Inequalities in Transitions to Home Care: A Longitudinal Analysis of the Canadian Longitudinal Study on Aging.

OBJECTIVES: To investigate inequalities in transitions to home care across a broad set of demographic and socioeconomic factors in Canadian middle-aged and older adults. DESIGN: Longitudinal, retrospective cohort study. SETTING AND PARTICIPANTS: A total of 51,338 community-dwelling adults aged 45+ years, using national data from the Canadian Longitudinal Study on Aging across 3 timepoints from 2011 to 2021. METHODS: We analyzed transitions in home care use using multistate Markov models, with home care use and nonuse as transient states, and loss to follow-up as a terminal state. We calculated hazard ratios for transitions between states adjusting for factors related to home care need (ie, functional limitations, chronic conditions) within the following equity strata: income, education, immigration history, sex, gender, rurality, racial background, and tangible social support. RESULTS: Across all timepoints, 5.4% of non-home care users transitioned to home care by the next timepoint and 33.2% of home care users continued to use home care at the next timepoint. Among non-home care users, identifying as a woman, female, White, completing higher levels of education, having higher income, and having less support available was associated with an increased likelihood of transitioning to home care use. Among home care users, higher income was also associated with a greater likelihood to discontinue using home care compared with lower income users. The association between income and home care use was stronger among female individuals. CONCLUSIONS AND IMPLICATIONS: We found meaningful differences in home care transitions across several equity strata. Individuals with higher income have greater ability to access to private care, creating inequity in access to home care services. Gendered factors such as income and social support have important associations with home care use. Home care planning and policy must address the unique barriers and disadvantages diverse populations face to ensure equitable use of home care and promote healthy aging.

Caregiving in long-term care before and during the COVID-19 pandemic: a scoping review.

PURPOSE: The COVID-19 pandemic magnified pre-existing socioeconomic, operational, and structural challenges in long-term care across the world. In Canada, the long-term care sector's dependence on caregivers as a supplement to care workers became apparent once restrictive visitation policies were employed. We conducted a scoping review to better understand the associations between caregiving and resident, formal and informal caregiver health in long-term care before and during the COVID-19 pandemic. METHODS: A literature search was performed using MEDLINE, AgeLine, Google Advanced, ArXiv, PROSPERO, and OSF. Pairs of independent reviewers screened titles and abstracts followed by a review of full texts. Studies were included if they reported biological, psychological, or social health outcomes associated with caregiving (or lack thereof). RESULTS: After screening and reviewing 252 records identified by the search strategy, a total of 20 full-text records were eligible and included in this review. According to our results, research on caregiving increased during the pandemic, and researchers noted restrictive visitation policies had an adverse impact on health outcomes for residents and formal and informal caregivers. In comparison, caregiving in long-term care prior to the pandemic, and once visitation policies became less restrictive, led to mostly beneficial health outcomes. CONCLUSION: Caregiver interventions, for the most part, appear to promote better health outcomes for long-term care residents and formal and informal caregivers. Suggestions to better support caregiving in long-term care settings are offered.

The relationship between patient experience and real-world digital health access in primary care: A population-based cross-sectional study.

Implementing digital health technologies in primary care is anticipated to improve patient experience. We examined the relationships between patient experience and digital health access in primary care settings in Ontario, Canada. We conducted a retrospective cross-sectional study using patient responses to the Health Care Experience Survey linked to health and administrative data between April 2019-February 2020. We measured patient experience by summarizing HCES questions. We used multivariable logistic regression stratified by the number of primary care visits to investigate associations between patient experience with digital health access and moderating variables. Our cohort included 2,692 Ontario adults, of which 63.0% accessed telehealth, 2.6% viewed medical records online, and 3.6% booked appointments online. Although patients reported overwhelmingly positive experiences, we found no consistent relationship with digital health access. Online appointment booking access was associated with lower odds of poor experience for patients with three or more primary care visits in the past 12 months (adjusted odds ratio 0.16, 95% CI 0.02-0.56). Younger age, tight financial circumstances, English as a second language, and knowing their primary care provider for fewer years had greater odds of poor patient experience. In 2019/2020, we found limited uptake of digital health in primary care and no clear association between real-world digital health adoption and patient experience in Ontario. Our findings provide an essential context for ensuing rapid shifts in digital health adoption during the COVID-19 pandemic, serving as a baseline to reexamine subsequent improvements in patient experience.

