Mapping implementation strategies to reach community-dwelling older adults in Northwest Switzerland.

BACKGROUND: In Northwestern Switzerland, recent legislation tackles the needs of community-dwelling older adults by creating Information and Advice Centers (IACs). IACs are a new service in the community that aims to assess the needs and provide information on age-related issues to community-dwelling older adults and their families. Previous studies reported difficulties in reaching community-dwelling older adults for community-based programs. We aimed to: 1) systematically identify implementation strategies to promote the IAC among community care providers, older adults and informal caregivers; 2) monitor the delivery of these strategies by the IAC management; and 3) describe the impact of those strategies on reach of community-dwelling older adults. This study was conducted as part of the TRANS-SENIOR project. METHODS: As part of the INSPIRE feasibility assessment, we conducted a pre-test post-test study between March and September 2022. The sample included 8,840 older adults aged 65 + visiting/calling or being referred to the IAC for the first time. Implementation strategies were selected using implementation mapping and organized in bundles for each group of community care providers and older adults/caregivers. Our evaluation included: estimation of fidelity to the delivery of implementation strategies and bundles by the IAC management and their coverage; referral source of older adults to the IAC; and impact of the strategies on reach of the IAC on the 65 + population living in the care region. Adaptations to the strategies were documented using the FRAME-IS. Descriptive statistics were calculated and reported. RESULTS: Seven implementation strategies were selected and organized in bundles for each community care provider and older adults and their caregivers. The lowest fidelity score was found in implementation strategies selected for nursing homes whereas the highest score corresponded to strategies targeting older adults and caregivers. "Informational visits" was the strategy with the lowest coverage (2.5% for nursing homes and 10.5% for hospitals and specialized clinics). The main referral sources were self-referrals and referrals by caregivers, followed by nursing homes. The IAC reach among the 65 + population was 5.4%. CONCLUSION: We demonstrated the use of implementation mapping to select implementation strategies to reach community-dwelling older adults. The reach was low suggesting that higher fidelity to the delivery of the strategies, and reflection on the causal pathway of the implementation strategies might be needed.

Protocol for a mixed methods feasibility and implementation study of a community-based integrated care model for home-dwelling older adults: The INSPIRE project.

BACKGROUND: Evaluations of integrated care models for home-dwelling frail older adults have shown inconclusive results on health and service outcomes. However, limited research has focused on the implementation of integrated care models. Applying implementation science methods may facilitate uptake of integrated care models, thus generating positive outcomes e.g., reduced hospital admissions. This paper describes the protocol to assess the feasibility of an integrated care model (featuring a four-step comprehensive geriatric assessment: screening, a multi-dimensional assessment, a coordinated individualized care plan and follow-up) designed for a new community-based center for home-dwelling older adults in Switzerland. The study includes the following objectives: 1) to assess implementation by a) monitoring respondents to the outreach strategies and describing the Center's visitors; b) assessing implementation outcomes related to the care model (i.e., adoption, acceptability, feasibility, fidelity) and implementation processes related to collaboration; and 2) assessing implementation costs. METHODS: For objective 1a, we will use a descriptive design to assess respondents to the outreach strategies and describe the Center's visitors. We will use a parallel convergent mixed methods design for objective 1b. Implementation outcomes data will be collected from meetings with the Center's staff, interviews with older adults and their informal caregivers, and reviewing older adults' health records at the Center. Implementation processes related to collaboration will be assessed through a questionnaire to external collaborators (e.g., GPs) towards the end of the study. For objective 2, implementation costs will be calculated using time-driven activity-based costing methods. Data collection is anticipated to occur over approximately six months. DISCUSSION: This study of a contextually adapted integrated care model will inform adaptations to the outreach strategies, care model and implementation strategies in one community center, prior to evaluating the care model effectiveness and potentially scaling out the intervention. TRIAL REGISTRATION: Feasibility study registration ID with clinicaltrials.gov: NCT05302310; registration ID with BMC: ISRCTN12324618.

Factors associated with health-related quality of life among home-dwelling older adults aged 75 or older in Switzerland: a cross-sectional study.

