Determinants of the use of Nursing Homes

SUMMARY Nursing homes (NH) were designed as a measure to appropriately reduce hospital care use, following an exponential growth of the hospital sector in the golden sixties. Correspondingly, a reform of the existing homes for the valid elderly proved necessary following a steady increase in the population of very elderly residents. For these patients, often requiring skilled care, the NH was established as an intermediary solution between expensive hospitals and the homes for the elderly, which are less costly to the state. The immediate cause was public spending cuts after the recession of the 70s. A Royal Decree of 2 December 1982 saw the legal establishment, programming and regulation of nursing homes. They have since seen a steady growth, from 5,200 beds in 1987 to 63,086 in 2010.Elderly people in need of care are defined as elderly who require nursing and paramedic care and assistance in their Activities of Daily Living (ADL), rather than specialist medical treatment. Nursing homes offer chronic care, in a home-like environment, to elderly people suffering from a lack of somatic or psycho geriatric self-reliance. Nursing homes have increasingly evolved into a complex mix of medical, nursing, material and social/emotional components. This is in contrast to a lack of global scientific research. There is a shortage of epidemiological data on NH residents in general. At present there is no single mandatory registration requirement, neither at a federal, nor at a Flemish regional level, with the exception of the transmission of care requirement data to the Belgian National Institute for Health and Disability Insurance. From a personal interest, a number of instititutions have compiled valuable resident data in their annual reports. However, a centralised database and adequate processing of this data is still lacking. The purpose of this doctorate is to gain insight into relevant aspects of the use of NHs, from the users perspective. Themes were researched in a logical order and described exploratory. Consequently in 5 interlinked articles we will look at (1) who, out of a group of elderly people, will enter a nursing home, (2) why/when an urgent request for NH admission was introduced, (3) which medical reasons/main diagnoses can lead to admission, (4) how hospital referrals are dealt with and finally (5) how long a mere NH stay lasts. Article 1 indirectly investigates the likelihood of entering a nursing home in a population aged over 60, from the perspective of their place of death. We conducted a mortality survey, between January 1999 and December 2000, in a small densely populated area in Belgium, with a high concentration of nursing homes, to validate the percentage of deceseased elderly of over 60 who stayed in a nursing home, and whether or not the place of death was coincidental. In our findings only 22% died at home, whereas the majority (78%) passed away in an institutional setting, either a hospital (50%) or a nursing home (28%). Both individual (age, gender and living situation) and social-contextual factors (the availability of a nursing home in the own parish) are determinates for a request for NH admission. Female and single elderly individuals account for the highest number of admissions and the use of a nursing home at the end of life is inversely associated with in-hospital death. The general conclusion is that the presence of a nursing home in the local community is a key predictor of the place of death. Article 2 brings forward the dependence for Instrumental Activities of Daily Living (I-ADL) as a trigger for an urgent request (within a period of 3 months after the onset of dependency) for nursing home admission. According to an admission cohort in 4 institutions in 2000/2001 household chores appeared to be a bigger deciding factor than physical disabilities. The value of classical/traditional parameters, which literature considers predictors of institutionalisation (gender, age, Katz category, marital status, disease, living conditions, Personal and Instrumental Activities of Daily Living (P-ADL and I-ADL) has been confirmed by our research but the stepwise logistic regression analysis identified I-ADL as the decisive factor. The higher the I-ADL scores are, the quicker a request for admission will come about.Since the postponement of a request for NH admission was predominantly determined by the ability to perform I-ADL activities, it is important to maximally offer the possibilities to perform these domestic chores to reduce unnecessary or early NH admission. Also private sector initiatives will be required to fill some gaps. Further development of sheltered housing, further extension of home-help services (timely and sufficient professional care) and support of informal care can help to delay or prevent institutionalisation. Article 3 investigates the primary diagnosis at the time of admission. Although need factors have a strong impact on NH admission, we examine in two independent studies (1993 and 2005) the underlying disease causing these disabilities. Primary diagnosis and secondary diagnoses were mapped by means of the International Classification of Diseases- 9th edition (ICD-9). For the first time a pathology registration encompassing the entire range of diseases, was applied in a nursing home population. The entire disease classification for NH residents included around 100 typical disorders and that range of specific disorders has seen little change in the course of 12 years. Mental disorders represent 49% of all admissions, somatic disorders 