Aging in place among home-dwelling older adults in Canton Basel-Landschaft: the INSPIRE Population Survey

Due to medical and technological advancements, many individuals in countries around the world are living longer (1). In Switzerland between 2020 and 2050, a rise from 18% to 26% for those aged 65 years or older and from 5% to 11% for those aged 80 years and older is foreseen (2). The gains in life expectancy, although a positive outcome, are not always enjoyed in full health and free of limitations. As individuals age, many of them may suffer from the presence of multi-morbidity and frailty (3, 4). Functional limitations as well as isolation and loneliness are also frequently reported among this population (3, 5-7). Moreover, these individuals usually receive care from different providers across various settings which can lead to their care being fragmented (8). Fragmentation of care is characterized by gaps in provision of care which could cause confusion and distress for older adults and their caregivers, as well as higher costs associated with unnecessary use of services (9). Despite challenges associated with aging, many older individuals prefer to remain living in their own environments for as long as possible (10, 11), an objective known as aging in place (12). Aging in place is linked to the ability to maintain independence and live a thriving and highly qualitative life within an individual’s own environment (13). It can therefore be fostered by designing environments that facilitate the mobility and engagement in social activities, which are important components for the health and quality of life of older adults (14). There is also an opportunity for countries to exploit existing and new assistive technologies, another pertinent facilitator of aging in place (15). Assistive technologies are an umbrella term including any device, equipment, instrument or software whose purpose is to maintain or improve an individual’s functional status and independence (16). To assist older adults to age in place and address their complex needs, the World Health Organization (WHO) has proposed an integrated care approach to support older adults’ independence and make aging in place possible (8, 17). Integrated care models are complex, dynamic interventions targeting multiple levels of the healthcare system, which often entail behavior change in the way various health and social care providers provide joint care (18, 19). To successfully develop and implement an integrated model of care, not only the perspectives of the healthcare providers, social care professionals or policymakers are essential, but also the needs and preferences of older adults and their informal caregivers (15, 20). Understanding the demographic and social characteristics of a target population, is also fundamental in planning, developing and implementing integrated care for older people (21). In 2018, an opportunity for integrated care for home-dwelling older adults was put forward by a new care law in Canton Basel-Landschaft in Switzerland (22). The INSPIRE project is working together with the local policymakers to support the development, implementation and evaluation of an integrated care model for home-dwelling adults aged 75 and above living in this region (23). The INSPIRE project is an implementation science project, positioned within the three phases (development, feasibility and effectiveness evaluation) of the Medical Research Council (MRC) for developing and implementing complex interventions (18). The project incorporates the recommendations of the MRC framework with several implementation science components such as contextual analysis, stakeholder involvement, as well as using implementation strategies and implementation outcomes to ensure the successful implementation and sustainability of the care model in Canton BL. During the development phase, an understanding of the context aids in ensuring the suitability of the intervention components for the implementation setting (23, 24). Therefore, we conducted the INSPIRE Population Survey (25, 26) as part of the contextual analysis, with the aim to understand the needs and preferences of older adults, as well as the support and services they currently require and anticipate needing in the future to maintain their independence and make aging in place possible. The overall goals of this dissertation are threefold. First, we aimed to describe the development of the INSPIRE Population Survey and the marketing strategy we used to reach as many home-dwelling older adults as possible, a population that is known to be challenging to recruit in research (27). Second, we used an ecological approach to dive deeper into the health-related quality of life of this population, as one of the main goals of aging in place. Finally, we investigated factors associated with openness to use assistive technologies that can facilitate independence among home-dwelling older adults and support them to age in place. Chapter 1 provides a general overview of challenges associated with caring for an aging population as well as the opportunities for integrated care for aging in place among home-dwelling older adults. The current literature on the concepts of quality of life and health-related quality of life, as well as the current state of the art on assistive technologies facilitating the autonomy of older adults is also provided. Chapter 2 follows with the dissertation aims. Chapter 3 chronicles the research conducted to develop the INSPIRE Population Survey, as well as an outline of the variables and measurements used in the survey (25). The work also describes the marketing strategy used for disseminating the survey and briefly reports on the response rate and participant characteristics. This population-based survey achieved a response rate of 30.7%, which is considerably high for postal surveys (28), particularly in those involving older adults (27). This accomplishment can be credited to the ongoing stakeholder involvement strategies we used, including early engagement of all stakeholders during the development of the questionnaire as well as its marketing. In Chapter 4, we evaluated HRQoL and factors related to it using an ecological outlook. The participants of our survey reported a high HRQoL, similar to findings from previous research (29, 30). We specifically looked at multilevel factors at the micro, meso and macro level related to how home-dwelling older adults perceived their HRQoL. This ecological perspective permitted the investigation of variables associated not only with the individual, but also with the environment around the older adult. We confirmed that among home-dwelling older adults, having a higher income, supplementary insurance, better education and generally a greater socio-economic status were associated with a higher HRQoL (31, 32). Our findings also validated previous studies indicating that individuals who report to be more frequently involved in one or more social activities, correspondingly report a higher HRQoL (33, 34). We also confirmed factors that negatively impact home-dwelling older adults’ HRQOL, as previously researched, like being older and female, having multimorbidity and polypharmacy, and being lonely or socially isolated (35-46). Chapter 5 presents the results from our study aiming to describe the current and anticipated use of assistive technologies among our participants, namely telemedicine, phone/SMS, wearables and assistive robots; as well the factors associated with openness to use such assistive technologies. We showcased that the current use of assistive technologies was rather low amid participants, compared to findings from two other surveys conducted on this topic among Swiss older adults (47, 48). Our results highlight a new finding that compared to current use, a higher percentage of home-dwelling older adults were open to using wearables and telemedicine in the future. We also found that openness to use assistive technologies in this population was positively associated with their current use, and also with receiving support from a spouse or a partner. Similar to the two previous surveys in Switzerland, openness to use assistive technologies was negatively associated with older age and with being female (47, 48). Chapter 6 presents a summary of the findings from the three preceding chapters and interprets them in the context of the current literature. Furthermore, methodological strengths and limitations of these studies are discussed. At last, reflections on the implication of this thesis for future research, policy and practice are presented. In conclusion, this dissertation was part of the development phase of an implementation science project aiming to implement and sustain an integrated care model for home-dwelling older adults. Our findings provide some important insight into the areas requiring the attention of care professionals and policymakers. We brought forward the need for considering the role the environment and the social network surrounding home-dwelling older adults play in fostering care that augments their quality of life and supports them in maintaining their desired independence. We also showed the potential assistive technologies have in attaining this goal, possibly also alleviating some of the burden of informal caregivers who are providing care and support for home-dwelling older adults. From a research, practice and policy position, we believe our findings have the prospective to provide a better scientific and policy approach in assuring older adults are reaching their goal to age in place

