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1.  Staff Interaction Strategies that Optimize Delivery of Transitional Care in a Skilled Nursing Facility: a Multiple Case Study 
Family & community health  2012;35(4):334-344.
After hospitalization, 1.5 million older adults each year receive post-acute care in skilled nursing facilities (SNF). Transitional care services, designed to prepare older SNF patients (and their family caregivers) for their transitions from a SNF to home, have rarely been studied. Thus, we conducted a longitudinal, multiple case study of transitional care provided in an SNF to explore the care processes and staff interaction strategies that SNF staff members used to optimize delivery of on transitional care. Using qualitative data from 89 interviews, 118 field observations, and 70 chart or document reviews, we observed that transitional care services were not solely formalized processes, but rather were embedded in the interactions among older adult patients, their family caregivers and members of interdisciplinary care teams. We found, moreover, that staff member interactions with patients and family caregivers increased the capacity of patient care teams for optimizing patient-centered care, information exchange, and coordination of transitional care.
doi:10.1097/FCH.0b013e31826666eb
PMCID: PMC3967871  PMID: 22929379
Transitional Care; Skilled Nursing Facilities; Older Adults; Family Caregivers; Interactions
2.  Stepping Down and Stepping In: Youth’s Perspectives on Making the Transition from Residential Treatment to Treatment Foster Care 
Older youth preparing to emancipate from the foster care system are often served in residential treatment settings where they have limited opportunities to practice skills for independent living in a community setting. Stepping these youth down to less restrictive environments such as treatment foster care is a growing trend, especially for youth with mental health issues. Yet, few studies have explored the youth’s perspective on making this transition. This study utilized qualitative interviews with youths who were participating in a treatment foster care intervention study (n=8) to gain their perspectives on the process of transitioning from residential care. Youths were interviewed right before they exited residential care and two months after placement in the new foster home. Youths reported hopes for gaining family in the new home as well as fears of placement disruption. Findings point to the need to enlist youths in discussion and problem solving about difficulties they anticipate in the new home and expectations for their relationship with the new foster parents. In addition, the struggles described after two months in the home point to the need for youths to build specific skills to better manage ongoing relationships with foster parents and for foster parent training on how to help build these skills.
doi:10.1016/j.childyouth.2011.08.031
PMCID: PMC3254092  PMID: 22247580
Older youth; Residential treatment; foster care; step down; mental health
3.  Residential services in Europe – findings from the DECLOC study 
Background and aims
This study aimed to collate and summarise statistical information on the number of people with disabilities living in all types of residential care but with a particular focus on those living in institutional care within 28 countries in Europe to analyse the costs and outcomes of the transition to community-based services in order to provide recommendations for agents in these countries to help bring about the change. The rationale for the study was to inform the political debate, to provide evidence and recommendations to support the move to community-based living for people with disabilities. The study aimed to collect data across client groups (intellectual disability, physical and sensory disability and mental illness) and across different age groups (children, adults and older adults).
Description of project
There were two phases to this study—the first provided a description of service types in each country and collated existing official statistics on the number of people with disabilities in the different types of residential services; the second phase analysed the existing body of knowledge on costs and outcomes of institutional and community-based services to provide conclusions and recommendations.
Conclusions
More than 1.45 million people with disabilities in Europe still live in residential care with 70% of these living in services with over 30 places. Data was better on people with intellectual disabilities than for other user groups but figures collated are none-the-less an underestimation. Drawing together such a mass of information served to highlight the extent of the work still needed to achieve the UN Convention on the Rights of People with Disabilities in almost all the countries included in terms of community-based services for all. It also highlighted the gaps in the available data. Challenges in the task of collating information included the lack of information collated at national level, the issue of varying definitions in use and inconsistency in how and where data was available.
Discussion
Most countries in Europe still have some way to go to be able to meet Article 31 of the UN Convention on the Rights of Persons with Disabilities. Recommendations focuses are offered to help bridge the gaps in data available on the situation of people with disabilities.
PMCID: PMC2707526
disabilities; residential care; institutions
4.  Risk of Nursing Home Admission Among Older Americans: Does States' Spending on Home- and Community-Based Services Matter? 
Objectives
States vary greatly in their support for home- and community-based services (HCBS) that are intended to help disabled seniors live in the community. This article examines how states' generosity in providing HCBS affects the risk of nursing home admission among older Americans and how family availability moderates such effects.
Methods
We conducted discrete time survival analysis of first long-term (90 or more days) nursing home admissions that occurred between 1995 and 2002, using Health and Retirement Study panel data from respondents born in 1923 or earlier.
