Estimates of hospital-to-nursing home placement delays have always been varied, and given Medicare's new Prospective Payment System (PPS) based on diagnosis-related groups (DRGs), they are likely to have changed again. Theory and previous research suggest that four patient characteristics are the main causes of delays: Medicaid as the patient's nursing home payer source; need for heavy care due to major physical or mental problems; admission to the hospital from a nursing home; and lack of social support. A pilot study of all 1,016 elderly awaiting nursing home placement in two admission cohorts (pre- and post-PPS) from the three largest hospitals in the county surrounding Charlotte, North Carolina--where nursing home beds are in short supply--indicates that other factors are more important. While most placements were delayed, delays were short. Multiple regression results show that Medicaid patients' delays were only about a day longer than those of private-pay patients. Of the many heavy-care conditions studied, only three were associated with delay. Patients without social support and patients admitted from a nursing home, discharged to a hospital-affiliated facility, or placed after PPS had shorter delays. Long delays were found among patients who had applied for Medicaid coverage but had not yet been certified as financially eligible. Nonwhites and males were also delayed. These findings, if replicated in other areas with perceived nursing home bed shortages, appear to have important implications not only for the usefulness of nursing home case-mix reimbursement and subacute levels of nursing home care, but for nursing home bed-need estimates, too, as well as for Medicaid eligibility determination practices and civil rights law enforcement.
On 1 April new arrangements came into force for arranging and funding residential care for elderly people in Britain. From now on those who seem to need full time care will be assessed first by care managers employed by local authority social services departments. This may lead to admission to an old people's home or a nursing home. Local authorities have been told to consult both users and carers about such decisions. But what about relatives who have not actually been giving care directly? The Relatives Association was set up last year as a voluntary organisation for the relatives and friends of older people living in residential homes. Below, its vice president, Mavis Nicholson, a journalist and broadcaster whose mother died of Alzheimer's disease in a residential home last year, gives her personal view of being such a relative. And Dorothy White, the association's founder, explains what the future may hold for elderly residents and their relatives.
As long-term nursing home care is likely to increase with the aging of the population, identifying chronic medical conditions is of particular interest. Although need factors have a strong impact on nursing home (NH) admission, the diseases causing these functional disabilities are lacking or unclear in the residents' file. We investigated the medical reason (primary diagnosis) of a nursing home admission with respect to the underlying disease.
This study is based on two independent, descriptive and comparative studies in Belgium and was conducted at two time points (1993 and 2005) to explore the evolution over twelve years. Data from the subjects were extracted from the resident's file; additional information was requested from the general practitioner, nursing home physician or the head nurse in a face-to-face interview. In 1993 we examined 1332 residents from 19 institutions, and in 2005 691 residents from 7 institutions. The diseases at the time of admission were mapped by means of the International Classification of Diseases - 9th edition (ICD-9). Longitudinal changes were assessed and compared by a chi-square test.
The main chronic medical conditions associated with NH admission were dementia and stroke. Mental disorders represent 48% of all admissions, somatic disorders 43% and social/emotional problems 8%. Of the somatic disorders most frequently are mentioned diseases of the circulatory system (35%) [2/3 sequels of stroke and 1/5 heart failure], followed by diseases of the nervous system (15%) [mainly Parkinson's disease] and the musculoskeletal system (14%) [mainly osteoarthritis]. The most striking evolution from 1993 to 2005 consisted in complicated diabetes mellitus (from 4.3 to 11.4%; p < 0.0001) especially with amputations and blindness. Symptoms (functional limitations without specific disease) like dizziness, impaired vision and frailty are of relevance as an indicator of admission.
Diseases like stroke, diabetes and mobility problems are only important for institutionalisation if they cause functional disability. Diabetes related complications as cause of admission increased almost three-fold between 1993 and 2005.
