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Table 1 Characteristics and summarized outcomes

From: The evidence for services to avoid or delay residential aged care admission: a systematic review

First author, date, country, study design Inclusion criteria No. of participants & mean age Intervention Duration of intervention & visit frequency Outcomes & time period Shortened results (intervention group c/f control)
Complex interventions
Beland 2006
Canada
RCT
(2 articles)
Aged ≥64 years; community-dwelling; French or English; participating caregiver; functional disability; no pending RAC admission. SIPA n = 606 Control n = 624
82 years
SIPA (System of Integrated Care for Older Persons): multidisciplinary teams with full clinical responsibility for delivering comprehensive community-based care & coordination across health and social welfare sectors Average length of enrolment was 572 days over the 662 day trial Institutional admission,
ED utilized,
Skilled RAC utilized.
Hospital utilized,
Number in hospital waiting RAC placement
Baseline & 12 months.
Skilled RAC admissions →.
Decreased waiting in hospital for RAC place.
Utilization or costs for ED, or acute hospital →.
Dalby
2000
Canada
RCT
Functional impairment or hospital admission or bereavement in the previous 6 mths; aged ≥70 yrs.; at risk of sudden deterioration in health; community dwelling; not involved in other studies or previous nurse visits. Intervention n = 73 (79.1 yrs)
Control n = 69 (78.1 yrs)
Nurse led assessment, care plan development and case management 14 months
Varied as needed by individual
RAC admission;
Health services utilization;
ED visits;
Hospital admissions
Baseline, 14mths f/up.
RAC admission →.
Health services utilization, visits to ED or overnight hospital admissions →.
Eloniemi-Sulkava 2001}
Finland
RCT
Aged ≥65 yrs.; dementia; living at home with informal caregiver; no other severe diseases that might lead to institutionalization. Intervention n = 53 (78.8 yrs)
Control n = 47 (80.1 yrs)
Comprehensive, case managed dementia support for client and carer (nurse led) 2 years
Individualised frequency of contacts from once a month to 5 times a day.
RAC admission; Deaths
Baseline, 1 & 2 yr. f/up.
RAC admission at 12 months was reduced.
RAC admission at 2 yrs. → .
Deaths →.
Eloniemi-Sulkava 2009
Finland
RCT
Spouse caring for a partner with dementia at home; dementia diagnosis; no other severe disease with prognosis < 6 months. Intervention n = 63 (78 yrs)
Control n = 62 (77 yrs)
Comprehensive, case managed dementia support for client and carer (nurse & geriatrician led) Maximum2 yrs– varied phased recruitment
Individualised, could be frequent contact
Admitted to RAC
Deaths
Baseline, 6, 12 & 24 mths f/up.
RAC admission at 12mths → .
Reduced RAC admission at 18mths.
RAC admission at 2 yrs. → .
Deaths at 24 months →.
Hammar 2007
Finland
Cluster RCT
Aged ≥65 years; discharged from hospital back home with home care services; primary admission
diagnosis was not cancer, dementia or psychiatric; able to answer mental status-test
Intervention n = 354
Control n = 314
81.7 yrs
Generic community care and case management (IHCaD-practice) commencing with hospital discharge planning, and tailored to municipalities needs. 6 month program
Frequency unclear
Admitted to RAC;
Deaths;
Finnish version of ADL;
hospital care;
HRQoL (NHP & EQ-5D)
Baseline, 3 wks & 6 mths f/up
RAC admission at 6mth → .
Deaths at 6mths → .
ADL change at 6mths → .
The EQ-5D change at 6mths → .
Hospital care at 3wks & 6mth → .
Mahoney 2007
USA
RCT
Aged ≥65; independently living; history of 2 falls in past year, or 1 injurious fall in past 2 yrs., or gait & balance problems; caregiver in the home. Intervention n = 174 (79.6 yrs)
Control n = 175 (80 yrs)
Multi-factorial falls prevention intervention linking participants to existing medical care & service networks. 12 month program
2 visits in-home first 3 weeks, then monthly phone contact
RAC admissions;
RAC days;
Mortality;
Barthel scores;
Depression (GDS);
Hospitalisation;
Hospital days;
Baseline, 12 mth f/up.