Recent functional decline and outpatient follow-up after hospital discharge: a cohort study.

BACKGROUND: Functional decline is common following acute hospitalization and is associated with hospital readmission, institutionalization, and mortality. People with functional decline may have difficulty accessing post-discharge medical care, even though early physician follow-up has the potential to prevent poor outcomes and is integral to high-quality transitional care. We sought to determine whether recent functional decline was associated with lower rates of post-discharge physician follow-up, and whether this association changed during the COVID-19 pandemic, given that both functional decline and COVID-19 may affect access to post-discharge care. METHOD: We conducted a retrospective cohort study using health administrative data from Ontario, Canada. We included patients over 65 who were discharged from an acute care facility during March 1st, 2019 - January 31st, 2020 (pre-COVID-19 period), and March 1st, 2020 - January 31st, 2021 (COVID-19 period), and who were assessed for home care while in hospital. Patients with and without functional decline were compared. Our primary outcome was any physician follow-up visit within 7 days of discharge. We used propensity score weighting to compare outcomes between those with and without functional decline. RESULTS: Our study included 21,771 (pre-COVID) and 17,248 (COVID) hospitalized patients, of whom 15,637 (71.8%) and 12,965 (75.2%) had recent functional decline. Pre-COVID, there was no difference in physician follow-up within 7 days of discharge (Functional decline 45.0% vs. No functional decline 44.0%; RR = 1.02, 95% CI 0.98-1.06). These results did not change in the COVID-19 period (Functional decline 51.1% vs. No functional decline 49.4%; RR = 1.03, 95% CI 0.99-1.08, Z-test for interaction p = 0.72). In the COVID-19 cohort, functional decline was associated with having a 7-day physician virtual visit (RR 1.15; 95% CI 1.08-1.24) and a 7-day physician home visit (RR 1.64; 95% CI 1.10-2.43). CONCLUSIONS: Functional decline was not associated with reduced 7-day post-discharge physician follow-up in either the pre-COVID-19 or COVID-19 periods. In the COVID-19 period, functional decline was positively associated with 7-day virtual and home-visit follow-up.

The interRAI COVID-19 vulnerability screener: Results of a health surveillance initiative for vulnerable adults in the community during the COVID-19 pandemic.

During the pandemic, the interRAI COVID-19 Vulnerability Screener (CVS) was used to identify community-dwelling older adults or adults with disabilities at risk of negative outcomes and facilitate triage for follow-up with health/social services. The interRAI CVS, a standardized self-report instrument administered virtually by a lay-person, includes COVID-19-related items and psychosocial and physical vulnerability. Our objective was to describe those assessed and identify sub-groups at highest risk of adverse outcomes. Seven community-based organizations in Ontario, Canada, implemented the interRAI CVS. We used descriptive statistics to report results and created a priority indicator for monitoring and/or intervention based on possible COVID-19 symptoms and psychosocial/physical vulnerabilities. We used logistic regression to examine the association between priority level and risk of poor outcomes using fair/poor self-rated health as a proxy measure. The sample included 942 adults assessed (April-November 2020; mean age=79). About 10% of individuals reported potential COVID-19 symptoms and <1% had a positive COVID-19 test/diagnosis. Of those with psychosocial/physical vulnerabilities (73.1%), most common were depressed mood (20.9%), loneliness (21.6%), and limited access to food/medications (7.5%). Overall, 45.7% had a recent doctor or nurse practitioner visit. Odds of fair/poor self-reported health were highest among those who reported both possible symptoms of COVID-19 and psychosocial/physical vulnerabilities (OR 10.9, 95% CI 5.96-20.12) compared to those with neither symptoms nor psychosocial/physical vulnerabilities. The sample represents a population largely unaffected by COVID-19 itself but with identified vulnerabilities. The interRAI CVS allows community providers to stay connected and obtain a better understanding of vulnerable individuals' needs during the pandemic.