This qualitative research using the focus group approach has gathered pertinent perceptions from the stakeholders in Chinese elderly care environment, including community-based and institutionalised elderly, medical providers, administrators and governmental officials. The study found that the elderly are willing to live in nursing homes when they are not in good physical condition and are dependent on others for their activities of daily living. The utilisation of nursing home care has gained acceptance in the community as more elders recognise its advantages. The elderly study subjects expressed interest in the service environment, as well as the cultural and recreational activities in nursing homes. Most participants were satisfied with the quality of nursing care. Administrators and providers in the nursing homes agreed that skilled nursing facilities appear to be more competitive because they require more licensed providers and other professional staff members. A majority of nursing homes face serious financial difficulties.
focus group; demand; supply; nursing home care; public policy; community-based needs; China
Studies on health-related quality of life (HRQOL) are missing for nursing home residents independent from their health conditions or interventions after admission. Our aim was to analyse if the care dependency of nursing home residents influence their HRQOL and to describe HRQOL of nursing home residents at the time of admission.
Eleven German nursing homes were randomly selected for a cross-sectional multicentre study from April 2008 until December 2009. HRQOL was measured with the Nottingham Health Profile (NHP) in the six domains “Physical Mobility”, ”Energy”, “Pain”, “Social Isolation”, “Emotional Reaction” and “Sleep”. Domain scores range from zero (good subjective health status) to 100 (poor subjective health status). Care dependency was evaluated using the Care Dependency Scale, age, sex, cognitive status and diseases were documented by the research assistants. Multivariate regression analysis was performed to quantify the influence of care dependency on HRQOL.
120 residents were included in total. HRQOL was mostly reduced in the domains “Physical Mobility” and ”Energy“ (mean scores >43.0), while impairment differences in the domains “Pain”, “Social Isolation”, “Emotional Reaction” and “Sleep” were only moderate (≤25.0). HRQOL was not influenced by the age. Women (n = 85) had a significantly poorer HRQOL in the domain “Pain” than men (mean score women: 29.5 ± 31.5; males: 14.9 ± 17.2; p = 0.011). Care dependency had an influence on the domain “Sleep” (ß = −0.195, p = 0.031), while the other domains were not influenced by care dependency. Residents with a low care dependency scored significantly lower (better HRQOL) in the domain “Sleep” than residents with a high care dependency (mean score 15.3; SD ± 19.0 versus mean score 32.8 SD ± 33.2; p < 0.02).
The level of care dependency has no influence on the HRQOL from the nursing home residents’ perspective apart from the domain “Sleep”. High care dependency residents have a lower HRQOL in the domain “Sleep” compared to moderate and low care dependency residents. We found a significantly lower HRQOL in women compared to men in the domain “Pain“.
Heath-related quality of life; Care dependency; Nursing home residents
OBJECTIVE: To develop a simple index able to identify at an early stage those elderly patients at high risk of requiring discharge to a residential or nursing home after admission to hospital for acute care. For these patients, early discharge planning might lead to a more effective management and reduce the length of hospitalisation. DESIGN, SETTING, AND PATIENTS: This was a prospective study conducted in two teaching hospitals in Paris, France. A total of 510 consecutive patients was included. They were aged 75 years or more and had been admitted to acute medical care units through the emergency department. MEASUREMENTS: Demographic data, social support, physical disability, mental disability, and pathologic status were assessed shortly after admission (within 24-48 hours). MAIN OUTCOME MEASURES: Outcome of hospitalisation was defined as discharge to home or residential/nursing home. RESULTS: The index, developed by multiple logistic regression, included six variables: the wish of patients' principal career about their returning home after acute hospitalisation, presence of a chronic condition, ability to perform toileting, ability to know the name of the hospital or the city, their age, and their living arrangements. The sensitivity of the index in identifying patients at high risk of requiring discharge to a residential/nursing home was 74.4%, the specificity 63.8% the positive predictive value was 57.8%, and the negative predictive value was 80.6%. CONCLUSIONS: The simple index, using data available very early in the course of hospitalisation, provides an accurate prediction of the hospitalisation outcome. The performance of the index should be tested in other populations and the practical benefits of risk screening should be assessed in a controlled trial to evaluate whether the intervention is useful and without any adverse effects.
