Exploring the role of a facilitator in supporting family carers when embedding the iSupport for Dementia programme in care services: A qualitative study.

AIMS: To explore stakeholders' perceptions of a facilitator's role in supporting carers when embedding iSupport for Dementia psychoeducation program, in care services. METHODS: A qualitative descriptive study design was applied. Data were collected from workshops and interviews with carers of people living with dementia (PLWD)and with health and social care professionals from two tertiary hospitals and two community aged care organisations across three Australian states between October 2021 and March 2022. A thematic analysis was used to analyse data. The COREQ guideline was followed to report our findings. RESULTS: A total of 30 family carers and 45 health and social care professionals participated in the study. Three main themes and seven subthemes were identified from the data. We described the main themes as (1) the facilitator's role at the time of dementia diagnosis, (2) the facilitator's role throughout the everyday dementia care journey and (3) the facilitator's role during transition moments. CONCLUSIONS: Caring for family members with dementia is demanding and stressful for carers. Embedding a facilitator-enabled iSupport for Dementia program in hospital and community aged care settings has the potential to mitigate sources of stress associated with care recipient factors, carer factors and care service factors, and improve the health and well-being of carers and those for whom they care. RELEVANCE TO CLINICAL PRACTICE: Our findings will inform the establishment of iSupport facilitators appointed by dementia care providers in hospital and community care settings and help determine their roles and responsibilities in delivering the iSupport program. Our findings relate to nurse-led and coordinated dementia care in hospital and community aged care settings. PATIENT OR PUBLIC CONTRIBUTION: This study was co-designed with stakeholders from two aged care organisations and two tertiary hospitals. The study participants were staff employed by these organisations and carers of PLWD who were service users.

Associations between Cognitive Function, Hospitalizations and Costs in Nursing Homes: A Cross-sectional Study.

In an Australian nursing home population, associations between cognitive function and 12-month hospitalizations and costs were examined. Participants with dementia had 57% fewer hospitalizations compared to those without dementia, with 41% lower mean hospitalization costs; poorer cognition scores were also associated with fewer hospitalizations. The cost per admission for those with dementia was 33% greater due to longer hospital stays (5.5 days versus 3.1 days for no dementia, p = .05). People with dementia were most frequently hospitalized for fractures. These findings have policy implications for increasing investment in accurate and timely diagnosis of dementia and fall and fracture prevention strategies to further reduce associated hospitalization costs.

Registry of Older South Australians (ROSA): framework and plan.

INTRODUCTION: Australia's ageing population puts significant demands on the aged care and healthcare sectors. To monitor the provision of aged care and healthcare services to older people, each government body has an individual data collection system. Together these systems can be the basis for creating the evidence necessary to support future allocation of resources for our ageing community. The Registry of Older South Australians (ROSA) is a cross-sector multidisciplinary (ie, aged care and healthcare) platform built to address the challenges of monitoring people in aged care settings. This protocol describes the ROSA's framework and plans. METHODS AND ANALYSIS: A registry to capture 16 000 South Australians/year undergoing an aged care eligibility assessment was designed. ROSA will contain information captured by the Commonwealth and South Australian state Health Authority, linked by two data integrating authorities, and housed on a secured data platform. ROSA will contain information on the sociodemographic, health, function, psychological, social, home and safety assessment and concerns characteristics, aged care services, general health services, and mortality of people receiving aged care services. Registered participants will be prospectively monitored until their death and yearly updates of their aged care and healthcare services information will be added to the registry. ETHICS AND DISSEMINATION: ROSA will longitudinally monitor the services provided to a population that puts costly demands on the state healthcare and aged care systems, identify unwanted variation, and underpin future research. ROSA's expected outputs include an annual report, a research agenda that focuses on high burden conditions and potentially economically impactful questions, educational materials, and risk profiling tools. ROSA was approved by the South Australian Department for Health and Ageing HREC (HREC/17/SAH/125) and the Australian Institute of Health and Welfare HREC (EO2018/2/429).

Direct health and residential care costs of people living with dementia in Australian residential aged care.

