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.

A comparative examination of models of service delivery intended to support community integration in the immediate period following inpatient rehabilitation for spinal cord injury.

STUDY DESIGN: Qualitative study using semi-structured interviews. OBJECTIVES: To describe and compare models of service delivery intended to support community integration in the immediate period following inpatient rehabilitation for SCI, and describe the characteristics of these models or approaches. SETTING: Spinal services from multiple international countries METHODS: Semi-structured interviews were completed with 12 participants from a convenience sample of ten spinal services from developed economies. Interviews were audio-recorded, transcribed verbatim and thematically analysed. RESULTS: Three themes were identified, and are described with supporting quotations. These are: Theme One-Models of service delivery (sub-themes: staffing, peer mentors, facilitating community integration during inpatient rehabilitation; Theme Two-Services provided (sub-themes: telehealth, vocational services, groups); Theme Three-Facilitating self-efficacy and self-management. CONCLUSIONS: A variety of models aimed at supporting community integration in the immediate period following inpatient rehabilitation for SCI were found. Multi-disciplinary staffing and involvement of peer mentors was common to all services. The importance of vocational rehabilitation was acknowledged by all participants, although the approaches taken to this varied. Telehealth has the potential to assist in self-management, particularly for patients who live a long distance from the spinal unit or are confined to the home for health reasons, and could be further developed. Although service models are greatly influenced by the funding context, the findings from this study can be used to inform service planning in this area.

The relationship between discharge medications and falls in post-hospitalised older adults: A 6-month follow-up.

OBJECTIVE: To identify discharge medications, especially psychotropic medications that are associated with falls, amongst older adults within 6 months following hospitalisation. METHODS: Negative binomial regression was used to examine relationships between discharge medications and falls in older post-hospitalised adults. Multiple regression that considered falls risk factors at discharge was performed. RESULTS: Data for 267 participants showed that discharge medications were not independently associated with falls postdischarge after adjustment for other falls risk factors. Male gender (adjusted incidence rate ratio [95% confidence interval, CI]) 2.15 [1.36-3.40]), higher depression scores (1.14 [1.05-1.25]) and co-morbidity of neurological disease other than stroke (5.98 [3.08-11.60]) were independently associated with an increased rate of falls. Higher depression scores (1.20 [1.11-1.31]) and co-morbidity of cancer (1.97 [1.20-3.25]) were independently associated with an increased rate of injurious falls in the 6 months postdischarge. CONCLUSION: Falls prevention strategies, other than hospital discharge medication management in the postdischarge older adults, warrant investigation.

Further validation of the Health Promoting Activities Scale with mothers of typically developing children.

BACKGROUND/AIM: The Health Promoting Activities Scale (HPAS) measures the frequency that mothers participate in self-selected leisure activities that promote health and wellbeing. The scale was originally validated on mothers of school-aged children with disabilities, and the current article extends this research using a comparative sample of mothers of typically developing school-aged children. METHOD: Australian mothers (N = 263) completed a questionnaire containing the HPAS, a measure of depression, anxiety and stress (DASS-21) and questions concerning their weight, height, sleep quality and demographics. Statistical analysis assessed the underlying structure, internal consistency and construct validity of the HPAS. Inferential statistics were utilised to investigate the construct validity. RESULTS: Exploratory factor analysis supported the unidimensionality of the HPAS. It showed good internal consistency (Cronbach's alpha = 0.78). Significantly lower HPAS scores were recorded for women who were obese; had elevated levels of depression, anxiety and stress; had poor quality sleep or had heavy caring commitments. The mean HPAS score in this sample (M = 32.2) was significantly higher than was previously reported for women of children with a disability (M = 21.6: P < 0.001). CONCLUSIONS: Further psychometric evaluation of the HPAS continues to support the HPAS as a sound instrument that measures the frequency that women participate in meaningful occupation that is associated with differences in mental health and wellbeing and other health indicators.

The Movement Assessment Battery for Children--Second Edition (MABC-2): a review and critique.

The Movement Assessment Battery for Children--Second Edition (MABC-2) is a recent revision of the well-known Movement Assessment Battery for Children (MABC). The MABC-2 is designed to identify and describe impairments in motor performance of children and adolescents 3 through 16 years of age. The Performance Test and the Checklist have been standardized using a larger, more representative normative sample. The evolution of the MABC-2 and research using the MABC is presented to provide a context for the MABC-2. The content of the MABC-2 is described including the scoring format, standardization sample, reliability, and validity. The MABC-2 includes four new items, the revision of some items, the creation of a 3- through 6-year and 11- through 16-year age bands, the combination of the 7- through 8- and 9- through 10-year age bands, and a system to assist with score interpretation. The Checklist has been reorganized and the total number of items reduced to 30. The primary weakness of the MABC-2 is the lack of evidence on reliability and validity. The quality, comprehensiveness, and rigor of reliability and validity studies reported in the test manual are variable. Considering the strengths and weakness of the MABC-2, it appears to be a clinically useful instrument, however, until further reliability and validity studies are completed, therapists should be guarded when basing their clinical decisions solely on MABC-2 test results.