health services research focusing on chronic care and ageing 1 hilde verbeek, phd department of...

Health Services Research Focusing on Chronic Care and Ageing 1

Hilde Verbeek, PhDDepartment of Health Services Research ADI Conference, March 8th 2012

QUALITY OF LIFE IN SMALL-SCALE, HOMELIKE CARE ENVIRONMENTS:

A QUASI-EXPERIMENTAL STUDY INTO EFFECTS ON RESIDENTS.


The Netherlands

• Dutch government stimulates small-scale, homelike care settings • 80 million euro program (2009-2011)

• Development of new small-scale living facilities• ICT and assistive technology in facilities

• In 2010 ± 25% small-scale living facilities in institutional dementia care– Aim within 5 year: 33%

• Little knowledge on effects


Small-scale homelike facilities• General characteristics of 28 units included:

– Small resident group (6-7) – Familiar, homelike environment

– Joint daily household– Integrated tasks nursing staff

– Resemblance archetypal home

• Worldwide several similar concepts (Verbeek et al. 2009. Int Psychogeriatr. 21:252-264)


Control group: Regular wards

• Criteria regular wards: (n=21 wards)

– Min. 20 residents per group– Staff have differentiated tasks– Organization daily life mainly determined by routines of the

nursing home

• Matching of residents at baseline on cognition and ADL profile– Previous research: differences between residents in small-

scale living and regular wards (Verbeek et al., 2010;Te Boekhorst et al. 2009)


Baseline

FU 6 months

FU 12 months

124 residents 135 residents

111 residents

93 residents

111 residents

97 residents

Small-scale Regular wards


Residents’ baseline characteristics SSL (n=124) RW (n=135) Age, years (SD) 82.4 (7.9) 83.1 (6.5) Women, % 80 70 Living condition prior to admission* , % At home Other institution

30 70

59 41

Length of Stay* , months (SD) 15.7 (11.3) 24.4 (22.0) Dementia type, % Alzheimer’s Disease Vascular Dementia Other Not Otherwise Specified

27 15 16 42

32 18 20 30

GDS, mean (SD) 5.3 (1.1) 5.1 (1.0) MMSE, mean (SD) 11.1 (7) 10.5 (6.6) CPS, mean (SD) 3.5 (1.4) 3.4 (1.4) ADL – H Scale, mean (SD) 3.1 (1.7) 3.3 (1.4) Comorbid diseases, # (SD) 4.3 (2.3) 3.8 (1.9)


Primary outcome measures

• Quality of Life (as measured with Qualidem)• Neuropsychiatric symptoms (NPI-NH)• Agitation (CMAI)

• Mixed-model multi-level analyses

(Verbeek et al. 2010. J Am Med Dir Assoc 11:662-670)


Quality of life

• No effects on total QoL

– No differences in trend and no difference in mean total score between groups

• Small-scale living facilities: adjusted mean score 18.3• Regular wards: adjusted mean score 18.5

0

5

10

15

20

m1 m2 m3

SSLF

RW


Quality of Life - Subscales

• Assessed by nursing staff:– Two scales significantly differed:– Residents in small-scale living had…

• Higher QoL “having something to do” (p<.001)• Lower QoL regarding “negative affect” (p=.01)

• Assessed by family caregivers:– Residents in small-scale living had…

• higher QoL regarding “having something to do” (p=.018), “ feeling at home” (p=.023) and “social relations” (p=.020)


Neuropsychiatric symptoms

• No overall effect– No differences in trend and no difference in mean total

score between groups • Small-scale living facilities: adjusted mean score NPI-NH 15.8• Regular wards: adjusted mean score 14.5

0

5

10

15

20

m1 m2 m3

small-scale

regular


Agitation

• Difference in trend– Small-scale living: agitation stable over time– Regular wards: agitation decreased over time– Significant difference after 12 months:

• Residents in small-scale living facilities displayed more agitated behavior (p=.035)

29

34

39

44

m1 m2 m3

small-scale

regular


Secondary outcomes

• Use of physical restraints (yes/no)• Psychotropic drug use (yes/no)

Generalized Estimating Equations (GEE)

• Social engagement (ISE from RAI-MDS)

• Mixed-model multi-level analyses


Promising results

• Fewer physical restraints (p=.003) and psychotropic drug use (p=.023) in small-scale living facilities– Differences were present at baseline and remained stable

over time– E.g use of belts: 1% vs 10%

• More social engagement for residents in small-scale living, although this disappeared over time (only at baseline after 6 months)


Neuropsychiatric symptoms & agitation

• Residents in small-scale living displayed:…

– More aberrant motor behavior at all measurements (p=.020; NPI-NH)

– More physically non-aggressive behavior (e.g. wandering) after 12 months (p=.001; CMAI)

…than residents in regular wards


Conclusion

• No effects on primary outcomes– Influence Dutch health care policy?

• Some promising effects on secondary outcomes (physical restraints, psychotropic drugs)

• Inconclusive effects behavior

• Automatic transition towards small-scale homelike care environments is not recommended – Focus should be on care program


Implications

• Changing role of nursing staff: adequate training and education of staff is essential– Knowledge and skills– Attitude towards care

• Small-scale homelike facilities have encouraged development of new care concepts– Which elements are effective, how and for whom?– Which and how can active ingredients be transferred to

other dementia care settings as well?


Thank youEmail: [email protected]

Funding:Maastricht UniversityProvince of Limburg5 Health care organizations(MeanderGroep, Orbis, Sevagram, Vivre & De Zorggroep)

Research group: dr. Hilde Verbeek dr. Erik van Rossumdr. Sandra MG Zwakhalenprof. Gertrudis IJM Kempen prof. Jan PH Hamers

health services research focusing on chronic care and ageing 1 hilde verbeek, phd department of...

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