The impact of long-term care interventions on healthcare utilisation among older persons: a scoping review of reviews.

BACKGROUND: As the ageing population grows, the demand for long-term care (LTC) services will rise, concurrently amplifying healthcare utilisation. This review aims to examine and consolidate information on LTC interventions that influence healthcare utilisation among older persons. METHODS: A scoping review was performed through a systematic search in PubMed, EBSCO CINAHL, EBM Reviews - Cochrane Database of Systematic Reviews, Embase, APA PsycInfo, EBM Reviews - Health Technology Assessment, and EBM Reviews - NHS Economic Evaluation Database. Systematic reviews with meta-analyses published between 1 January 2010 and 2 June 2022 among older persons aged 60 and above were included. The characteristics of LTC interventions were mapped to the World Health Organization (WHO) Healthy Ageing Framework. The effect sizes of healthcare utilisations for LTC interventions were recalculated using a random-effects model. The methodological quality was assessed with the AMSTAR-2 checklist, while the quality of evidence for each association was evaluated using GRADE. RESULTS: Thirty-seven meta-analyses were included. The most prominent domain of the healthy ageing framework was managing chronic conditions. One hundred twelve associations between various LTC interventions and healthcare utilisations were identified, with 22 associations impacting healthcare utilisation. Four interventions were supported by suggestive or convincing evidence. Preventive home visits were found to reduce hospital admission (OR: 0.73, 95% CI: 0.59, 0.91, p = 0.005), caregiver integration during discharge planning (OR: 0.68, 95% CI: 0.57, 0.81, p < 0.001), and continuity of care (OR: 0.76, 95% CI: 0.61, 0.95, p = 0.018) reduced hospital readmission, and perioperative geriatric interventions reduced the length of hospital stay (MD: -1.50, 95% CI: -2.24, -0.76, p < 0.001). None of the associations impacted emergency department visits, medication use, and primary care utilisations with convincing evidence. Most reviews received low methodological quality. CONCLUSION: The findings suggest that LTC interventions could benefit from transitioning to a community-based setting involving a multidisciplinary team, including carers. The spectrum of services should incorporate a comprehensive assessment to ensure continuous care.

Nursing home closures and access to post-acute care and long-term care services in rural areas.

PURPOSE: Nursing home closures have raised concerns about access to post-acute care (PAC) and long-term care (LTC) services. We estimate the additional distance rural residents had to travel to access PAC and LTC services because of nursing home closures. METHODS: We identify nursing home closures and the availability of PAC and LTC services in nursing homes, home health agencies, and hospitals with swing beds using the Medicare Provider of Services file (2008-2018). Using distances between ZIP codes, we summarize distances to the closest provider of PAC and LTC services for rural and urban ZIP codes with nursing home closures from 2008 to 2018 and no nursing homes in 2018. FINDINGS: Compared to urban ZIP codes, rural ZIP codes experiencing nursing home closure had higher distances to the closest nursing home providing PAC (6.4 vs. 0.94 miles; p < 0.05) and LTC services (7.2 vs. 1.1 miles; p < 0.05), and these differences remain even after accounting for the availability of home health agencies and hospitals with swing beds. Distances to the closest providers with PAC and LTC services were even higher for rural ZIP codes with no nursing homes in 2018. About 6.1%-15.7% of rural ZIP codes with a nursing home closure or with no nursing homes had no PAC or LTC providers within 25 miles. CONCLUSIONS: Nursing home closures increased distances to nursing homes, home health agencies, and hospitals with swing beds for rural residents. Access to PAC and LTC services is a concern, especially for rural areas with no nursing homes.

Covid-19 and excess mortality in medicare beneficiaries.

