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| Journal of the New Zealand Medical Association,
24-September-2004, Vol 117 No 1202
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Risk factors for entry into residential care after a support
needs assessment
Mark Weatherall, Timothy Slow, Kimmo Wiltshire
A new model for the provision of support services for people
with activity limitation (disability) was introduced into New Zealand in the
early 1990s. In this service model, there was an explicit separation of
healthcare services pertaining to the assessment of people with activity
limitation—together with the co-ordination of support services for needs
identified as part of this assessment from services that provided treatment and
rehabilitation for people with disease, impairment, and activity
limitation.
The motivations for this policy were complex, but included a
(not usually stated) assumption that a social model of activity limitation
management would lead to a reduction in costs for the provision of residential
care for older people, by allowing so-called ‘aging in place’. As
part of this policy, a nationally consistent instrument, the Support Needs
Assessment Form (SNAF), was
introduced.1
This instrument was to be used throughout New Zealand to
provide for consistency of assessment. In passing, it is of interest to note
that the instrument was developed by a consensus approach managed by the New
Zealand Ministry of Health and that no proper clinical assessment of the utility
of the instrument was ever performed. The ‘separation’ policy was
implemented to variable extent throughout New Zealand and has not been subjected
to any serious scientific scrutiny.
However the use of a standard instrument has given rise to
the opportunity to use ‘SNAF’ data collected about people who
request support services to examine what factors might predict the use of
long-term residential care as a support service.
In New Zealand, residents of long-term care facilities make
up about 6.5% of the population aged over 65
years.2 There is a high prevalence of disease,
impairment, and activity limitation in this very frail population.
A 1993 census of all people living in long-term care in
Auckland, the largest city in New Zealand with a population of about one million
people,3 found, for example, that 67% of
residents had a mobility disorder and 50% had continence problems. A more recent
survey of people living in long-term care in another centre in New Zealand found
that nearly three-quarters of residents had
dementia.4,5
MethodsBackground—The
Support Needs Assessment and Service Coordination agency based in Wellington,
New Zealand has developed an administrative database with details about the
assessments carried out and services recommended for people requesting support
services.
The database includes items from the modified Support
Needs Assessment Form used in Wellington and, in particular, whether a person is
thought (by the assessor) to have cognitive problems, mobility problems, or
continence problems. In addition, the database includes some details of the
services recommended and, in particular, whether residential care services were
recommended. This study is based on the 12 months of data from this
administrative database, August 2001 to August 2002.
Statistical
analysis—This was by logistic regression, modelling the probability
that residential care was recommended after the support needs assessment.
Potential explanatory variables were age, sex—and whether cognitive
problems, mobility problems, or continence problems (urinary or faecal) were
present. Interactions between these predictors were also examined. A backwards
selection using a probability for leaving a term in the model of 0.1 was used to
select the final model. SAS version 8.2 (SAS Institute, NC, 1999) was
used.6
Results2060 assessments for people aged
over 65 years were performed during in the 12 months. A basic description of the
subjects is shown in Table 1.
Table 1 Description of subjects
The
univariate analysis for each potential risk factor is shown in Table
2.
Table 2. Univariate odds ratios for the risk of
residential care (higher odds ratio means at greater risk)
For the multivariate model, interaction terms between age
and continence status, and mobility and cognitive impairment, were statistically
significant. The final model incorporating terms for age, cognitive impairment,
continence problems, and mobility problems as well as the stated interaction
terms fit the data well with a deviance of 5.80 on 9 degrees of freedom (p=0.76)
and a Hosmer and Lemeshow goodness of fit test with a value of 2.06 on 7 degrees
of freedom (p=0.95). The multivariate analysis including interaction terms is
shown in Table 3.
Table 3. Multivariate odds ratios for the risk of
residential care (higher odds ratio means at greater risk)
DiscussionSince 1996, several published
studies have examined the risk factors for residential care
utilisation.7–23 The most common risk
factors were worse activity of daily living status (13 studies), living and
family arrangements (11 studies), decreased cognitive function (10 studies),
older age (7 studies)—and each of a diagnosis of Alzheimer’s
disease, caregiver characteristics, worse self assessed health status, and
ethnicity (2 to 3 studies).
