Aim: to identify whether pre-admission assessment of elderly applicants could be an effective means of identifying actual need for long term care Methods: 105 applicants to long term care were assessed at source for suitability for admission. Assessment instruments used were OARS and CAPE. All subjects were followed up after 3 months to assess actual outcome. Findings: Assessment findings showed that of the study group (n=105), 22% could remain in the community, 21% could benefit from hospital care / rehabilitation and 57% required institutionalisation. Unmet need was identified in applicants in the community (n=40) for home help, day care, social worker, physiotherapy, occupational therapy and community nursing. Conclusion: Pre-admission assessment appropriately identifies the actual needs of applicants to long-term care and prevents inappropriate admission.peer-reviewe

Dimech, Joseph

Fiorini, Anthony

English

OAR@UM

28 Malta Medical Journal    Volume 15   Issue 02   November 2003GRADE (score) Typical level of SupportA   (12 – 10) Little or no demand on caring agencies.B   (  9 -    6) Warden-supervised accommodation, orat home with support; and independentolder people.C   (  5 -    2) Need considerable support to stay athome; in social service homes;in hospitals.D   (  1 -   -3) Usually institutionalised.E   ( less than –3) Need a great deal of nursing attention;psychogeriatric care.Table 1: Recommendations for care needs based upon theCAPE Survey ScoreSource: Pattie AH, Gilleard CJ. Manual of the Clifton assess-ment procedures for the elderly.Pre-admission Assessmentof Elderly Applicants to Long-term CareOriginal ArticleJoseph Dimech, Anthony FioriniAbstractAim: to identify whether pre-admission assessment ofelderly applicants could be an effective means of identifyingactual need for long term careMethods: 105 applicants to long term care were assessedat source for suitability for admission. Assessment instrumentsused were OARS and CAPE. All subjects were followed up after3 months to assess actual outcome.Findings: Assessment findings showed that of the studygroup (n=105), 22% could remain in the community, 21% couldbenefit from hospital care / rehabilitation and 57% requiredinstitutionalisation. Unmet need was identified in applicantsin the community (n=40) for home help, day care, social worker,physiotherapy, occupational therapy and community nursing.Conclusion: Pre-admission assessment appropriatelyidentifies the actual needs of applicants to long-term care andprevents inappropriate admission.IntroductionWith advancing age, elderly people are more prone to de-velop health-related problems, which lead to disability and de-pendency1. The outcome when associated with an inappro-priate support network could strongly challenge domestic com-petence and lead to institutionalisation2. In spite of this reality,most elderly people would prefer to continue leading full andactive lives in their own homes3, it being widely recognised thatcare in the community generally gives a better level of qualityof life than is offered in institutional care4.Joseph Dimech MD, MGerSt Vincent de Paul Residence for the Elderly, Luqa, MaltaEmail: dimport@mail.global.net.mtAnthony Fiorini MD, FRCP (Lond)Zammit Clapp Hospital, Sliema, MaltaEmail: anthony.fiorini@gov.mtKeywordsadmission, assessment, elderly, long term careOne of the widely recognised problems related toinstitutionalisation is inappropriate admission to care5, a phe-nomenon that has also been reported in Maltese studies6,7,8. Suchinappropriate admission to care implies an improper use ofbeds, which are expensive to run, scarce to find9, and could in-dicate an underutilisation of community support services. Oneof the reasons behind such misplacement to care is said to beinappropriate pre-admission assessment10. Contrary to post-admission assessment, intervention before admission could helpto better identify the actual problems that are being faced bythe client and carers11 , and therefore address unmet need forsupport services in the community12. On the other hand admis-sion to continuing care in association with dependency may beinappropriate if a remediable health condition is present9. Con-sequently, pre-admission assessment would also help to iden-tify health problems that could benefit from specialised hospi-tal care and rehabilitation13. The ultimate aim would be to leavethe assessment team in the best possible position to recommendappropriate forms of care that would best identify the client’scapacity and preference to remain at home14.MethodsDuring 1997/8, 105 consecutive elderly applicants (aged 60years and over) seeking permanent admission to St. Vincent dePaul Residence (SVPR) were assessed at source by a member ofthe geriatric medical team within 3 days of receipt of the appli-cation for admission. Applicants originating from the commu-nity were assessed for community care needs by utilising theMalta Medical Journal    Volume 15   Issue 02   November 2003 29Older American Resources and Services (OARS) Multidimen-sional Functional Assessment Questionnaire15. Applicants inhospital or other residential homes were not exposed to thisneeds assessment as they had been admitted for too long a timeto be able to give an accurate account of their community careneeds.All applicants within the study were ultimately assessed forsuitability for admission to long term care. Due regard was givento the stated reasons behind the request for admission, themedico-social state which included an appreciation of socialdependency16, and unmet need. Suitability for admission wasalso guided by the Clifton Assessment Procedures for the Eld-erly Survey Score (CAPE)17. The validity of the CAPE, whichgrades physical and mental state to 5 levels of dependency, hasbeen reported to be related to recommendations to appropri-ate levels of care18 (see Table 1)At the time of the study, decision about placement of appli-cants seeking admission to care, was based upon an analysis ofthe medico-social information that was documented by the re-ferring Medical Practitioner on the application form for admis-sion. No study findings were disclosed to the admitting team inorder not to have any bearing on outcome.  