We estimated excess mortality in Medicare recipients in the United States with probable and confirmed Covid-19 infections in the general community and amongst residents of long-term care (LTC) facilities. We considered 28,389,098 Medicare and dual-eligible recipients from one year before February 29, 2020 through September 30, 2020, with mortality followed through November 30th, 2020. Probable and confirmed Covid-19 diagnoses, presumably mostly symptomatic, were determined from ICD-10 codes. We developed a Risk Stratification Index (RSI) mortality model which was applied prospectively to establish baseline mortality risk. Excess deaths attributable to Covid-19 were estimated by comparing actual-to-expected deaths based on historical (2017-2019) comparisons and in closely matched concurrent (2020) cohorts with and without Covid-19. Overall, 677,100 (2.4%) beneficiaries had confirmed Covid-19 and 2,917,604 (10.3%) had probable Covid-19. A total of 472,329 confirmed cases were community living and 204,771 were in LTC. Mortality following a probable or confirmed diagnosis in the community increased from an expected incidence of about 4.0% to actual incidence of 7.5%. In long-term care facilities, the corresponding increase was from 20.3% to 24.6%. The absolute increase was therefore similar at 3-4% in the community and in LTC residents. The percentage increase was far greater in the community (89.5%) than among patients in chronic care facilities (21.1%) who had higher baseline risk of mortality. The LTC population without probable or confirmed Covid-19 diagnoses experienced 38,932 excess deaths (34.8%) compared to historical estimates. Limitations in access to Covid-19 testing and disease under-reporting in LTC patients probably were important factors, although social isolation and disruption in usual care presumably also contributed. Remarkably, there were 31,360 (5.4%) fewer deaths than expected in community dwellers without probable or confirmed Covid-19 diagnoses. Disruptions to the healthcare system and avoided medical care were thus apparently offset by other factors, representing overall benefit. The Covid-19 pandemic had marked effects on mortality, but the effects were highly context-dependent.

[Changes in trends of diseases requiring long-term care in an aging community].

Objectives　The purpose of this study was to identify the changes in trends of leading diseases that require long-term care within a 5-year period in an area with a rapidly growing aging population.Methods　Data were obtained from newly registered primary insured individuals for long-term care insurance in Sapporo Minami Ward. There were 2,538 participants in FY2018 and 4,089 in FY2013 and FY2014.　Disorders diagnosed by a primary doctor were categorized into groups using a long-term care questionnaire survey from the Comprehensive Survey of Living Conditions. The difference in the frequency of diseases between the survey years was examined using a chi-square test.Results　In men, there was no significant change in the frequency of diseases that require long-term care within the 5-year period. In women, the frequency of cerebrovascular diseases significantly reduced (7.8% for FY2013 and 2014 vs. 5.6% for FY2018; P=0.008) and fractures and falls significantly increased (9.5% vs. 13.8%; P=0.001).　Regarding the diseases in the severe-level category of long-term care insurance, malignancy was the most frequent disorder in men, followed by stroke. In women, the frequency of fractures and falls increased (10.5% vs. 17.7%; P=0.002) and subsequently became the most frequently occurring disorder. Similarly, the frequency of fractures and falls increased significantly (9.2% vs. 12.5%; P=0.004) in the mild-level long-term care insurance category.Conclusion　For women, fractures and falls increased within the 5-year period, indicating the need to introduce a prompt preventive program. Lifestyle-related diseases such as malignancy and cerebrovascular diseases have become the main reason for shortening a healthy lifespan. This finding highlights the importance of preventing lifestyle-related diseases.

[Needs of long-term nursing in the COVID-19 pandemic]. / Bedarfe der Langzeitpflege in der COVID-19-Pandemie.

The SARS-CoV­2 virus and the associated disease COVID-19 pose major challenges to healthcare systems worldwide. Especially the vulnerable group of people in need of long-term care is at risk of suffering a severe course of the disease or of dying from the infection.In a nationwide cross-sectional study the situation and needs of inpatient and outpatient long-term care facilities during the SARS-CoV­2 pandemic were assessed and analyzed using an online survey.Participants from 531 institutions postulated the need for uniform recommendations for action on SARS-CoV­2, adequate and affordable protective and hygiene materials, serial tests in the institutions, well-founded advice on the implementation of interventions, a specific pandemic plan and supporting public relations work by the media. This calls for higher nursing remuneration, better staffing levels and greater appreciation of the nursing profession.In order to protect the vulnerable group of people in need of nursing care from a SARS-CoV­2 infection, long-term care must be given a stronger focus in health policy measures during the pandemic.

Family Communication in Long-Term Care During a Pandemic: Lessons for Enhancing Emotional Experiences.