Care coordination is an important aspect of nursing care especially for elderly patients admitted to an acute care setting. In Singapore care coordination and transitional care nursing is a new concept of care nevertheless important but unexplored.
The objective of this paper is to explore the characteristics of elderly patients receiving care coordination, determine care gaps and intervention during home visit and telephonic review.
Research design and sampling
A designed questionnaire was used to collect information on the patient’s demography, social and clinical profile and determine post discharge activities using Eric Coleman’s four pillars tool. A pilot study of ten questionnaires was conducted. The retrospective data from the patient’s index admission from the last six months (Nov ’08–April ’09) was analyzed using SPSS version 16.
Total of 517 patients were recruited from October 2008 to March 2009. Majority, 69% were above 70 years old of which 57% female and 76% lives with their children. Clinical information demonstrates that 53% had 3–6 co-morbidities and 58% were taking more than five medications. The abbreviated mental test score were 6.2, 6% were depressed and delirium was present in 14% of patients.
Only 65 patients (0.1%) had home visits and telephonic review done whilst 97% of the remaining had only telephonic review done. Those who had both telephonic and home visit review, medications advice and compliance were checked only in 0.8% (at one week) and 1.6% (at one month) whilst during home visit this was done in 12.2% of patients as medication discrepancy were apparent at home. As for appointment compliance and compilation were done in 0.8% at one week and 51% at four weeks of telephonic review compared to during home visit only 4.8%. Caregivers education was emphasized in 14% of patients at home visit, 2% at one week and 4% at one month of telephonic review.
The result showed that home visit is effective in exploring medication compliance, advice and emphasizing caregiver education, managing appointments can be effectively done through telephone review.
This study demonstrates the vital role of home visit for elderly patient to safely transit between hospitals to home.
care coordination; telephonic review; characteristics of elderly
Although stroke is recognised as a major factor in admission to nursing home care, data is lacking on the extent and nature of the disabilities and dependency in nursing homes arising from stroke. A national study conducted in nursing homes can quantify the number of residents with stroke in nursing homes, their disability and levels of dependency.
A cross-sectional survey research design was used. A total of 572 public and private nursing homes were identified nationally and a stratified random selection of 60 nursing homes with 3,239 residents was made. In half of the nursing homes (n = 30) efforts were made to interview all residents with stroke Survey instruments were used to collect data from residents with stroke and nursing home managers on demography, patient disability, and treatment.
Across all nursing homes (n = 60), 18% (n = 570) of the residents had previously had a stroke. In homes (n = 30), where interviews with residents with stroke (n = 257), only 7% (n = 18) residents were capable of answering for themselves and were interviewed. Data on the remaining 93% (n = 239) residents were provided by the nursing home manager. Nurse Managers reported that 73% of residents with stroke had a high level of dependency. One in two residents with stroke was prescribed antidepressants or sedative medication. Only 21% of stroke residents were prescribed anticoagulants, 42% antiplatelets, and 36% cholesterol lowering medications. Stroke rehabilitation guidelines were lacking and 68% reported that there was no formal review process in place.
This study provides seminal findings on stroke and nursing home services in Ireland. We now know that one in six nursing home residents in a national survey are residents with a stroke, and have a wide range of disabilities. There is currently little or no structured care (beyond generic care) for stroke survivors who reside in nursing homes in Ireland.
An increasing numbers of deaths occur in nursing homes. Knowledge of the course of development over the years in death rates and predictors of mortality is important for officials responsible for organizing care to be able to ensure that staff is knowledgeable in the areas of care needed. The aim of this study was to investigate the time from residents' admission to Icelandic nursing homes to death and the predictive power of demographic variables, health status (health stability, pain, depression and cognitive performance) and functional profile (ADL and social engagement) for 3-year mortality in yearly cohorts from 1996-2006.