All subjects weresubsequently followed up after 3 months to assess outcome.ResultsThe mean age of the study group (n=105) was 78.5y(SD=7.5), with 78 subjects (74%) being aged 75 years and over.Regarding reason/s precipitating the request for admission, 95(90%) claimed deterioration of health, 60 (57%) indicated in-sufficient carer support, and 32 (30%) stated that they couldnot cope alone. On the other hand, 20 (19%) claimed that lone-liness was a main factor behind their request for admission,whilst 8 (8%) mentioned problems related to housing.Of the subjects studied, 60 cases (57%) originated from ahospital environment, 40 cases (38%) were from the commu-nity, whilst 5 subjects (5%) originated from another Old People’sHome.Of the sub-group originating from the community (n= 40),unmet need was identified for home help (15%), social worker(30%), physiotherapy (22%) and community nursing (7%) (seeTable 2).Table 2: Unmet need for community support services inapplicants originating from the community (n=40)%Home Help 15Day Care 10Handyman Service 8Incontinence Service 7Telecare 5Respite Care for carers 4Social Worker 30Physiotherapy 22Occupational Therapy 20Community Nursing 7Table 3: The recommendations for care according to theorigin of the study group(N = 105)Recommendations Community Hospitals Homes TotalRemain at home 4 0 0 4Home with support 11 6 0 17Rehousing 2 0 0 2Hospital care/Rehab.F/up later on 7 15 0 22Residential Care 6 7 0 13Nursing Care 8 32 5 45Psychogeriatric care 2 0 0 2Total 40 60 5 105After evaluation of all data, each subject in the study group(N=105) was given an appropriate recommendation for care (seeTable 3) based on options which were available locally at thetime of the study:• 17 (16%) could remain in the community with/withoutsupport. In all these cases, the client showed a predispositionto consider staying at home.• 6 (6%) hospitalised subjects could have been dischargedback to the community with support. All six cases showed apredisposition to return back to their homes.• 22 (21%) required hospital care and/or rehabilitation witha decision about placement being left to a later date. Fifteen(15) of these subjects were in hospital whilst 7 subjects hadapplied from the community. In all these cases it was feltthat there was good potential for improvement and theirrelatives were ready to consider helping in the support athome if their elderly family member improved with care.• 60 (57%) of the study group required institutionalisation,75% of this subgroup required nursing care. Of these 60subjects, 16 originated from the community, 39 subjectswere in hospital, whilst 5 subjects were living in anotherResidential Home.DiscussionSVPR is a residential complex for elderly people that pro-vides a mixture of flatlet, residential, nursing andpsychogeriatric beds to 1050 elderly residents. It has been theage-old practice in this institution to primarily base suitabilityfor admission to care on semi-structured documentation as pro-vided by the client’s GP on the formal Application Form. Thiswas evidenced by the fact that at the 3 month follow up, none ofthe applicants under study that originated from the commu-nity or a hospital had received an alternative form of pre-ad-mission assessment. Whilst the Application Form aims to pro-vide a multi-dimensional picture of the state of health of theclient to help in the selection process, in many instances, it isknown not to be the case 19. One of the direct consequences ofsuch a method of selection is that the decision about placementto care would tend to be based on unreliable information risk-ing an inappropriate outcome.Newly admitted residents to SVPR are given a detailed post-30 Malta Medical Journal    Volume 15   Issue 02   November 2003admission geriatric multi-disciplinary assessment, which is car-ried out in a purpose-built  ‘Admission and Assessment Unit’.Such a unit plays a leading role in problem identification and inthe channelling of new residents to an appropriate long stayenvironment which best meets their needs. However contraryto pre-admission input, post-admission assessment does notfulfill a significant role to help avoid inappropriate admissionto care11. This is because by the time of admission, a definitedecision about placement to continuing care would already havebeen taken by both the client and carers alike and therefore itwould be very unlikely to be reversed. In fact at the 3 monthfollow up, none of the 41 subjects that were admitted to SVPR,were discharged back to the community.Application for admission to long term care is frequently adirect consequence