Results
State HCBS effects were conditional on child availability among older Americans. Living in a state with higher HCBS expenditures was associated with lower risk of nursing home admission among childless seniors (p < .001). However, the association was not statistically significant among seniors with living children. Doubling state HCBS expenditures per person aged 65 or older would reduce the risk of nursing home admission among childless seniors by 35%.
Discussion
Results provided modest but important evidence supportive of increasing state investment in HCBS. Within-state allocation of HCBS resources, however, requires further research and careful consideration about fairness for individual seniors and their families as well as cost effectiveness.
PMCID: PMC2093949  PMID: 17507592
5.  Community care: the independent sector. 
BMJ : British Medical Journal  1996;313(7059):740-743.
The independent sector, which consists of the voluntary and private sectors, is a vital element in supporting older people in the community. The voluntary sector, coordinated by the Council for Voluntary Service and the National Council for Voluntary Organisations, provides a variety of services, including practical help, reassurance and companionship, and advice, information, campaigning, and advocacy. The private sector owns all of the nursing homes and most of the residential homes and is gradually becoming more involved with the provision of services to help support older people in their own homes. With this increase in size and importance of the independent sector over recent years, there is now a real need for greater communication between the private, voluntary, and statutory agencies in any one region. In some areas, forums made up of representatives of these various sectors meet to discuss relevant issues and construct local policies, thus allowing a more coordinated approach to the delivery of services.
Images
PMCID: PMC2352092  PMID: 8819449
6.  The Impact of a Community-based Pilot Health Education Intervention for Older People as Caregivers of Orphaned and Sick Children as a Result of HIV and AIDS in South Africa 
The increasing HIV and AIDS epidemic in South Africa poses a substantial burden to older people, in particular older women who mainly provide care for sick adult children and their grandchildren who have become orphaned and rendered vulnerable by the death or illness of their parents. In this study, 202 isiXhosa speaking older caregivers from Motherwell in the Eastern Cape Province of South Africa were trained to provide care for grandchildren and adult children living with HIV or AIDS. Based on a community needs assessment, a health education intervention comprising four modules was designed to improve skills and knowledge which would be used to assist older people in their care-giving tasks. Some topics were HIV and AIDS knowledge, effective intergenerational communication, providing home-based basic nursing care, accessing social services and grants, and relaxation techniques. Structured one-on-one interviews measured differences between pre-intervention and post-intervention scores among those who attended all four modules vs. those that missed one or more of the sessions. The results demonstrated that older people who participated in all four workshops perceived themselves more able and in control to provide nursing care. The participants also showed a more positive attitude towards people living with HIV or AIDS and reported an increased level of HIV and AIDS knowledge. The results provided valuable information upon which the development of future interventions may be based and psychosocial and structural needs of the older caregivers may be addressed by relevant stakeholders.
doi:10.1007/s10823-009-9101-2
PMCID: PMC2784496  PMID: 19813083
AIDS; Care-giving; HIV; Older people; South Africa
7.  How effective are programs at managing transition from hospital to home? A case study of the Australian transition care program 
BMC Geriatrics  2012;12:6.
Background
An increasing demand for acute care services due in part to rising proportions of older people and increasing rates of chronic diseases has led to new models of post-acute care for older people that offer coordinated discharge, ongoing support and often a focus on functional restoration. Overall, review of the literature suggests there is considerable uncertainty around the effectiveness and resource implications of the various model configurations and delivery approaches. In this paper, we review the current evidence on the efficacy of such programs, using the Australian Transition Care Program as a case study.
Discussion
The Australian Transition Care Program was established at the interface of the acute and aged care sectors with particular emphasis on transitions between acute and community care. The program is intended to enable a significant proportion of care recipients to return home, rather than prematurely enter residential aged care, optimize their functional capacity, and reduce inappropriate extended lengths of hospital stay for older people. Broadly, the model is configured and targeted in accordance with programs reported in the international literature to be effective. Early evaluations suggest good acceptance of the program by hospitals, patients and staff. Ultimately, however, the program's place in the array of post-acute services should be determined by its demonstrated efficacy relative to other services which cater for similar patient groups.