BACKGROUND: HRQoL is an indicator of individuals' perception of their overall health, including social and environmental aspects. As a multidimensional concept, HRQoL can be influenced by a multitude of factors. Studies of HRQoL and factors associated with it among home-dwelling older adults have often been limited to inpatient settings or to a sub-population with a chronic disease. Studying HRQoL and its correlating factors among this population, by providing an ecological lens on factors beyond the individual level, can provide a better understanding of the construct and the role of the environment on how they perceive their HRQoL. Thus, we aimed to assess the HRQoL and investigate the correlates of HRQOL among home-dwelling older adults, guided by the levels of the ecological model. METHODS: This is a cross-sectional population survey conducted in 2019 in Canton Basel-Landschaft, in northwestern Switzerland, and includes a sample of 8786 home-dwelling older adults aged 75 and above. We assessed HRQoL by using the EQ-index and the EQ-VAS. The influence of independent variables at the macro, meso and micro level on HRQoL was tested using Tobit multiple linear regression modelling. RESULTS: We found that having a better socio-economic status as denoted by higher income, having supplementary insurance and a higher level of education were all associated with a better HRQoL among home-dwelling older adults. Furthermore, being engaged in social activities was also related to an improved HRQoL. On the other hand, older age, female gender, presence of multimorbidity and polypharmacy as well as social isolation and loneliness were found to all have a negative impact on HRQoL. CONCLUSIONS: Understanding factors related to HRQoL by using an ecological lens can help identify factors beyond the individual level that impact the HRQoL of home-dwelling older adults. Our study emphasises the importance of social determinants of health and potential disparities that exists, encouraging policymakers to focus on policies to reduce socio-economic disparities using a life-course approach, which consequently could also impact HRQoL in later stages of life.

A multi-level perspective on perceived unmet needs for home support in home-dwelling older adults in the Swiss context: a secondary data analysis of a population study.

BACKGROUND: Unmet needs for home support occur when any support services perceived by older people as needed are not being received. Not meeting these needs can negatively impact older adults' quality of life, and increase health care utilization, hospitalizations, institutionalizations, or death. To date there is no consensus in how to define and assess these unmet needs. In parallel, previous research of factors associated with unmet needs for home support has mostly focused on factors at the micro level. Thus, this paper aims to identify the prevalence of unmet needs for home support among a home-dwelling older population and the factors at the macro, meso and micro levels contributing to them. METHODS: Using an ecological approach we identified multi-level factors associated with the presence of unmet needs for home support among the home-dwelling older population (aged 75+) in Switzerland. This is a secondary cross-sectional analysis of the INSPIRE Population Survey of home-dwelling older adults (n = 8,508) living in Basel-Landschaft in Switzerland, conducted as part of the TRANS-SENIOR Project. Prevalence of perceived unmet needs for home support was self-reported, using a dichotomized question. Multiple logistic regression analyses were performed to investigate the associations of factors at each level with unmet needs for home support. RESULTS: 4.3% of participants reported unmet needs for home support, with a median age of 81 years. 45.1% had private health insurance and 6.3% needed additional government support. Being a recipient of other type of government support (OR = 1.65; 95% CI = 1.17-2.29) (macro-); the use of transportation services (OR = 1.74; 95% CI = 1.15-2.57) (meso-); and feeling depressed (OR = 1.40; 95% CI = 1.06-1.85) or abandoned (OR = 2.60; 95% CI = 1.96-3.43) (micro-) increased odds of having perceived unmet needs for home support. Having a private health insurance (macro-) (OR = 0.63; 95% CI = 0.49-0.80), speaking Swiss-German (OR = 0.44; 95% CI = 0.24-0.88) or German (OR = 0.47; 95% CI = 0.24-0.98), having a high level of education [primary (OR = 0.48; 95% CI = 0.24-1.02); secondary (OR = 0.49; 95% CI = 0.25-1.03); tertiary (OR = 0.38; 95% CI = 0.19-0.82); other (OR = 0.31 (0.12-0.75)], having a high score of self-perceived health status [score ≥ 76 (OR = 0.42; 95% CI = 0.20-0.96)] and having informal care (OR = 0.57; 95% CI = 0.45-0.73), among others (micro-) were associated with decreased odds of having perceived unmet needs for home support. CONCLUSION: Our study findings highlight the role of socio-economical inequality in the perception of unmet needs for home support in home-dwelling older adults. In order to address unmet needs in home-dwelling older adults, healthcare leaders and policy makers should focus on strategies to reduce socio-economic inequalities at the different levels in this population.

Health and social care of home-dwelling frail older adults in Switzerland: a mixed methods study.

