Supporting Older People to Live Safely at Home - Findings from Thirteen Case Studies on Integrated Care Across Europe

Developing a comprehensive model of home-based long-term care for older people in Iran: a multi-method study

INTRODUCTION

With the increasing aging population, the demand for care that fosters independence in older adults is rising. Complications from hospitalization and the preference for aging in place highlight the need for geriatric home care systems. This study aims to develop a comprehensive home-based care model specifically for Iranian seniors and evaluate its feasibility.

METHODS

This study employed a multi-phase approach in Iran. It began with a mixed-methods analysis, including a survey on caregiver reliance, followed by qualitative interviews to identify challenges in home care services. Phase 2 involved a scoping review of home care frameworks from various countries. In Phase 3, an initial model was created based on previous findings and relevant documents in Iran. In the fourth phase, feedback was gathered from an expert panel selected through purposive sampling, with discussions recorded and concluding at saturation. The feedback was then integrated into the final model. Additionally, in a Delphi study, experts evaluated the model components using a four-point Likert scale, calculating the content validity index (CVI) for each item. A CVI of 79% or higher indicated validity, and continuous feedback led to iterative refinements.

RESULTS

Following the design of the initial model, an expert panel convened with 15 participants to review the framework. The final model comprises seven key components: leadership and governance, legislative framework, financial framework, human resource management system, information management system, and control and monitoring system. Results from the Delphi study indicated that with a CVI exceeding 80%, this model is deemed a valid framework for delivering home-based care.

CONCLUSION

This study presents a comprehensive model that serves as a valuable guide for policymakers seeking to implement integrated home care with professional oversight. By doing so, it aims to enhance the quality of care and improve stakeholder satisfaction.

Depression and Its Effect on Geriatric Rehabilitation Outcomes in Switzerland's Aging Population

Background and Objectives: Depression is a common mental problem in the older population and has a significant impact on recovery and general well-being. A comprehensive understanding of the prevalence of depressive symptoms and their effects on functional outcomes is essential for improving care strategies. The primary aim of this study was to determine the prevalence of depressive symptoms in older patients undergoing geriatric rehabilitation and to assess their specific impact on their functional abilities. Materials and Methods: A retrospective study was conducted at the Lucerne Cantonal Hospital in Wolhusen, Switzerland, spanning from 2015 to 2020 and including 1159 individuals aged 65 years and older. The presence of depressive symptoms was assessed using the Geriatric Depression Scale (GDS) Short Form, while functional abilities were evaluated using the Functional Independence Measure (FIM) and the Tinetti test. Data analysis was performed using TIBCO Statistica 13.3, with statistical significance set at p < 0.05. Results: Of the participants, 22.9% (N = 266) exhibited depressive symptoms, with no notable differences between genders. Although all patients showed functional improvements, the duration of rehabilitation was prolonged by two days (p = 0.012, d = 0.34) in those with depressive symptoms. Alarmingly, 76% of participants were classified as at risk of falling based on the Tinetti score. However, no significant correlation was found between the GDS and Tinetti scores at admission (p = 0.835, r = 0.211) or discharge (p = 0.336, r = 0.184). The results from the non-parametric Wilcoxon matched-pairs test provide compelling evidence of significant changes in FIM scores when comparing admission scores to those at discharge across all FIM categories. Conclusions: Depressive symptoms are particularly common in geriatric rehabilitation patients, leading to prolonged recovery time and increased healthcare costs. While depressive symptoms showed no correlation with mobility impairments, improvements in functional status were directly associated with reduced GDS scores. Considering mental health during admission and planning is critical in optimizing rehabilitation outcomes.

Socio-Healthcare for Older People in the Mediterranean Basin: An Integrative Review and Quality Appraisal

OBJECTIVES

The aging Mediterranean Basin population presents complex challenges for healthcare systems, which require innovative care approaches. The study aimed to critically assess 19 socio-healthcare practices in the Mediterranean Basin that target the elderly population by analyzing their theoretical foundations, integration of care services, ethical considerations, gender-specific approaches, and use of technology.

DESIGN

An integrative literature review was conducted using a structured methodology.

SAMPLE

Diverse sources across multiple languages were searched, with the inclusion criteria focusing on the alignment of socio-healthcare practices with the components of the nursing metaparadigm, the incorporation of transversal values, and relevance to the elderly population.

RESULTS

The socio-healthcare practices exhibited common themes, such as person-centered care, interdisciplinary collaboration, and incorporation of technology for coordinated care delivery. Ethical principles of autonomy, dignity, and respect were central, with some socio-healthcare practices addressing gender-specific care needs. Evidence-based findings emphasized holistic care, integration, ethics, and innovation in elderly socio-healthcare.

CONCLUSIONS

New eldercare frameworks should integrate these aspects, which offer a comprehensive approach to addressing the complex needs of elderly patients. Managers should design systems prioritizing patient well-being, whereas policymakers should develop equitable and high-quality care policies that collectively improve the well-being of the elderly population in the Mediterranean Basin.

