Effectiveness of non-pharmacological interventions delivered at home for urinary and faecal incontinence with homebound older people: systematic review of randomised controlled trials.

INTRODUCTION: Incontinence is a common, distressing condition, most prevalent in older people. There is an unmet need for effective interventions to support continence. This review focuses on non-pharmacological interventions to reduce incontinence among homebound older people. Aim: to identify interventions with potential to be delivered by care workers, nurses or family members in a person's home. METHODS: Multiple databases were searched until 15 September 2023 for randomised controlled trials reporting home-based interventions for incontinence for older people (≥65 years) living at home. Two reviewers independently screened titles, abstracts and papers against inclusion criteria, then assessed for the Risk of Bias (RoB2). A third reviewer resolved the discrepancies. Primary data were extracted and synthesised. RESULTS: A full-text review of 81 papers identified seven eligible papers (1996-2022, all USA), including n = 636 participants (561 women and 75 men). Two studies focusing on multicomponent behavioural interventions showed benefit, as did one study of transcutaneous tibial nerve stimulation self-administered through electrode-embedded socks. Three, which included cognitively impaired people, reported improvement with toileting assistance programmes, but the effects were not all significant. Results were inconclusive from a study examining the effects of fluid intake adjustments. Interventions were delivered by nurses, three in collaboration with family caregivers. No faecal incontinence interventions met the criteria. CONCLUSION: There is scant evidence for continence supporting interventions delivered in older people's own homes. With an ageing population often reliant on family or social care workers well-placed to support continence promotion and policy drives for services to support older people remaining at home, this evidence gap needs addressing.

Proud but Powerless: A Qualitative Study of Homecare Workers´ Work Experiences and Their Suggestions for How Care for Homebound Older Adults Can Be Improved.

Many older adults with complex care needs live at home due to ageing-in-place policies. This study explored homecare workers' experiences and suggestions for improvements of care. Twelve semi-structured interviews were analyzed thematically, and revealed pride, capability, and satisfaction in their work, yet they feel undervalued and lack support. They advocate for integrated care models, recognition of their competence, flexible work approaches, and committed leadership. This would enhance patient care and address their own working conditions, addressing concerns from being relegated to the bottom of the hierarchy. They emphasize the need for comprehensive approaches, spanning from housekeeping to end-of-life palliative care.

A protocol for stakeholder engagement in deliver-EE: A pragmatic randomized comparative effectiveness trial evaluating effects of meal delivery on the ability of homebound older adults to remain in the community.

BACKGROUND: Few clinical trials include a detailed protocol for stakeholder engagement in the design and execution of the clinical trial. Deliver-EE is a pragmatic clinical trial to assess how different types of home-delivered meals can affect older adults' health and well-being. We present the protocol for stakeholder engagement in this national, multi-site trial and initial findings from our efforts. METHODS: Twenty-nine participants were recruited to two stakeholder advisory panels. The "Lived Experience Perspectives" panel is defined as the clients, caregivers, and meal delivery drivers with first-hand knowledge and lived experiences with meal delivery. The "System Perspectives" panel is defined as representatives from the larger financial, clinical, regulatory, and operational environments in which meal delivery to homebound older adults operate. Together, these two groups holistically represent interested parties that coordinate the interdependent elements of meal delivery to homebound older adults in order to: 1) inform our understanding of what matters most to older adults, their families, and the larger health and social care systems; 2) provide strategies to overcome challenges conducting the study; 3) enhance dissemination and uptake of study findings; and 4) identify opportunities for future research. RESULTS: Although stakeholder partners share a common goal of using home-delivered meals as a method to improve outcomes for homebound older adults, individuals have different goals for participating as advisors in this research. CONCLUSIONS: Understanding what individual stakeholders hope to gain from their participation is critical in designing an effective engagement protocol and critical for meaningful and rigorous stakeholder engagement in clinical trials.

Partners in vaccination: A community-based intervention to promote COVID-19 vaccination among low-income homebound and disabled adults.

