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Corresponding author Katherine S. McGilton, PhD, KITE, Toronto Rehabilitation Institute, University Health Network, 130 Dunn Ave, Toronto, ON M6K 2R7, Canada.
KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, OntarioLawrence S. Bloomberg, Faculty of Nursing, University of Toronto, Toronto, Ontario
KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, OntarioInstitute for Clinical Evaluative Science, Toronto, OntarioInstitute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, OntarioLawrence S. Bloomberg, Faculty of Nursing, University of Toronto, Toronto, Ontario
KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, OntarioRehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Ontario
Institute for Clinical Evaluative Science, Toronto, OntarioSchools of Pharmacy and Public Health & Health Systems, University of Waterloo, Waterloo, Ontario, Canada
Institute for Clinical Evaluative Science, Toronto, OntarioInstitute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
Older adults with dementia access home care services more often than those without.
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Most commonly older adults with dementia received personal/home care services.
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Of this population, 44% receive no physiotherapy, despite lower functional scores.
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Patterns in home care service received differ by sex.
Abstract
Objective
To describe differences in home care use in the 30 days after discharge from inpatient rehabilitation after a hip fracture among older adults with dementia compared with those without dementia.
Design
Retrospective cohort study of individually linked health administrative data.
Setting
Community-dwelling older adults after discharge from inpatient rehabilitation facilities in Ontario, Canada.
Participants
A total of 17,263 older adults (N=17,263), of whom 2489 had dementia (14.4%), who were treated for hip fracture in acute care and then admitted to inpatient rehabilitation facilities between January 1, 2011 and March 31, 2017.
Interventions
Not applicable.
Main Outcome Measures
The proportion receiving home care services and number of visits (physiotherapy, occupational therapy, nursing, personal/homemaking) in the 30 days after discharge were compared by dementia status with multivariate models, stratified by sex.
Results
Compared with those without dementia, adults with dementia were older, had lower functional scores, and were more likely to receive home care services in the 30 days after discharge from inpatient rehabilitation (87.0% vs 79.0%, P<.001), including personal/homemaking services (66.1% vs 46.4%, P<.001) and occupational therapy (45.3% vs 37.4, P<.001) but not physiotherapy (55.8% vs 56.2%, P=.677) or nursing (19.6% vs 18.7%, P=.268). After adjustment, older adults with dementia were more likely to receive home care in both men (odds ratio [OR] =2.01; 95% confidence interval [CI], 1.57-2.57) and women (OR=1.50; 95% CI, 1.30-1.74) as well as more services (rate ratio men=1.60; 95% CI, 1.44-1.79; rate ratio women=1.50; 95% CI, 1.41-1.60).
Conclusions
Among older adults discharged from inpatient rehabilitation, older adults with dementia received home care services more often than older adults without dementia. However, irrespective of sex and dementia status, almost half of this population (44%) did not receive physiotherapy. We recommend that, resources permitting, all older adults receive physiotherapy to facilitate recovery.
Older adults with dementia and/or delirium are particularly vulnerable to functional decline after a fracture-related hospitalization, because they have more complex care needs with greater risks of complications and care demands compared with those without dementia.
The National Model of Care for Hip Fracture Surgery recommends that most older adults, including those with dementia, should receive inpatient rehabilitation after their acute care stay followed by home with rehabilitation/home care as required.
After a hip fracture, there are significant disparities in the availability and provision of inpatient rehabilitative care and services for older adults with dementia, because only a minority of older adults with dementia gain access to inpatient rehabilitation (27.1%) despite evidence that outcomes do not significantly differ among those with and without cognitive impairment.
Differences in health care and social services use have been identified among men and women. Previous research demonstrates that men use home care at a lower rate than women
Benefits of home health care after inpatient rehabilitation for hip fracture have been demonstrated; older adults who receive additional home health services were less likely to be hospitalized and have fewer nursing home admissions than those who received inpatient rehabilitation only.
However, it is not clear what types of services older adults with hip fractures are able to access once back home or how cognitive status or sex influence home care services older adults receive, given that these factors have been found to influence home care services received with other older adult cohorts.
At present there are no national models of care standards that provide guidance on what level or type of home care services are required post inpatient rehabilitation to maintain and improve function once older adults are discharged from rehabilitation, especially in the critical first month back at home, which is referred to as the “successful community discharge” period for this population.
The lack of comprehensive data on home care services postdischarge precludes policymakers and health care agencies from understanding the extent and nature of unmet needs among older community-dwelling adults with and without dementia and the resources required to meet these needs to mitigate adverse care transitions.