Summary
Currently there is a lack of robust evaluation to provide convincing evidence of efficacy, either from a patient outcome or cost reduction perspective. As the program expands and matures, there will be opportunity to scrutinise the systematic effects, with lessons for both Australian and international policy makers and clinical leaders.
doi:10.1186/1471-2318-12-6
PMCID: PMC3314563  PMID: 22416921
8.  A survey of access to medical services in nursing and residential homes in England. 
BACKGROUND: Residential and nursing homes make major demands on NHS services. AIM: To investigate patterns of access to medical services for residents in homes for older people. DESIGN OF STUDY: Telephone survey. SETTING: All nursing and dual registered homes and one in four residential homes located in a stratified random sample of 72 English primary care group/trust (PCG/T) areas. METHOD: A structured questionnaire investigating home characteristics, numbers of general practitioners (GPs) or practices per home, homes' policies for registering new residents with GPs, existence of payments to GPs, GP services provided to homes, and access to specialist medical care. RESULTS: There were wide variations in the numbers of GPs providing services to individual homes; this was not entirely dependent on home size. Eight percent of homes paid local GPs for their services to residents; these were more likely to be nursing homes (33%) than residential homes (odds ratio [OR] = 10.82, [95% CI = 4.48 to 26.13], P<0.001) and larger homes (OR for a ten-bed increase = 1.51 [95% CI = 1.28 to 1.79], P<0.001). Larger homes were more likely to encourage residents to register with a 'home' GP (OR for a ten-bed increase = 1.16 [95% CI = 1.04 to 1.31], P = 0.009). Homes paying local GPs were more likely to receive one or more additional services, over and above GPs' core contractual obligations. Few homes had direct access to specialist clinicians. CONCLUSION: Extensive variations in homes' policies and local GP services raise serious questions about patient choice, levels of GP services and, above all, about equity between residents within homes, between homes and between those in homes and in the community.
PMCID: PMC1314355  PMID: 12120725
9.  Community-based intervention to improve dietary habits and promote physical activity among older adults: a cluster randomized trial 
BMC Geriatrics  2013;13:8.
Background
The fastest growing age group globally is older adults, and preventing the need for long-term nursing care in this group is important for social and financial reasons. A population approach to diet and physical activity through the use of social services can play an important role in prevention. This study examined the effectiveness of a social health program for community-dwelling older adults aimed at introducing and promoting physical activity in the home at each individual’s pace, helping participants maintain good dietary habits by keeping self-check sheets, and determining whether long-standing unhealthy or less-than-ideal physical and dietary habits can be changed.
Method
This cluster randomized trial conducted at 6 community centers in an urban community involved 92 community-dwelling older adults aged 65–90 years. The intervention group (3 community centers; n = 57) participated in the social health program “Sumida TAKE10!” which is an educational program incorporating the “TAKE10!® for Older Adults” program, once every 2 weeks for 3 months. The control group (3 community centers; n=35) was subsequently provided with the same program as a crossover intervention group. The main outcome measures were changes in food intake frequency, food frequency score (FFS), dietary variety score (DVS), and frequency of walking and exercise. The secondary outcome measures were changes in self-rated health, appetite, and the Tokyo Metropolitan Institute of Gerontology (TMIG) Index of Competence score.
Results
Compared to baseline, post-intervention food intake frequency for 6 of 10 food groups (meat, fish/shellfish, eggs, potatoes, fruits, and seaweed), FFS, and DVS were significantly increased in the intervention group, and interaction effects of FFS and DVS were seen between the two groups. No significant differences were observed between baseline and post-intervention in the control group. Frequency of walking and exercise remained unchanged in both groups, and no significant difference in improvement rate was seen between the groups. Self-rated health was significantly increased in the intervention group. Appetite and TMIG Index of Competence score were unchanged in both groups.
Conclusions
The social health program resulted in improved dietary habits, as measured by food intake frequency, FFS, and DVS, and may improve self-rated health among community-dwelling older adults.
Trial registration number
UMIN000007357
doi:10.1186/1471-2318-13-8
PMCID: PMC3560222  PMID: 23343312
Social health program; Community-dwelling older adults; Dietary variety; Physical activity; Self-rated health
10.  The Effects of the Balanced Budget Act of 1997 on Home Health and Hospice in Older Adult Cancer Patients 
Medical care  2009;47(3):279-285.
Background
Home health and hospice services can constitute important elements in the continuum of care for older adults diagnosed with cancer. The Balanced Budget Act of 1997 (BBA) included provisions affecting those services.
Objectives
The first aim of this study is to assess the effect of the BBA of 1997 on home health and hospice service utilization in older cancer patients. The second aim is to estimate the effect of the BBA of 1997 on costs associated specifically with home health and hospice services and on total costs of care. The final aim is evaluate the effect of the BBA of 1997 on mortality in these patients.
Research Design
Longitudinal analysis using the Surveillance, Epidemiology and End Results-Medicare Database, covering a service area that includes 26% of the U.S. population.
Participants
Community-dwelling Medicare beneficiaries aged 65+.
Measures
Utilization rates of home health and hospice services; costs associated with those services, and total costs of care; and mortality.