RAC admissions →.
Fewer RAC days per year.
Hospitalisation →.
Hospital days →.
Barthel scores →.
Mean change in GDS score →.
Markle-Reid 2013
Canada
RCT
Trial 1: > 75 years;
eligible for personal support services; not eligible for nursing.
Trial 2: > 75 years;
eligible for personal support services; at risk for falls.
Trial 3: confirmed diagnosis of stroke or transient ischaemic attack in past 18 months; eligible for home care services
Trial 1: Intervention n = 144
Control n = 144
83.8 yrs.
Trial 2: Intervention n = 54
Control n = 55
84 yrs.
Trial 3: Intervention n = 52
Control n = 49
74.3 yrs
3 different health promotion, disease prevention interventions targeting functional decline and frailty Trial 1:
5 home visits over 6mths (nursing)
Trial 2:
median of 19.5 home visits by the interD team over 6mths
Trial 3:
median of 24 home visits by the interD team over 12mths
Long term care (RAC) admissions;
Mortality;
SF-36 score;
Depression (CES-D).
Baseline, 6 & 12 mths f/up.
Trial 1:
RAC long-term care →.
Mortality →.
Improved SF-36 mental health & emotional components.
Reduced depression.
Number of falls →.
Trial 2:
RAC long-term care →.
Mortality →.
SF-36 scores →.
Reduced falls
Trial 3:
RAC long-term care →.
Mortality →.
SF-36 scores →.
Number of falls →.
Nakanishi 2018
Japan
Cluster-RCT
Aged > 65 years; Home-living patients with diagnosed dementia Intervention n = 141
(83.7 yrs)
Control n = 142
(84.9 yrs)
Challenging behaviour dementia training for care professionals; assessment of client behaviours & unmet needs; action plan; individualised multi-D treatment; behaviour monitoring; case management 6mth program
Could have frequent contacts
RAC placement;
Mortality;
Challenging behaviour (NPI-NH);
Pain (Abbey pain scale);
Cognition (SMQ);
Barthel Index for ADLs;
Medication use
Baseline, 6mths
RAC admission →.
Mortality →.
Challenging behaviours significantly improved in intervention group.
Other outcomes →.
Phung
2013
Denmark
RCT
Home-living patients diagnosed within the past 12 months with AD, mixed AD with vascular component or Lewy body dementia; ≥50 years; MMSE score ≥ 20; having one participating primary caregiver.
All patients met DSM-IV criteria for dementia, NINCDS-ADRDA criteria for probable AD or McKeith criteria for Lewy body dementia. No severe somatic or psychiatric comorbidities
Intervention n = 163 (76.5 yrs)
Control n = 167 (75.9 yrs)
Counselling, training, information and support for patients with mild dementia and their caregivers (DAISY) 8-12mths program
Phone contact every 3–4 weeks, 7 individual sessions, 5 group sessions
Patients: RAC admissions;
MMSE;
Cornell Depression Scale (CDS);
Health related QoL (EQ-VAS);
QoL-AD;
EuroQoL EQ-5D;
Neuropsychiatric Inventory (NPIQ);
ADSC-ADLs;
Mortality;
Carers: Geriatric Depression
Scale (GPS); Health related QoL (EQ-VAS);
Baseline, 6, 12 & 36 mths f/up.
RAC admission →.
MMSE changes →.
CDS changes →.
EQ-VAS changes→.
QoL-AD changes→.
NPIQ changes →.
ADSC-ADL changes →.
Mortality →.
Samus
2014
USA
RCT
Aged 70+ yrs.; English-speaking; community-residing; reliable partner; dementia or other cognitive disease; > 1 unmet need on JHDCNA; not in crisis (no signs of abuse, neglect, risk of danger to self/others) Intervention n = 110 (84.0 yrs)
Control n = 193 (83.9 yrs)
Interdisciplinary team case management, care planning, education & support for people with dementia (MIND) 18mth program
Monthly contact
Days at home;
RAC placement;
Mortality;
QOL-AD;
ADRQL-40;
QOL-AD-Informant;
Neuropsychiatric Inventory (NPIQ);
Depression (CSDD)
Baseline, 9 & 18 mths f/up.