The samples consisted of residents (N = 2206) admitted to nursing homes in Iceland in 1996-2006, who were assessed once at baseline with a Minimum Data Set (MDS) within 90 days of their admittance to the nursing home. The follow-up time for survival of each cohort was 36 months from admission. Based on Kaplan-Meier analysis (log rank test) and non-parametric correlation analyses (Spearman's rho), variables associated with survival time with a p-value < 0.05 were entered into a multivariate Cox regression model.
The median survival time was 31 months, and no significant difference was detected in the mortality rate between cohorts. Age, gender (HR 1.52), place admitted from (HR 1.27), ADL functioning (HR 1.33-1.80), health stability (HR 1.61-16.12) and ability to engage in social activities (HR 1.51-1.65) were significant predictors of mortality. A total of 28.8% of residents died within a year, 43.4% within two years and 53.1% of the residents died within 3 years.
It is noteworthy that despite financial constraints, the mortality rate did not change over the study period. Health stability was a strong predictor of mortality, in addition to ADL performance. Considering these variables is thus valuable when deciding on the type of service an elderly person needs. The mortality rate showed that more than 50% died within 3 years, and almost a third of the residents may have needed palliative care within a year of admission. Considering the short survival time from admission, it seems relevant that staff is trained in providing palliative care as much as restorative care.
General acceptance of a patterned progression of dependency in activities of daily living has led to the widespread practice of simply counting the individual's basic ADL dependencies to reflect his or her self-care needs and level of impairment. This method is convenient, and it is practical to the extent that individuals do fit a scaled pattern of dependency that allows some meaningful comparison among individuals and between groups to be made. This research, based on 3,611 Medicaid cases in Virginia, reports that 36 percent of those individuals screened for nursing home admission do not match a commonly accepted pattern of dependency. The analyses include a logistic regression procedure to explain the characteristics of the "ADL divergent" cases and a Guttman scaling procedure on the ADL data for the sample. Results of the analyses indicate that a Guttman scaling procedure does as well as, but not better than, the original Katz ADL scale, with both scales describing approximately two-thirds of the cases in the sample.
Regarding demographic changes in Germany it can be assumed that the number of elderly and the resulting need for long term care is increasing in the near future. It is not only an individual's interest but also of public concern to avoid a nursing home admission. Current evidence indicates that preventive home visits can be an effective way to reduce the admission rate in this way making it possible for elderly people to stay longer at home than without home visits. As the effectiveness and cost-effectiveness of preventive home visits strongly depends on existing services in the social and health system existing international results cannot be merely transferred to Germany. Therefore it is necessary to investigate the effectiveness and cost-effectiveness of such an intervention in Germany by a randomized controlled trial.
The trial is designed as a prospective multi-center randomized controlled trial in the cities of Halle and Leipzig. The trial includes an intervention and a control group. The control group receives usual care. The intervention group receives three additional home visits by non-physician health professionals (1) geriatric assessment, (2) consultation, (3) booster session.
The nursing home admission rate after 18 months will be defined as the primary outcome. An absolute risk reduction from a 20% in the control-group to a 7% admission rate in the intervention group including an assumed drop out rate of 30% resulted in a required sample size of N = 320 (n = 160 vs. n = 160).
Parallel to the clinical outcome measurement the intervention will be evaluated economically. The economic evaluation will be performed from a society perspective.
To the authors' knowledge for the first time a trial will investigate the effectiveness and cost-effectiveness of preventive home visits for people aged 80 and over in Germany using the design of a randomized controlled trial. Thus, the trial will contribute to the existing evidence on preventive home visits especially in Germany.
A thorough understanding of the literature generated from research in care homes is required to support evidence-based commissioning and delivery of healthcare. So far this research has not been compiled or described. We set out to describe the extent of the evidence base derived from randomized controlled trials conducted in care homes.