Building on past work, the objectives of this current study were to (1) describe the proportion and number of home care services received, by type, in the 30 days after discharge from inpatient rehabilitation after a hip fracture among older adults with and without dementia and (2) explore sex differences in the patterns of home care use.
Methods
Study design, setting, and data
We used health administrative databases from Ontario, Canada, to conduct a population-based retrospective cohort study of older adults discharged from an inpatient rehabilitation facility after an acute care hospitalization for hip fracture. The Ontario publicly funded health care program provides virtually all residents with universal access to hospital-based acute and rehabilitation care, other facility-based care such as inpatient psychiatric and nursing home beds, physician services, and medically necessary home-based health care services. The databases used for this study were linked using encoded identifiers and analyzed at Institute for Clinical Evaluative Science (ICES). ICES is an independent, nonprofit research institute whose legal status under Ontario's health information privacy law allows it to collect and analyze health care and demographic data, without consent, for health system evaluation and improvement. The use of data in this study was authorized under section 45 of Ontario's Personal Health Information Protection Act, which does not require review by a research ethics board.
Study cohort
We included Ontario residents, aged ≥66 years, who were discharged from an acute care hospital in the province with a most responsible diagnosis of hip fracture (International Statistical Classification of Diseases, 10th revision codes: S72.01, S72.08, S72.09, S72.10, S72.19, S72.20) between January 1, 2011 and March 31, 2017. Hospital stays in Ontario were ascertained using the Canadian Institute for Health Information (CIHI)’s Discharge Abstract Database, which contains administrative and clinical information for all discharges from acute care facilities in the province. As in previous work, we excluded in-hospital fractures, pathologic fractures, and fractures due to major trauma
because the services required for recovery are different. We also removed those who were residing in nursing homes and those receiving inpatient or outpatient palliative care before hospital admission.
Among this initial cohort we restricted to older adults who were admitted to an inpatient rehabilitation facility within 7 days postdischarge. Inpatient rehabilitation stays were captured using CIHI's National Rehabilitation Reporting System. The date of discharge from inpatient rehabilitation to the community was defined as our study index date. We excluded those who died before discharge and those who were re-admitted to facility-based care (eg, older adults no longer residing in the community) in the 7 days after discharge. We selected 7 days to ensure that older adults were in the community for a least a week to have the opportunity to receive home care services after discharge. If an older adult had multiple rehabilitation stays that qualified, we selected the earliest episode for analysis. See figure 1 for the cohort creation flowchart.
We used a validated case definition applied to health administrative data to determine older adults who were diagnosed with dementia prior to index date.
Identification of physician-diagnosed Alzheimer’s disease and related dementias in population-based administrative data: a validation study using family physicians’ electronic medical records.
With physician-diagnosed dementia serving as the reference standard, an algorithm of 1 hospitalization, or 3 physician visits separated by 30 days over a 2 year period, or a prescription for a cholinesterase inhibitor had a sensitivity of 79%, specificity of 99%, positive predictive value of 80%, and negative predictive value of 99%.
Home care service use
The Home Care Database captures all home-based visits provided by publicly funded community care health service workers. We extracted all home-based visits in the 30 days after the index date and retained the type of service visit to identify receipt of care from specific providers. For individuals who died or were readmitted to facility-based care within 30 days, we only measured home care services and person-time of follow-up prior to these censoring events. During the study period in Ontario, access and delivery of home care services were managed through 14 regional coordination centers across the province.
Baseline characteristics
Age, sex, and postal code at hip fracture admission were determined using Ontario's Registered Persons Database. We used the older adult's postal code to determine whether they resided in a rural area, which were defined as communities with <10,000 inhabitants that were outside of the commuting zone of metropolitan areas.
We also computed the Charlson Comorbidity Index using diagnostic information located on the CIHI's Discharge Abstract Database hip fracture hospitalization record.
Additional information on the hospital record was used to determine the length of hospital stay and the time to surgical repair after admission. Administrative and clinical information was also collected from the CIHI's National Rehabilitation Reporting System to calculate the length of inpatient rehabilitation stay, as well as the total, cognitive, and motor FIM at inpatient rehabilitation discharge, where higher scores represent greater functional independence.
In the year before hospital admission, we used diagnostic information from earlier hospital records to identify individuals with a previous fall or fragility fracture and used the Home Care Database to identify individuals with previous home care service use. Similarly, in the 5 years before hospital admission, we determined the prevalence of specific health conditions using hospital records.