Increase in mean days at home.
Reduced RAC placement or death.
[RAC admit not reported separately]
Improved self-reported QOL (QOL-AD).
Proxy rated QOL (ADRQL-40; QOL-AD-Informant) → .
NPS (NPI-Q), or participant depression (CSDD) Intervention →.
Senior
2014
New Zealand
RCT
Age ≥ 65 years (≥55 years for Māori); at high risk of institutionalisation but not placed; communicate in English. Intervention n = 52 (81.9 yrs)
Control n = 53 (83.6 yrs)
Case-managed restorative care service delivered in short-stay residential aged care facilities and at participants’ residences (Promoting Independence Programmes) 2 yr. program
Could have frequent contacts
RAC placements;
Deaths
Baseline, 24 mths f/up.
RAC placements →.
Deaths →.
Shapiro 2002
USA
RCT
Elders on a waiting list for community aged care; scored moderate risk based on Axs of chronic health conditions, ADL limitations, & other measures of physical & psychological impairment. Intervention n = 40 (77.7 yrs)
Control n = 65
(77.1 yrs)
Case managed, early intervention social service program for low-income elders 18mth program
Monthly contact
Institutionalised (RAC admission);
Deaths;
Depression (12-item Center for Epidemiological Studies Depression scale)
Baseline, 3, 6, 9, 12, 15 & 18 mths f/up.
RAC admission →.
Death →.
Improved OR for RAC admission or death.
Depression →.
Spoorenberg 2018
Netherlands
RCT
Age > 75 years; registered with a participating GP; not receiving other integrative care Intervention n = 747
(80.6 yrs)
Control
n = 709
(80.8 yrs)
Stratified by risk profile
Individualised program to maintain health & independence. Case managed, care plans, self management, information sessions, targeted support (EMBRACE) 12 mths
Could be frequent contacts
Institutionalised (RAC admission); Deaths; Health status (EQ-5D-3 L, INTERMED-E-SA, GFI, Katz-15); Wellbeing (GWI, QoL); Self management (SMAS = 30), PIH-OA)
Baseline, 12mths
RAC admission →.
Death →.
Deterioration in ADLs in intervention group (p = 0.04)
Other health status →
Wellbeing →.
Self management →.
Single focus interventions
Byles 2004
Australia
RCT
Veterans or war widows with full entitlements from DVA; aged ≥70 years; community dwelling. Intervention n = 942
Control n = 627
Annual or 6 monthly in-home assessments, provision of health materials, and report and liaison with GP. 3 year program Permanent admission to a RAC; deaths;
SF-36 scores;
Hospital admissions;
Baseline, 1 yr., 2 yr. & 3 yr. f/up.
Increased permanent RAC admission.
Number of deaths →.
SF-36 scores →.
Hospital admission →.
Gill
2002
USA
RCT
Aged ≥75 years; community dwelling; physically frail; can walk; speak English; MMSE score ≥ 20; life expectancy of > 12 mths; no major health event <6mths Intervention n = 94 (82.8 yrs)
Control n = 94 (83.5 yrs)
Home exercise program led by physical therapist to improve mobility and balance 6 month program
16 visits over 6 months - varied
RAC admissions;
Deaths;
Baseline, 3, 7 & 12 months f/up
RAC admission by 12 mth f/up →.
Number of days spent in a RAC by 12mths → .
Deaths during 12 mth → .
Hebert 2001
Canada
RCT
On Quebec Health Insurance Plan list; Aged > 75 years; community dwelling; born between 1 December & 30 April; spoke English or French Intervention n = 250 (80.2 yrs)
Control n = 253 (80.3 yrs)
Nursing assessment, report and recommendations to GP, monthly phone review 1 year program
Monthly contact
Admitted to RAC; Health service utilization;
Functional Measurement Autonomy (SMAF);
General Wellbeing Schedule (GWBS);
Social provisions scale (SPS);
Deaths
Baseline, 12 mths f/up.
Admission to RAC → .
Mean scores in SMAF, GWBS, SPS → .