Results
Home health utilization rates dropped substantially and hospice utilization rates increased following the BBA. Medicare costs for home health services declined as did total Medicare costs, but hospice costs increased. There was no discernable effect on mortality rates.
Conclusions
The BBA was successful in containing the costs of home health services and resulted in savings in overall costs of care for older cancer patients. Reduction in utilization of home health services did not appear to negatively affect outcomes. The BBA may have contributed to the trend of increasing use of hospice care.
doi:10.1097/MLR.0b013e3181893c77
PMCID: PMC2759602  PMID: 19194333
Home Health; Hospice; Balanced Budget Act of 1997; Cost Analysis
11.  Utilization and costs of home-based and community-based care within a social HMO: trends over an 18-year period 
Abstract
Purpose
Our objective was to describe the utilization and costs of services from 1985 to 2002 of a Social Health Maintenance Organization (SHMO) demonstration project providing a benefit for home-based and community-based as well as short-term institutional (HCB) care at Kaiser Permanente Northwest (KPNW), serving the Portland, Oregon area. The HCB care benefit was offered by KPNW as a supplement to Medicare's acute care medical benefits, which KPNW provides in an HMO model. KPNW receives a monthly per capita payment from Medicare to provide medical benefits, and Medicare beneficiaries who choose to join pay a supplemental premium that covers prescription drugs, HCB care benefits, and other services. A HCB care benefit of up to $12,000 per year in services was available to SHMO members meeting requirement for nursing home certification (NHC).
Methods
We used aggregate data to track temporal changes in the period 1985 to 2002 on member eligibility, enrollment in HCB care plans, age, service utilization and co-payments. Trends in the overall costs and financing of the HCB care benefit were extracted from quarterly reports, management data, and finance data.
Results
During the time period, 14,815 members enrolled in the SHMO and membership averaged 4,531. The proportion of SHMO members aged 85 or older grew from 12 to 25%; proportion meeting requirements for NHC rose from 4 to 27%; and proportion with HCB care plans rose from 4 to 18%. Costs for the HCB care benefit rose from $21 per SHMO member per month in 1985 to $95 in 2002. The HCB care costs were equivalent to 12% to 16% of Medicare reimbursement. The HCB program costs were covered by member premiums (which rose from $49 to $180) and co-payments from members with care plans. Over the 18-year period, spending shifted from nursing homes to a range of community services, e.g. personal care, homemaking, member reimbursement, lifeline, equipment, transportation, shift care, home nursing, adult day care, respite care, and dentures. Rising costs per month per SHMO member reflected increasing HCB eligibility rather than costs per member with HCB care, which actually fell from $6,164 in 1989 to $4,328 in 2002. Care management accounted for about one-quarter of community care costs since 1992.
Conclusions
The Kaiser Permanente Northwest SHMO served an increasingly aged and disabled membership by reducing costs per HCB member care plan and shifting utilization to a broad range of community care services. Supported by a disability-based Medicare payment formula and by SHMO beneficiaries willing to pay increasing premiums, KPNW has been able to offer comprehensive community care. The model could be replicated by other HMOs with the support of favorable federal policies.
PMCID: PMC1395522  PMID: 16773166
integration; home care; managed care; care management; long-term care financing; community care
12.  Residential and Health Care Transition Patterns Among Older Medicare Beneficiaries Over Time 
The Gerontologist  2010;51(2):170-178.
Purpose: To describe annual care transition patterns across residential and health care settings and assess consistency in care transition patterns across years.
Design and Methods:  This retrospective cohort study used the Medicare Current Beneficiary Survey (2000–2005). The sample comprised beneficiaries aged 65 years and older (N = 57,684 person-years of observation). We defined annual care transition patterns by combining 4 types of settings: C (community), F (facility), S (skilled nursing facility—SNF), and H (hospital). We compared weighted frequencies of transition patterns across years. We counted repeated/multiple transitions that involved movement into hospital and SNF settings and compared them by demographic characteristics.
Results:  Care transition patterns remained consistent from year to year. Approximately 22% of the study population experienced a transition annually. The most frequent transition pattern was transition to the hospital and back. Care transition patterns were enormously heterogeneous with more than 230 unique patterns; approximately 1 in 4 community-dwelling (∼23%) and most facility-dwelling (∼60%) beneficiaries with at least one transition had a unique transition pattern. Beneficiaries residing in a facility were more likely to undergo multiple transitions to hospitals and SNFs compared with community-dwelling beneficiaries.