Implementation of a Comprehensive and Personalised Approach for Older People with Psychosocial Frailty in Valencia (Spain): Study Protocol for a Pre-Post Controlled Trial

With ageing, the risk of frailty increases, becoming a common condition that exposes older people to an increased risk of multiple adverse health outcomes. In Valencia (Spain), the ValueCare project develops and applies a value-based care approach that addresses the multidimensional nature of frailty by implementing integrated and personalized care to tackle psychosocial frailty. A pre-post controlled design with a baseline measurement at inclusion, at the end of implementation and a follow-up measurement after 6 months of intervention. In Valencia (Spain), 120 participants over 65 years of age are recruited from primary care centres to receive the ValueCare comprehensive and personalised care plan according to the results and are compared with 120 participants receiving "usual care". An assessment questionnaire is designed using validated instruments, and a personalised care plan is developed specifically for each participant based on the results obtained. The study protocol has been registered under the ISRCTN registration number ISRCTN25089186. Addressing frailty as a multidimensional and multifactorial risk condition requires the development and implementation of comprehensive assessments and care. In this context, this study will provide new insights into the feasibility and effectiveness of a value-based methodology for integrated care supported by ICT for older people experiencing frailty.

First steps towards the deinstitutionalization of older adults: A protocol for the implementation of a complex intervention

BACKGROUND

Nursing homes are becoming increasingly important as end-of-life care facilities. However, many older adults want to stay in their homes as they age.

OBJECTIVE

To assess the feasibility of a deinstitutionalization process on selected institutionalized older adults who are willing to initiate the process.

METHODS

This study, divided into two phases, will be carried out over 15 months on 241 residents living in two nursing homes in Navarra (Spain). The first phase has a cross-sectional design. We will identify the factors and covariates associated with feasibility and willingness to participate in a deinstitutionalization process by bivariate analysis, essential resources for the process and residents to participate in the process. The second phase has a complex interventional design to implement a deinstitutionalization process. An exploratory descriptive and comparative analysis will be carried out to characterize the participants, prescribed services and the impact deinstitutionalization intervention will have over time (quality of life will be the main outcome; secondary variables will be health, psychosocial, and resource use variables). This study will be accompanied by a pseudo-qualitative and emergent sub-study to identify barriers and facilitators concerning the implementation of this process and understand how intervention components and context influence the outcomes of the main study. Intervention components and the way the intervention is implemented will be of great relevance in the analysis.

DISCUSSION

Alternatives to institutionalization with adapted accommodation and community support can allow people who wish to return to the community.

TRIAL REGISTRATION

NCT05605392.

Factors associated with perceptions of dignity and well-being among older people living in residential care facilities in Sweden. A national cross-sectional study

The care of older people living in residential care facilities (RCFs) should promote dignity and well-being, but research shows that these aspects are lacking in such facilities. To promote dignity and well-being, it is important to understand which associated factors to target. The aim of this study was to examine the associations between perceived dignity and well-being and factors related to the attitudes of staff, the care environment and individual issues among older people living in RCFs. A national retrospective cross-sectional study was conducted in all RCFs for older people within 290 municipalities in Sweden. All older people 65 years and older (n = 71,696) living in RCFs in 2018 were invited to respond to the survey. The response rate was 49%. The survey included the following areas: self-rated health, indoor-outdoor-mealtime environment, performance of care, attitudes of staff, safety, social activities, availability of staff and care in its entirety. Data were supplemented with additional data from two national databases regarding age, sex and diagnosed dementia. Descriptive statistics and ordinal logistic regression models were used to analyse the data. Respondents who had experienced disrespectful treatment, those who did not thrive in the indoor-outdoor-mealtime environment, those who rated their health as poor and those with dementia had higher odds of being dissatisfied with dignity and well-being. To promote dignity and well-being, there is a need to improve the prerequisites of staff regarding respectful attitudes and to improve the care environment. The person-centred practice framework can be used as a theoretical framework for improvements, as it targets the prerequisites of staff and the care environment. As dignity and well-being are central values in the care of older people worldwide, the results of this study can be generalised to other care settings for older people in countries outside of Sweden.

“The Devices Themselves Aren’t the Problem”—Views of Patients and Their Relatives on Medical Technical Aid Supply in Home Mechanical Ventilation: An Explorative Qualitative Study

(1) The supply of medical technical aids and the instructions on using them is critical for home-mechanically ventilated patients and their relatives. However, limited evidence exists on the needs-based nature of this care. (2) Aim: To gain insights into users’ views on this form of care, to identify key challenges, and to derive empirically sound preliminary recommendations for its future design. (3) Methods: An explorative qualitative interview study was performed in Germany. Semi-structured interviews were conducted with home-mechanically ventilated patients and their relatives. Patients were selected through purposive sampling. Interviews were audio-recorded, transcribed, and analysed using a content analysis approach. (3) Results: 27 patients and 9 relatives were interviewed. From their point of view, ventilation-specific equipment is generally reliable and is seen as a belonging of the patient. However, if the patient lacks competence in using the technology or if information or instructions are neglected, ambiguous and unsafe situations easily arise. (4) Conclusions: The present study is one of the first to provide insights into technical aid supply in home-mechanical ventilation from the users’ point of view. It highlights the need for continuous professional support and for evidence-based educational strategies that promote safety among the users of technical aids in home care.