Deaths Intervention →.
Health service utilization →.
Holland 2005
UK
RCT
Aged ≥80 yrs.; emergency hospital admission; discharged to own home or warden controlled accommodation; prescribed ≥2 drugs on discharge; no dialysis treatment. Intervention n = 429 (85.4 yrs)
Control n = 426 (85.5 yrs)
Home visit for medication review and education by pharmacist following hospital discharge 6–8 week program
2 visits
RAC admissions;
Mortality;
EQ-5D (QoL);
Emergency readmissions;
Baseline, 3 & 6 mths f/up.
RAC admissions →.
Reduced emergency readmissions.
Increased GPs home visits.
Deaths →.
Change in QoL EQ-5D scores →.
Lenaghan 2007
UK
RCT
>  80 years; living in own home; prescribed ≥4 daily medicines; & ≥ 1 criteria present: living alone; mental confusion vision; hearing impairment;prescribed medicines associated with medication-related morbidity; or prescribed > 7 regular oral medicines. Intervention n = 68 (84.5 yrs)
Control n = 66 (84.1 yrs)
Home visits by pharmacist for medication review and education 2 visits in 8 weeks RAC admissions;
Deaths;
EQ-5D (QoL)
Unplanned hospital admissions
Baseline, 6 mths f/up.
RAC admissions →.
Deaths →.
The EQ-5D scores →.
Unplanned hospital admissions →.
Luukinen 2006
Finland
RCT
Home dwelling; history of recurrent falls in past year, or at ≥1 risk factor for disability in ADLs or mobility. Intervention n = 243
Control n = 243
88 yrs
Community exercise program to prevent disability 18–24 month program
Bimonthly contact
RAC admission;
Mobility score;
Balance impairment;
ADL
Baseline, end of intervention & f/up.
RAC admission →.
Severe mobility restrictions at f/up →.
Reduction in impaired balance.
Improved mobility scores.
ADL score improvement →.
Newbury 2001
Australia
RCT
≥75 years; attending 1 of 6 GP practice sites; community dwelling; no dementia diagnosis Control n = 50 (80.76 yrs)
Intervention n = 50 (78.96 yrs)
Two annual 75+ Health Assessments with report back to GP 2 year program
Annual assessments
Institution (RAC) admissions;
Barthel ADL;
Self-rated health;
Deaths;
Folstein MMS;
GDS 15;
SF-36
Baseline, 12 mths f/up.
RAC admission →.
Barthel ADL → .
Self-rated health →.
Deaths →.
Folstein MMS Intervention →.
GDS 15 Intervention →.
SF-36 → .
Pardessus 2002
France
RCT
Aged ≥65 yrs.; hospitalized for falling; discharged home; no cognitive impairment; fall not secondary to medical or therapeutic problems; access to phone. Intervention n = 30 (83.51 yrs)
Control n = 30 (82.9 yrs)
Single occupational therapy home visit to address risk of falls 12mth program
1 x home visit
RAC admissions;
Functional autonomy measurement
system (SMAF);
Total ADL;
Total IADL;
Recurring fall;
Hospitalization for fall;
Hospitalization for another cause;
Deaths
Baseline, 6 & 12 mths f/up
RAC admission →.
Total SMAF 6–12 months Intervention →.
Total ADL scores at 6 or 12mths → .
Total IADL scores at 6 or 12mths → .
Total SMAF at 6 or 12mths → .
Recurring fall →.
Hospitalization for fall →.
Hospitalisation for another cause →.
Death →.
Spice
2009
United Kingdom
Cluster RCT
Aged ≥65 yrs.; community living; ≥2 falls in previous year; not presenting to ED with most recent fall; life expectancy > 1 yr.; abbreviated mental test score ≥ 7; English speakers. Controls n = 159 (83 yrs)
Primary care n = 136 (83 yrs)
Secondary care n = 210 (81 yrs)
Primary care intervention group – GP assessment to identify falls risk; referrals as needed.
Secondary care intervention group - multi-disciplinary Day Hospital falls prevention assessment with referrals as needed
12 months
Monthly contact
RAC admissions;
Falls;
Fall-related hospital admissions;
Mobility (Get up & go test)
Baseline, 12 mths f/up.