BACKGROUND: Care managers (CM) for low-income disabled clients may address COVID-19 vaccine hesitancy with specific training. OBJECTIVE: To assess the Partners in Vaccination (PIV) that trained CMs of a homecare program for disabled adults to promote COVID-19 vaccination. METHODS: We randomized 78 CMs to PIV intervention (N = 38) or control (N = 40). PIV featured motivational interviewing (MI) skills and educational materials for unvaccinated clients. The primary outcome was first COVID-19 vaccination between December 1, 2021 and June 30, 2022 for clients of intervention CMs versus control CMs. Mixed method analysis included key informant interviews conducted from 5/24/22 to 7/25/22 with CMs, administrators, and clients about the PIV intervention. RESULTS: Among 1939 clients of 78 study CMs, 528 (26.8 %) were unvaccinated by December 1, 2021 (274 clients of intervention CMs; 254 clients of control CMs). These clients' mean age was 62.3 years old (SD = 22.4) and 54 % were Black or Hispanic/Latino. First vaccination rate did not differ for intervention and control groups (6.2 % vs. 5.9 %, p = .89) by 6/30/2022. Barriers to addressing COVID-19 vaccination from interviews with 7 CMs and administrators were competing responsibilities and potentially antagonizing clients. Seven interviewed clients (five vaccinated and two unvaccinated) cited concerns about vaccination they heard from their family/friends and belief that risks of COVID-19 infection may be less than vaccination. Yet, some clients were receptive to physician recommendations. CONCLUSION: Training CMs to promote COVID-19 vaccination for disabled clients did not increase first vaccination rates. CMs preferred their usual role of coordinating care and, even after the training, expressed discomfort with this potentially polarizing topic.

Expectation, Attitude, and Barriers to Receiving Telehomecare Among Caregivers of Homebound or Bedridden Older Adults: Qualitative Study.

BACKGROUND: In recent years, telehomecare has become an increasingly important option for health care providers to deliver continuous care to their patients. OBJECTIVE: This study aims to explore the expectations, attitudes, and barriers to telehomecare among caregivers of homebound or bedridden older adults. METHODS: This qualitative study used semistructured interviews to explore caregivers' perspectives on telehomecare for homebound or bedridden older adults. The study adhered to the SRQR (Standards for Reporting Qualitative Research) guidelines. Participants were selected using convenience sampling from caregivers of homebound or bedridden older adults with experience in both in-person home visits and telehomecare services provided by the Department of Family Medicine at Chiang Mai University, in an urban area of Chiang Mai Province in Northern Thailand. Semistructured interviews were conducted. The interviews were audio recorded with participant consent and transcribed verbatim. The framework method was used, involving multiple readings of transcripts to facilitate familiarization and accuracy checking. The study used the technology acceptance model and comprehensive geriatric assessment as the analytical framework. RESULTS: The study included 20 caregivers of older adult patients. The patients were predominantly female (15/20, 75%), with an average age of 86.2 years. Of these patients, 40% (n=8) of patients were bedridden, and 60% (n=12) of patients were homebound. Caregivers expressed generally positive attitudes toward telehomecare. They considered it valuable for overall health assessment, despite recognizing certain limitations, particularly in physical assessments. Psychological assessments were perceived as equally effective. While in-person visits offered more extensive environmental assessments, caregivers found ways to make telehomecare effective. Telehomecare facilitated multidisciplinary care, enabling communication with specialists. Caregivers play a key role in care planning and adherence. Challenges included communication issues due to low volume, patient inattention, and faulty devices and internet signals. Some caregivers helped overcome these barriers. The loss of information was mitigated by modifying signaling equipment. Technology use was a challenge for some older adult caregivers. Despite these challenges, telehomecare offered advantages in remote communication and resolving scheduling conflicts. Caregivers varied in their preferences. Some preferred in-person visits for a broader view, while others favored telehomecare for its convenience. Some had no strong preference, appreciating both methods, while others considered the situation and patient conditions when choosing between them. Increased experience with telehomecare led to more confidence in its use. CONCLUSIONS: Caregivers have positive attitudes and high expectations for telehomecare services. Although there may be barriers to receiving care through this mode, caregivers have demonstrated the ability to overcome these challenges, which has strengthened their confidence in telehomecare. However, it is important to enhance the skills of caregivers and health care teams to overcome barriers and optimize the use of telehomecare.

