Re-design of Aged Care Environments is Key to Improved Care Quality and Cost Effective Reform of Aged and Health System Care

Models for delivery and co-ordination of primary or secondary health care (or both) to older adults living in aged care facilities

BACKGROUND

The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co-ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost-effectiveness of alternative models of providing health care to ACF residents.

OBJECTIVES

Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost-effectiveness of the alternative models.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included individual and cluster-randomised trials, and cost/cost-effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co-ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co-ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline-recommended care, health-related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work-related satisfaction and work-related stress of ACF staff.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care.

MAIN RESULTS

We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co-ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low-certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I2 = 53%; 8 trials, 1263 participants; low-certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low-certainty evidence) and adherence to guideline-recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health-related quality of life of ACF residents (MD -0.016, 95% CI -0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low-certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate-certainty evidence). We did not pool the cost-effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co-ordination of care), we are uncertain of the cost-effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low.

AUTHORS' CONCLUSIONS

Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health-related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost-effectiveness of alternative models of care due to the limited, disparate data available.

How the interrelated physical, social and organizational environment impacts daily life of residents with dementia on a Green Care Farm

Green Care Farms (GCF) are innovative long-term care environments and an alternative to regular nursing homes in the Netherlands. Following a culture change movement, GCFs have radically altered the care environment. Research suggests positive effects on residents. However, knowledge is limited regarding their physical, social and organizational environment. This article explores the care environment of 24-h GCFs for people with dementia and its impact on residents and their daily life. An ethnographic study using mixed methods was carried out at a GCF in the Netherlands between June and October 2021. Researchers lived on the GCF and completed 28 days of participatory observations in three groups. During the day, informal conversations were held with residents (n = 48), staff and family members. Twenty four semi-structured interviews were conducted with residents, their family members, staff and the managers, complemented by a focus group with staff. The physical environment was additionally assessed with the OAZIS-dementia tool. Data collection methods informed each other. Qualitative data was thematically analyzed, quantitative data descriptively. Four themes were identified as crucial during daily life on the GCF: stimulating the senses, engaging in purposeful activities, sharing responsibilities and creating a community in a new home. Realizing these topics in practice, physical, social and organizational environmental components were highly interrelated. The physical environment encouraged and facilitated meaningful in-/outdoor activities and social encounters. The organizational environment supported the use of the physical environment by aligning processes and transporting the vision. The social environment focused on collaboration and creating a home-like atmosphere by including residents in household- and farm chores. This community-building led to more meaningful activities and social interaction. In conclusion, this study revealed the central influence of the management in paving the way for a new form of care delivery. As leaders shape the three environments, the organization influences the design of the physical environment and the actions taking place within it. By creating a community, the care home benefits residents, their families and staff equally. The conscious interrelation and harmonization of the physical, social and organizational components of a long-term care environment has the potential to improve the daily life of residents.

Robust cross-country comparison of children meeting 24-HR movement guidelines: an odds solution for binary effect efficiency measures

Aim

International comparisons of public health measures relative to observed best practice are increasingly important for evaluating community health promotion strategies and policies such as meeting or not meeting public health guidelines. This study aimed to identify methods enabling robust evaluation with such binary effect measures at a population level.

Subject and methods

Conventional efficiency comparisons of binary effect proportions are problematic due to a lack of consistency with alternate framing of resulting relative risks. In this paper, we illustrate such inconsistent efficiency measures comparing the proportion of school age children (9–11 years) meeting or not meeting integrated movement guidelines (IMGs) across the 12 countries from the International Study of Childhood Obesity, Lifestyle and the Environment (ISCOLE) study. IMGs jointly consider physical activity, sleep and sedentary behaviours. An odds method is developed to enable consistent efficiency comparison with alternative framing of binary effects.

Results

A novel odds solution to relative risk problems arising with conventional efficiency comparison of binary effects with alternative framing is shown to provide consistent efficiency measures relative to best practice. Furthermore, this technical advancement is shown to extend to consistent indirect comparison and evidence translation.

Conclusion

Robust methods for international cross-country comparison of binary effect measures such as meeting or not meeting guidelines are identified with a novel odds ratio method. This novel solution is particularly important for health promotion evaluation of IMGs given the need for consistent comparison in evaluating practice evidence of what works now and consistent evidence translation of treatment effects as and when they emerge.

Human Rights to Inclusive Living and Care for Older People With Mental Health Conditions

Although older persons wish to age at home, many older persons with mental health conditions and psychosocial disability (MHC-PSD) spend the last few years of their life in residential facilities. This paper will examine the impact of ageism and human rights violations manifested in environmental design, specifically regarding social isolation, loneliness, inadequate psychosocial, environmental, recreational and spiritual support. This is compounded by failure to meet basic care needs-nutrition, hydration, pain and medication support. This paper highlights two innovative initiatives from the Netherlands, which show that older persons' rights can be maintained in innovative, collective living arrangements. It is concluded that the creation of inclusive and safe environments for older persons with MHC-PSD can facilitate the enjoyment of Human Rights.

Active Lives South Australia health economic analysis: an evidence base for the potential of health promotion strategies supporting physical activity guidelines to reduce public health costs while improving wellbeing

Aim

The COVID-19 pandemic has threatened individual and population wellbeing and strategies to jointly address these challenges within budget constraints are required. The aim of our research is to analyse evidence from the Active Lives South Australia study to consider the potential of physical activity (PA) health promotion strategies to be health-system cost saving while addressing wellbeing challenges.

Methods

The Active Lives South Australia study compares adult populations who meet and do not meet physical activity (PA) guidelines (150+ minutes of weekly physical activity) with respect to their subjective wellbeing and health care utilisation.

Subject and results

Adults who met PA guidelines had better wellbeing across all aspects with and without adjustment for age, sex and income covariates. Analysis showed significant associations between meeting guidelines and lower probabilities of visiting and utilisation of GPs, specialist doctors, other health professionals, hospital inpatient admissions, outpatient clinic and emergency department visits, and an overall A$1760 lower cost per person annually. Controlling for age, sex and income, health expenditure for adults who met PA guidelines was significantly lower by A$1393 per person annually. That translated to A$804 million potential annual SA health system cost saving by shifting all adults to meeting PA guidelines.

Conclusion

There is significant potential for effective health promotion strategies to be net cost saving while addressing wellbeing challenges of COVID-19 recovery where they can shift target populations from not meeting to meeting PA guidelines.