Admission to RAC →
Reduced falls.in Secondary Care Gp.
Falls in Primary Care Gp → .
Mobility score →.
Fall-related hospital admissions →.
Thomas 2007
Canada
RCT
Aged ≥75 years; no formal home care services; receiving informal care; not in RAC or other long term care; has a primary caregiver; English speaking; mentally competent. Intervention (1) n = 175 (80.7 yrs)
Intervention (2) n = 170 (80.4 yrs)
Control n = 175 (80.7 yrs)
Annual functional assessments with either (1) elders and carers only given results only, or (2) also offered help with referrals 4 year program
Annual contact
Institutional (RAC) admissions;
Deaths;
Self-efficacy;
Self-rated health status;
Caregiver burden
Baseline, yr1, yr2, yr3, yr4.
RAC admissions →.
Deaths →.
Self-efficacy →.
Self-rated health status →.
Caregiver burden →.
Vass
2005
Denmark
RCT
Aged 75-80 yrs.; Non-institutionalised; Intervention n = 1798
Control n = 1688
75 yr. and 80 yr. cohorts
Educational program for healthcare professionals and GPs in geriatric assessment and recognising early functional decline 3 year program
6 monthly contact
RAC admissions;
Mortality;
Functional ability
Baseline, 3 yr. f/up.
RAC admissions →.
Mortality →.
Improved functional ability in the 80 yr. old.
Improved functional ability in the 75 yr. olds.
OTHER RCTs (not clearly complex nor minimal interventions)
Caplan 2004
Australia
RCT
Aged ≥75 yrs.; discharged from ED; community dwelling. Intervention n = 370 (82.1 yrs)
Control n = 369 (82.4 yrs)
In-home assessment following ED presentation, with 28 days community support from hospital-based MultiD team 4 weeks RAC admission;
ED admission;
Hospital admission;
Mortality.
Baseline, 3, 6, 12 & 18 months f/up.
RAC admission →.
Reduced emergency admission to hospital.
Increased time to first ED admission.
Mortality →.
Kono
2012
Japan
RCT
Aged ≥65 years; need support to live at home; living at home; not used formal long-term care services for the past 3 months. Intervention n = 161 (80.3 yrs)
Control n = 162 (79.6 yrs)
Routine preventive home visits 6 monthly Every 6 months for 2 years Institutional admissions (RAC or group home);
Deaths;
Admitted to hospital;
Decline in ADLs;
Depression
Baseline, 1 & 2 yr. f/up
Institutionalized at 2 yr. → .
Deaths at 2 yrs. → .
Hospital admissions →.
Less decline in ADLs ability.
Reduced depression.
Increased utilisation of community long-term care.
Kono
2004
Japan
RCT
Aged > 65; living at home; walk independently; need some assistance to live in the community; went outdoors <3x/wk. Intervention n = 59 (82.5 yrs)
Control n = 60 (82.9 yrs)
Preventive home visits by public health nurses 3 monthly Home visits every 3 months for 18 months Living at home;
RAC admissions;
Mortality;
ADLs;
Social support;
Functional status
Baseline, 18 mths f/up.
Living at home →.
Admitted to RAC → .
Deaths →.
Less declining ADLs.
Social support →.
Rockwood 2000
Canada
RCT
Frailty (concern about community living, or recent bereavement, or hospitalization, or acute illness); frequent physician contact; multiple medical problems; polypharmacy; adverse drug events; functional impairment or functional decline; diagnostic uncertainty. Intervention n = 95 (81.4 yrs)
Control n = 87 (82.2 yrs)
Implementation of Comprehensive Geriatrician Assessment recommendations by a mobile geriatric assessment team. 3mth program
Range 1–6 contacts
RAC admissions;
Goal Attainment Scale (GAS);
Deaths
Baseline, 3, 6 & 12 mths f/up.
RAC admissions →.
Improved Goal Attainment (GAS).
Deaths →.
