, test, and refine new measures of mood disturbance that combined clinician and self-rated items. We examined validity and internal consistency across diverse care settings and populations.

RESULTS

The composite scale combining both clinician and self-report ratings and the self-report only variant showed different distributions across populations and settings with most severe signs of disturbed mood in community mental health settings and lowest severity in the general population prior to the COVID-19 pandemic. The self-report and composite measures were strongly correlated with each other but differed most in populations with high rates of missing values for self-report due to cognitive impairment (e.g., nursing homes). Evidence of reliability was strong across care settings, as was convergent validity with respect to depression/mood disorder diagnoses, sleep disturbance, and self-harm indicators. In a general population survey, the correlation of the self-reported mood scale with Kessler-10 was 0.73.

CONCLUSIONS

The new interRAI mood scales provide reliable and valid mental health measures that can be applied across diverse populations and care settings. Incorporating a person-centered approach to assessment, the composite scale considers the person's perspective and clinician views to provide a sensitive and robust measure that considers mood disturbances related to dysphoria, anxiety, and anhedonia.

Quality of care plans in long-term care facilities for the older persons-How well is information from RAI assessments utilised in care planning?

BACKGROUND

In Finland, care plans at long-term care facilities (LTCF) for the older persons should be based on information from Resident Assessment Instrument (RAI) assessments and the principles of structured data. Hence, managers are responsible for ensuring that the RAI system is used to a satisfactory extent, the provided information is used in care planning, and that staff members are competent at composing high-quality care plans.

AIM

To explore the congruence between first-line managers' assessments of the extent to which care plans include RAI information and separately observed RAI-related contents of care plans.

METHODS

The study was based on a descriptive, cross-sectional survey of first-line managers (n = 15) from three LTCF organisations and a randomly selected sample of care plans (n = 45) from two LTCF organisations in Finland. Manager responses and analysis of care plans were reviewed at a general level. The data were gathered in 2019 and analysed using statistical methods and content analysis.

RESULTS

First-line managers' assessments of the extent to which their units' care plans included RAI information did not match the observed care plan contents. The care plan analysis revealed that managers significantly overestimated the extent to which care plans included RAI-related content.

CONCLUSION

Managers at LTCF organisations need more training to be able to sufficiently support their staff in using RAI information to draft high-quality care plans.

IMPLICATION FOR PRACTICE

Care plans must include a higher level of information related to RAI assessments. To develop competencies in drafting high-quality care plans, training related to RAI information utilisation on all aspects of the care plan should be emphasised and training should be provided to first-line managers and more broadly across the nursing staff.

Changes in home care clients' characteristics and home care in five European countries from 2001 to 2014: comparison based on InterRAI - Home Care data

Background

Policymakers advocate extended residence in private homes as people age, rather than relocation to long-term care facilities. Consequently, it is expected that older people living in their own homes will be frailer and have more complex health problems over time. Therefore, community care for aging people is becoming increasingly important to facilitate prevention of decline in physical and cognitive abilities and unnecessary hospital admission and transfer to a nursing home. The aim of this study was to examine changes in the characteristic of home care clients and home care provided in five European countries between 2001 and 2014 and to explore whether home care clients who are most in need of care receive the care required.

Methods

This descriptive study used data from two European research projects, Aged in Home Care (AdHOC; 2001–2002) and Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of Community Care (IBenC; 2014–2016). In both projects, the InterRAI-Home Care assessment tool was used to assess a random sample of home care clients 65 years and older in five European countries. These data facilitate a comparison of physical and cognitive health and the provided home care between countries and study periods.

Results

In most participating countries, both cognitive (measured on the Cognitive Performance Scale) and functional ability (measured on the Activities of Daily Living Hierarchy scale) of home care clients deteriorated over a 10-year period. Home care provided increased between the studies. Home care clients who scored high on the physical and cognitive scales also received home care for a significantly higher duration than those who scored low.

Conclusion

Older people in several European countries remain living in their own homes despite deteriorating physical and cognitive skills. Home care services to this group have increased. This indicates that the government policy of long-term residence at own home among older people, even in increased frailty, has been realised.

Prognosis does not change the landscape: palliative home care clients experience high rates of pain and nausea, regardless of prognosis

BACKGROUND

Most individuals who typically receive palliative care (PC) tend to have cancer and a relatively short prognosis (< 6 months). People with other life-limiting illnesses can also benefit from a palliative care approach. However, little is known about those who receive palliative home care in Ontario, Canada's largest province. To address this gap, the goal of this project was to understand the needs, symptoms and potential differences between those with a shorter (< 6 months) and longer prognosis (6+ months) for individuals receiving PC in the community.

METHODS

A cross-sectional analysis was conducted using interRAI Palliative Care (interRAI PC) assessment data collected between 2011 and 2018. Individuals with a shorter prognosis (< 6 months; n = 48,019 or 64.1%) were compared to those with a longer prognosis (6+ months; n = 26,945) across several clinical symptoms. The standardized difference (stdiff), between proportions, was calculated to identify statistically meaningful differences between those with a shorter and longer prognosis. Values of the stdiff of 0.2 or higher (absolute value) indicated a statistically significant difference.

RESULTS

Overall, cancer was the most prevalent diagnosis (83.2%). Those with a shorter prognosis were significantly more likely to experience fatigue (75.3% vs. 59.5%; stdiff = 0.34) and shortness of breath at rest (22.1% vs. 13.4%; stdiff = 0.23). However, the two groups were similar in terms of severe pain (73.5% vs. 66.5%; stdiff = - 0.15), depressive symptoms (13.2% vs. 10.7%; stdiff = 0.08) and nausea (35.7% vs. 29.4%; stdiff = 0.13).