Implications: The study provides a description of annual care transition patterns across six years. Knowledge of the consistency of care transition patterns may serve as a baseline from which to compare future patterns and aid in designing interventions targeted at specific transitions.
doi:10.1093/geront/gnq105
PMCID: PMC3058132  PMID: 21177399
Care transitions; Medicare; Medicare Current Beneficiary Survey; Natural history
13.  Oral Health Status of Older Adults in Kentucky: Results from the Kentucky Elder Oral Health Survey 
The purpose of the Kentucky Elder Oral Health Survey (KEOHS) was to assess the oral health status of Kentuckians 65 and older.
The KEOHS consisted of a self-administered questionnaire and a clinical examination. Recruitment occurred from May 2002 through March 2005 of persons aged 65 and older (n=1386) whose functional ability was classified by residential setting. Independent elders living in their own homes were designated as “well-elders,” those who lived in skilled nursing facilities and who were functionally dependent were designated as “nursing home elders,” and those older adults who were considered frail were designated as “homebound elders.”
Significant associations were found between the functional ability of the elders and demographic characteristics. While elders who were homebound reported the highest rate of barriers to care, dental insurance, affordability, and transportation were consistently reported as barriers for all groups of elders.
This study has established the baseline oral health status of older adults in Kentucky and the data shows-differences that exist for various community living situations.
doi:10.1111/j.1754-4505.2010.00154.x
PMCID: PMC3732100  PMID: 20831736
Living Situation; Access to Care; Elders; survey; oral health; Kentucky
14.  Addressing the problems associated with general practitioners' workload in nursing and residential homes: findings from a qualitative study. 
BACKGROUND: Caring for older people in residential and nursing homes makes major demands on general practitioners (GPs). AIM: To investigate the perceptions and experiences of home managers and GPs of the provision of general medical services for older residents. DESIGN OF STUDY: In-depth qualitative study. SETTING: Forty-two nursing and residential homes in five locations in England, interviewing home managers and eight of their residents' GPs. METHOD: Semi-structured face-to-face and telephone interviews. RESULTS: Most homes endorse principles of continuity of care and patient choice. Although many homes therefore deal with a large number of GPs, with the inherent difficulties of coordinating care and duplication of GP effort, limitations in residents' choice of GP result in the majority of residents in many homes being registered with only one or two practices. Contracts between homes and GPs may provide opportunities for improving medical care but do not guarantee additional services and have implications for patient choice and residents' fees. Visits on request form the bulk of GPs' workload in homes but can be hard to obtain for residents and may not be appropriate. Regular weekly surgeries are preferred by many homes but may have additional workload implications for GPs. CONCLUSION: The assumption that patient choice and continuity in medical care are paramount for older people in nursing and residential homes is questioned. While recognition of the additional workload for GPs working in these settings is necessary, this should be accompanied by additional NHS remuneration. Further research is urgently required to identify which models of GP provision would most benefit both residents and GPs.
PMCID: PMC1314510  PMID: 12817356
15.  Variation in Older Americans Act Caregiver Service Use, Unmet Hours of Care, and Independence Among Hispanics, African Americans, and Whites 
Home- and community-based services (HCBS) are underused by minority seniors and their caregivers, despite greater rates of disability. We examined racial/ethnic variation among 1,749 Hispanic, African American, and Whites receiving Older Americans Act Title III caregiver services in 2009. In addition, we identified the volume of services used by caregivers, their unmet hours of respite care, and the relationship between service use and seniors’ ability to live independently. Minority caregivers cared for seniors in urban areas who had higher rates of disability, poverty, and Medicaid coverage. Hispanics had the highest rate of unmet hours of care, while caregiver services were less likely to help African Americans remain at home. Minorities sought services through community agencies and were more educated than demographically similar national cohorts. Greater efforts to reach minority caregivers of less educated, disabled seniors in urban areas and through community agencies may reduce unmet needs and support independent living.
doi:10.1080/01621424.2012.755143
PMCID: PMC3583214  PMID: 23438508
African Americans; caregiver support services; Mexican Americans; Older Americans Act
16.  Support and Assessment for Fall Emergency Referrals (SAFER 1) trial protocol. Computerised on-scene decision support for emergency ambulance staff to assess and plan care for older people who have fallen: evaluation of costs and benefits using a pragmatic cluster randomised trial 
Background
Many emergency ambulance calls are for older people who have fallen. As half of them are left at home, a community-based response may often be more appropriate than hospital attendance. The SAFER 1 trial will assess the costs and benefits of a new healthcare technology - hand-held computers with computerised clinical decision support (CCDS) software - to help paramedics decide who needs hospital attendance, and who can be safely left at home with referral to community falls services.