Examining the Effect of the First Wave of the COVID-19 Pandemic on Home Care Recipients' Instrumental Activities of Daily Living Capacity.

OBJECTIVE: To examine the effect of the pandemic on, and factors associated with, change in home care (HC) recipients' capacity for instrumental activities of daily living. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: HC recipients in Ontario, Canada, between September 1, 2018, and August 31, 2020, who were not totally dependent on others and not severely cognitively impaired at baseline. METHODS: Data were collected with the interRAI Home Care assessment. Outcomes of interest were declines in instrumental activities of daily living. Factors hypothesized to be associated with declining function were entered as independent variables into multivariable generalized estimating equations, and results were expressed as odds ratios (ORs) with 95% confidence intervals (CIs). Those significant at P < .01 were retained in the final models. RESULTS: There were 6786 and 5019 HC recipients in the comparison and pandemic samples, respectively. Between baseline and follow-up for the 2 groups, 34.1% and 42.1% of HC recipients declined in shopping, whereas 25.2% and 30.5% declined in transportation capacity in the comparison and pandemic sample, respectively. For shopping, those with cognitive impairment (OR 0.83, 95% CI 0.76-0.89) and receiving formal care (OR 0.72, 95% CI 0.62-0.85) were less likely to decline, whereas those who were older (OR 1.91, 95% CI 1.69-2.16) and had unstable health (OR 1.31, 95% CI 1.16-1.48) were more likely. For transportation, those receiving informal (OR 0.71, 95% CI 0.61-0.81) or formal care (OR 0.56, 95% CI 0.47-0.67) were less likely to decline, whereas those who were older (OR 1.81, 95% CI 1.58-2.07) and had unstable health (OR 1.35, 95% CI 1.119-1.54) were more likely. CONCLUSIONS AND IMPLICATIONS: The pandemic was associated with a decline in HC recipients' capacity for shopping and transportation. HC recipients who are older and have unstable health may benefit from preventive strategies.

Social Engagement and Distress Among Home Care Recipients During the COVID-19 Pandemic in Ontario, Canada: A Retrospective Cohort Study.

OBJECTIVES: To examine factors associated with distressing social decline and withdrawal during the COVID-19 pandemic for home care recipients. DESIGN: Retrospective cohort. SETTING AND PARTICIPANTS: Home care recipients age 18 years or older in Ontario, Canada without severe cognitive impairment with an assessment and follow-up between September 1, 2018 and August 31, 2020. METHODS: Data were collected using the interRAI home care. Outcomes of interest were distressing decline in social participation and social withdrawal. Independent variables were entered into multivariable longitudinal generalized estimating equations. Interaction terms with the pandemic were tested. Those significant at P < .01 were retained in final models and reported as odds ratios (ORs), 95% confidence intervals (CIs). RESULTS: We compared 26,492 and 19,126 home care recipients before and during the pandemic, respectively. The pandemic was associated with greater odds of experiencing distressing social decline (OR 1.28, 95% CI 1.22‒1.34) and withdrawal (OR 1.09, 95% CI 1.04‒1.15). Living alone (OR 1.13, 95% CI 1.05‒1.22), frailty (OR 3.21, 95% CI 2.76‒3.73), health instability (OR 2.22, 95% CI 2.02‒2.44), and depression (OR 2.14, 95% CI 2.01‒2.29) increased the odds of distressing social decline. Older age (OR 0.71, 95% CI 0.65‒0.77), functional impairment (OR 0.58, 95% CI 0.51‒0.67), and receiving caregiving (OR 0.73, 95% CI 0.67‒0.79) decreased the odds. Home care recipients with mild/moderate dementia were less likely to experience distressing social decline during the pandemic. Those who lived alone were more likely. Frailty (OR 9.49, 95% CI 7.69‒11.71) and depression (OR 2.76, 95% CI 2.55‒3.00) increased the odds of social withdrawal. Functional impairment (OR 0.32, 95% CI 0.27‒0.39), congestive heart failure (OR 0.77, 95% CI 0.70‒0.84), and receiving caregiving (OR 0.50, 95% CI 0.46‒0.55) decreased the odds. Home care recipients age 18‒64 years and older than 75 years were less likely to experience social withdrawal during the pandemic. CONCLUSIONS AND IMPLICATIONS: Social support interventions should focus on supporting those living alone, with frailty, health instability, or depression.