CONCLUSIONS

These results highlight the importance of earlier identification of individuals who could benefit from a palliative approach to their care as individuals with a longer prognosis also experience high rates of symptoms such as pain and nausea. Providing PC earlier in the illness trajectory has the potential to improve an individual's overall quality of life throughout the duration of their illness.

Paramedics assessing patients with complex comorbidities in community settings: results from the CARPE study

Objectives

The aim for this study was to provide information about how community paramedicine home visit programs best “navigate” their role delivering preventative care to frequent 9-1-1 users by describing demographic and clinical characteristics of their patients and comparing them to existing community care populations.

Methods

Our study used secondary data from standardized assessment instruments used in the delivery of home care, community support services, and community paramedicine home visit programs in Ontario. Identical assessment items from each instrument enabled comparisons of demographic, clinical, and social characteristics of community-dwelling older adults using descriptive statistics and z-tests.

Results

Data were analyzed for 29,938 home care clients, 13,782 community support services clients, and 136 community paramedicine patients. Differences were observed in proportions of individuals living alone between community paramedicine patients versus home care clients and community support clients (47.8%, 33.8%, and 59.9% respectively). We found higher proportions of community paramedicine patients with multiple chronic disease (87%, compared to 63% and 42%) and mental health-related conditions (43.4%, compared to 26.2% and 18.8% for depression, as an example).

Conclusion

When using existing community care populations as a reference group, it appears that patients seen in community paramedicine home visit programs are a distinct sub-group of the community-dwelling older adult population with more complex comorbidities, possibly exacerbated by mental illness and social isolation from living alone. Community paramedicine programs may serve as a sentinel support opportunity for patients whose health conditions are not being addressed through timely access to other existing care providers.

Protocol registration

ISRCTN 58273216.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43678-021-00153-4.

Substitutes or complements between informal and formal home care in the Canadian longitudinal study on aging: Functional impairment as an effect modifier

In Canada and around the world, policy makers are struggling with funding between informal care and formal home care. Understanding the relationship between the two types of care is helpful to inform funding allocations. In this study, we examined the relationship between informal care and formal home care and assessed whether this relationship varies across levels of functional impairment using the Canadian Longitudinal Survey of Aging (CLSA). Our study population was baseline CLSA participants between 2011 and 2015 who were functionally impaired. We used self-reported measures of total hours of informal and formal home care received over 12 months and evaluated their relationship using a two-part model and an instrumental variable method. Our results emphasized the importance of accounting for the potential endogeneity of informal care. We consistently found that there was a negative relationship between informal care hours and the probability of receiving formal home care among middle-aged and older adults and a negative coefficient of the interaction term between informal care hours and functional impairment level. The results suggest that there is a substitution relationship between informal care and formal home care and that this substitution relationship is stronger for highly impaired middle-aged and older individuals. Our findings will help policy makers understand the complexity of the relationship between informal and formal home care and implement policies accordingly.

Psychometric Properties, Feasibility, and Acceptability of the Self-Reported interRAI Check-Up Assessment

OBJECTIVES

To assess the feasibility, acceptability, and psychometric properties of the self-report version of the interRAI Check-Up (CUSR).

DESIGN

Cross-sectional study of participant ratings of item content and difficulty completing the CUSR. Participants were also randomly assigned to complete the assessment by themselves or with help from a lay interviewer.

SETTINGS AND PARTICIPANTS

A total of 184 older adults from diverse backgrounds, served by 6 Canadian organizations in Ontario and Nova Scotia were recruited. Settings ranged from retirement communities for healthy older adults to assisted living facilities.

MEASURES/METHODS

Time to complete the interRAI CUSR was tracked automatically. Participants self-reported on what items they wanted to have modified, added, or deleted. The also rated whether items were embarrassing or difficult to complete. Psychometric properties were examined between the 2 approaches to completion and were benchmarked against existing reports on psychometric properties of clinician-led home care assessments.

RESULTS

The interRAI CUSR takes about 28 minutes to complete with both self-administered and lay interviewer approaches. The convergent validity and reliability of CUSR is comparable to those of clinician-based assessments like the Resident Assessment Instrument-Home Care. Most participants had no difficulty completing the assessment, and none rated the task as very difficult. Poor self-rated health and difficulty with phone use were predictive of any difficult in completing the assessment in a multivariate logistic regression. Most participants reported that CUSR adequately described their health needs, but arthritis, hypertension, and mental health issues were identified as items to be added by participants.

CONCLUSIONS AND IMPLICATIONS

The CUSR is an appropriate, feasible assessment system with good psychometric properties for use with general populations, including primary care, community services, and patient-reported outcome measurement studies. Interoperability with other interRAI assessments makes it an ideal system to use to obtain a longitudinal view of the person's needs over time.

Adjusting Client-Level Risks Impacts on Home Care Organization Ranking

Quality indicators (QIs) based on the Resident Assessment Instrument-Home Care (RAI-HC) offer the opportunity to assess home care quality and compare home care organizations’ (HCOs) performance. For fair comparisons, providers’ QI rates must be risk-adjusted to control for different case-mix. The study’s objectives were to develop a risk adjustment model for worsening or onset of urinary incontinence (UI), measured with the RAI-HC QI bladder incontinence, using the database HomeCareData and to assess the impact of risk adjustment on quality rankings of HCOs. Risk factors of UI were identified in the scientific literature, and multivariable logistic regression was used to develop the risk adjustment model. The observed and risk-adjusted QI rates were calculated on organization level, uncertainty addressed by nonparametric bootstrapping. The differences between observed and risk-adjusted QI rates were graphically assessed with a Bland-Altman plot and the impact of risk adjustment examined by HCOs tertile ranking changes. 12,652 clients from 76 Swiss HCOs aged 18 years and older receiving home care between 1 January 2017, and 31 December 2018, were included. Eight risk factors were significantly associated with worsening or onset of UI: older age, female sex, obesity, impairment in cognition, impairment in hygiene, impairment in bathing, unsteady gait, and hospitalization. The adjustment model showed fair discrimination power and had a considerable effect on tertile ranking: 14 (20%) of 70 HCOs shifted to another tertile after risk adjustment. The study showed the importance of risk adjustment for fair comparisons of the quality of UI care between HCOs in Switzerland.