OBJECTIVE: Family visits with residents at long-term care (LTC) facilities have been restricted during the COVID-19 pandemic. The objective was to examine what communication methods, other than in-person visits, during the pandemic were associated with greater positive and lower negative emotional experiences for LTC residents and their family members and friends. DESIGN: Cross-sectional. SETTING: Nationally targeted online survey. PARTICIPANTS: One hundred sixty-one community-dwelling adults who had a family member or friend in a LTC facility. MEASUREMENTS: The Positive and Negative Affect Scale was used to assess participant's own emotions and perceived resident emotions during the pandemic. Questions were asked about nine communication methods other than physical visits (e.g., phone, video-conference, e-mail, and letters) in terms of frequency of use during the pandemic. Sociodemographics, resident health, and facility factors were assessed and used as covariates where indicated. RESULTS: During the pandemic, greater phone frequency was associated with less participant negative emotions (ß = -0.17). Greater e-mail frequency was associated with more perceived resident positive emotions (ß = 0.28). Greater frequency of letters delivered by staff was associated with more participant negative emotions (ß = 0.23). Greater frequency of letters delivered by staff and the postal service were associated with more perceived resident negative emotions (ß = 0.28; ß = 0.34, respectively). CONCLUSION: These findings highlight the importance of synchronous, familiar methods of communication like the phone and email between families and LTC residents to maintain their emotional well-being when in-person visits are restricted.

Context matters: a qualitative study of the practicalities and dilemmas of delivering integrated chronic care within primary and secondary care settings in a rural Malawian district.

BACKGROUND: With the increasing double burden of communicable and non-communicable diseases (NCDs) in sub-Saharan Africa, health systems require new approaches to organise and deliver services for patients requiring long-term care. There is increasing recognition of the need to integrate health services, with evidence supporting integration of HIV and NCD services through the reorganisation of health system inputs, across system levels. This study investigates current practices of delivering and implementing integrated care for chronically-ill patients in rural Malawi, focusing on the primary level. METHODS: A qualitative study on chronic care in Phalombe district conducted between April 2016 and May 2017, with a sub-analysis performed on the data following a document analysis to understand the policy context and how integration is conceptualised in Malawi; structured observations in five of the 15 district health facilities, selected purposively to represent different levels of care (primary and secondary), and ownership (private and public). Fifteen interviews with healthcare providers and managers, purposively selected from the above facilities. Meetings with five non-governmental organisations to study their projects and support towards chronic care in Phalombe. Data were analysed using a thematic approach and managed in NVivo. RESULTS: Our study found that, while policies supported integration of various disease-specific programmes at point of care, integration efforts on the ground were severely hampered by human and health resource challenges e.g. inadequate consultation rooms, erratic supplies especially for NCDs, and an overstretched health workforce. There were notable achievements, though most prominent at the secondary level e.g. the establishment of a combined NCD clinic, initiating NCD screening within HIV services, and initiatives for integrated information systems. CONCLUSION: In rural Malawi, major impediments to integrated care provision for chronically-ill patients include the frail state of primary healthcare services and sub-optimal NCD care at the lowest healthcare level. In pursuit of integrative strategies, opportunities lie in utilising and expanding community-based outreach strategies offering multi-disease screening and care with strong referral linkages; careful task delegation and role realignment among care teams supported with proper training and incentive mechanisms; and collaborative partnership between public and private sector actors to expand the resource-base and promoting cross-programme initiatives.

Eight-year post-trial follow-up of health care and long-term care costs of tele-based health coaching.

OBJECTIVE: To evaluate the long-term effect of telephone health coaching on health care and long-term care (LTC) costs in type 2 diabetes (T2D) and coronary artery disease (CAD) patients. DATA SOURCES/STUDY SETTING: Randomized controlled trial (RCT) data were linked to Finnish national health and social care registries and electronic health records (EHR). Post-trial eight-year economic evaluation was conducted. STUDY DESIGN: A total of 1,535 patients (≥45 years) were randomized to the intervention (n = 1034) and control groups (n = 501). The intervention group received monthly telephone health coaching for 12 months. Usual health care and LTC were provided for both groups. PRINCIPAL FINDINGS: Intention-to-treat analysis showed no significant change in total health and long-term care costs (intervention effect €1248 [3 percent relative reduction], CI -6347 to 2217) in the intervention compared to the control group. There were also no significant changes among subgroups of patients with T2D or CAD. CONCLUSIONS: Health coaching had a nonsignificant effect on health care and long-term care costs in the 8-year follow-up among patients with T2D or CAD. More research is needed to study, which patient groups, at which state of the disease trajectory of T2D and cardiovascular disease, would best benefit from health coaching.