Statistical analysis
A previous diagnosis of dementia at the time of acute care admission was our main exposure of interest. We compared the baseline characteristics of older adults with and without a diagnosis of dementia using standardized differences. We compared the proportion of home care services received after discharge and the rate of home care services per person-month using descriptive statistics. Logistic regression models were used to assess the association between dementia status and the odds of receiving at least one type of home care service (overall and by service type) within 30 days and reported with odds ratios (ORs) and 95% confidence intervals (CIs). Negative binomial models (with the log of follow-up time [in person-months] as an offset parameter) were used to compare the relative differences in home care service volumes (overall and by service type) received within 30 days by dementia status and reported with relative rates (RRs) and 95% CIs. We created unadjusted models and then multivariate models to adjust for demographic and health status characteristics (age, rural residence, Charlson Comorbidity Index, time to hip surgery, length of acute care stay, length of inpatient rehabilitation stay [dichotomized at 30 days], previous falls, previous fragility fractures, hospitalizations and diagnoses in the past 5 years prior to hospital admission: hip fracture, pressure ulcer, stroke, delirium, other neurologic disorder, cardiac arrhythmia, diabetes). FIM scores and prior home care use were not included in the models because they were highly correlated with dementia diagnosis. All of the above analyses were stratified by sex.
All statistical tests were 2-tailed and used P<.05 as the level of statistical significance. We used SAS version 9.4a to conduct all analyses.
Results
The cohort consisted of 17,263 older adults who were discharged from acute care with a hip fracture and admitted to inpatient rehabilitation in Ontario between 2011 and 2017 (see fig 1). Descriptive statistics on demographic and clinical characteristics are given in table 1. The mean age of the cohort was 83.1 years and most were women (73.3%). Overall, 14.4 % of the population had dementia (14.1% among men and 14.5% among women). Compared with those without dementia, older adults with dementia were older and more often from nonrural areas. They also had a higher number of comorbidities and increased likelihood of hospitalizations before their hip fracture, longer rehabilitation stays, and lower cognitive and physical function scores at discharge. Older adults with dementia were nearly twice as likely to have received home care prior to their hip fracture (49.7%), compared with those without dementia (28.1%). These findings were consistent both overall and when stratified by sex.
Table 1Demographic and clinical characteristics of older adults discharged from acute care with a hip fracture and admitted to an inpatient rehabilitation facility in Ontario, Canada, between January 1, 2011 and March 31, 2017
What proportion of older adults receive home care services after inpatient rehabilitation for hip fracture?
Compared with those without dementia, older adults with dementia were more likely to receive home care services in the 30 days after discharge from inpatient rehabilitation (87.0% vs 79.0%, P<.001) with a mean of 17 visits per month, compared with a mean of 11 visits for older adults without dementia (P<.001). This pattern was consistent both overall and when stratified by sex (table 2).
Table 2Types and rates of home care services received by older adults with hip fracture within 30 days after discharge from inpatient rehabilitation in Ontario, Canada, stratified by a previous diagnosis of dementia and sex
What types and volumes of services were used after inpatient rehabilitation for hip fracture?
Physiotherapy was the most common type of home care services received by older adults without dementia (56.2%) and second most common for older adults with dementia (55.8%); however, the difference in physiotherapy use between the 2 groups was not statistically significant (P=.677). Both groups received a mean of 2 visits from the physiotherapist. Personal/homemaking services provided by personal support workers were received by 46.4% of older adults without dementia vs 66.1% of individuals with dementia (P<.001), where older adults with dementia received 12 personal/homemaking visits within the first 30 days, as opposed to 6 visits received by older adults without dementia (P<.001). Visits by occupational therapists were the third most common type of home care services received by both groups: 45.3% vs 37.4% (P<.001) for older adults with and without dementia, respectively. On average, both groups received 1 visit from the occupational therapist. Interestingly, only 19.6% of older adults with dementia and 18.7% of older adults without dementia received nursing home care visits, where both groups received a mean of 1.5 visits from the nurse within their first 30 days of being home. These patterns were consistent both overall and when stratified by sex (see table 2).
Is previous diagnosis of dementia associated with home care after inpatient rehabilitation for hip fracture?