Protocol for a mixed methods feasibility and implementation study of a community-based integrated care model for home-dwelling older adults: The INSPIRE project

Evaluations of integrated care models for home-dwelling frail older adults have shown inconclusive results on health and service outcomes. However, limited research has focused on the implementation of integrated care models. Applying implementation science methods may facilitate uptake of integrated care models, thus generating positive outcomes e.g., reduced hospital admissions. This paper describes the protocol to assess the feasibility of an integrated care model (featuring a four-step comprehensive geriatric assessment: screening, a multi-dimensional assessment, a coordinated individualized care plan and follow-up) designed for a new community-based center for home-dwelling older adults in Switzerland. The study includes the following objectives: 1) to assess implementation by a) monitoring respondents to the outreach strategies and describing the Center's visitors; b) assessing implementation outcomes related to the care model (i.e., adoption, acceptability, feasibility, fidelity) and implementation processes related to collaboration; and 2) assessing implementation costs.; For objective 1a, we will use a descriptive design to assess respondents to the outreach strategies and describe the Center's visitors. We will use a parallel convergent mixed methods design for objective 1b. Implementation outcomes data will be collected from meetings with the Center's staff, interviews with older adults and their informal caregivers, and reviewing older adults' health records at the Center. Implementation processes related to collaboration will be assessed through a questionnaire to external collaborators (e.g., GPs) towards the end of the study. For objective 2, implementation costs will be calculated using time-driven activity-based costing methods. Data collection is anticipated to occur over approximately six months.; This study of a contextually adapted integrated care model will inform adaptations to the outreach strategies, care model and implementation strategies in one community center, prior to evaluating the care model effectiveness and potentially scaling out the intervention.; Feasibility study registration ID with clinicaltrials.gov: NCT05302310; registration ID with BMC: ISRCTN12324618

Factors associated with health-related quality of life among home-dwelling older adults aged 75 or older in Switzerland: a cross-sectional study