Innovating Long-Term Care Provision in Mediterranean Welfare States: A Comparison Between Italy and Israel.

Social innovations in long-term care (LTC) may be useful in more effective responses to the challenges of population aging for Western societies. One of the most investigated aspects in this regard is the role of family/informal care and strategies to improve its integration into the formal care system, yielding a more holistic care approach that may enhance opportunities for aging in place. This article reports the findings of a comparative research focusing on the Italian and Israeli LTC systems as representative of the Mediterranean "family-based" care model. To analyze the innovative solutions that have been adopted or are needed to improve LTC provision in these two contexts, focus groups and expert interviews have been carried out in both countries to identify the most relevant challenges and responses to them and to highlight promising policies and strategies to be adopted or up-scaled in the future. These include multidisciplinary case and care management, a stronger connection between prevention and LTC provision, and more systematic recognition of the role and limits of informal caregivers' contributions.

Claims data-based analysis of the influence of individual and regional characteristics on the utilisation of long-term care by people with dementia in Baden-Wurttemberg, Germany.

BACKGROUND: Challenges of future dementia care include increasing shortage of qualified healthcare providers and decreasing potential of informal care by relatives. In order to meet those challenges, changes in dementia care are needed. These changes should be based on data of both care utilisation and care supply. The aim of this study was to provide insight into individual and regional characteristics that influence the utilisation of long-term care by people with dementia. METHODS: The study was a retrospective cross-sectional analysis of claims-based data and other available data referring to one index year. All data were aggregated for small geographic districts. The study population comprised people with a dementia diagnosis, 65 years and older in Baden-Wuerttemberg and insured by the largest health insurer. Utilisation of nursing home care, informal care, and respite care was analysed using binary coded logistic multilevel analyses. RESULTS: Seventy nine thousand three hundred forty-nine people with dementia were included in the analyses. Nursing home care was used by 20.4%, informal care by 30.6%, and respite care by 3.5% of people with dementia. Individual characteristics that influence care utilisation included age, sex and the level of care dependency. The utilisation of informal care (OR = 1.713) and respite care (OR = 2.036) was higher in rural districts than in city districts. Respite care supply had an effect on the utilisation of respite care (OR = 1.173). CONCLUSIONS: The study found differences between districts in the utilisation of long-term care for dementia. These differences were largely explained by the composition of the population within the districts. An exception was the utilisation of respite care, which was higher in districts which have higher supply. Individual characteristics that influenced care utilisation are age, sex, level of care dependency and, with regard to informal care, comorbidity. Further research should be conducted on a small-area level, include further individual characteristics as well as other care and living forms.

The burden of respiratory infections among older adults in long-term care: a systematic review.

BACKGROUND: Respiratory infections among older adults in long-term care facilities (LTCFs) are a major global concern, yet a rigorous systematic synthesis of the literature on the burden of respiratory infections in the LTCF setting is lacking. To address the critical need for evidence regarding the global burden of respiratory infections in LTCFs, we assessed the burden of respiratory infections in LTCFs through a systematic review of the published literature. METHODS: We identified articles published between April 1964 and March 2019 through searches of PubMed (MEDLINE), EMBASE, and the Cochrane Library. Experimental and observational studies published in English that included adults aged ≥60 residing in LTCFs who were unvaccinated (to identify the natural infection burden), and that reported measures of occurrence for influenza, respiratory syncytial virus (RSV), or pneumonia were included. Disagreements about article inclusion were discussed and articles were included based on consensus. Data on study design, population, and findings were extracted from each article. Findings were synthesized qualitatively. RESULTS: A total of 1451 articles were screened for eligibility, 345 were selected for full-text review, and 26 were included. Study population mean ages ranged from 70.8 to 90.1 years. Three (12%) studies reported influenza estimates, 7 (27%) RSV, and 16 (62%) pneumonia. Eighteen (69%) studies reported incidence estimates, 7 (27%) prevalence estimates, and 1 (4%) both. Seven (27%) studies reported outbreaks. Respiratory infection incidence estimates ranged from 1.1 to 85.2% and prevalence estimates ranging from 1.4 to 55.8%. Influenza incidences ranged from 5.9 to 85.2%. RSV incidence proportions ranged from 1.1 to 13.5%. Pneumonia prevalence proportions ranged from 1.4 to 55.8% while incidence proportions ranged from 4.8 to 41.2%. CONCLUSIONS: The reported incidence and prevalence estimates of respiratory infections among older LTCF residents varied widely between published studies. The wide range of estimates offers little useful guidance for decision-making to decrease respiratory infection burden. Large, well-designed epidemiologic studies are therefore still necessary to credibly quantify the burden of respiratory infections among older adults in LTCFs, which will ultimately help inform future surveillance and intervention efforts.