Applying a trauma-informed approach to home visits.

The concept of trauma and traumatic stress and its impact on health and mental health has been studied for nearly half a century. Trauma-informed care (TIC) is person-centered care designed and delivered based on knowledge of the ubiquity of trauma. It requires building an understanding of the role that trauma plays in the lives and health outcomes of survivors. In doing so, it helps promote physical, psychological, and emotional safety for both clinicians and patients. Trauma and traumatic events are cumulative over the lifespan, and individuals who have experienced trauma are at higher risk for re-traumatization and poorer health outcomes. TIC approaches have been applied in many healthcare settings successfully; however, to date, there have not been any recommendations made about applying these approaches to care of homebound older adults, even though it may be surmised that this population is at an especially high risk for prior trauma and entering a person's safe space could be especially sensitive for trauma survivors. This paper serves to provide specific recommendations for applying a trauma-informed approach to a home visit and provides recommendations to home-based primary care groups and health systems about implementing universal trauma-informed care to homebound older adults.

Outreach to Low-Income Homebound Older Adults to Increase Access to COVID-19 Self-Test Kits, Missouri, 2022.

COVID-19 self-test kits were distributed to low-income, older adults (n = 2532) with their home-delivered or congregate meals in May 2022. Later, a convenience sample (n = 1108) were contacted for follow-up, and 606 (55%) were reached. Among 79% who remembered getting the test, only 34% already had a test kit, but nearly all liked receiving it (91%) and reported they would use or had used it (93%). Partnering with meal-delivery service providers was feasible to increase access to COVID-19 self-tests for low-income older adults. (Am J Public Health. 2024;114(S1):S65-S68. https://doi.org/10.2105/AJPH.2023.307485).

Korean primary health care program for people with disabilities: do they really want home-based primary care?

BACKGROUND: Despite many studies on home-based primary care (HBPC)-related benefits and challenges, little is known about the perspectives of potential target groups of the care and their intention or preference for using it. This study aimed to explore the demand for HBPC from the perspective of people with disabilities (PWDs) and caregivers and identify relevant determinants for that demand. METHODS: Data from the population-based survey conducted in the Gyeonggi Regional Health & Medical Center for People with Disabilities in South Korea were analyzed. Logistic regression analysis was performed to identify relevant determinants for the demand on HBPC. RESULTS: Overall, 22% of respondents required HBPC, and 34.7% of persons aged ≥ 65 years demanded it. Older adults with disability, homebound status, and a need for assistance with daily living activities were associated with a demand for HBPC. Though having severe disability, only 19.49% of self-reported respondents demanded for HBPC, while 39.57% of proxy-reported respondents demanded for HBPC. Among self-reported group, only marital status was a predictor associated with a demand for HBPC. In contrast, among proxy-reported groups, PWDs with external physical disabilities, or with unmet medical needs due to availability barriers reported a higher demand for HBPC. CONCLUSIONS: The demand for HBPC does not derive from the medical demands of the users themselves, but rather the care deficit by difficulty in getting out of the house or in outpatient care. Beyond an alternative to office-based care, HBPC needs to be considered to solve the care deficit and as well as to deal with PWDs' medical problems.

Promoting Connection in the Faith Community Through Letter Writing.

ABSTRACT: Faith community nurses can reduce loneliness and provide connection for homebound members of faith communities through promotion of letter writing. Undergraduate nursing students who were matched with members of their own faith community wrote letters to older adults for 10 weeks as a community service-learning project. Data from the UCLA Loneliness Scale pre- and post-intervention showed reduced loneliness and greater connection among recipients of the letters.

Caregiver Experiences Participating in a Home-Based Primary Care Program: A Pragmatic Evaluation Including Qualitative Interviews and Quantitative Surveys.