A systematic mapping review was conducted of the randomized controlled trials (RCTs) conducted in care homes. Medline was searched for “Nursing Home”, “Residential Facilities” and “Homes for the Aged”; CINAHL for “nursing homes”, “residential facilities” and “skilled nursing facilities”; AMED for “Nursing homes”, “Long term care”, “Residential facilities” and “Randomized controlled trial”; and BNI for “Nursing Homes”, “Residential Care” and “Long-term care”. Articles were classified against a keywording strategy describing: year and country of publication; randomization, stratification and blinding methodology; target of intervention; intervention and control treatments; number of subjects and/or clusters; outcome measures; and results.
3226 abstracts were identified and 291 articles reviewed in full. Most were recent (median age 6 years) and from the United States. A wide range of targets and interventions were identified. Studies were mostly functional (44 behaviour, 20 prescribing and 20 malnutrition studies) rather than disease-based. Over a quarter focussed on mental health.
This study is the first to collate data from all RCTs conducted in care homes and represents an important resource for those providing and commissioning healthcare for this sector. The evidence-base is rapidly developing. Several areas - influenza, falls, mobility, fractures, osteoporosis – are appropriate for systematic review. For other topics, researchers need to focus on outcome measures that can be compared and collated.
Health care policies in many countries aim to enable people with dementia to live in their own homes as long as possible. However, at some point during the disease the needs of a significant number of people with dementia cannot be appropriately met at home and institutional care is required. Evidence as to best practice strategies enabling people with dementia to live at home as long as possible and also identifying the right time to trigger admission to a long-term nursing care facility is therefore urgently required. The current paper presents the rationale and methods of a study generating primary data for best-practice development in the transition from home towards institutional nursing care for people with dementia and their informal caregivers. The study has two main objectives: 1) investigate country-specific factors influencing institutionalization and 2) investigate the circumstances of people with dementia and their informal caregivers in eight European countries. Additionally, data for economic evaluation purposes are being collected.
This paper describes a prospective study, conducted in eight European countries (Estonia, Finland, France, Germany, Netherlands, Sweden, Spain, United Kingdom). A baseline assessment and follow-up measurement after 3 months will be performed. Two groups of people with dementia and their informal caregivers will be included: 1) newly admitted to institutional long-term nursing care facilities; and 2) receiving professional long-term home care, and being at risk for institutionalization. Data will be collected on outcomes for people with dementia (e.g. quality of life, quality of care), informal caregivers (e.g. caregiver burden, quality of life) and costs (e.g. resource utilization). Statistical analyses consist of descriptive and multivariate regression techniques and cross-country comparisons.
The current study, which is part of a large European project 'RightTimePlaceCare', generates primary data on outcomes and costs of long-term nursing care for people with dementia and their informal caregivers, specifically focusing on the transition from home towards institutional care. Together with data collected in three other work packages, knowledge gathered in this study will be used to inform and empower patients, professionals, policy and related decision makers to manage and improve health and social dementia care services.
Dementia; Long-term care; Professional home care; Nursing homes
National estimates are provided, for the first time, of the number of hospitalizations in a year for elderly persons who also experience some nursing home use, and patterns for this interaction are described. In 1987, 816,000 persons were transferred from nursing homes to hospitals, constituting 8.5 percent of all Medicare hospital admissions for persons ages 65 and older. Another 347,000 hospital stays involved people admitted from the community and discharged to a nursing home. The reporting of discharge destination on Medicare hospital bill data in 1987 also is analyzed. It was found that these data may have underreported a nursing home as the destination by between 15 and 20 percent. The magnitude of hospitalizations of nursing home residents suggests that programs aimed at improving nursing home care might have an important impact on total days of hospital care, and that it is important to learn more about the optimal use of expensive hospital care.
The elderly mentally ill make considerable demands on health and social services. To evaluate the need for these services a one-day census of all people aged 65 and over was carried out in an area containing 220 000 people (40 000 over 65). Data were obtained on the nursing needs and psychiatric state of the 2162 elderly people in hospital or local authority residential homes for the elderly, or living at home receiving care from the community nursing service. One-third were classified as having psychiatric problems, more than half of them being outside hospital. Residential homes and community nurses play a significant part in caring for the elderly mentally ill, and an integrated but flexible manpower policy is important.