Implementation evaluation of a stepped approach to home care assessment using interRAI systems in Ontario, Canada.

In Ontario, new home care clients are screened with the interRAI Contact Assessment and only those expected to require longer-term services receive the comprehensive RAI-Home Care assessment. Although Ontario adopted this two-step approach in 2010, it is unknown whether the assessment guidelines were implemented as intended. To evaluate implementation fidelity, the purpose of this study is to compare expected to actual client profiles and care co-ordinator practice patterns. We linked interRAI CA and RAI-HC assessments and home care referrals and services data for a retrospective cohort of adult home care clients admitted in FY 2016/17. All assessments were done by trained health professionals as part of routine practice. Descriptive analyses were used to evaluate congruency between recommended and actual practice. Adjusted cause-specific hazards and logistic approaches were used to examine time to RAI-HC assessment and being a high-priority client. Of 225,989 unique home care clients admitted to the publicly funded home care program, about three-quarters of clients were assessed with the interRAI CA only (27.9% completed the Preliminary Screener only and 46.6% completed both the Preliminary Screener and Clinical Evaluation). There was substantial agreement between the skip logic and completion of the Clinical Evaluation section (Cohen's kappa = 0.67 [95% CI: 0.66-0.67]). One-quarter of clients were assessed with both the interRAI CA and RAI-HC. As expected, RAI-HC assessed clients were older, reported more health needs, and often received home care services for >6 months. Clients in higher Assessment Urgency Algorithm (AUA) levels were significantly more likely to receive a RAI-HC assessment and be assigned to a higher home care priority level; however, 28.3% of clients in the highest AUA level did not receive a RAI-HC assessment. We conclude that the use of the interRAI CA and RAI-HC balances the investment of time and resources with the information and tools to deliver high-quality, holistic, and client-centred care. The interRAI CA guides the care co-ordinator to screen every client for a broad range of possible needs and tailor further assessment to each client's unique needs. We recommend integrating the AUA into provincial assessment guidelines as well as developing a new quality indicator focused on measuring access to the home care system.

Patterns of home care assessment and service provision before and during the COVID-19 pandemic in Ontario, Canada.

OBJECTIVE: The objective was to compare home care episode, standardised assessment, and service patterns in Ontario's publicly funded home care system during the first wave of the COVID-19 pandemic (i.e., March to September 2020) using the previous year as reference. STUDY DESIGN AND SETTING: We plotted monthly time series data from March 2019 to September 2020 for home care recipients in Ontario, Canada. Home care episodes were linked to interRAI Home Care assessments, interRAI Contact Assessments, and home care services. Health status measures from the patient's most recent interRAI assessment were used to stratify the receipt of personal support, nursing, and occupational or physical therapy services. Significant level and slope changes were detected using Poisson, beta, and linear regression models. RESULTS: The March to September 2020 period was associated with significantly fewer home care admissions, discharges, and standardised assessments. Among those assessed with the interRAI Home Care assessment, significantly fewer patients received any personal support services. Among those assessed with either interRAI assessment and identified to have rehabilitation needs, significantly fewer patients received any therapy services. Among patients receiving services, patients received significantly fewer hours of personal support and fewer therapy visits per month. By September 2020, the rate of admissions and services had mostly returned to pre-pandemic levels, but completion of standardised assessments lagged behind. CONCLUSION: The first wave of the COVID-19 pandemic was associated with substantial changes in Ontario's publicly funded home care system. Although it may have been necessary to prioritise service delivery during a crisis situation, standardised assessments are needed to support individualised patient care and system-level monitoring. Given the potential disruptions to home care services, future studies should examine the impact of the pandemic on the health and well-being of home care recipients and their caregiving networks.