HRQoL is an indicator of individuals' perception of their overall health, including social and environmental aspects. As a multidimensional concept, HRQoL can be influenced by a multitude of factors. Studies of HRQoL and factors associated with it among home-dwelling older adults have often been limited to inpatient settings or to a sub-population with a chronic disease. Studying HRQoL and its correlating factors among this population, by providing an ecological lens on factors beyond the individual level, can provide a better understanding of the construct and the role of the environment on how they perceive their HRQoL. Thus, we aimed to assess the HRQoL and investigate the correlates of HRQOL among home-dwelling older adults, guided by the levels of the ecological model.; This is a cross-sectional population survey conducted in 2019 in Canton Basel-Landschaft, in northwestern Switzerland, and includes a sample of 8786 home-dwelling older adults aged 75 and above. We assessed HRQoL by using the EQ-index and the EQ-VAS. The influence of independent variables at the macro, meso and micro level on HRQoL was tested using Tobit multiple linear regression modelling.; We found that having a better socio-economic status as denoted by higher income, having supplementary insurance and a higher level of education were all associated with a better HRQoL among home-dwelling older adults. Furthermore, being engaged in social activities was also related to an improved HRQoL. On the other hand, older age, female gender, presence of multimorbidity and polypharmacy as well as social isolation and loneliness were found to all have a negative impact on HRQoL.; Understanding factors related to HRQoL by using an ecological lens can help identify factors beyond the individual level that impact the HRQoL of home-dwelling older adults. Our study emphasises the importance of social determinants of health and potential disparities that exists, encouraging policymakers to focus on policies to reduce socio-economic disparities using a life-course approach, which consequently could also impact HRQoL in later stages of life

The INSPIRE Population Survey: development, dissemination and respondent characteristics

BACKGROUND Most older adults prefer to continue living at home despite increasing care needs and demand for services. To aid in maintaining independence, integrated care models for community-dwelling older people are promoted as the most cost-effective approach. The implementation of such care models is challenging and often the end-users are not involved or their needs are not considered. We conducted a population survey in order to understand the needs and preferences of home-dwelling older adults living in Canton Basel-Landschaft, Switzerland. The aims of this paper are to chronicle the development of the INSPIRE Population Survey, outline its variables and measurements, describe the marketing strategy utilized for survey dissemination and report on the response rate and respondent characteristics. METHODS The INSPIRE Population Survey, conducted between March and August 2019, is a cross-sectional survey of older adults aged 75 and older living at home in Canton Basel-Landschaft. The questionnaire was developed by expert input and stakeholder involvement. Its readability and acceptability were pilot-tested with older people. To ensure the likelihood of a high and representative response rate, a meticulous step-by-step marketing strategy was developed prior to the dissemination of the questionnaire. RESULTS The overall response rate was 30.7% (n = 8,846), with variations between 20.6 and 34.5% across the different care regions in the canton. A generally higher response rate was found in the care regions with a higher density and which bordered the urban city of Basel. We received support from local stakeholders, policy makers and media through using a broad combination of marketing channels and targeting our community partners who have a strong relationship with our target audience. CONCLUSIONS Although recruiting older adults in research is challenging, our study shows that a high response rate can be achieved by developing the survey through expert input and by involving all important stakeholders, including older adults, throughout the entire process

Health and social care of home-dwelling frail older adults in Switzerland : a mixed methods study

Home-dwelling frail older adults are often faced with multimorbidity and complex care needs, requiring health and social care systems that support frail older adults to age in place. The objective of this paper was to investigate the types of formal health and social care as well as informal care and social support used by home-dwelling frail older adults; whether they perceive their support as sufficient; and their experience with and preferences for care and support

Implementation fidelity of a multifactorial in-hospital fall prevention program and its association with unit systems factors: a single center, cross-sectional study