The Great Escape. Centenarians' exceptional health

BACKGROUND

Centenarians escapers are those who reached 100 years of age without the diagnosis of any of the common age-related diseases and exploring their characteristics will inform about successful ageing. No previous study has examined centenarians free of common chronic diseases amongst New Zealand centenarians.

METHODS

Retrospective observational cross-sectional review of a national dataset determining the prevalence of depression, dementia, diabetes and hypertension, smoking, physical activity and social relationships among older adults (aged 60-99 years) and centenarians. Participants were all older New Zealanders living independently in the community who completed the international Residential Assessment Instrument-Home Care (interRAI-HC) assessment during the study's 5-year period (July 2013-June 2018).

RESULTS

The assessments of 292 centenarians (mean age 101.03, SD 1.27 years) and 103,377 elderly (mean age 81.7, SD 5.7 years) were analysed. Compared to the elderly, centenarians were more likely to be female (74.7%, compared with 59.3% elderly, p < 0.001). Centenarians free of common chronic diseases did not differ from other centenarians on any of the analysed variables. Reduction in smoking rates and steady high rates of social engagement were associated with reaching a centenarian status free of common chronic diseases compared with older adults.

CONCLUSIONS

Not smoking and being socially engaged throughout older age were associated with being a centenarian free of common chronic diseases. This study adds to our understanding the complexities of attaining exceptional longevity.

Factors Associated With Hospital Presentation of Self-Harm Among Older Canadians in Long-Term Care: A 12-Year Cohort Study

OBJECTIVES

This study aimed to examine the incidence of, and factors associated with, hospital presentation for self-harm among older Canadians in long-term care (LTC).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

The LTC data were collected using Resident Assessment Instrument-Minimum Data Set (RAI-MDS) and Resident Assessment Instrument-Home Care (RAI-HC), and linked to the Discharge Abstract Database (DAD) with hospital records of self-harm diagnosis. Adults aged 60+ at first assessment between April 1, 2003, and March 31, 2015, were included.

METHODS

Adjusted hazard ratios (HRs) of self-harm for potentially relevant factors, including demographic, clinical, and psychosocial characteristics, were calculated using Fine & Gray competing risk models.

RESULTS

Records were collated of 465,870 people in long-term care facilities (LTCF), and 773,855 people receiving home care (HC). Self-harm incidence per 100,000 person-years was 20.76 [95% confidence interval (CI) 20.31-25.40] for LTCF and 46.64 (44.24-49.12) for HC. In LTCF, the strongest risks were younger age (60-74 years vs 90+: HR, 6.00; 95% CI, 3.24-11.12), psychiatric disorders (bipolar disorder: 3.46; 2.32-5.16; schizophrenia: 2.31; 1.47-3.62; depression: 2.29; 1.80-2.92), daily severe pain (2.01; 1.30-3.11), and daily tobacco consumption (1.78; 1.29-2.45). For those receiving HC, the strongest risk factors were younger age (60-74 years vs 90+: 2.54; 1.97-3.28), psychiatric disorders (2.20; 1.93-2.50), daily tobacco consumption (2.08; 1.81-2.39), and frequent falls (1.98; 1.46-2.68). All model interactions between setting and factors were significant.

CONCLUSIONS AND IMPLICATIONS

There was lower incidence of hospital presentation for self-harm for LTCF residents than HC recipients. We found sizable risks of self-harm associated with several modifiable risk factors, some of which can be directly addressed by better treatment and care (psychiatric disorders and pain), whereas others require through more complex interventions that target underlying factors and causes (tobacco and falls). The findings highlight a need for setting- and risk-specific prevention strategies to address self-harm in the older populations.

The Complexity of Living with Diabetes and Urinary Incontinence for Older Adults with Multiple Chronic Conditions Receiving Home Care Services: An Interpretive Description Study

Over 40% of older adults with diabetes receiving home-care services experience urinary incontinence. However, experiential knowledge is lacking on how these older adults live with diabetes and incontinence. Interpretive description methodology was used to explore the experiences of 18 older adults with diabetes and urinary incontinence receiving home-care services in Ontario, Canada. Five themes emerged from the findings: (a) enduring urinary incontinence: "patch it in pads"; (b) struggling to manage diabetes, incontinence, and multiple chronic conditions: "a balancing act"; (c) covering the costs of care: "I can't afford it"; (d) counting on a caregiver: "he does everything"; and (e) home-care services not meeting my needs: "it's not individual." These findings suggest that living with urinary incontinence and diabetes is a complex and challenging experience. This evidence could inform the provision of comprehensive home care to support self-care for this population.

Resource allocation decision-making in dementia care with and without budget constraints: a qualitative analysis

Introduction: Health systems in many different countries have increasingly been reorienting the delivery of dementia care to home and community care settings. This paper provides information on how health and social care professionals (HSCPs) in Ireland make decisions on resource allocation for people with dementia living at home and how resource constraints affect their decisions and choices. Methods: A balance of care approach was used to assess resource allocation across six dementia case types, from low to high needs. Workshops were held with 24 HSCPs from multiple disciplines. Participants allocated services in two scenarios: allocation with and without a budget constraint. Nominal group technique was used to structure discussions around resource allocation in both scenarios. Thematic analysis was applied to analyse the qualitative data using a general inductive approach. Results: The following themes influenced allocative deliberations: whose needs are being met; what needs are identified; decision making context; decision making process; and allocation outcomes. Participants were proficient in making decisions, using 'decision rules' or heuristics to help them make decisions under fixed budget rules and sticking to conventional provision when constraints were in place. Conclusions: Freedom from a budget constraint allowed HSCPs to consider a broader range of services and to take a more expansive view on what needs should be considered, with a particular emphasis on adopting a proactive, preventative approach to the allocation of resources. The effect of the budget constraint overall was to narrow all considerations, using heuristics to limit the type of needs addressed and the range of services and supports provided. The consequences were a largely reactive, less personalised system of care. The findings emphasise the need for an integrated and comprehensive assessment process that is more concerned with individualised responses rather than relying on existing models of care alone.