of a crisis situation, which affects the do-mestic competence of the applicant and the capacity of infor-mal carers to cope. Faced with such a situation of stress, mis-guided drastic measures are frequently taken withinstitutionalisation being viewed as a solution to all worries.The findings of this study however, clearly show that timelyexpert geriatric assessment in this acute phase of stress, fre-quently unveils solutions which avert the need forinstitutionalisation. In fact, the identification of a health condi-tion that could improve with adequate care and rehabilitation,could lead to a diminution in disability and subsequent needfor care. Likewise, the exposure of unmet need for support ser-vices in the community - if subsequently met in an adequateand timely fashion - would do a lot to help support the informalnetwork of care and ultimately enable the elderly person to copeat home.Elderly applicants waiting in acute hospital care for admis-sion to continuing care are misplaced in a hospital environmentfor want of an available long-stay bed. They are thus frequentlylabelled as ‘social cases’ or ‘bed-blockers’. The study resultsshowed that such cases formed up to nearly two-thirds of sub-jects that were indicated for admission to continuing care. Onthe other hand, there still remained a significant number ofapplicants originating from the community that likewise quali-fied for institutionalisation. Therefore one could argue that in-take to long term care should include a case-mix from both ori-gins, the balance of which could depend on an arbitrary ap-praisal of individual risk and administrative needs. Pre-admis-sion assessment could thus play a leading role in helping to setup waiting lists for admission to care20.The study results also showed that pre-admission geriatricassessment could also be useful to hospitalised applicants forlong term care. In fact 6 such patients could have been dis-charged home if adequate community support were to bemobilised. Likewise 15 such hospitalised applicants were notedto be still recovering from acute medical problems that werepotentially remediable. Therefore in such cases, the continua-tion of acute care coupled with further rehabilitation could leadto a diminution of dependency, thus facilitating a favourableoutcome of discharge back home with support.ConclusionThe results of this study show that pre-admission assess-ment to long term care, if supported by adequate communityservices and acute geriatric beds, could avoid misplacement toinstitutional care. Such a favourable outcome may help in re-ducing the number of blocked beds in acute hospitals, and fulfilthe desire of the majority of elderly people, who prefer life inthe community environment of their choice, for as long as ishumanely possible.References1. Our Healthier Nation. BGS Newsletter 1998;June(suppl):10.2. Cohen CA, Gold DP, Shulman KI, Wortley JT, McDonald G,Wargon M. Factors determining the decision to institutionalizedemented individuals: a prospective study. The Gerontologist1993;33(6):714 –720.3. Bury M. The future of aging – changing perceptions and realities.In: Brocklehurst J, Tallis RC, Fillit HM, eds. Textbook of geriatricmedicine and gerontology. London: Churchill Livingstone,1992;21–25.4. Tinker A. Older people in modern society. 4th ed. London:Longman, 1997;40.5. Lubel D. The Royal Commision on long-term care for the elderly.BGS Newsletter 1998; June(suppl):7.6. Cachia JM. Care of the elderly in Malta. Masters Dissertation:LSHTM, University of London,UK. 1985;30-31.7. Tonna V. The insitutional element in residential care at St.Vincent de Paule Residence. Diploma Dissertation: Insititute ofGerontology, University of Malta, Malta. 1992:33-58.8. Dimech J, Fiorini A. A study of admissions to St.Vincent de PauleResidence for the Elderly - Malta. Bold 1994;4(3): 22–27.9. BGS compendium of guidelines, policy statements and statementsof good practice. London: British Geriatrics Society, 1993(Section 8).10. Quartararo M, O’Neill TJ, Tang C, MacMaster M. Assessing theresidential care needs of nursing home applicants. Aust J PublicHealth 1991;15(3):222–227.11. Pitt B. Psychogeriatrics. 2nd ed. UK, Churchill Livingstone,1991;137-138.12. Coleman PG. Social gerontology in the Netherlands; a review ofthe current research. The Gerontologist 1975;15(June):257–263.13. Planning for the old and very old. Br Med J 1979;ii: 952.14. Sharma SS, Aldous J, Robinson M. Assessing applicants for partIII accommodation: is a formal clinical assessment worthwhile?Public Health 1994;108:91–97.15. Fillenbaum GG. The well being of the elderly: approaches tomutidimensional assessment. Geneva, WHO offset publication,1984;No. 84.16. George S. Measures of dependency: their use in assessing the needfor residential care for the elderly. Journal of Public HealthMedicine 1991;13(3):178–181.17. Pattie AH, Gilleard CJ. Manual of the Clifton assessmentprocedures for the elderly (CAPE). London: Hodder andStoughton, 1979.18. Pattie AH. A survey version of the Clifton assessment proceduresfor the elderly (CAPE). British Journal of Clinical Psychology1981;20:173–178.19. Laferla A. Is institutionalisation of Maltese older persons really alast resort? Diploma Dissertation: Institute of Gerontology,University of Malta, Malta. 1997;38.20.Marshall M, Boaden N. Residential care: how can we makeadmission less haphazard?  Modern Geriatrics 1978;January:30–33.