BACKGROUND: Home-dwelling frail older adults are often faced with multimorbidity and complex care needs, requiring health and social care systems that support frail older adults to age in place. The objective of this paper was to investigate the types of formal health and social care as well as informal care and social support used by home-dwelling frail older adults; whether they perceive their support as sufficient; and their experience with and preferences for care and support. METHODS: Using an explanatory sequential mixed methods design, we first conducted a secondary analysis of a subset of cross-sectional data from the ImplemeNtation of a community-baSed care Program for home dwelling senIoR citizEns (INSPIRE) population survey using descriptive analysis. Subsequently, we analyzed existing data from interviews in the parent study to help explain the survey results using applied thematic analysis. Results were organized according to adapted domains and concepts of the SELFIE framework and integrated via a joint display table. RESULTS: Of the parent population survey respondents, 2314 older adults indicating frailty were included in the quantitative arm of this study. Interview data was included from 7 older adults who indicated frailty. Support from health and social, formal and informal caregivers is diverse and anticipated to increase (e.g., for 'care and assistance at home' and 'meal services'). Informal caregivers fulfilled various roles and while some older adults strongly relied on them for support, others feared burdening them. Most participants (93.5%) perceived their overall support to meet their needs; however, findings suggest areas (e.g., assessment of overall needs) which merit attention to optimize future care. CONCLUSIONS: Given the anticipated demand for future care and support, we recommend efforts to prevent fragmentation between health and social as well as formal and informal care.

Adaptation of time-driven activity-based costing to the evaluation of the efficiency of ambulatory care provided in the emergency department.

Objectives: The aim of this study was: (1) to adapt the time-driven activity-based costing (TDABC) method to emergency department (ED) ambulatory care; (2) to estimate the cost of care associated with frequently encountered ambulatory conditions; and (3) to compare costs calculated using estimated time and objectively measured time. Methods: TDABC was applied to a retrospective cohort of patients with upper respiratory tract infections, urinary tract infections, unspecified abdominal pain, lower back pain and limb lacerations who visited an ED in Québec City (Canada) during fiscal year 2015-2016. The calculated cost of care was the product of the time required to complete each care procedure and the cost per minute of each human resource or equipment involved. Costing based on durations estimated by care professionals were compared to those based on objective measurements in the field. Results: Overall, 220 care episodes were included and 3080 time measurements of 75 different processes were collected. Differences between costs calculated using estimated and measured times were statistically significant for all conditions except lower back pain and ranged from $4.30 to $55.20 (US) per episode. Differences were larger for conditions requiring more advanced procedures, such as imaging or the attention of ED professionals. Conclusions: The greater the use of advanced procedures or the involvement of ED professionals in the care, the greater is the discrepancy between estimated-time-based and measured-time-based costing. TDABC should be applied using objective measurement of the time per procedure.

The INSPIRE Population Survey: development, dissemination and respondent characteristics.

BACKGROUND: Most older adults prefer to continue living at home despite increasing care needs and demand for services. To aid in maintaining independence, integrated care models for community-dwelling older people are promoted as the most cost-effective approach. The implementation of such care models is challenging and often the end-users are not involved or their needs are not considered. We conducted a population survey in order to understand the needs and preferences of home-dwelling older adults living in Canton Basel-Landschaft, Switzerland. The aims of this paper are to chronicle the development of the INSPIRE Population Survey, outline its variables and measurements, describe the marketing strategy utilized for survey dissemination and report on the response rate and respondent characteristics. METHODS: The INSPIRE Population Survey, conducted between March and August 2019, is a cross-sectional survey of older adults aged 75 and older living at home in Canton Basel-Landschaft. The questionnaire was developed by expert input and stakeholder involvement. Its readability and acceptability were pilot-tested with older people. To ensure the likelihood of a high and representative response rate, a meticulous step-by-step marketing strategy was developed prior to the dissemination of the questionnaire. RESULTS: The overall response rate was 30.7% (n = 8,846), with variations between 20.6 and 34.5% across the different care regions in the canton. A generally higher response rate was found in the care regions with a higher density and which bordered the urban city of Basel. We received support from local stakeholders, policy makers and media through using a broad combination of marketing channels and targeting our community partners who have a strong relationship with our target audience. CONCLUSIONS: Although recruiting older adults in research is challenging, our study shows that a high response rate can be achieved by developing the survey through expert input and by involving all important stakeholders, including older adults, throughout the entire process.

A Contextual Analysis and Logic Model for Integrated Care for Frail Older Adults Living at Home: The INSPIRE Project.

INTRODUCTION: Implementation science methods and a theory-driven approach can enhance the understanding of whether, how, and why integrated care for frail older adults is successful in practice. In this study, we aimed to perform a contextual analysis, develop a logic model, and select preliminary implementation strategies for an integrated care model in newly created information and advice centers for older adults in Canton Basel-Landschaft, Switzerland. METHODS: We conducted a contextual analysis to determine factors which may influence the integrated care model and implementation strategies needed. A logic model depicting the overall program theory, including inputs, core components, outputs and outcomes, was designed using a deductive approach, and included stakeholders' feedback and preliminary implementation strategies. RESULTS: Contextual factors were identified (e.g., lack of integrated care regulations, existing community services, and a care pathway needed). Core components of the care model include screening, referral, assessment, care plan creation and coordination, and follow-up. Outcomes included person-centred coordinated care experiences, hospitalization rate and symptom burden, among others. Implementation strategies (e.g., nurse training and co-developing educational materials) were proposed to facilitate care model adoption. CONCLUSION: Contextual understanding and a clear logic model should enhance the potential for successful implementation of the integrated care model.