An increasing number of elderly patients in nursing home care appears to be presenting to hospital for acute medical admission. A survey of acute hospital care was undertaken to establish accurately the number and character of such admissions. A total of 1300 acute medical beds was surveyed in Northern Ireland in June 1996 and January 1997 on a single day using a standardised proforma. Demographic details, diagnosis and length of admission were recorded. A total of 84 patients over the age of 65 (mean 79.5 years) admitted from nursing home care was identified in June 1996 and a total of 125 (mean 83.3 years) in January 1997. A total of 88 (70%) of admissions in 1997 were accompanied by a general practitioner's letter. The assessing doctor judged that 12 (9.6%) of admissions in 1997 could have had investigations and or treatment reasonably instituted in a nursing home. The proportion of acute medical beds occupied by nursing home residents was 6% in June 1996 rising to 10% in January 1997. The study accurately identifies the significant contribution of nursing home patients to acute medical admissions and the low proportion in whom admission was unnecessary. Closure of long stay hospital facilities should be accompanied by investment in community medical services and also reinvestment in acute hospital care for elderly people.
A growing elderly population coupled with a reduction in hospital long term care has led to an increase in the independent nursing home sector. This is an expensive resource. Proper placement is therefore essential to ensure its efficient use. Prior to the introduction of care management there was no standard assessment procedure for admission to nursing home care from different sources. A nursing home population (n = 624) in North and West Belfast was studied and mental scores, levels of disability, and the source of admission to the nursing home recorded. Residents admitted from geriatric medical units (n = 132) were compared with those from general medical and surgical wards (n = 168) and those from home (n = 243). Residents who were admitted from a geriatric unit were the most disabled, those admitted from home were the least and those from general wards had intermediate levels of disability (p < 0.005). This is likely to be the result of different assessment procedures for prospective nursing home residents. With the introduction of care management, it is hoped that standardised assessment will follow. The roles of different medical specialists in this process is not yet clear. Further study is needed to assess the appropriateness of placement in nursing homes under care management.
A survey of all elderly people aged 65 years and over from North and West Belfast receiving long-term care in residential and nursing homes, and in psycho-geriatric and geriatric care was undertaken. A total of 967 subjects was studied and physical dependency and mental impairment documented. The high dependency of residents in geriatric and psycho-geriatric care was highlighted, with greater levels of dependency than among those receiving nursing home care. Professional assessment prior to admission should be common to all long-term care facilities and is essential if services for the projected demographic increase in numbers of very elderly people are to be provided, and inappropriate admission and expenditure avoided.
Most of the research concerning place of death focuses on terminally ill patients (cancer patients) while the determinants of place of death of the elderly of the general population are not intensively studied. Studies showed the influence of gender, age, social-economical status and living arrangements on the place of death, but a facet not taken into account so far is the influence of the availability of nursing homes.
We conducted a survey of deaths, between January 1999 and December 2000 in a small densely populated area in Belgium, with a high availability of nursing homes (within 5 to 10 km of the place of residence of every elderly). We determined the incidence of total mortality (of subjects >60 years) from local official death registers that we consulted via the priest or the mortician of the local parish, to ask where the decedent had died and whether the deceased had lived in a nursing home. We compared the distribution of the places of death between parishes with a nursing home and with parishes without nursing home.
240 women and 217 men died during the two years study period. Only 22% died at home, while the majority (78%) died in an institutional setting, either a hospital (50%) or a nursing home (28%). Place of death was influenced by individual factors (age and gender) and the availability of a nursing home in the 'own' parish. The chance of in-hospital death was 65% higher for men (95% Confidence Interval [CI]: 14 to 138%; p = 0.008) and decreased by 4% (CI: -5.1% to -2.5%; p < 0.0001) for each year increase in age. Independent of gender and age, the chance of in-hospital death was 41% (CI: -60% to -13%; p = 0.008) lower in locations with a nursing home.