Methods/Design
Pragmatic cluster randomised trial with a qualitative component. We shall allocate 72 paramedics ('clusters') at random between receiving the intervention and a control group delivering care as usual, of whom we expect 60 to complete the trial.
Patients are eligible if they are aged 65 or older, live in the study area but not in residential care, and are attended by a study paramedic following an emergency call for a fall. Seven to 10 days after the index fall we shall offer patients the opportunity to opt out of further follow up. Continuing participants will receive questionnaires after one and 6 months, and we shall monitor their routine clinical data for 6 months. We shall interview 20 of these patients in depth. We shall conduct focus groups or semi-structured interviews with paramedics and other stakeholders.
The primary outcome is the interval to the first subsequent reported fall (or death). We shall analyse this and other measures of outcome, process and cost by 'intention to treat'. We shall analyse qualitative data thematically.
Discussion
Since the SAFER 1 trial received funding in August 2006, implementation has come to terms with ambulance service reorganisation and a new national electronic patient record in England. In response to these hurdles the research team has adapted the research design, including aspects of the intervention, to meet the needs of the ambulance services.
In conclusion this complex emergency care trial will provide rigorous evidence on the clinical and cost effectiveness of CCDS for paramedics in the care of older people who have fallen.
Trial Registration
ISRCTN10538608
doi:10.1186/1471-227X-10-2
PMCID: PMC2824628  PMID: 20102616
17.  What factors are associated with having an advance directive among older adults new to long-term care services? 
Objectives
To explore differences in having an advance directive among older adults newly transitioned to long-term services and support settings (LTSS; i.e., nursing homes, NH; assisted living facilities, ALF; home and community-based services, H&CBS).
Design
Cross sectional survey.
Setting
LTSS in New York and Pennsylvania.
Participants
Four-hundred and seventy older adults who recently started receiving LTSS. Included in this analyses, N=442 (ALF: n=153; NH: n=145; H&CBS: n=144).
Measurements
Interviews consisted of questions about advance directives (Living will and Health Care Power of Attorney-HCPOA), significant health changes in the six month prior to the start of long-term care support services, Mini-Mental State Examination, and basic demographics.
Results
Sixty-one percent (270/442) of older adults receiving LTSS reported having either a living will and/or a HCPOA. ALF residents reported having an advance directive more frequently than NH residents and older adults receiving LTSS in their own home (living will: Χ2[2]= 120.9; P < .001; HCPOA: Χ2[2]= 69.1; P < .001). In multivariate logistic regression models, receiving LTSS at an ALF (OR = 5.01; P < .001), being white (OR = 2.87; P < .001), having greater than 12 years of education (OR = 2.50; P < .001) and experiencing a significant health change in last 6-months (OR = 1.97; P = .007) were predictive of having a living will. Receiving LTSS at an ALF (OR = 4.16; P < .001), having greater than 12 years of education (OR = 1.74, P = 0.022), and having had a significant change in health in the last six months (OR = 1.61; P = .037) were predictive in having a HCPOA in this population of LTSS recipients.
Conclusions
These data provide insight into advance directives and older adults new to LTSS. Future research is needed to better understand the barriers to completing advance directives before and during enrollment in LTSS as well to assess advance directive completion changes over time for this population of older adults.
doi:10.1016/j.jamda.2010.12.010
PMCID: PMC3134595  PMID: 21450235
nursing home; assisted living; advanced care planning; PACE
18.  A systematic mapping review of Randomized Controlled Trials (RCTs) in care homes 
BMC Geriatrics  2012;12:31.
Background
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.
Methods
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.
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.
Conclusions
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.
doi:10.1186/1471-2318-12-31
PMCID: PMC3503550  PMID: 22731652
19.  Predictors of institutionalisation in people with dementia 
Method: Longitudinal study of a cohort of people with dementia and their carers in contact with old age psychiatric services in south London.
Results: 100 people with dementia and their main family carer were recruited. At six month follow up 22 were in residential care, 63 in the community, 8 had died, and for 7 there were missing data. Between six and 12 months, 7 of the 63 in the community went into residential care, 4 died, and 12 were lost to follow up. The most striking finding is the 20-fold protective effect of having a co-resident carer (odds ratio 0.05, 95% confidence intervals 0.01 to 0.42, p=0.006). Higher ratings of behavioural problems in the person with dementia were also statistically significantly associated with transition into residential care as was the psychological domain of quality of life of the carer.