A study of admissions to St.Vincent de Paule Residence for the Elderly -

A survey version of the Clifton assessment procedures for the elderly (CAPE).

Assessing applicants for part III accommodation: is a formal clinical assessment worthwhile? Public Health

Assessing the residential care needs of nursing home applicants.

BGS compendium of guidelines, policy statements and statements of good practice. London: British Geriatrics Society,

Care of the elderly in Malta. Masters Dissertation: LSHTM,

Factors determining the decision to institutionalize demented individuals: a prospective study.

Is institutionalisation of Maltese older persons really a last resort? Diploma Dissertation:

Manual of the Clifton assessment procedures for the elderly (CAPE). London: Hodder and

Measures of dependency: their use in assessing the need for residential care for the elderly.

Older people

Planning for the old and very old.

Residential care: how can we make admission less haphazard? Modern Geriatrics

Social gerontology in the Netherlands; a review of the current research. The Gerontologist 1975;15(June):257–263.

The future of aging – changing perceptions and realities.

The insitutional element in residential care at St. Vincent de Paule Residence. Diploma Dissertation: Insititute of Gerontology,

The Royal Commision on long-term care for the elderly. BGS Newsletter

The well being of the elderly: approaches to mutidimensional assessment. Geneva, WHO offset publication,

Pre-admission assessment of elderly applicants to long-term care

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Pre-admission assessment of elderly applicants to long-term care

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