Adjusted logistic regression models confirmed earlier findings: a previous diagnosis of dementia was positively associated with use of at least one home care service after discharge in both men (OR=2.01; 95% CI, 1.5-2.57) and women (OR=1.50; 95% CI, 1.3-1.74). Results were similar when examining the volume of home care received within 30 days of discharge from inpatient rehabilitation: dementia diagnosis was positively associated with more home care service use in men (RR=1.60; 95% CI, 1.44-1.79) and women (RR=1.50; 95% CI, 1.41-1.60). The association between dementia status and receiving at least 1 home care service was strongest for personal/homemaking services, and the estimates were higher for men (OR=2.68; 95% CI, 2.25-3.20) than for women (OR=1.88; 95% CI, 1.69-2.09). Additionally, both men (RR=2.04; 95% CI, 1.68-2.49) and women (RR=1.77; 95% CI, 1.60-1.96) with dementia received a greater volume of personal/homemaking services compared with those without dementia. Receipt of physiotherapy and nursing, both in terms of receiving at least 1 service and the volume of services received, was not different between those with and without dementia after adjustment. Associations between a previous diagnosis of dementia and receipt and volume of all home care services are provided in table 3.
Table 3Association between a previous diagnosis for dementia and receipt of home care of services by older adults with hip fracture within 30 days after discharge from inpatient rehabilitation in Ontario, Canada, stratified by sex
Full model adjusted for age, sex, rural residence, Charlson Comorbidity Index, time to hip surgery, length of acute care stay, length of inpatient rehabilitation stay, previous falls, previous fragility fractures, and hospitalizations and diagnoses in the past 5 years before hospital admission: hip fracture, pressure ulcer, stroke, delirium, other neurological disorder, cardiac arrhythmia, and diabetes.
Other home care services can include services provided by dietitians, speech language pathologists, and/or social workers.
1.58 (1.24-2.01)
<.001
1.48 (1.16-1.89)
.002
1.35 (0.86-2.13)
.197
1.32 (0.84-2.09)
.230
1.70 (1.28-2.25)
<.001
1.71(1.29-2.28)
<.001
Full model adjusted for age, sex, rural residence, Charlson Comorbidity Index, time to hip surgery, length of acute care stay, length of inpatient rehabilitation stay, previous falls, previous fragility fractures, and hospitalizations and diagnoses in the past 5 years before hospital admission: hip fracture, pressure ulcer, stroke, delirium, other neurological disorder, cardiac arrhythmia, and diabetes.
† Full model in men and women with no adjustment for sex.
‡ Patients without dementia are the reference category.
§ Odds for receipt of at least 1 home care service at 1 month after discharge computed using logistic regression.
‖ Other home care services can include services provided by dietitians, speech language pathologists, and/or social workers.
¶ Relative rate for volume of home care services received 1 month after discharge computed using negative binomial regression.
Our study provides several important findings regarding the effect of dementia on receipt of home care services after discharge from an inpatient rehabilitation program. It highlights the difference in home care services that community-dwelling older adults receive after inpatient rehabilitation stay for hip fracture. To our knowledge, there are no studies reporting on these associations for a cohort of older adults (mean age 83y) composed of adults with dementia (14%) and with multiple comorbidities discharged from inpatient rehabilitation.
This large population-based study found variations in the home care services that community-dwelling older adults with and without dementia receive after inpatient rehabilitation. People with dementia were more likely to receive home care services (and higher volumes of service) than those without dementia in the first 30 days of being at home. Up to 87% of older adults with dementia received some type of home care: most received support from personal support workers (66%), 45% received occupational therapy, and 56% received physiotherapy. Adjusted models confirmed that previous diagnosis of dementia was positively associated with increased use of home care and a higher number of services per person-month, and this was primarily driven by use of personal support services. Patterns were similar in women and men. These findings highlight several shortcomings of the home care services provided in Ontario, which will be considered below.
There is limited evidence on the optimal dose of home care services and the type of providers required after an inpatient rehabilitation stay. This stems from the reality that there is a lack of research on inpatient rehabilitation involving older adults with dementia after hip fracture surgery, and the evidence that exists provides limited information related to the specific rehabilitation practices, the staff delivering the programs, and the required training.
However, in a recent study, older adults who transitioned to independent living after receiving inpatient rehabilitation showed significant improvement in their physical performance measures, with marked deterioration in their fear of falling.
The investigators propose extended rehabilitation at home particularly for those with higher levels of complexity, including those with cognitive impairment.
Considering that older adults with dementia may need cueing and prompting to regain their abilities in performing activities of daily living independently and will need assistance with regaining their mobility, it is essential that occupational therapists and physiotherapists are in their home to provide this type of guidance. Unfortunately, only half of the population is receiving this guidance, and older adults with dementia receive significantly fewer occupational therapy visits than those without dementia. Furthermore, 1-2 visits on average from these therapists may not be sufficient. Previous studies have shown that at-home physical therapy (PT) interventions lead to significant improvement in activities of daily living in medically complex older adults including those with dementia, with a higher number of PT (eg, >5) visits showing greater improvements.