The aim of this evaluation was to assess caregiver experience and burden during their first year in a geriatric home-based primary care (HBPC) program with qualitative interviews and surveys. HBPC included in-home visits for homebound, older adult patients. Seventeen caregivers, with varied amount of experience with HBPC, participated in semi-structured interviews. Change in caregiver burden from baseline was captured for 44 caregivers at 3 months post-enrollment, 27 caregivers at 6 months, and 22 caregivers at 12 months. Satisfaction survey was administered at these timepoints, but the last response of 48 caregivers was analyzed. Caregiver interviews revealed three themes: caregiving stressors, reliance on HBPC in relation to other medical care, and healthcare in the home. Surveyed caregivers were highly satisfied, but burden did not change substantially over the 1 year intervention. Caregivers appreciated HBPC reduced patient transportation and provided satisfactory primary care, but additional research is needed to tailor this care to reduce caregiver burden.

Dysphagia in Older Adults is Associated With Food Insecurity and Being Homebound.

Objective: Our aim was to evaluate relationships between swallowing difficulty (dysphagia) and social determinants of health (SDOH) in older adults ≥65 years. Method: Cross-sectional analyses were performed in community-dwelling Medicare beneficiaries from the National Health & Aging Trends Study (NHATS). The primary exposure was self-reported difficulty chewing/swallowing in the prior month. Dependent measures included a variety of SDOH outcomes (e.g., food insecurity [FI]). Weighted logistic regression models were estimated to determine associations between dysphagia and SDOH outcomes. Results: Of 4041 participants, 428 (10.6%) self-reported dysphagia. In the adjusted model, dysphagia was associated with significantly increased odds for FI (odds ratio [OR] = 1.48, 95% confidence interval [CI] = 1.06, 2.07, p = .023) and being homebound (OR = 1.32, 95% CI = 1.13, 1.55, p= < .001). Discussion: Older adults with dysphagia had increased odds of FI and being homebound. These associations have implications for health-promoting interventions at the individual and policy levels in older adults.

If You Give Them Away, It Still May Not Work: Challenges to Video Telehealth Device Use Among the Urban Homebound.

The growing homebound population may particularly benefit from video telehealth. However, some patients do not have the ability or resources to successfully use this modality. This report presents the experience of a large urban home-based primary care program disseminating cellular-enabled tablets with basic instruction to a subset of its patients who would not otherwise have had the ability to engage in video telehealth. Program goals included: increasing the number of patients able to engage in video encounters and leveraging technology to help achieve greater equity. While 123 homebound patients received devices for telehealth, only one-third successfully utilized them. We identified multiple barriers to telehealth utilization beyond physical access to a device, including a lack of skill. Efforts to increase video encounters among patient groups who are less experienced with technology cannot simply rely on device provision or basic instruction but must include reinforced learning strategies combined with ongoing technical assistance.

The heterogeneity of the homebound: A latent class analysis of a national sample of homebound older adults.

BACKGROUND: Homebound status is a final common pathway for people with a variety of diseases and conditions. There are 7 million homebound older adults in the United States. Despite concerns regarding their high healthcare costs and utilization and limited access to care, the unique subsets within the homebound population are understudied. Better understanding of distinct homebound groups may enable more targeted and tailored approaches to care delivery. Therefore, in a nationally representative sample of homebound older adults we used latent class analysis (LCA) to examine distinct homebound subgroups based on clinical and sociodemographic characteristics. MATERIALS AND METHODS: Using data from the National Health and Aging Trends Study (NHATS) 2011-2019, we identified 901 newly homebound persons (defined as never/rarely leaving home or leaving home only with assistance and/or difficulty). Sociodemographic, caregiving context, health and function, and geographic covariates were derived from NHATS via self-report. LCA was used to identify the existence of distinct subgroups within the homebound population. Indices of model fit were compared for models testing 1-5 latent classes. Association between latent class membership and 1 year mortality was examined using a logistic regression. RESULTS: We identified four classes of homebound individuals differentiated by their health, function, sociodemographic characteristics, and caregiving context: (i) Resource constrained (n = 264); (ii) Multimorbid/high symptom burden (n = 216); (iii) Dementia/functionally impaired (n = 307); (iv) Older/assisted living (n = 114). One year mortality was highest among the older/assisted living subgroup (32.4%) and lowest among the resource constrained (8.2%). CONCLUSIONS: This study identifies subgroups of homebound older adults characterized by distinct sociodemographic and clinical characteristics. These findings will support policymakers, payers, and providers in targeting and tailoring care to the needs of this growing population.