A comparison of 3 frailty measures and adverse outcomes in the intake home care population: a retrospective cohort study

BACKGROUND

In Ontario, Canada, nearly all home care patients are assessed with a brief clinical assessment (interRAI Contact Assessment [interRAI CA]) on admission. Our objective was to compare 3 frailty measures that can be operationalized using the interRAI CA.

METHODS

We conducted a retrospective cohort study using linked patient-level assessment and administrative data for all Ontario adult (≥ 18 yr) home care patients assessed with the interRAI CA in 2014. We employed multivariable logistic models to compare the Changes in Health, End-stage disease and Signs and Symptoms Scale for the Contact Assessment (CHESS-CA), Assessment Urgency Algorithm (AUA) and the Frailty Index for the Contact Assessment (FI-CA) that was created for this study. Our outcomes of interest were death, hospital admission and emergency department visits within 90 days, and assessor-rated need for comprehensive geriatric assessment (CGA).

RESULTS

In 2014, there were 228 679 unique adult home care patients in Ontario assessed with the interRAI CA. Controlling for age, sex and health region, being in a higher frailty level defined by any measure increased the likelihood of experiencing adverse outcomes. Among all assessments, CHESS-CA was best suited for predicting death and hospital admission, and either AUA or FI-CA for predicting perceived need for CGA. Previous emergency department visits were more predictive of future visits than frailty. Model fit was independent of whether the assessment was completed over the phone or in person.

INTERPRETATION

Frailty measures from the interRAI CA identified patients at higher risk for death, hospital admission and perceived need for CGA. In jurisdictions where the CHESS-CA and AUA are already built into the electronic home care platform, such as Ontario, patients identified as high risk should be prioritized for proactive referral and care planning, and may benefit from greater involvement of primary care and other health professionals in the circle of care.

Resource allocation decision-making in dementia care with and without budget constraints: a qualitative analysis

Introduction: Health systems in many different countries have increasingly been reorienting the delivery of dementia care to home and community care settings. This paper provides information on how health and social care professionals (HSCPs) in Ireland make decisions on resource allocation for people with dementia living at home and how resource constraints affect their decisions and choices. Methods: The study employed a balance of care approach to assess resource allocation across six dementia case types, ranging from low to high needs. Decision-making workshops were held with 24 HSCPs from a range of backgrounds. Participants were asked to allocate services and supports across dementia case types in two scenarios: allocation with and without a budget constraint. Nominal group technique was used to structure discussions around resource allocation in both scenarios. Thematic analysis was applied to analyse the qualitative data using a general inductive approach. Results: The following themes influenced allocative deliberations: whose needs are being met; what needs are identified; decision making context; decision making process; and allocation outcomes. Participants used 'decision rules' or heuristics to help them make decisions under fixed budget rules. Conclusions: Freedom from a budget constraint allowed HSCPs to consider a broader range of services and to take a more expansive view on what needs should be considered, with a particular emphasis on adopting a proactive, preventative approach to the allocation of resources. The effect of the budget constraint overall was to narrow all considerations, using heuristics to limit the type of needs addressed and the range of services and supports provided. The consequences were a largely reactive, less personalised system of care. The findings emphasise the need for an integrated and comprehensive assessment process that is more concerned with individualised responses rather than relying on existing models of care alone.

Older adults with dual sensory loss in rehabilitation show high functioning and may fare better than those with single sensory loss

The population of older adults that have Dual Sensory Loss (DSL) is increasing, yet most research to date has focused on single sensory impairment and is inconclusive as to whether DSL is associated with worse impact on health and well-being over single sensory loss. The primary aim of this study was to characterize the health and functioning of community-dwelling older adults with DSL who were receiving sensory rehabilitation, using an understudied assessment: the interRAI Community Health Assessment (CHA). The secondary aim was to investigate whether older adults with DSL had worse health-related outcomes than their peers with only vision loss (VL) or only hearing loss (HL). We report and compare the interRAI CHA results in a sample of 200 older adults (61+ years of age) who had DSL, VL or HL. Overall, all sensory impairment groups showed high functioning in the areas of cognition, communication, activities of daily living, depression, and psycho-social well-being. DSL was not always associated with worse outcomes compared to a single sensory loss. Rather, the results varied depending on the tasks assessed, as well as which groups were compared. Our findings highlight that despite the negative impact of sensory losses, community-dwelling older adults receiving sensory rehabilitation services tend to have overall good health and a high level of independence. These results also show that DSL is not always associated with worse outcomes compared to a single sensory loss. Further research is needed to better characterize older adults with DSL who have more severe sensory and cognitive difficulties than those in our sample, and among those who are not receiving rehabilitation services.