Demographic, but especially social-contextual factors determine where elderly will end their life. The majority of elderly in Flanders die in an institution. Age, gender and living situation are predictors of the place of death but the embedment of a nursing home in the local community seems to be a key predictor.
GPs often perceive home-visit requests as a time-consuming aspect of general practice. The new general medical services contract provides for practices to be relieved of responsibility for home-visits, although there is no model for the transfer of care. One such model could be to employ nurse practitioners to manage such requests. Nurse practitioners can effectively substitute for GPs in managing same-day in-hours emergency care in the surgery, but their role in managing all such requests, including those requiring home visits, has not been assessed.
To explore the feasibility and clinical management outcomes of nurse practitioner management of same-day care requests, including those requiring home visits, to inform a proposed randomised controlled trial.
Design of study
Non-randomised comparative trial.
One large general practice (14 600 patients) in south London.
Nurse practitioner assessment and management of all same-day care requests for 2 days per week was compared with normal GP management on another 2 days, over a 6-month period. Clinical management outcome data were collected from patient records and from data-collection forms completed by a nurse practitioner and GPs. Patient and staff satisfaction was assessed by questionnaire.
The nurse practitioner was more likely than GPs to assess patients in person, less likely to give advice alone, and more likely to issue a prescription. There was no significant difference between the nurse practitioner and GPs regarding any other clinical management outcomes or patient satisfaction; however, the response rate of the patient satisfaction questionnaire in this pilot study was poor.
Nurse practitioner management of acute in-hours care requests, including home visits, appears feasible in practice and merits further assessment.
house calls; nurse practitioners; primary health care
The increase in the number of people with dementia will lead to greater demand for residential care. Currently, large nursing homes are trying to transform their traditional care for residents with dementia to a more home-like approach, by developing small-scale living facilities. It is often assumed that small-scale living will improve the quality of life of residents with dementia. However, little scientific evidence is currently available to test this. The following research question is addressed in this study: Which (combination of) changes in elements affects (different dimensions of) the quality of life of elderly residents with dementia in long-term care settings over the course of one year?
A longitudinal comparative study in traditional and small-scale long-term care settings, which follows a quasi-experimental design, will be carried out in Belgium and the Netherlands. To answer the research question, a model has been developed which incorporates relevant elements influencing quality of life in long-term care settings. Validated instruments will be used to evaluate the role of these elements, divided into environmental characteristics (country, type of ward, group size and nursing staff); basic personal characteristics (age, sex, cognitive decline, weight and activities of daily living); behavioural characteristics (behavioural problems and depression); behavioural interventions (use of restraints and use of psychotropic medication); and social interaction (social engagement and visiting frequency of relatives). The main outcome measure for residents in the model is quality of life. Data are collected at baseline, after six and twelve months, from residents living in either small-scale or traditional care settings.
The results of this study will provide an insight into the determinants of quality of life for people with dementia living in traditional and small-scale long-term care settings in Belgium and the Netherlands. Possible relevant strengths and weaknesses of the study are discussed in this article.
BACKGROUND: Timely recognition and prevention of health problems among elderly people have been shown to improve their health. In this randomized controlled trial the authors examined the impact of preventive home visits by a nurse compared with usual care on the outcomes of frail elderly people living in the community. METHODS: A screening questionnaire identified eligible participants (those aged 70 years or more at risk of sudden deterioration in health). Those randomly assigned to the visiting nurse group were assessed and followed up in their homes for 14 months. The primary outcome measure was the combined rate of deaths and admissions to an institution, and the secondary outcome measure the rate of health services utilization, during the 14 months; these rates were determined through a medical chart audit by a research nurse who was blind to group allocation. RESULTS: The questionnaire was mailed to 415 elderly people, of whom 369 (88.9%) responded. Of these, 198 (53.7%) were eligible, and 142 consented to participate and were randomly assigned to either the visiting nurse group (73) or the usual care group (69). The combined rate of deaths and admissions to an institution was 10.0% in the visiting nurse group and 5.8% in the usual care group (p = 0.52). The rate of health services utilization did not differ significantly between the 2 groups. Influenza and pneumonia vaccination rates were significantly higher in the visiting nurse group (90.1% and 81.9%) than in the usual care group (53.0% and 0%) (p < 0.001). INTERPRETATION: The trial failed to show any effect of a visiting nurse other than vastly improved vaccination coverage.