A comparison of 3 frailty measures and adverse outcomes in the intake home care population: a retrospective cohort study.

BACKGROUND: In Ontario, Canada, nearly all home care patients are assessed with a brief clinical assessment (interRAI Contact Assessment [interRAI CA]) on admission. Our objective was to compare 3 frailty measures that can be operationalized using the interRAI CA. METHODS: We conducted a retrospective cohort study using linked patient-level assessment and administrative data for all Ontario adult (≥ 18 yr) home care patients assessed with the interRAI CA in 2014. We employed multivariable logistic models to compare the Changes in Health, End-stage disease and Signs and Symptoms Scale for the Contact Assessment (CHESS-CA), Assessment Urgency Algorithm (AUA) and the Frailty Index for the Contact Assessment (FI-CA) that was created for this study. Our outcomes of interest were death, hospital admission and emergency department visits within 90 days, and assessor-rated need for comprehensive geriatric assessment (CGA). RESULTS: In 2014, there were 228 679 unique adult home care patients in Ontario assessed with the interRAI CA. Controlling for age, sex and health region, being in a higher frailty level defined by any measure increased the likelihood of experiencing adverse outcomes. Among all assessments, CHESS-CA was best suited for predicting death and hospital admission, and either AUA or FI-CA for predicting perceived need for CGA. Previous emergency department visits were more predictive of future visits than frailty. Model fit was independent of whether the assessment was completed over the phone or in person. INTERPRETATION: Frailty measures from the interRAI CA identified patients at higher risk for death, hospital admission and perceived need for CGA. In jurisdictions where the CHESS-CA and AUA are already built into the electronic home care platform, such as Ontario, patients identified as high risk should be prioritized for proactive referral and care planning, and may benefit from greater involvement of primary care and other health professionals in the circle of care.

Adverse Events in Home Care: Identifying and Responding with interRAI Scales and Clinical Assessment Protocols.

Outcomes of adverse events in home care are varied and multifactorial. This study tested a framework combining two health measures to identify home care recipients at higher risk of long-term care placement or death within one year. Both measures come from the Resident Assessment Instrument-Home Care (RAI-HC), a standardized comprehensive clinical assessment. Persons scoring high in the Method for Assigning Priority Levels (MAPLe) algorithm and Changes in Health, End-stage disease, Signs and Symptoms (CHESS) scale were at the greatest risk of placement or death and more than twice as likely to experience either outcome earlier than others. The target group was more likely to trigger mood, social relationship, and caregiver distress issues, suggesting mental health and psychosocial interventions might help in addition to medical care and/or personal support services. Home care agencies can use this framework to identify home care patients who may require a more intensive care coordinator approach.

Derivation and validation of the Personal Support Algorithm: an evidence-based framework to inform allocation of personal support services in home and community care.

BACKGROUND: Personal support services enable many individuals to stay in their homes, but there are no standard ways to classify need for functional support in home and community care settings. The goal of this project was to develop an evidence-based clinical tool to inform service planning while allowing for flexibility in care coordinator judgment in response to patient and family circumstances. METHODS: The sample included 128,169 Ontario home care patients assessed in 2013 and 25,800 Ontario community support clients assessed between 2014 and 2016. Independent variables were drawn from the Resident Assessment Instrument-Home Care and interRAI Community Health Assessment that are standardised, comprehensive, and fully compatible clinical assessments. Clinical expertise and regression analyses identified candidate variables that were entered into decision tree models. The primary dependent variable was the weekly hours of personal support calculated based on the record of billed services. RESULTS: The Personal Support Algorithm classified need for personal support into six groups with a 32-fold difference in average billed hours of personal support services between the highest and lowest group. The algorithm explained 30.8% of the variability in billed personal support services. Care coordinators and managers reported that the guidelines based on the algorithm classification were consistent with their clinical judgment and current practice. CONCLUSIONS: The Personal Support Algorithm provides a structured yet flexible decision-support framework that may facilitate a more transparent and equitable approach to the allocation of personal support services.

Location, Location, Location: Characteristics and Services of Long-Stay Home Care Recipients in Retirement Homes Compared to Others in Private Homes and Long-Term Care Homes.