Falls are a common, costly global public health burden. In hospitals, multifactorial fall prevention programs have proved effective in reducing falls' incidence; however, translating those programs accurately into daily clinical practice remains challenging. This study's aim was to identify ward-level system factors associated with implementation fidelity to a multifactorial fall prevention program (StuPA) targeting hospitalized adult patients in an acute care setting.; This retrospective cross-sectional study used administrative data on 11,827 patients admitted between July and December 2019 to 19 acute care wards at the University Hospital Basel, Switzerland, as well as data on the StuPA implementation evaluation survey conducted in April 2019. Data were analysed using descriptive statistics, Pearson's coefficients and linear regression modelling for variables of interest.; The patient sample had an average age of 68 years and a median length of stay of 8.4 (IQR: 2.1) days. The mean care dependency score was 35.4 points (ePA-AC scale: from 10 points (totally dependent) to 40 points (totally independent)); the mean number of transfers per patient -(e.g., change of room, admission, discharge) was 2.6 (range: 2.4- 2.8). Overall, 336 patients (2.8%) experienced at least one fall, resulting in a rate of 5.1 falls per 1'000 patient days. The median inter-ward StuPA implementation fidelity was 80.6% (range: 63.9-91.7%). We found the mean number of inpatient transfers during hospitalisation and the mean ward-level patient care dependency to be statistically significant predictors of StuPA implementation fidelity.; Wards with higher care dependency and patient transfer levels showed higher implementation fidelity to the fall prevention program. Therefore, we assume that patients with the highest fall prevention needs received greater exposure to the program. For the StuPA fall prevention program, our results suggest a need for implementation strategies contextually adapted to the specific characteristics of the target wards and patients

Effectiveness of implementation strategies for the improvement of guideline and protocol adherence in emergency care : a systematic review

Objective Guideline and protocol adherence in prehospital and in-hospital emergency departments (EDs) is suboptimal. Therefore, the objective of this systematic review was to identify effective strategies for improving guideline and protocol adherence in prehospital and ED settings. Design Systematic review. Data sources PubMed (including MEDLINE), CINAHL, EMBASE and Cochrane. Methods We selected (quasi) experimental studies published between 2004 and 2018 that used strategies to increase guideline and protocol adherence in prehospital and in-hospital emergency care. Pairs of two independent reviewers performed the selection process, quality assessment and data extraction. Results Eleven studies were included, nine of which were performed in the ED setting and two studies were performed in a combined prehospital and ED setting. For the ED setting, the studies indicated that educational strategies as sole intervention, and educational strategies in combination with audit and feedback, are probably effective in improving guideline adherence. Sole use of reminders in the ED setting also showed positive effects. The two studies in the combined prehospital and ED setting showed similar results for the sole use of educational interventions. Conclusions Our review does not allow firm conclusion on how to promote guideline and protocol adherence in prehospital emergency care, or the combination of prehospital and ED care. For ED settings, the sole use of reminders or educational interventions and the use of multifaceted strategies of education combined with audit and feedback are all likely to be effective in improving guideline adherence

INSPIRE: Koordinierte Versorgung, damit ältere Menschen möglichst lange zu Hause bleiben können

status: publishe

Mapping implementation strategies to reach community-dwelling older adults in Northwest Switzerland

Abstract Background In Northwestern Switzerland, recent legislation tackles the needs of community-dwelling older adults by creating Information and Advice Centers (IACs). IACs are a new service in the community that aims to assess the needs and provide information on age-related issues to community-dwelling older adults and their families. Previous studies reported difficulties in reaching community-dwelling older adults for community-based programs. We aimed to: 1) systematically identify implementation strategies to promote the IAC among community care providers, older adults and informal caregivers; 2) monitor the delivery of these strategies by the IAC management; and 3) describe the impact of those strategies on reach of community-dwelling older adults. This study was conducted as part of the TRANS-SENIOR project. Methods As part of the INSPIRE feasibility assessment, we conducted a pre-test post-test study between March and September 2022. The sample included 8,840 older adults aged 65 + visiting/calling or being referred to the IAC for the first time. Implementation strategies were selected using implementation mapping and organized in bundles for each group of community care providers and older adults/caregivers. Our evaluation included: estimation of fidelity to the delivery of implementation strategies and bundles by the IAC management and their coverage; referral source of older adults to the IAC; and impact of the strategies on reach of the IAC on the 65 + population living in the care region. Adaptations to the strategies were documented using the FRAME-IS. Descriptive statistics were calculated and reported. Results Seven implementation strategies were selected and organized in bundles for each community care provider and older adults and their caregivers. The lowest fidelity score was found in implementation strategies selected for nursing homes whereas the highest score corresponded to strategies targeting older adults and caregivers. “Informational visits” was the strategy with the lowest coverage (2.5% for nursing homes and 10.5% for hospitals and specialized clinics). The main referral sources were self-referrals and referrals by caregivers, followed by nursing homes. The IAC reach among the 65 + population was 5.4%. Conclusion We demonstrated the use of implementation mapping to select implementation strategies to reach community-dwelling older adults. The reach was low suggesting that higher fidelity to the delivery of the strategies, and reflection on the causal pathway of the implementation strategies might be needed

Bevölkerungsbefragung Basel-Landschaft. Kantonaler Bericht

status: publishe