OBJECTIVES: This analysis estimates the whole-of-system direct costs for people living with dementia in residential care by using a broad health and social care provision perspective and compares it to people without dementia living in residential care. METHODS: Data were collected from 541 individuals living permanently in 17 care facilities across Australia. The annual cost of health and residential care was determined by using individual resource use data and reported by the dementia status of the individuals. RESULTS: The average annual whole-of-system cost for people living with dementia in residential care was approximately AU$88 000 (US$ 67 100) per person in 2016. The cost of residential care constituted 93% of the total costs. The direct health care costs were comprised mainly of hospital admissions (48%), pharmaceuticals (31%) and out-of-hospital attendances (15%). While total costs were not significantly different between those with and without dementia, the cost of residential care was significantly higher and the cost of health care was significantly lower for people living with dementia. CONCLUSION: This study provides the first estimate of the whole-of-system costs of providing health and residential care for people living with dementia in residential aged care in Australia using individual level health and social care data. This predominantly bottom-up cost estimate indicates the high cost associated with caring for people with dementia living permanently in residential care, which is underestimated when limited cost perspectives or top-down, population costing approaches are taken.

The diagnostic accuracy of the Kimberley Indigenous Cognitive Assessment (KICA) tool: a systematic review.

OBJECTIVES: The objective of this study was to conduct a systematic review of evidence for the accuracy of the Kimberley Indigenous Cognitive Assessment (KICA) tool in supporting the diagnosis of dementia in Indigenous Australian populations. METHODS: Cross-sectional diagnostic accuracy studies of the KICA with an appropriate reference standard published to November 2015 were included. Comparison to an alternative cognitive assessment tool was required in non-remote populations. Case control analyses were excluded. RESULTS: Four studies were included: one of the KICA-Cog and KICA-Carer, one of the KICA Screen, and two of the modified-KICA. All tools developed for remote populations had a sensitivity of ≥76% and a specificity of ≥71% for the diagnosis of dementia. The KICA-Cog and KICA-Carer conducted in series had the highest sensitivity and specificity (91% and 94% respectively). In an urban and regional population, the mKICA had similar accuracy to the Mini-Mental State Examination (MMSE) (AUC 0.93, 95% CI 0.88-0.99 vs 0.94, 95% CI 0.89-0.99). Key risk of bias limitations related to lack of pre-determined cut-points and population selection methods. CONCLUSION: The use of the KICA in remote Indigenous Australians may assist in timely diagnosis of dementia in this population. Using the KICA-Cog and KICA-Carer in series may maximise specificity, decreasing false positive results without compromising sensitivity.

An Empirical Comparison of the EQ-5D-5L, DEMQOL-U and DEMQOL-Proxy-U in a Post-Hospitalisation Population of Frail Older People Living in Residential Aged Care.

OBJECTIVE: To empirically compare the measurement properties of the DEMQOL-U and DEMQOL-Proxy-U instruments to the EQ-5D-5L and its proxy version (CEQ-5D-5L) in a population of frail older people living in residential aged care in the post-hospitalisation period following a hip fracture. METHODS: A battery of instruments to measure health-related quality of life (HRQoL), cognition, and clinical indicators of depression, pain and functioning were administered at baseline and repeated at 4 weeks' follow-up. Descriptive summary statistics were produced and psychometric analyses were conducted to assess the levels of agreement, convergent validity and known group validity between clinical indicators and HRQoL measures. RESULTS: There was a large divergence in mean (SD) utility scores at baseline for the EQ-5D-5L and DEMQOL-U [EQ-5D-5L mean 0.21 (0.19); DEMQOL-U mean 0.79 (0.14)]. At 4 weeks' follow-up, there was a marked improvement in EQ-5D-5L scores whereas DEMQOL-U scores had deteriorated. [EQ-5D-5L mean 0.45 (0.38); DEMQOL-U mean 0.58 (0.38)]. The EQ-5D and CEQ-5D-5L were more responsive to the physical recovery trajectory experienced by frail older people following surgery to repair a fractured hip, whereas the DEMQOL-U and DEMQOL-Proxy-U appeared more responsive to the changes in delirium and dementia symptoms often experienced by frail older people in this period. CONCLUSIONS: This study presents important insights into the HRQoL of a relatively under-researched population of post-hospitalisation frail older people in residential care. Further research should investigate the implications for economic evaluation of self-complete versus proxy assessment of HRQoL and the choice of preference-based instrument for the measurement and valuation of HRQoL in older people exhibiting cognitive decline, dementia and other co-morbidities.

The relationship between in-hospital location and outcomes of care in patients diagnosed with dementia and/or delirium diagnoses: analysis of patient journey.