Two studies found increased domestic support services (that
protected against moving into residential care), and one study that showed
increased domestic support services were associated with an increased risk of
moving to residential care.
Consistent with this previous work, the current study found
that in all persons of older age, mobility problems and cognitive problems were
associated with a higher risk of entry into residential care. Continence
problems were usually not identified as a separate risk factor, but subsumed
under the rubric of activity of daily living problems, in the previous work.
Medically recognised urinary incontinence has been found to be an important risk
factor for entry into residential
care.24
There was interaction between continence problems and age,
with the effect of continence problems being more pronounced for people aged
less than 80 years. There was also an interaction between cognitive problems and
mobility problems, with the effect of cognitive problems being more marked in
those with mobility problems. Interactions between risk factors are not examined
consistently in the previous work in this area; this is an important issue for
future research as it appears the risk associated with functional factors on
moving into residential care (in particular) depends on the particular
functional profile.
Weaknesses of the study include the fact that it relies on
an accurate assessment on the part of the healthcare workers completing the
‘SNAF’. The healthcare workers who complete the assessment tool have
a common training; however, the inter-rater reliability of the healthcare
workers has not been established. The simple nature of the coding of problems in
the particular areas may mitigate this uncertainty.
Some of the recommendations for residential care were
assessments from a lesser to a greater level of dependency within institutional
care, as in New Zealand there are two ‘levels’ of residential care;
thus this analysis is not one of purely community dwelling older
adults.
For purposes of the simple coding, urinary and faecal
incontinence were not distinguished. Finally, the analysed data represents the
activities of only one assessment and service co-ordination service, and may not
be able to be generalised to other similar services in New Zealand or
internationally.
A social model of care may not be an ideal way to promote
aging in place. Two recent systematic
reviews.25,26 of home-based support for older
people reached similar conclusions.
Home support seems to be useful, and in particular may
reduce the risk of nursing home admission—if the home support is
accompanied by a multi-dimensional geriatric assessment and follow-up; includes
multiple follow up home visits; and furthermore if there is a long-term
intervention strategy to modify risk factors for deterioration in health and
function.
A recent controlled trial where home-support workers also
provided a geriatric assessment and rehabilitation style of
care27 was associated with a lower risk of
entering residential care.
Analysis of the influence of home support services on the
risk of entry to residential care is conflicting. A report of the influence of
home-based support services28 was unable to
demonstrate that provision of home support services was associated with
decreased utilisation of residential care, while another
report12 found an association between increased
home-support service spending and services, and lower risk of residential
care.
The conclusions that can be drawn from the study (reported
in this paper for health service planning in New Zealand) are that cognitive
impairment, mobility disorders, and urinary incontinence occur more commonly in
older adults who have a recommendation for long-term residential care. This
recommendation occurred in a very large proportion of subjects.
The success of a social model of care, in promoting
‘aging in place’, has not been convincingly demonstrated in
randomised clinical trials—and given the very high proportion of older
people who had residential care recommended in this study, this model of care
may not reduce the risk of use of long-term care in New Zealand.
A more collaborative approach, between assessment and
service co-ordination services, and geriatric and rehabilitation services (that
integrates a clinical, diagnostic, therapeutic and rehabilitative approach to
older people) may offer better outcomes.
Those persons at most risk for entry into residential care
may benefit the most from this model of care—people with mobility
problems, continence problems, cognitive problems, and the very elderly (ie,
persons aged over 80 years).
Author information:
Mark Weatherall, Senior Lecturer, Rehabilitation Research and Teaching Unit,
Department of Medicine, Wellington School of Medicine and Health Sciences, Otago
University, Wellington; Timothy Slow, Manager; Kimmo Wiltshire, Analyst, Capital
Support, Porirua
Correspondence: Dr
Mark Weatherall, Department of Medicine, Wellington School of Medicine and
Health Sciences, PO Box 7343, Wellington South, Wellington. Fax: (04) 389 5427;
email: markw@wnmeds.ac.nz
References:
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