Measuring Older Peoples' Experiences of Person-Centred Coordinated Care: Experience and Methodological Reflections from Applying a Patient Reported Experience Measure in SUSTAIN

Introduction

While several evaluation studies on (cost-)effectiveness of integrated care have been conducted in recent years, more insight is deemed necessary into integrated care from the perspective of service users. In the context of a European project on integrated care for older people living at home (SUSTAIN), this paper shares the experience and methodological reflections from applying a Patient Reported Experience Measure (PREM) on person-centred coordinated care -the P3CEQ- among this population.

Methods

A combination of quantitative and qualitative data and analysis methods was used to assess the usability and the quality of applying a PREM among older people presenting complex care needs, using the P3CEQ delivery in SUSTAIN as a case study. 228 service users completed the P3CEQ and nine SUSTAIN researchers participated in a consultation about their experience administering the questionnaire. P3CEQ scores were analysed quantitatively using principal component analysis and multilevel linear regression. P3CEQ open responses and researcher notes collected when administering the questionnaire were thematically analysed.

Results

Service user inclusion was high and most P3CEQ items had low non-response rates. Quantitative analysis and researcher experience indicate the relevance of face-to-face administration for obtaining such an amount of data in this population group. The presence of a carer increased inclusion of more vulnerable respondents, such as the cognitively impaired, but posed a challenge in data interpretation. Although several P3CEQ items were generally understood as intended by questionnaire developers, the analysis of open responses highlights how questions can lead to diverging and sometimes narrow interpretations by respondents. Cognitive impairment and a higher educational attainment were associated with lower levels of perceived person-centredness of care.

Conclusion

This study shows essential preconditions to meaningfully collect and analyse PREM data on older peoples' experiences with integrated care: face-to-face administration away from care providers, collection of reasons for non-response and open comments providing nuances to answers, and multilevel modelling taking into account diversity in the target population. Several areas of improvement for future PREM use in this population have been identified: use of administration and coding guides, inclusion of clear and easy to understand definitions and examples illustrating what questions do and do not mean, measures of the expectations of person-centred coordinated care, and procedures ensuring sound ethical research. These methodological learnings can enhance future evaluation of integrated care from a service user perspective.

Typology of Family Support in Home Care for Iranian Older People: A Qualitative Study

The world population is rapidly aging. In older people, age-related biological decline in most body systems causes functional decline, an increase in dependence, and an increased need for support, especially by their family members. The aim of this study was to explore the main aspects of family support for older parents in home care. This qualitative study was conducted using a deductive qualitative content analysis approach. Participants were 21 older parents living in their own homes, as well as four family members of some participants. Data were collected using semi-structured interviews and then were analyzed using the primary matrix developed based on the existing literature. The main aspects of family support for older parents were grouped into five predetermined categories and one new category: "instrumental support", "financial support", "psycho-emotional support", "healthcare-related support", "informational-technological support", and "social preference support ". Family support for older people in home care is a multi-dimensional phenomenon. Family members can identify the needs of their older parents and provide them with appropriate support in collaboration with healthcare professionals to enhance their quality of life, autonomy, and satisfaction with life.

Games of uncertainty: the participation of older patients with multimorbidity in care planning meetings - a qualitative study

BACKGROUND

Active patients lie at the heart of integrated care. Although interventions to increase the participation of older patients in care planning are being implemented in several countries, there is a lack of knowledge about the interactions involved and how they are experienced by older patients with multimorbidity. We explore this issue in the context of care-planning meetings within Norwegian municipal health services.

METHODS

This qualitative study drew on direct observations of ten care-planning meetings and an interview with each patient right after the meeting. Following a stepwise-deductive induction approach, the analysis began inductively and then considered the interactions through the lens of game theory.

RESULTS

The care-planning interactions were influenced by uncertainty about the course of the disease and how to plan service delivery. In terms derived from game theory, the imaginary and unpredictable player 'Nature' generated uncertainty in the 'game' of care planning. The 'players' assessed this uncertainty differently, leading to three patterns of game. 1) In the 'game of chance', patients viewed future events as random and uncontrollable; they felt outmatched by the opponent Nature and became passive in their decision-making. 2) In the 'competitive game', participants positioned themselves on two opposing sides, one side perceiving Nature as a significant threat and the other assigning it little importance. The two sides negotiated about how to accommodate uncertainty, and the level of patient participation varied. 3) In the 'coordination game', all participants were aligned, either in viewing themselves as teammates against Nature or in ascribing little importance to it. The level of patient participation was high.

CONCLUSIONS

In care planning meetings, the level of patient participation may partly be associated with how the various actors appraise and respond to uncertainty. Dialogue on uncertainty in care-planning interventions could help to increase patient participation.