We examine recipients of publicly funded ongoing care in a single Ontario jurisdiction who reside in three different settings: long-stay home care patients in private homes and apartments, other patients in retirement homes and residents of long-term care homes, using interRAI assessment instruments. Among home care patients, those in retirement homes have higher proportions of dementia and moderate cognitive impairment, less supportive informal care systems as well as more personal care and nursing services above those provided by the public home care system, more frequent but shorter home support visits and lower than expected public home care expenditures. These lower expenditures may be because of efficiency of care delivery or by retirement homes providing some services otherwise provided by the public home care system. Although persons in each setting are mostly older adults with high degrees of frailty and medical complexity, long-term care home residents show distinctly higher needs. We estimate that 40% of retirement home residents are long-stay home care patients, and they comprise about one in six of this Community Care Access Centre's long-stay patients.

Predicting Adverse Outcomes After Discharge From Complex Continuing Care Hospital Settings to the Community.

PURPOSE OF STUDY: The purpose was to identify risk and protective factors assessed at complex continuing care (CCC) admission that were associated with three adverse outcomes (death, readmission, and incidence of or failure to improve possible depression) for persons discharged from CCC to the community with home care services. PRIMARY PRACTICE SETTINGS: CCC, home care, community. METHODOLOGY AND SAMPLE: The sample included all CCC patients in Ontario assessed with the Resident Assessment Instrument-Minimum Data Set 2.0 between January 2003 and December 2010 and who were subsequently assessed with the Resident Assessment Instrument-Home Care within 6 months of discharge to the community (n = 9,940). Separate multivariable logistic regression models were developed for each outcome. RESULTS: Within 6 months, 4.9% of the sample had died, 6.5% were readmitted to any Ontario CCC facility, and 13.7% showed symptoms of new possible depression or failure to improve possible depression. Heart failure, chronic obstructive pulmonary disease (COPD), health instability, intravenous/tube feed, and pressure ulcer were associated with increased risk of death. Difficulty with comprehension, possible depression, COPD, unstable conditions, acute episode or flare-up, short-term prognosis, worsening self-sufficiency, and having either patient or caregiver optimistic about discharge were associated with increased risk of readmission. Existing depressive symptoms or depression, unsettled relationships, multimorbidity, and polypharmacy were associated with risk for incidence of or failure to improve possible depression. Optimism about rehabilitation potential and high social engagement were protective against readmission and depressive outcomes, respectively. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Person-level clinical data collected on admission to CCC can be used to identify high-risk patients and trigger early discharge planning processes and other in-home interventions. These results support the sharing of information between settings, and highlight key areas in which care teams in CCC and case managers in home care organizations can work together to support the transition to home and potentially reduce adverse postdischarge outcomes.

Is dengue a disease of poverty? A systematic review.

Policy prescriptions for combating dengue fever tend to focus on addressing environmental and social conditions of poverty. However, while poverty has long been considered a determinant of dengue, the research evidence for such a relationship is not well established. Results of a systematic review of the research literature designed to identify and assess the current state of the empirical evidence for the dengue-poverty link reveal a mixed story. Of 260 peer-reviewed articles referencing dengue-poverty relationships, only 12 English-language studies empirically assessed these relationships. Our analysis covering various social and economic conditions of poverty showed no clear associations with dengue rates. While nine of the 12 studies demonstrated some positive associations between measures of dengue and poverty (measured inconsistently through income, education, structural housing condition, overcrowding, and socioeconomic status), nine also presented null results and five with negative results. Of the five studies relating to access to water and sanitation, four reported null associations. Income and physical housing conditions were more consistently correlated with dengue outcomes than other poverty indicators. The small size of this sample, and the heterogeneity of measures and scales used to capture conditions of poverty, make it difficult to assess the strength and consistency of associations between various poverty indicators and dengue outcomes. At present, the global body of eligible English-language peer-reviewed literature investigating dengue-poverty relationships is too small to support a definitive relationship. We conclude that more research, particularly using standardized measures of both outcomes and indicators, is needed to support evidence-informed policies and approaches.