Reliability and validity of the Mandarin version of the Continuity Assessment Record and Evaluation for older people who are transferred between hospitals and nursing homes in China

To date, assessment tools for older people are different between hospitals and nursing homes in China. The difference between assessment tools can lead to poor communication of information between hospitals and nursing homes, which causes discontinuity of care and adverse outcomes when older people are transferred between these different settings. Continuity Assessment Record and Evaluation (CARE) is a comprehensive geriatric assessment tool developed in the United States of America. This study aimed to evaluate the reliability and validity of the Mandarin Version of CARE for older people who are transferred between hospitals and nursing homes. Using a convenience sampling method, 120 older people in hospitals and 120 older people in nursing homes in Shanghai were selected to test the internal consistency, interrater reliability and criterion-related validity of CARE from May to November 2017. When used among hospital, 70.0% (7/10) of the subscales had a Cronbach's alpha coefficients of greater than 0.7, 94.3% (50/53) of the items had an intraclass correlation coefficient (ICC) of greater than 0.75. When used in nursing homes, 90.0% (9/10) of the subscales had a Cronbach's alpha coefficients of greater than 0.7, 94.3% (50/53) of the items had an ICC of greater than 0.75. For both settings, the correlation coefficients of the subscales with their corresponding instruments for criterion-related validity were all greater than 0.8 (p < .01). The Mandarin version of CARE exhibits good reliability and validity. It can be used as an assessment tool for transition between hospitals and nursing homes.

Cross-sectional Study of Prevalence and Correlates of Urinary Incontinence in Older Home-Care Clients With Type 2 Diabetes in Ontario, Canada

OBJECTIVES

Urinary incontinence (UI) is a burdensome condition for older adults with diabetes receiving home-care services, yet little is known about the prevalence and correlates of UI in this population. The objective of this cross-sectional study, informed by a complexity model, was to determine the prevalence and correlates of UI in older adults with diabetes receiving home care in Ontario, Canada.

METHODS

In this study, we analyzed population-level data of the most recently completed Resident Assessment Instrument for Home Care from 2011 to 2016 for older (≥65 years) home-care clients with diabetes. Older adults with daily or multiple daily episodes of UI were compared with adults who were continent or had less than daily UI on sociodemographic, functional, psychosocial and clinical variables. Multiple logistic regression was used to determine correlates of UI in this population.

RESULTS

Of 118,519 older adults with diabetes, 39,945 (33.7%) had daily or multiple daily episodes of UI. Correlates of UI included: impaired function in activities of daily living (odds ratio [OR], 5.31; 95% confidence interval [CI], 5.14‒5.50), cognitive impairment (OR, 2.37; 95% CI, 2.28‒2.47), female sex (OR, 1.87; 95% CI, 1.82‒1.93), multiple (≥2) chronic conditions (OR, 1.83; 95% CI, 1.74‒1.93), presence of a distressed caregiver (OR, 1.31; 95% CI, 1.27‒1.35), making economic trade-offs (OR, 1.23; 95% CI, 1.11‒1.34) and falls (OR, 1.22; 95% CI, 1.19‒1.26).

CONCLUSIONS

Urinary incontinence is common among older adults with diabetes using home-care services. Targeted interventions are required to address the social, functional and clinical factors associated with UI in this population.

Home care quality indicators based on the Resident Assessment Instrument-Home Care (RAI-HC): a systematic review

BACKGROUND

One way of measuring the quality of home care are quality indicators (QIs) derived from data collected with the Resident Assessment Instrument-Home Care (RAI-HC). In order to produce meaningful results for quality improvement and quality comparisons across home care organizations (HCOs) and over time, RAI-HC QIs must be valid and reliable. The aim of this systematic review was to identify currently existing RAI-HC QIs and to summarize the scientific knowledge on the validity and reliability of these QIs.

METHODS

A systematic review was performed using the electronic databases PubMed, CINAHL, Embase, PsycINFO and Cochrane Library. Studies describing the development process or the psychometric characteristics of RAI-HC QIs were eligible. The data extraction involved a general description of the included studies as well as the identified RAI-HC QIs and information on validity and reliability. The methodological quality of the identified RAI-HC QI sets was assessed using the Appraisal of Indicators through Research and Evaluation (AIRE) instrument.

RESULTS

Four studies out of 659 initial hits met the inclusion criteria. The included studies described the development and validation process of three RAI-HC QI sets comprising 48 unique RAI-HC QIs, which predominantly refer to outcome of care. Overall, the validity and reliability of the identified RAI-HC QIs were not sufficiently tested. The methodological quality of the three identified RAI-HC QI sets varied across the four AIRE instrument domains. None of the QI sets reached high methodological quality, defined as scores of 50% and higher in all four AIRE instrument domains.

CONCLUSIONS

This is the first review that systematically summarized and appraised the available scientific evidence on the validity and reliability of RAI-HC QIs. It identified insufficient reporting of RAI-HC QIs validation processes and reliability as well as missing state-of-the-art methodologies. The review provides guidance as to what additional validity and reliability testing are needed to strengthen the scientific soundness of RAI-HC QIs. Considering that RAI-HC QIs are already implemented and used to measure and compare quality of home care, further investigations on RAI-HC QIs reliability and validity is recommended.

Cross-Sectional Nutrition Profile of Palliative Home Care Clients in Ontario and Performance of the interRAI Palliative Care Nutrition Clinical Assessment Protocol

BACKGROUND

The nutrition profile of palliative home care clients is unknown. This study describes this group and their nutrition issues and evaluates the performance of the interRAI nutrition Clinical Assessment Protocol (CAP).

METHODS

This was a cross-sectional secondary analysis using Ontario interRAI Palliative Care (interRAI PC) Assessment data. The sample represents 74,963 unique Ontario home care clients assessed between 2011 and 2018. Frequencies and standardized differences (stdiffs) of nutrition characteristics were presented for cancer (n = 62,394) and noncancer (n = 12,569) diagnostic subgroups. Rates of triggering the nutrition CAP were presented by nutrition issue to evaluate its performance.

RESULTS

Of this sample, 16.7% were ≥85 years of age, 52.6% had a prognosis between 6 weeks and 6 months, and 41.4% required assistance with eating. The prevalence was higher among those with nervous/mental/behavioral disorders (72.6%) compared with those with cancer (37.6%; stdiff = 0.75). However, most nutrition issues experienced were similar (stdiff < 0.20) across diagnostic groups. Of the entire sample, 21% triggered the nutrition CAP, indicating a need for further evaluation or intervention. Yet, 73.4% of those who experienced dry mouth, 71.8% of those who required assistance with eating, and 68.4% of those who received a nutrition consult within the last 3 days did not trigger the nutrition CAP.