An Organizational Assessment of 34 Home Delivered Meals Programs that Engaged and Assisted Homebound Individuals With Obtaining the COVID-19 Vaccine During the Pandemic.

Vaccinating homebound individuals during the COVID-19 pandemic presented several challenges, including time and cost of engaging this group. In Los Angeles County, the departments of Public Health and Aging and Disabilities turned to home delivered meals programs (HDMs) for help with this public health priority. A mixed-method organizational assessment of 34 HDMs was conducted during March-April 2022 to describe these efforts. Most HDMs were nonprofit (67.6%) and had <25 staff (58.8%). Overall, they served a large catchment area before and during COVID-19, providing services to an estimated total of 24,995 clients/week and delivering 19,511 meals/day. A majority (82.4%) reported engaging their clients to facilitate COVID-19 vaccinations. As of early 2022, <6% of these HDMs' homebound clients were unvaccinated. These programs' efforts to assist older individuals who were homebound during the pandemic represent a potentially underutilized model of public-nonprofit/not-for-profit partnership for improving vaccine delivery and uptake in this hard-to-reach population.

Frailty and Nutrition Risk Predict Falls and Emergency Department Visits in Home-Delivered Meal Clients.

Home-delivered meal programs improve health outcomes for older adults who are homebound, yet some clients need additional services and support to maintain independence. This study sought to identify program clients at the highest risk for adverse outcomes. Nutrition risk and Frailty Index scores were used to predict client-reported falls, emergency department visits, and hospitalizations over a six-month period for 258 Meals on Wheels clients in one Midwestern community. A multivariate binomial logistic regression model adjusting for both Frailty Index and nutrition risk scores with age, gender, poverty, and race accounted for 13.2% of the variation in falls and 22% of the variation in emergency department visits. Neither study variable was predictive of hospitalizations. Nutrition risk and Frailty Index scores, together, produced a more robust picture of client risk than with either score alone; these tools could be used by service providers to prioritize additional support services.

The impact of a nutrition counseling program on the use of hospital services for Meals on Wheels clients.

Home-delivered meals have shown considerable promise in overcoming nutritional challenges among homebound older adults facing food insecurity and the risk of diabetes, while nutrition counseling provides knowledge and skills for diabetes management. The purpose of this study was to identify the impact of a program combining nutrition counseling with home-delivered meals by examining the use of hospital services 6 months before and after participating in the program. This study included 1009 clients who are at risk for diabetes and who received home-delivered meals and nutrition counseling via Meals on Wheels in Fort Worth, Texas. Hospital service data were extracted from a regional claims database. Generalized linear models were performed to examine changes in use of hospital services 6 months before and after program participation. The mean number of emergency department visits and hospitalizations decreased from 0.69 to 0.50 (p < .001) and from 0.35 to 0.22 (p < .001), respectively. The findings of this study indicate that combining structured nutritional counseling with home-delivered meals may contribute to reducing healthcare use among older adults facing the challenges of diabetes and food insecurity.

Outcomes of home-based primary care for homebound older adults: A randomized clinical trial.

BACKGROUND: Homebound older adults are medically complex and often have difficulty accessing outpatient medical care. Home-based primary care (HBPC) may improve care and outcomes for this population but data from randomized trials of HBPC in the United States are limited. METHODS: We conducted a randomized controlled trial of HBPC versus office-based primary care for adults ages ≥65 years who reported ≥1 hospitalization in the prior 12 months and met the Medicare definition of homebound. HBPC was provided by teams consisting of a physician, nurse practitioner, nurse, and social worker. Data were collected at baseline, 6- and 12-months. Outcomes were quality of life, symptoms, satisfaction with care, hospitalizations, and emergency department (ED) visits. Recruitment was terminated early because more deaths were observed for intervention patients. RESULTS: The study enrolled 229 patients, 65.4% of planned recruitment. The mean age was 82 (9.0) years and 72.3% had dementia. Of those assigned to HBPC, 34.2% never received it. Intervention patients had greater satisfaction with care than controls (2.26, 95% CI 1.46-3.06, p < 0.0001; effect size 0.74) and lower hospitalization rates (-17.9%, 95% CI -31.0% to -1.0%; p = 0.001; number needed to treat 6, 95% CI 3-100). There were no significant differences in quality of life (1.25, 95% CI -0.39-2.89, p = 0.13), symptom burden (-1.92, 95% CI -5.22-1.37, p = 0.25) or ED visits (1.2%, 95% CI -10.5%-12.4%; p = 0.87). There were 24 (21.1%) deaths among intervention patients and 12 (10.7%) among controls (p < 0.0001). CONCLUSION: HBPC was associated with greater satisfaction with care and lower hospitalization rates but also more deaths compared to office-based primary care. Additional research is needed to understand the nature of the higher death rate for HBPC patients, as well as to determine the effects of HBPC on quality of life and symptom burden given the trial's early termination.