Conclusion: These findings powerfully illustrate the pivotal role carried out by carers of people with dementia; interventions directly targeted at helping them to maintain this role would be supported by these data. These data also suggest that strategies directed at improving carer quality of life and at the resolution of behavioural disorder in the person with dementia may also have particular value.
doi:10.1136/jnnp.74.9.1315
PMCID: PMC1738636  PMID: 12933944
20.  Community-Based Home Healthcare Project for Korean Older Adults 
Objectives
The aim of this study was to identify the effects of community-based home healthcare projects that influence service performances with regard to Korean national long-term care insurance services in older adults.
Methods
The project's applicants were 18 operational agencies in national long-term care institutions in Korea, and participants were care recipients (n = 2263) registered in long-term care institutions. We applied our healthcare system to the recruited participants for a 3-month period from October 2012 to December 2012. We measured the community-based home healthcare services such as long-term care, health and medical service, and welfare and leisure service prior to and after applying the community-based home healthcare system.
Results
After the implementation of community-based home healthcare project, all community-based home healthcare services showed an increase than prior to the project implementation. The nutrition management service was the most increased and its increase rate was 628.6%. A comparison between the long-term care insurance beneficiaries and nonbeneficiaries showed that health and medical services’ increase rate of nonbeneficiaries was significantly higher than beneficiaries (p < 0.001).
Conclusion
Our community-based home healthcare project might improve the service implementation for older adults and there was a difference in the increase rate of health and medical services between Korean national long-term care insurance beneficiaries and nonbeneficiaries.
doi:10.1016/j.phrp.2013.09.002
PMCID: PMC3845225  PMID: 24298438
community care; home healthcare; long-term care insurance; older adults
21.  Lower urinary tract symptoms and falls risk among older women receiving home support: a prospective cohort study 
BMC Geriatrics  2013;13:46.
Background
Although lower urinary tract symptoms have been associated with falls, few studies have been undertaken to understand this relationship in vulnerable community dwelling older adults. The purpose of this study was to describe the relationship over time of falls risk and lower urinary tract symptoms among community based older women receiving home support services.
Methods
A prospective cohort study which took place in an urban setting in western Canada. Participants were 100 older women receiving home care or residing in assisted living with home support services and were followed for six months. Demographic characteristics were collected at baseline, with the Timed Up and Go (TUG), International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms (ICIQ-FLUTS), and self-report of falls collected at baseline, 3 and 6 months. Descriptive statistics were used to summarize demographic data. Differences between the three visits were analyzed using the Friedman test with post hoc analysis and associations between variables by the Spearman Rank-Order Correlation Coefficient.
Results
One hundred women initially enrolled; 88 and 75 remained at three months and six months. Mean age = 84.3 years; 91% reported at least one urinary symptom at baseline and 35% reported falling in the six months prior to enrollment; 15.9% reported falling between the baseline and three months and 14.6% between three and six months. Mean TUG scores at each time point indicated falls risk (27.21, 29.18 and 27.76 seconds). Significant correlations between TUG and ICIQ-FLUTS (r = 0.33, p < .001; r = 0.39, p < .001) as well as TUG and overactive bladder scores (r = 0.25, p = .005; r = 0.28, p < .008) were found at baseline and three months, but not six months.
Conclusions
The association of lower urinary tract symptoms and falls risk in this group of vulnerable community dwelling older women at baseline and three months has potential clinical relevance. Lack of correlation at six months may be due loss of less robust participants, illuminating the difficulty in following frailer groups over time. Further studies are needed to understand the contribution of urinary symptoms to falls risk, and clinicians should incorporate continence assessment within falls risk assessment.
doi:10.1186/1471-2318-13-46
PMCID: PMC3658922  PMID: 23672343
Falls; Aged; Incontinence; Older women
22.  Do social networks affect the use of residential aged care among older Australians? 
BMC Geriatrics  2007;7:24.
Background
Older people's social networks with family and friends can affect residential aged care use. It remains unclear if there are differences in the effects of specific (with children, other relatives, friends and confidants) and total social networks upon use of low-level residential care and nursing homes.
Methods
Data were drawn from the Australian Longitudinal Study of Ageing. Six waves of data from 1477 people aged ≥ 70 collected over nine years of follow-up were used. Multinomial logistic regressions of the effects of specific and total social networks on residential care use were carried out. Propensity scores were used in the analyses to adjust for differences in participant's health, demographic and lifestyle characteristics with respect to social networks.
Results
Higher scores for confidant networks were protective against nursing home use (odds ratio [OR] upper versus lower tertile of confidant networks = 0.50; 95%CI 0.33–0.75). Similarly, a significant effect of upper versus lower total network tertile on nursing home use was observed (OR = 0.62; 95%CI 0.43–0.90). Evidence of an effect of children networks on nursing home use was equivocal. Nursing home use was not predicted by other relatives or friends social networks. Use of lower-level residential care was unrelated to social networks of any type. Social networks of any type did not have a significant effect upon low-level residential care use.