Trends in ageing and ageing-in-place and the future market for institutional care: scenarios and policy implications.

In several OECD countries the percentage of elderly in long-term care institutions has been declining as a result of ageing-in-place. However, due to the rapid ageing of population in the next decades future demand for institutional care is likely to increase. In this paper we perform a scenario analysis to examine the potential impact of these two opposite trends on the demand for institutional elderly care in the Netherlands. We find that the demand for institutional care first declines as a result of the expected increase in the number of low-need elderly that age-in-place. This effect is strong at first but then peters out. After this first period the effect of the demographic trend takes over, resulting in an increase in demand for institutional care. We argue that the observed trends are likely to result in a growing mismatch between demand and supply of institutional care. Whereas the current stock of institutional care is primarily focussed on low-need (residential) care, future demand will increasingly consist of high-need (nursing home) care for people with cognitive as well as somatic disabilities. We discuss several policy options to reduce the expected mismatch between supply and demand for institutional care.

Re-imagining the role of the physiotherapist when managing people with long-term conditions.

The rising prevalence of long-term conditions (LTCs) is placing increasing pressures on healthcare systems. With the future prospect that more individuals will experience multiple comorbidities, LTCs are becoming a growing concern. This article aims to discuss the challenges faced by and the opportunities afforded to physiotherapists when caring for people with LTCs. It highlights the complexity of managing people with LTCs and the demands faced by physiotherapists when working within a transitioning healthcare service that necessitates cost-effective yet, sustainable care. It considers ways that interventions can be optimized to not only support individuals with LTCs to improve their quality of life, but live an existence that has meaning and purpose. It also explores health promotion strategies that could be influential in changing the future healthcare landscape, by helping to prevent the occurrence of LTCs. The wider intention is to facilitate discussion of the future role of the physiotherapy profession in LTC management, in the hope that a shared vision can be created that is inspiring and transformative. A vision that imagines a physiotherapy service that is resilient to change and contemporary in approach, which continues to evolve to support the changing needs of people with LTCs.

Homeowner Behavior, Health Status, and Medicaid Payment Eligibility: Evidence from the Deficit Reduction Act of 2005.

This paper analyzes the effect of a change in the status of housing equity as a protected asset for Medicaid long-term care payment eligibility. A difference-in-difference-in-differences strategy is employed to estimate the effect of the policy on the housing equity holdings of potentially treated individuals. Using a panel of unmarried homeowners, the policy induced treated individuals who were likely to require long-term care to hold less housing equity by values of $82,000 to $193,000 relative to control individuals. This equates to relative reductions of 12 to 29 percent for treated individuals after the policy change. Similar effects are not observed when considering health measures less predictive of long-term care services and for a sample of married households who were unlikely affected by the policy. These estimates confirm the importance of the housing asset as a shelter for Medicaid eligibility.

Classification of long-term care wards and their functional characteristics: analysis of national hospital data in Japan.