BACKGROUND: The discrepancy between the number of admissions and the allocation of hospital beds means that many patients admitted to hospital can be placed in units or wards other than that which specialise in the patient's primary health issue (home-ward). These patients are called 'outlier' patients. Risk factors and health system outcomes of hospital care for 'outlier' patients diagnosed with dementia and/or delirium are unknown. Therefore, the aim of this research was to examine patient journeys of people with dementia and/or delirium diagnoses, to identify risk factors for 'inlier' or 'outlier' status and patient or health system outcomes (consequences) of this status. METHODS: A retrospective, descriptive study compared patients who had dementia and/or delirium according to the proportion of time spent on the home ward i.e. 'inliers' or 'outliers'. Data from the patient journey database at Flinders Medical Centre (FMC), a public hospital in South Australia from 2007 and 2014 were extracted and analysed. The analysis was carried out on the patient journeys of people with a dementia and/or delirium diagnosis. RESULTS: When 6367 inpatient journeys with dementia and/or delirium within FMC were examined, the Emergency Department (ED) Length of Stay (LOS) after being admitted as inpatient was prolonged for 'outlier' patients compared to 'inlier' patients (OR: 1.068, 95% CI: 1.057-1.079, p = 0.000). However, the inpatient LOS for'outlier' patients was only marginally shorter than that of the 'inlier' patients (OR: 0.998, 95% CI: 0.998-0.998, p = 0.000). The chances of dying within 48 h of admission increased for 'outlier' patients (OR: 1.973, 95% CI: 1.158-3.359, p = 0.012) and their Charlson co-morbidity Index was higher (OR: 1.059, 95% CI: 1.021-1.10, p = 0.002). Completion of discharge summaries within 2 days post-discharge for 'outlier' patients was compromised (OR: 1.754, 95% CI: 1.492-2.061, p = 0.000).Additionally, 'outlier' patients were more likely to be discharged to another hospital for other care types not offered at FMC (OR: 1.931, 95% CI: 1.559-2.391, p = 0.000). CONCLUSION: An examination of the patient journeys at FMC has determined that the health system outcomes for patients with dementia and/or delirium who are admitted outside of their home-ward are affected by in-hospital location despite the homogenous nature of the study population.

Cost-effectiveness of individualized nutrition and exercise therapy for rehabilitation following hip fracture.

OBJECTIVE: To undertake a cost-utility analysis of the Individual Nutrition Therapy and Exercise Regime: A Controlled Trial of Injured, Vulnerable Elderly (INTERACTIVE) trial. DESIGN: Cost-utility analysis of a randomized controlled trial. SUBJECTS: A total of 175 patients following a hip fracture were allocated to receive either alternate weekly visits from a physical therapist and dietitian (intervention group), or social visits for 6 months (control group). METHODS: Costs for utilization of hospitals, health and community services were compared with quality-adjusted life years gained, calculated from responses to the Assessment of Quality of Life instrument. RESULTS: There were minimal differences in mean costs between the intervention ($AUD 45,331 standard deviation (SD): $AUD 23,012) and the control group ($AUD 44,764 SD: $AUD 20,712, p = 0.868), but a slightly higher mean gain in quality-adjusted life years in the intervention group (0.155, SD: 0.132) compared with the control group (0.139, SD: 0.149, p = 0.470). The incremental cost-effectiveness ratio was $AUD 28,350 per quality-adjusted life year gained, which is below the implied cost-effectiveness threshold utilized by regulatory authorities in Australia. CONCLUSION: A comprehensive 6-month programme of therapy from dietitians and physical therapists could be provided at a relatively low additional cost in this group of frail older adults, and the incremental cost-effectiveness ratio indicates likely cost-effectiveness, although there was a very high level of uncertainty in the findings.

Costs and advance directives at the end of life: a case of the 'Coaching Older Adults and Carers to have their preferences Heard (COACH)' trial.

BACKGROUND: Total costs associated with care for older people nearing the end of life and the cost variations related with end of life care decisions are not well documented in the literature. Healthcare utilisation and associated health care costs for a group of older Australians who entered Transition Care following an acute hospital admission were calculated. Costs were differentiated according to a number of health care decisions and outcomes including advance directives (ADs). METHODS: Study participants were drawn from the Coaching Older Adults and Carers to have their preferences Heard (COACH) trial funded by the Australian National Health and Medical Research Council. Data collected included total health care costs, the type of (and when) ADs were completed and the place of death. Two-step endogenous treatment-regression models were employed to test the relationship between costs and a number of variables including completion of ADs. RESULTS: The trial recruited 230 older adults with mean age 84 years. At the end of the trial, 53 had died and 80 had completed ADs. Total healthcare costs were higher for younger participants and those who had died. No statistically significant association was found between costs and completion of ADs. CONCLUSION: For our frail study population, the completion of ADs did not have an effect on health care utilisation and costs. Further research is needed to substantiate these findings in larger and more diverse clinical cohorts of older people. TRIAL REGISTRATION: This study was registered on 13/12/2007 with the Australian New Zealand Clinical Trial Registry ( ACTRN12607000638437 ).