Prophylactic Administration of Diphenhydramine to Reduce Neuroleptic Side Effects in the Acute Care Setting: A Systematic Review and Meta-Analysis.

BACKGROUND: Neuroleptics are commonly prescribed drugs to treat acute conditions (e.g., migraines) in the emergency department, but can cause serious adverse effects. Using diphenhydramine to prevent these adverse effects is very common but remains controversial. OBJECTIVE: We performed a systematic review to determine whether prophylactic administration of diphenhydramine reduces the incidence of neuroleptic adverse effects in patients with acute conditions. METHODS: Medline, Embase, Cochrane, PsycInfo, and Web of Science were searched for randomized controlled trials evaluating any neuroleptic with diphenhydramine vs. the same neuroleptic with any inactive agent. Primary outcome was incidence of any extrapyramidal adverse effect. Secondary outcomes were akathisia, rescue medication, subjective restlessness, neuroleptic malignant syndrome, and sedation. Independent reviewers scanned identified citations, extracted data, and assessed risk of bias. Meta-analysis was performed using random effect models. RESULTS: Of 1566 identified citations, nine studies (n = 1648 patients) met eligibility criteria. Four studies were specifically designed to compare the incidence of neuroleptic adverse effects with and without co-administration of diphenhydramine. Four studies were at high risk of bias. In primary analysis, diphenhydramine had no effect on the incidence of extrapyramidal symptoms (7 studies, n = 1393, risk ratio [RR] 0.75; 95% confidence interval [CI] 0.44-1.31) or akathisia (5 studies, n = 1094; RR 0.78; 95% CI 0.33-1.82) or any of the secondary outcomes. In subgroup analysis, diphenhydramine was associated with a significant decrease in extrapyramidal adverse effects compared with placebo (4 studies, n = 705; RR 0.61; 95% CI 0.41-0.90). Dosage analysis yielded no further information. CONCLUSIONS: When compared with placebo, diphenhydramine was associated with a significant reduction of extrapyramidal adverse effects. Overall quality of evidence is low. Further studies are warranted.

Core components and impact of nurse-led integrated care models for home-dwelling older people: A systematic review and meta-analysis.

BACKGROUND: Integrated care models are highly recommended to overcome care fragmentation in the multimorbid older population. Nurses are potentially ideally situated to fulfil the role as care coordinator to guide integrated care. No systematic review has been conducted specifically focusing on the impact of nurse-led integrated care models for older people in community settings. OBJECTIVES: To identify core components of nurse-led integrated care models for the home-dwelling older population; to describe patient, service and process outcomes; and to evaluate the impact of these care models on quality of life, activities of daily living, hospitalisation, emergency department visits, nursing home admissions and mortality. DESIGN: Systematic review and meta-analysis. DATA SOURCES: English, Dutch, French, German and Spanish articles selected from PubMed and CINAHL, hand-search of reference lists of the included articles and grey literature. REVIEW METHODS: A systematic search was conducted to identify prospective experimental or quasi-experimental studies detailing nurse-led integrated care models in the older home-dwelling population. Study characteristics and reported outcomes were tabulated. The core components of the models were mapped using the Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE (SELFIE) framework. A random effects meta-analysis was conducted to study the overall effectiveness of the included care models on health-related quality of life, activities of daily living, hospitalisation, emergency department visits, nursing home admissions or mortality. Risk of bias was appraised using the revised Cochrane risk-of-bias tool for randomized trials and ROBINS-I tool for non-randomized studies. RESULTS: Nineteen studies were included studying a total of 22,168 patients. Core components of integrated care for multimorbid patients such as the involvement of a multidisciplinary team, high risk screening, tailored holistic assessment and an individualized care plan, were performed in a vast majority of the studies; however variability was observed in their operationalisation. Twenty-seven different patient, provider and service outcomes were reported, ranging from 1 to 13 per study. The meta-analyses could not demonstrate a beneficial impact on any of the predefined outcomes. Most included studies were of high risk for several biases. CONCLUSION: The summarized evidence on nurse-led integrated care models in home-dwelling older people is inconclusive and of low quality. Future studies should include key components of implementation research, such as context analyses, process evaluations and proximal outcomes, to strengthen the evidence-base of nurse-led integrated care.