Although physiotherapy (PT) plays an important role in improving activities of daily living (ADL functioning) and discharge rates, it is unclear how many nursing home residents receive treatment. Furthermore, there is a lack of insight into the determinants that influence the decision for treatment. In this study, we investigated how many nursing home residents receive PT. In addition, we analysed the factors that contribute to the variation in the provision of PT both between nursing homes and between residents.
A random sample of 600 elderly residents was taken from a random sample of 15 nursing homes. Residents had to be admitted for rehabilitation or for long-term care. Data were collected through interviews with the nursing home physician and the physiotherapist. Multilevel analysis was used to define the variation in the provision of PT and the factors that are associated with the question whether a resident receives PT or not. Furthermore the amount of PT provided was analysed and the factors that are associated with this.
On average 69% of the residents received PT. The percentage of patients receiving treatment differed significantly across nursing homes, and especially the number of physiotherapists available, explained this difference between nursing homes. Residents admitted to a somatic ward for rehabilitation, and male residents in general, were most likely to receive PT. Residents who were treated by a physiotherapist received on average 55 minutes (sd 41) treatment a week. Residents admitted for rehabilitation received more PT a week, as were residents with a status after a total hip replacement.
PT is most likely to be provided to residents on a somatic ward, recently admitted for rehabilitation to a nursing home, which has a relatively large number of physiotherapists. This suggests a potential under-use of PT for long-term residents with cognitive problems. It is recommended that physiotherapists reconsider which residents may benefit from treatment. This may require a shift in the focus of physiotherapists from 'recovery and discharge' to 'quality of life and well-being'.
Although international studies have documented that patients’ transitions between care providers are associated with the risk of adverse events and uncoordinated care, research directed towards the quality and safety of transitional care between primary and secondary health and care services, especially for the elderly receiving care from multiple healthcare providers due to complex health problems, is lacking. This study investigates how different aspects of transitional care can explain the quality and safety of elderly healthcare services in Norway. The overall aim of the study was to explore different aspects of transitional care of the elderly, in different contexts and how they might explain the quality and safety of care.
Methods and analysis
The study applies a case study design. Two cases are chosen: one city-based hospital and one rural hospital with associated nursing homes and home-based nursing services. Admission and discharge to/from hospital to/from nursing homes or home-based nursing services constitute the main focal areas of the study, including the patient, next-of-kin and the professional perspective. The qualitative methods employed include participant observation, individual interviews and document analysis. To ensure trustworthiness in the data analysis, we will apply analyst triangulation and member checks. A total impression of the data material will first be created in a systematic text condensation approach. Second, the qualitative data analysis will involve in-depth analyses of two specific themes: the risk perspective and the patient perspective in transitional care.
Ethics and dissemination
The study is approved by the Norwegian Regional Committees for Medical and Health Research Ethics. The study is based on informed written consent, and informants can withdraw from the study at any point in time. Interview and observation data material will be managed confidentially.
It will be disseminated at research conferences, in peer-reviewed journals and through public presentations to people outside the academic community.
This study presents an analysis of the allocative efficiency of case managers for the community-based elderly in an environment in which case management and a range of home and community-based services were available and directly linked to a mandatory preadmission screening program for nursing home applicants. We collected data for a one-year follow-up period on client placement, health and functional status, informal support, and use of health and social services for clients in two urban and two rural counties that participated in the Minnesota Pre-Admission Screening/Alternative Care Grants Program (PAS/ACG). We found that among those receiving ACG-supported services, the relationship between variation in the level of support for home and community-based services and the length of time elderly clients remained in the community suggested that case managers were allocating home and community-based services in a reasonably efficient manner. This finding offers support for using case managers to target services to the elderly.