BACKGROUND: In a rapidly aging society that has promoted extensive reforms of the healthcare system, clarifying functional patterns in long-term care wards is important for developing regional healthcare policies. This study aimed to classify patterns of inpatient characteristics among Japanese long-term care wards and to examine hospital/ward characteristics. METHODS: We analyzed data from 1856 long-term care wards extracted from the 2014 Annual Report for Functions of Medical Institutions in Japan. We classified five clusters of long-term care wards based on inpatients' medical acuity/activities of daily living using cluster analysis, and compared hospital/ward characteristics across the clusters with a chi-square test or analyses of variance. RESULTS: Cluster 1 was low medical acuity/high activities of daily living (n = 175); cluster 2, medium medical acuity/high activities of daily living (n = 340); cluster 3, medium medical acuity/low activities of daily living (n = 461); cluster 4, high medical acuity/low activities of daily living (n = 409); and cluster 5, mixed (n = 471). Although clusters 1 and 2 had similar higher proportions of home discharge (48.1% and 34.6%, respectively), there was a difference in length of hospital stay between the clusters (154.6 and 216.6 days, respectively). On the other hand, clusters 3 and 4 experienced a longer length of hospital stay (295.7 and 239.8 days, respectively) and a higher proportion of in-hospital deaths (42.7% and 50.2%, respectively). Characteristics of cluster 5 were not significantly different from the average of overall wards. CONCLUSIONS: There were distinctive differences across hospitals in their use of long-term care wards. Wards with different functions have different support needs; the clusters with high activities of daily living needed support in promoting home discharge, while those with low activities of daily living needed support in providing quality end-of-life care. Our results can be useful for constructing the future regional healthcare system. This study also suggests introducing a standardized patient classification system in long-term care settings.

Follow-up after arthroplasty of the hip and knee : are we over-servicing or under-caring?

The number of arthroplasties of the hip and knee is predicted to increase rapidly during the next 20 years. Accompanying this is the dilemma of how to follow-up these patients appropriately. Current guidelines recommend long-term follow-up to identify patients with aseptic loosening, which can occur more than a decade postoperatively. The current guidelines and practices of orthopaedic surgeons vary widely. Existing models take up much clinical time and are expensive. Pilot studies using 'virtual' clinics and advanced-practice physiotherapists have shown promise in decreasing the time and costs for orthopaedic surgeons and patients. This review discusses current practices and future trends in the follow-up of patients who have an arthroplasty. Cite this article: Bone Joint J 2018;100-B:6-10.

Future Costs of Long-term Care in Japan and Sweden.

Population aging is expected to increase long-term care (LTC) costs in both Japan and Sweden. This study projected LTC costs for 2010 through 2040 for different assumptions of population change, LTC need by age group and gender, and LTC provided per level of need and cost in Japan and Sweden. Population data were taken from the official national forecasts. Needs projections were based on epidemiological data from the Nihon University Japanese Longitudinal Study of Aging and the Swedish Survey of Living Conditions. Data on LTC provision by need and cost were taken from nine Japanese municipalities collected by assessments in the LTC insurance system and from surveys in eight Swedish municipalities. Total initial costs were calibrated to official national figures. Two projections based on two different scenarios were made for each country from 2010 to 2040. The first scenario assumed a constant level of need for LTC by age group and gender, and the other assumed a continuation of the present LTC need trends until 2025. For Japan, this resulted in a projected cost increase of 93% for the one and 80% for the other; for Sweden it was 52% and 24%, respectively. The results reflected differences in population aging and health development.

Quantitative Properties of the Macro Supply and Demand Structure for Care Facilities for Elderly in Japan.

As the Asian country with the most aged population, Japan, has been modifying its social welfare system. In 2000, the Japanese social care vision turned towards meeting the elderly's care needs in their own homes with proper formal care services. This study aims to understand the quantitative properties of the macro supply and demand structure for facilities for the elderly who require support or long-term care throughout Japan and present them as index values. Additionally, this study compares the targets for establishing long-term care facilities set by Japan's Ministry of Health, Labor and Welfare for 2025. In 2014, approximately 90% of all the people who were certified as requiring support and long-term care and those receiving preventive long-term care or long-term care services, were 75 years or older. The target increases in the number of established facilities by 2025 (for the 75-years-or-older population) were calculated to be 3.3% for nursing homes; 2.71% for long-term-care health facilities; 1.7% for group living facilities; and, 1.84% for community-based multi-care facilities. It was revealed that the establishment targets for 2025 also increase over current projections with the expected increase of the absolute number of users of group living facilities and community-based multi-care facilities. On the other hand, the establishment target for nursing homes remains almost the same as the current projection, whereas that for long-term-care health facilities decreases. These changes of facility ratios reveal that the Japanese social care system is shifting to realize 'Ageing in Place'. When considering households' tendencies, the target ratios for established facilities are expected to be applied to the other countries in Asia.