CONCLUSIONS

Nutrition issues are prevalent in palliative home care clients, regardless of diagnosis; yet the nutrition CAP identified a small fraction of this group. There is a need to focus research and care guidelines toward life-limiting illnesses beyond cancer and address nutrition-related issues in this population.

Fatigue, sleep and depression: An exploratory interRAI study of older adults

An association between fatigue and depression was reported for older adults. We examined the association between fatigue, sleep and depression from interRAI-HC assessments of community dwelling older people (65+ years). Interview data from 5,950 participants who completed their first interRAI-HC assessment was analysed (mean age, 81.3 ± 7.1 years; 60.2% female). Only 873 (15%) reported "severe" fatigue. Nearly half reported minor sleep problems. Depression was diagnosed in 693 participants (11.6%). Depression explained only 0.2% of fatigue. This calls for further studies that may help in understanding the relationship between fatigue and depression across the life-cycle.

The interRAI Suite of Mental Health Assessment Instruments: An Integrated System for the Continuum of Care

The lives of persons living with mental illness are affected by psychological, biological, social, economic, and environmental factors over the life course. It is therefore unlikely that simple preventive strategies, clinical treatments, therapeutic interventions, or policy options will succeed as singular solutions for the challenges of mental illness. Persons living with mental illness receive services and supports in multiple settings across the health care continuum that are often fragmented, uncoordinated, and inadequately responsive. Appropriate assessment is an important tool that health systems must deploy to respond to the strengths, preferences, and needs of persons with mental illness. However, standard approaches are often focused on measurement of psychiatric symptoms without taking a broader perspective to address issues like growth, development, and aging; physical health and disability; social relationships; economic resources; housing; substance use; involvement with criminal justice; stigma; and recovery. Using conglomerations of instruments to cover more domains is impractical, inconsistent, and incomplete while posing considerable assessment burden. interRAI mental health instruments were developed by a network of over 100 researchers, clinicians, and policy experts from over 35 nations. This includes assessment systems for adults in inpatient psychiatry, community mental health, emergency departments, mobile crisis teams, and long-term care settings, as well as a screening system for police officers. A similar set of instruments is available for child/youth mental health. The instruments form an integrated mental health information system because they share a common assessment language, conceptual basis, clinical emphasis, data collection approach, data elements, and care planning protocols. The key applications of these instruments include care planning, outcome measurement, quality improvement, and resource allocation. The composition of these instruments and psychometric properties are reviewed, and examples related to homeless are used to illustrate the various applications of these assessment systems.

No seasonal influence on cognitive performance in a national sample of older adults in New Zealand

OBJECTIVES

A recent North American study reported seasonal differences in cognitive functioning in older adults. We assessed seasonality of cognitive functioning in a large data set of older adults in New Zealand.

METHODS

The International Residential Assessment Instrument-Home Care (interRAI-HC) data set was analysed using a non-parametric method for testing seasonal distribution of cognitive and depression scale scores.

RESULTS

Participants were 73 285 New Zealanders 65 years and older who completed their first interRAI-HC assessment (mean age, 81.4 years; 57% female). We analysed this sample cross-tabulating season (summer, autumn, winter and spring) and the Cognitive Performance Scale (CPS) score (Kruskal-Wallis test, P = 0.45). Month-by-month CPS scores also demonstrated no variation (Spearman's test, P = 0.96). There was no association between season of assessment and the Depression Rating Scale score, ruling out variability in affect impacting on cognitive performance (Kruskal-Wallis test, P = 0.99).

CONCLUSION

Our findings, limited to the Southern Hemisphere, demonstrate a lack of seasonality in cognitive performance and impairment in older adults.

Detection of vision and /or hearing loss using the interRAI Community Health Assessment aligns well with common behavioral vision/hearing measurements

This study's main objective was to assess the sensitivity and specificity of the interRAI Community Health Assessment (CHA) for detecting the presence of vision loss (VL), hearing loss (HL) or both (Dual Sensory Loss, DSL) when compared against performance-based measures of vision and hearing. The interRAI CHA and the Montreal Cognitive Assessment (MoCA) were administered to 200 adults (61+ years of age) who had VL, HL or DSL. We calculated the sensitivity and specificity of the interRAI CHA for detecting sensory impairments using as the gold standard performance based measurements of hearing (pure-tone audiogram) and vision (distance acuity) as determined from the rehabilitation centre record. Results were divided according to participants' cognitive status, as measured by the MoCA and the Cognitive Performance Scale (CPS, embedded within the interRAI CHA). Overall, sensitivity was 100% for VL, 97.1% for HL, and 96.9% for DSL. Specificity was at least 93% in all three groups. In participants who failed the MoCA (i.e., at risk of mild cognitive impairment), the sensitivity was 100% for VL, 96.8% for HL and 96.2% for DSL; in those who were not at risk, the sensitivity was 100% for VL, and 97.4% for HL and DSL. In participants classified by the CPS as borderline intact or mild cognitively impaired, sensitivity was 100% in all groups; in those classified as cognitively intact, sensitivity was 100% for VL, 97.0% for HL, and 96.8% for DSL. These results suggest that the interRAI CHA detects VL, HL, and DSL in high agreement with performance-based measurements of vision and hearing. The interRAI CHA shows high accuracy even in participants with mild cognitive difficulties. Since results were found in a specific population of older rehabilitation clients who all had sensory difficulties, further research is needed to understand its role in screening in other more diverse groups.