43% and social/emotional problems 8%. The main chronic medical conditions associated with NH admission were dementia and stroke. In our study 81% of the residents having dementia was female. However globally there is insufficient establishment of correct diagnosis of dementia and dementia subtypes, which means that the differential diagnosis of dementia insufficiently permeated the NHs.Of the somatic disorders most frequently mentioned are diseases of the circulatory system (35%) [2/3 sequels of stroke and 1/5 heart failure], followed by diseases of the nervous system (15%) [mainly Parkinsons disease] and the musculoskeletal system (14%) [mainly osteoarthritis]. The most striking evolution from 1993 to 2005 consisted in complicated diabetes mellitus, especially with amputations and blindness. Diabetes related complications as cause of admission increased almost three-fold between 1993 and 2005. Diseases such as stroke, diabetes and mobility problems are only important for institutionalisation if they cause functional disability. Proper care can reduce these functional disabilities and postpone or prevent NH admission. Our results highlight the importance of an effective prevention, detection and treatment of people who are at risk of, or suffer from these diseases. An adjusted and concise classification system for pathology registration would be useful to compile a medical database in an efficient, reliable and rapid manner. This will require accuracy of diagnosis and standardisation of diagnostic criteria together with an appropriate and user-friendly encoding system to achieve both somatic and mental disorders. Article 4 focuses on frequency and causes of hospitalisation of nursing home residents. Despite a mixed case of comparable resident profiles in the various settings (age, gender, level of disability and pathology type) we did not find uniformity in the referrals to hospitals. Based on a convenience sample we retrospectively describe the entire hospital history of each deceased resident during the calendar year 2000 in seven institutions. Out of the 265 screened residents, 65% were sent to the hospital at least once during their stay in the home; 31% twice, 13% three times and 6% over three times. The percentage varies per institution from 44 to 80% which is statistically significant. The mean number of hospital days was 14.9. No significant difference in length of hospital stay was found. The degree of hospitalisation of residents admitted varied between 1.3 and 2.6 with an average of 1.95 admissions per admitted resident. The indication for hospitalisation was subdivided into 11 relevant categories. This categorisation was developed from experience and included 97% of all admissions. The remainder category accounted for 3%. The most important reason for hospitalisation was for the patient to be kept under observation (53%) especially for respiratory and gastro-intestinal complaints. Further reasons were fractures 15% (meanly hip), surgery 11%, CVA 11%, and terminal hospitalisations 7%.Residents increasingly expect the NH to provide integral and optimal care where hospital referrals are exceptional, as well as medically and ethically justifiable. Clinical guidelines can be an important tool.Assuming there were no global differences in residents characteristics between the different homes, this study found remarkable differences in hospitalisation referrals. Based on experience and literature, we conclude that the prevalence of hospital referrals can be used as a quality indicator of NH care. Article 5 aims to shed light on the difficult-to-calculate length of a nursing home stay of elderly in need of care. The lack of clear insights is global. The average length of stay, calculated based on two mortality cohorts, was in 1998 and in 2000 respectively 22 and 18 months. There are no disparaties between the institutions averages, however substantial individual differences between elderly occur. The regression analysis indicates that women, patients with dementia, and residents category B account for the longest stays. On the other hand, it was observed that the older the patient is at the time of admission, the shorter the length of stay is likely to be. Although there is a trend linking the duration of the stay to the quality of care, the data do not allow such analysis. Nursing home length of stay is for the most part unpredictable because it is dependent on a range of factors such as the characteristics of the elderly, care before admission, the admission behaviour of the facility, medical evolution (e.g. medication against Alzheimers disease), the increasing or decreasing prevalence of certain disorders, the creation or extension of a variety of alternative residence and care systems as well as differences in service, but finally also indirectly dependent on government policy. When elderly people in chronic need of care turn to residential care remains unpredictable because there are so many different factors to take into consideration. In general discussion and conclusion we reflect on the main findings of this doctoral research and offer some suggestions. The three main proposals concern 1) the completion and refining of support care for elderly with various caring needs, taking into account the necessary diversity; 2) a more accurate diagnosis of dementia together with further attention to primary, secondary and tertiary prevention in case of risk diseases; and finally 3) the introduction of both efficient and concise registration of main parameters.

Jaar van publicatie:2011

Toegankelijkheid:Closed