Multidisciplinary care needs in an Australian tertiary teaching hospital.

BACKGROUND: The ageing of the Australian population is placing increasing demand on the nation's healthcare system. This study set out to describe the level of need for multidisciplinary care in an Australian tertiary hospital setting. METHODS: A cross-sectional audit by case note review of all patients on acute medical and surgical wards in an Australian tertiary hospital. The primary outcome was an identified need for multidisciplinary assessment and intervention. RESULTS: A total of 60% of the 295 inpatients audited required multidisciplinary care. Of those who were admitted to geriatric and rehabilitation units, 84% required multidisciplinary care. Patients in acute medical and surgical units also had substantial multidisciplinary care needs. Age was a significant influence with 79% of those aged 86 and above having multidisciplinary care needs, whilst only 38% of those aged 55 or less required multidisciplinary care. Difficulties with mobility, need for assistance with self-care, and continence problems were associated with higher requirement for multidisciplinary care. CONCLUSIONS: In the hospital population, significant multidisciplinary care needs exist. These needs are not limited to inpatients that are elderly or admitted to geriatric or rehabilitation units. This has implications for planning, funding, provision of health care resources, and training of medical and allied health staff.

Falls in hospitalized patients: can nursing information systems data predict falls?

Falls among inpatients are the most frequently reported critical incidents in hospitals and can have tragic consequences that affect morbidity and mortality. The present study aimed to determine whether certain nursing units of care identified on patient care plans can be used to predict falls among hospitalized inpatients. A retrospective analysis of 7167 inpatient admissions in the 2002 calendar year was conducted. Faller status was ascertained from the hospital's accident and incident monitoring system, and nursing units of care activated in the hospital's nursing information system were identified. Twelve nursing units of care predicted falls. Logistic regression analyses showed that nursing units of care related to patient safety, confusion, incontinence, medication, mobility, and sleep were significant risk factors for falls among inpatients. The number of nursing units of care activated also predicted falls. Data collected from nursing information systems can be used to identify patients at high risk of falls.

Experience of a falls and injuries risk assessment clinic.

AIM: To describe the first 2 years of operation of a specialist Falls Clinic providing assessment of falls risk and individual preventive interventions in a public hospital setting. METHOD: Drawing from the available falls prevention evidence, a multidisciplinary Falls Clinic involving specialist medical assessment, physiotherapy assessment and treatment was established. RESULTS: Over 2 years, 386 patients were seen in the clinic with the majority referred by a GP. The most frequent intervention for patients was referral to a Falls Education Program run by allied health staff at the hospital. Patients attending balance and exercise classes through this program showed significant improvement in physiotherapy test scores, reducing their risk of falls. The detection and treatment of osteoporosis was another important outcome for older persons attending the clinic. CONCLUSIONS: The Falls Clinic provides access to evidence-based strategies for patients. Waiting lists for the clinic have increased dramatically since its inception. Ideally many of the interventions should be available in the primary care setting to increase access for those in the community at risk of falls.

An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing.

BACKGROUND: efficient strategies are needed to provide specialist advice in nursing homes to ensure quality medical care. We describe a case conference intervention involving a multidisciplinary team of health professionals. OBJECTIVES: to evaluate the impact of multidisciplinary case conferences on the appropriateness of medications and on patient behaviours in high-level residential aged care facilities. DESIGN: cluster-randomised controlled trial. SETTING: ten high-level aged care facilities. PARTICIPANTS: 154 residents with medication problems and/or challenging behaviours were selected for case conference by residential care staff. INTERVENTION: two multidisciplinary case conferences involving the resident's general practitioner, a geriatrician, a pharmacist and residential care staff were held at the nursing home for each resident. MEASUREMENTS: outcomes were assessed at baseline and 3 months. The primary outcome was the Medication Appropriateness Index (MAI). The behaviour of each resident was assessed via the Nursing Home Behaviour Problem Scale. RESULTS: 45 residents died before follow-up. Medication appropriateness improved in the intervention group [MAI mean change 4.1, 95% confidence interval (CI) 2.1-6.1] compared with the control group (MAI mean change 0.4, 95% CI -0.4-1.2; P < 0.001). There was a significant reduction in the MAI for benzodiazepines (mean change control -0.38, 95% CI -1.02-0.27 versus intervention 0.73, 95% CI 0.16-1.30; P = 0.017). Resident behaviours were unchanged after the intervention and the improved medication appropriateness did not extend to other residents in the facility. CONCLUSION: multidisciplinary case conferences in nursing homes can improve care. Outreach specialist services can be delivered without direct patient contact and achieve improvements in prescribing.