Comparing Changes and Transitions of Home Care Clients in Retirement Homes and Private Homes

Long-stay home care clients mostly reside in private homes or retirement homes, and the type of residence may influence risk factors for long-term care placement. This multi-state analytic study uses RAI-Home Care and administrative data from the Hamilton Niagara Haldimand Brant Local Health Integration Network to model conceptualized states of risk at baseline through a 13-month follow-up period. Modifiable risk factors in these states were client loneliness or depressive symptoms, and caregiver distress. A higher adjusted likelihood of being discharged deceased was found for the lowest-risk clients in retirement homes. Adjusting for client, service, and caregiver characteristics, retirement home residency was associated with higher likelihood of placement in a long-term care home; reduced caregiver distress; and increased client loneliness/depression. As an alternative to private home settings as the location for aging in place among these long-stay home care clients, retirement home residency represents some trade-offs between client and informal caregiver.

Development and validation of a screener based on interRAI assessments to measure informal caregiver wellbeing in the community

Background

Informal caregivers are invaluable partners of the health care system. However, their caring responsibilities often affect their psychological wellbeing and ability to continue in their role. It is of paramount importance to easily identify caregivers that would benefit from immediate assistance.

Methods

In this nonexperimental cohort study, a cross-sectional analysis was conducted among 362 informal caregivers (mean age 64.1 years, SD ± 13.1) caring for persons with high care needs (mean age 78.6 years, SD ± 15.0). Caregivers were interviewed using an interRAI-based self-reported survey with 82 items covering characteristics of caregivers including key aspects of wellbeing. A factor analysis identified items in the caregiver survey dealing with subjective wellbeing that were compared against other wellbeing measures. A screener, called Caregiver Wellbeing Index (CWBI), consisting of four items with response scores ranging from 0 to 2 was created. The CWBI was validated in a follow-up study in which 1020 screeners were completed by informal caregivers of home care clients. Clinical assessments of the care recipients (n = 262) and information on long-term care home (LTCH) admission (n = 176) were linked to the screener dataset. The association between the CWBI scores and caregiver and care recipient characteristics were assessed using logistic regression models and chi-square tests. The reliability of CWBI was also measured.

Results

The CWBI scores ranging from zero to eight were split in four ‘wellbeing’ levels (excellent, good, fair, poor). In the validation study, fair/poor psychological wellbeing was strongly associated with caregiver reports of inability to continue in their role; conflict with family; or feelings of distress, anger, or depression (P < 0.0001). Caregivers caring for a care recipient that presented changes in behavior, cognition, and mood were more likely to present fair/poor wellbeing (P < 0.0001). Additionally, caregivers with high CWBI scores (poor wellbeing) were also more likely to provide care for someone who was admitted to a LTCH (OR 3.52, CI 1.32–9.34) after controlling for care recipient and caregiver characteristics. The Cronbach alpha value 0.89 indicated high reliability.

Conclusion

The CWBI is a valid screener that can easily identify caregivers that might benefit from further assessment and interventions.

Evaluation of a staff training programme to reimplement a comprehensive health assessment

Background

Health information systems with applications in patient care planning and decision support depend on high-quality data. A postacute care hospital in Ontario, Canada, conducted data quality assessment and focus group interviews to guide the development of a cross-disciplinary training programme to reimplement the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0 comprehensive health assessment into the hospital's clinical workflows.

Methods

A hospital-level data quality assessment framework based on time series comparisons against an aggregate of Ontario postacute care hospitals was used to identify areas of concern. Focus groups were used to evaluate assessment practices and the use of health information in care planning and clinical decision support. The data quality assessment and focus groups were repeated to evaluate the effectiveness of the training programme.

Results

Initial data quality assessment and focus group indicated that knowledge, practice and cultural barriers prevented both the collection and use of high-quality clinical data. Following the implementation of the training, there was an improvement in both data quality and the culture surrounding the RAI-MDS 2.0 assessment.

Conclusions

It is important for facilities to evaluate the quality of their health information to ensure that it is suitable for decision-making purposes. This study demonstrates the use of a data quality assessment framework that can be applied for quality improvement planning.

Predicting hospital and emergency department utilization among community-dwelling older adults: Statistical and machine learning approaches

OBJECTIVE

The objective of this study was to compare the performance of several commonly used machine learning methods to traditional statistical methods for predicting emergency department and hospital utilization among patients receiving publicly-funded home care services.

STUDY DESIGN AND SETTING

We conducted a population-based retrospective cohort study of publicly-funded home care recipients in the Hamilton-Niagara-Haldimand-Brant region of southern Ontario, Canada between 2014 and 2016. Gradient boosted trees, neural networks, and random forests were tested against two variations of logistic regression for predicting three outcomes related to emergency department and hospital utilization within six months of a comprehensive home care clinical assessment. Models were trained on data from years 2014 and 2015 and tested on data from 2016. Performance was compared using logarithmic score, Brier score, AUC, and diagnostic accuracy measures.

RESULTS

Gradient boosted trees achieved the best performance on all three outcomes. Gradient boosted trees provided small but statistically significant performance gains over both traditional methods on all three outcomes, while neural networks significantly outperformed logistic regression on two of three outcomes. However, sensitivity and specificity gains from using gradient boosted trees over logistic regression were only in the range of 1%-2% at several classification thresholds.

CONCLUSION

Gradient boosted trees and simple neural networks yielded small performance benefits over logistic regression for predicting emergency department and hospital utilization among patients receiving publicly-funded home care. However, the performance benefits were of negligible clinical importance.

Comparison of Psychosocial Variables Associated With Loneliness in Centenarian vs Elderly Populations in New Zealand

IMPORTANCE

Loneliness is associated with reduced health-related quality of life and increased morbidity and mortality and typically worsens with aging.

OBJECTIVES

To evaluate associations between demographic and psychosocial variables and loneliness, examine any age-specific associations, and compare centenarians (aged ≥100 years) with elderly people (aged 65-99 years).