Discussion
Better confidant and total social networks predict nursing home use in a large cohort of older Australians. Policy needs to reflect the importance of these particular relationships in considering where older people want to live in the later years of life.
doi:10.1186/1471-2318-7-24
PMCID: PMC2174923  PMID: 17916238
23.  Student-Directed Learning in a Community Geriatrics Advanced Pharmacy Practice Experience 
Objectives
To assess a community geriatrics advanced pharmacy practice experience (APPE) that aimed to improve students' attitudes towards older adults and provide a student-directed learning experience.
Design
Students provided blood pressure monitoring and medication counseling to older adults living in a low-income residential facility as part of a required 6-week ambulatory care service-learning APPE. Pre-experience and post-experience essays on students' perceptions of the elderly and their intended and actual learning were retrospectively reviewed using a qualitative process to determine whether the course objectives were met.
Assessment
Many students initially described older adults in factual terms or using negative descriptors. Most expressed a desire to increase their knowledge of diseases commonly occurring in and drugs commonly prescribed for the elderly or to improve specific skills. Many students initially had difficulty articulating clear and measurable learning objectives and appropriate assessment metrics, which are important components of self-directed learning. The final essays revealed many students learned more about the humanistic aspects of care than they had anticipated.
Conclusion
This community-based geriatrics experience improved students' attitudes towards working with older adults and provided practice in developing and assessing their personal learning objectives.
PMCID: PMC1636948  PMID: 17136175
student-directed learning; community pharmacy geriatrics; advanced pharmacy practice experience; service learning
24.  Managing sleep disturbances in adult family homes: Recruitment and implementation of a behavioral treatment program 
This article describes a Sleep Education Program (SEP) designed to teach owner/operators and direct care staff working in adult family homes (AFHs) how to improve the sleep and nighttime behavior of older residents with dementia. There have been no sleep intervention studies conducted in adult family homes, and strategies that are known to improve sleep in community-dwelling older adults or nursing home residents may not be feasible or effective in AFHs because of their unique care environment. The SEP was developed based on experiences treating sleep disturbances in community-dwelling older adults with dementia (the Nighttime Insomnia Treatment and Education in Alzheimer's Disease [NITE-AD] study). In this paper, we address both the clinical and empirical challenges faced by researchers recruiting and intervening in adult family homes, raise issues pertinent to assessment of residents and staff, and discuss implications for evaluating the impact of behavioral treatments for sleep/wake disturbances in AFH residents.
doi:10.1016/j.gerinurse.2008.05.001
PMCID: PMC2643363  PMID: 19215811
adult family homes; sleep; dementia; community residential care; board and care facilities; long-term care
25.  Community falls prevention for people who call an emergency ambulance after a fall: randomised controlled trial 
Objective To evaluate whether a service to prevent falls in the community would help reduce the rate of falls in older people who call an emergency ambulance when they fall but are not taken to hospital.
Design Randomised controlled trial.
Setting Community covered by four primary care trusts, England.
Participants 204 adults aged more than 60 living at home or in residential care who had fallen and called an emergency ambulance but were not taken to hospital.
Interventions Referral to community fall prevention services or standard medical and social care.
Main outcome measures The primary outcome was the rate of falls over 12 months, ascertained from monthly diaries. Secondary outcomes were scores on the Barthel index, Nottingham extended activities of daily living scale, and falls efficacy scale at baseline and by postal questionnaire at 12 months. Analysis was by intention to treat.
Results 102 people were allocated to each group. 99 (97%) participants in the intervention group received the intervention. Falls diaries were analysed for 88.6 person years in the intervention group and 84.5 person years in the control group. The incidence rates of falls per year were 3.46 in the intervention group and 7.68 in the control group (incidence rate ratio 0.45, 95% confidence interval 0.35 to 0.58, P<0.001). The intervention group achieved higher scores on the Barthel index and Nottingham extended activities of daily living and lower scores on the falls efficacy scale (all P<0.05) at the 12 month follow-up. The number of times an emergency ambulance was called because of a fall was significantly different during follow-up (incidence rate ratio 0.60, 95% confidence interval 0.40 to 0.92, P=0.018).
Conclusion A service to prevent falls in the community reduced the fall rate and improved clinical outcome in the high risk group of older people who call an emergency ambulance after a fall but are not taken to hospital.
Trial registration Current Controlled Trials ISRCTN67535605.
doi:10.1136/bmj.c2102
PMCID: PMC2868162  PMID: 20460331

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