Preparo dos pais para a desospitalização de crianças em uso de traqueostomia e gastrostomia / Preparación de los padres para la deshospitalización de niños en uso de traqueostomía y gastrostomía / Parents' preparation for the dehospitalization of children using tracheostomy and gastrostomy

RESUMO Objetivo: relatar a experiência de uma ação educativa para o preparo dos pais para a desospitalização de crianças em uso de traqueostomia e gastrostomia. Método: relato de experiência sobre uma ação educativa, que é parte de um Programa de Treinamento de um hospital público de alta complexidade referência em pediatria, no período de dezembro de 2017 a dezembro de 2018. Resultados: o preparo dos responsáveis para a desospitalização de crianças em uso de traqueostomia e gastrostomia foi feito a partir de 5 etapas: 1) Instruções aos pais; 2) Treinamento dos pais para manuseio do dispositivo utilizado pela criança; 3) Manipulação dos dispositivos pelos pais sob supervisão do enfermeiro; 4) Feedback oferecido pela Enfermagem; e 5) Avaliação da ação educativa. Considerações finais: Acredita-se que a educação terapêutica fornecida aos envolvidos contribuiu na qualificação do cuidado à criança em uso de traqueostomia e gastrostomia, favorecendo sua qualidade de vida e reduzindo as intercorrências domiciliares relacionadas ao manuseio inadequado dos dispositivos em questão.

resumen Objetivo: relatar la experiencia de una acción educativa para la preparación de los padres para la deshospitalización de niños en uso de traqueostomía y gastrostomía. Método: relato de experiencia sobre una acción educativa, que hace parte de un Programa de Entrenamiento de un hospital público de alta complejidad referencia en pediatría, en el período de diciembre de 2017 a diciembre de 2018. Resultados: la preparación de los responsables para la deshospitalización de niños en uso de traqueostomía y gastrostomía se hizo a partir de 5 etapas: 1) Instrucciones a los padres; 2) Entrenamiento de los padres para manejo del dispositivo utilizado por el niño; 3) Manipulación de los dispositivos por los padres bajo supervisión del enfermero; 4) Feedback ofrecido por la Enfermería; y 5) Evaluación de la acción educativa. Consideraciones finales: Se cree que la educación terapéutica proporcionada a los involucrados contribuyó en la calificación del cuidado del niño en uso de traqueostomía y gastrostomía, favoreciendo su calidad de vida y reduciendo las complicaciones domiciliarias relacionadas con el manejo inadecuado de los dispositivos en cuestión.

ABSTRACT Objective: to report the experience of an educational action for the preparation of parents for the dehospitalization of children using tracheostomy and gastrostomy. Method: experience report on an educational action, which is part of a Training Program of a public hospital of high complexity reference in pediatrics, from December 2017 to December 2018. Results: the preparation of those responsible for the dehospitalization of children using tracheostomy and gastrostomy was made from 5 stages: 1) Instructions to parents; 2) Training of parents to handle the device used by the child; 3) Manipulation of the devices by parents under the supervision of the nurse; 4) Feedback offered by Nursing; and 5) Evaluation of educational action. Final considerations: It is believed that the therapeutic education provided to those involved contributed to the qualification of care for children using tracheostomy and gastrostomy, favoring their quality of life and reducing home complications related to inadequate handling of the devices in question.