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective, observational, cross-sectional study, previously collected data from all New Zealanders 65 years and older who completed their first international Resident Assessment Instrument-Home Care (interRAI-HC) assessment during the study period (January 1, 2013, to November 27, 2017) were reviewed. Participants were people living independently in the community who were requesting or referred for assessment with a potential need for support services.

MAIN OUTCOMES AND MEASURES

The interRAI-HC is a 236-item, electronically recorded assessment that encompasses a comprehensive range of aspects of an older person's life, including physical, psychological, and cognitive domains. Eight main items from the interRAI-HC data set were analyzed to describe the population and evaluate the core psychosocial components of aging, namely, age, sex, race/ethnicity, marital status, living arrangements, family support, depression, and loneliness. Loneliness was evaluated by the participants' response to the assessment statement, "Says or indicates that he/she feels lonely."

RESULTS

A total of 73 286 New Zealanders (mean age, 81.4 years; age range, 65-109 years; 41 641 [56.9%] female) participated in the study. The assessments of 191 centenarians (mean [SD] age, 100.9 [1.2] years) and 73 095 elderly people (mean [SD] age, 81.4 [7.6] years) were analyzed. Centenarians vs elderly people were more likely to be female (136 [71.2%] vs 41 488 [56.8%]; P < .001), and the populations differed by marital status (widowed: 170 [89.0%] vs 31 554 [43.2%]; overall P < .001) and depression status (70.2% vs 59.5% free of depression; overall P = .008). Centenarians were less likely to be lonely compared with elderly people, with a 22% lower risk of loneliness for a typical centenarian (aged 100.9 years) compared with a typical elderly person (aged 81.4 years) in unadjusted analyses (relative risk, 0.78; 95% CI, 0.67-0.92; P = .002). In the fully adjusted model, there was a 32% reduction in loneliness for a centenarian compared with an elderly person (relative risk, 0.68; 95% CI, 0.58-0.79; P < .001). Living with others, having family support, and lacking depression were associated with lower risk of loneliness.

CONCLUSIONS AND RELEVANCE

Centenarians are a unique group to study as a model of successful aging. The sample of centenarians in this study appeared to be less lonely than other groups studied internationally. The study identified multiple psychosocial variables that were associated with the risk of loneliness, including living arrangements, family support, and depression. Knowing these variables may help our society address risk factors for loneliness in older people.

Measuring health related quality of life (HRQoL) in community and facility-based care settings with the interRAI assessment instruments: development of a crosswalk to HUI3

Background

Health-related quality of life (HRQoL) measures are of interest because they can be used to describe health of populations and represent a broader health outcome for population health analyses than mortality rates or life expectancy. The most widely used measure of HRQoL for deriving estimates of health-adjusted life expectancy is the Health Utilities Index Mark 3 (HUI3). The HUI3 is available in most national surveys administered by Statistics Canada, and has been used as part of a microsimulation model to examine the impact of neurological conditions over the life course. Persons receiving home care and nursing home services are often not well-represented in these surveys; however, interRAI assessment instruments are now used as part of normal clinical practice in these settings for nine Canadian provinces/territories. Building on previous research that developed a HUI2 crosswalk for the interRAI assessments, the present study examined a new interRAI HRQoL index crosswalked to the HUI3.

Methods

interRAI and survey data were used to examine the distributional properties of global and domain-specific interRAI HRQoL and HUI3 index scores, respectively. Three populations were considered: well-elderly persons not receiving home care, home care clients and nursing home residents.

Results

The mean HUI3 and interRAI HRQoL index global scores declined from independent healthy older persons to home care clients, followed by nursing home residents. For the home care and nursing home populations, the interRAI HRQoL global estimates tended to be lower than HUI3 global scores obtained from survey respondents. While there were some statistically significant age, sex and diagnostic group differences in global scores and within attributes, the most notable differences were between populations from different care settings.

Discussion

The present study provides strong evidence for the validity of the interRAI HRQoL based on comparisons of distributional properties with those obtained with survey data based on the HUI3. The results demonstrate the importance of admission criteria for home care and nursing home settings, where function plays a more important role than demographic or diagnostic criteria. The interRAI HRQoL has a distinct advantage because it is gathered as part of normal clinical practice in care settings where interRAI instruments are mandatory and are used to assess all eligible persons in those sectors. In particular, those with severe cognitive and functional impairments (who tend to be under-represented in survey data) will be evaluated using the interRAI tools. Future research should build on this work by providing direct, person-level comparisons of interRAI HRQoL index and HUI3 scores, as well as longitudinal analyses to examine responsiveness to change.

Derivation and validation of the Personal Support Algorithm: an evidence-based framework to inform allocation of personal support services in home and community care

Background

Personal support services enable many individuals to stay in their homes, but there are no standard ways to classify need for functional support in home and community care settings. The goal of this project was to develop an evidence-based clinical tool to inform service planning while allowing for flexibility in care coordinator judgment in response to patient and family circumstances.

Methods

The sample included 128,169 Ontario home care patients assessed in 2013 and 25,800 Ontario community support clients assessed between 2014 and 2016. Independent variables were drawn from the Resident Assessment Instrument-Home Care and interRAI Community Health Assessment that are standardised, comprehensive, and fully compatible clinical assessments. Clinical expertise and regression analyses identified candidate variables that were entered into decision tree models. The primary dependent variable was the weekly hours of personal support calculated based on the record of billed services.

Results

The Personal Support Algorithm classified need for personal support into six groups with a 32-fold difference in average billed hours of personal support services between the highest and lowest group. The algorithm explained 30.8% of the variability in billed personal support services. Care coordinators and managers reported that the guidelines based on the algorithm classification were consistent with their clinical judgment and current practice.

Conclusions

The Personal Support Algorithm provides a structured yet flexible decision-support framework that may facilitate a more transparent and equitable approach to the allocation of personal support services.