In addition, written instructions have shown to be less effective than in-person PT-facilitated interventions in older adults with hip fractures, leading to statistically significant worse improvements in activities of daily living scales and physical performance tests.
Assistance with cleaning and preparing meals is also required on returning home after a hip fracture, and having personal support workers providing personal/homemaking services in the homes of older adults with hip fractures is a vital service for this purpose. Older adults receiving most services from personal support workers is consistent with a recent report from Home Care Ontario that suggests that short-term personal/homemaking staff visits are being prioritized over physiotherapist visits, potentially compromising older adults’ recovery potential.
Further evaluation into optimal services required to support recovery will become increasingly important to reduce long-term care admissions for this vulnerable population.
Many community-dwelling adults with dementia (approximately 45%) did not have access to physiotherapists and occupational therapists despite being more functionally impaired at discharge from rehabilitation than those without dementia. Accessing rehabilitation experts after acute care might be difficult because older adults with dementia may be perceived by home care coordinators as not benefitting from these services because they may have difficulty with recall or following instructions.
Staffs’ assumptions that older adults with dementia are not appropriate for rehabilitation given their lack of rehabilitation potential lead to a lack of referrals for physiotherapists to treat them in their homes.
Our findings provide support for research previously conducted with clinicians who perceived that if older adults with dementia post hip fracture were treated in the community, treatment would rely heavily on the use of support workers because of resource pressures and the difficulty justifying why physical therapists were required.
To further understand the rates of services provided to older adults with dementia after inpatient rehabilitation, we investigated how many older adults were receiving services prior to the fall. As it turns out, almost 50% of older adults with dementia before the fall were receiving home care services. This finding not only demonstrates the vulnerability of those individuals prior to the fracture but speaks to an untapped potential resource. Fall prevention can potentially be improved by further educating home care staff on how to assess functional decline and provide interventions. Previous studies have shown significant improvement in functional capacity and overall well-being in frail older adults who received exercise interventions at home by trained home care workers.
Several study limitations should be noted. First, we chose to investigate a cohort of older adults with an inpatient rehabilitation stay and it is known that access to this care setting varies significantly across the province of Ontario.
However, we did not examine variation in availability and access to inpatient rehabilitation. Second, our study design reflected our interest in better understanding the extent and type of home care services received by older adults after inpatient rehabilitation. Consequently, we do not have comparable information on older adults with dementia who did not receive inpatient rehabilitation, although other studies suggest that their outcomes are considerably poorer in terms of mortality and long-term care admission outcomes.
Third, our findings are limited by the available data; we do not know the reasons for the level or type of services provided, nor could we ascertain home care referrals that were made but declined by the older adult or caregiver
or the specific tasks performed by each type of home care service provider during their visit. Further, we did not have access to measures potentially relevant to home care use, including the availability of a caregiver at home
Fourth, we are only able to capture publicly funded home care services. Waitlists to receive publicly funded home care in Ontario are long and privately retained home care services are becoming increasingly popular.
In summary, older adults with dementia are accessing health services more often than older adults without dementia; however, just over half of this population receives physiotherapy. Most of the services received after the hip fracture are from personal support workers and patterns are similar in women and men. We recommend that, given their lower functional scores at time of discharge than those without dementia, therapists be available to all adults with dementia to facilitate recovery. Further information is required to identify best home care pathways for older adults after inpatient rehabilitation.
Supplier
a. SAS version 9.4, SAS Institute Inc.
Acknowledgments
We thank Yi Cheng, MSc, and Elyse Corn, MSc, for assistance with study coordination.
References
Odén A
McCloskey EV
Kanis JA
Harvey NC
Johansson H.
Burden of high fracture probability worldwide: secular increases 2010-2040.
Identification of physician-diagnosed Alzheimer’s disease and related dementias in population-based administrative data: a validation study using family physicians’ electronic medical records.
Supported in part by a research grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC) to the Ontario QUILT (Quality for Individuals who require Long-Term support) Network (grant no. 255) and the Walter and Maria Schroeder Institute for Brain Innovation & Recovery. This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC). The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. Parts of this material are based on data and/or information compiled and provided by the Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions, and statements expressed in the material are those of the authors and not necessarily those of CIHI.
FIM total function scores were recorded at discharge from rehabilitation facility.
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