Scott
2004
USA
RCT
Aged ≥60 yrs.; ≥ 11 outpatient clinic visits in the prior 18 months; ≥1 chronic conditions; able to attend clinic; no serious cognitive impairment. Intervention n = 14 (74.2 yrs)
Control n = 149 (74.1 yrs)
Monthly group meetings for education, support & health review led by patients’ GP and a nurse 2 yr. program
Monthly contact
Skilled nursing facility (RAC) admissions; Hospital admissions;
Pharmacy services;
Health facility visits;
ADLs;
Self-reported Quality of life;
Baseline, 24 mths f/up.
RAC admissions →.
Reduced hospital admissions.
Reduced emergency visits.
Improved self-reported quality of life.
Increased self-efficacy.
ADLs →.
Pharmacy services →.
Hospital outpatient visits →.
Sommers 2000
USA
Cluster RCT
Aged > 65; not in RAC; 1+ visit to GP past 3mths; English speaking; Indep in mobility toileting feeding; Dependant in 1+ IADL; 2+ chronic conditions; not terminally ill; no dementia or metastatic disease. Intervention n = 280 (77 yrs)
Control n = 263 (78 yrs)
Collaborative care from a GP, nurse and social worker for chronically ill elders (chronic disease self-management model) 3 yr. program
Contact at least 6 weekly
RAC admissions;
Symptom scale;
SF-36;
Health Activities Questionnaire (HAQ);
Depression (GDS);
Medication count;
Nutrition checklist;
Hospital admissions;
GP office visits;
Deaths;
Social activities;
Baseline, yr1 & yr2
RAC admissions →.
Reduced hospital admissions.
Fewer GP office visits/yr.
Symptom scale, SF-36, HAQ, GDS, Medication count and Nutrition checklist Intervention →.
Deaths →.
Stuck
2000
Switzerland
RCT
Community living; Age 75+; German speaking; not terminal disease Intervention n = 264
82 yrs.
Control n = 527
81.5 yrs
Annual geriatric assessments with quarterly preventative home visits by a nurse 3 yr. program
3 monthly contact
RAC admissions;
Functional status;
Mortality
Baseline, 1 yr., 2 yr., 3 yr. f/up.
RAC admissions →.
Dependent in ADL or iADLs →.
Mortality →.
Van Hout 2010
The Netherlands
RCT
Aged ≥75 yrs.; living at home; meet criteria for frailty Intervention n = 331 (81.3 yrs)
Control n = 320 (81.5 yrs)
Geriatric assessments by nurses, personalized care plans and preventative home visiting 18mth program
3 monthly contact
Institutional (RAC) admissions;
Deaths;
Hospital admissions;
SF-36;
ADL;
IADL;
Emergency visits
Baseline, 6 & 18 mths f/up.
RAC admission →.
Death →.
Hospital admissions →.
Emergency visits →.
ADLs & iADLs →.
  1. → Indicates no significant difference between outcomes of intervention and control groups
  2. AD-Alzheimer’s disease; ADL-activities of daily living; ADRQL-40-Alzheimer’s Disease Rated Quality of Life-40 item; ADSC-ADL-Alzheimer’s Disease Cooperative Study Activities of Daily Living Scales; CDS-Cornell depression scale; CES-D-Centre for Epidemiological Studies Depression Scale; CSDD-Cornell Scale for Depression in Dementia; DSM-IV- Diagnostic and Statistical Manual of Mental Disorders version 4; DVA-Department of Veterans Affairs; ED-emergency department; EuroQoL - A generic utility measure used to characterize current health states; EQ-5D-EuroQol five dimensions questionnaire; EQ-5D-3 L -EuroQoL-5D-3 level version; EQ-VAS-EuroQol Visual Analogue Scales; Folstein MMS-Folstein Mini-Mental State; GAS-goal attainment scale; GDS-geriatric depression scale; GFI −15 item measure of frailty; GP-General Practitioner; GWBS-general wellbeing schedule; GWI –Groningen Wellbeing Index; HAQ-health activities questionnaire; IADL-instrumental activities of daily living; IHCaD-practice-generic prototype of care/case management-practice; INTERMED-E-SA – measure of complexity of care needs; Katz-15 – meaure of ADL limitations; MMSE-mini-mental state examination; Multi-D-multidisciplinary; JHDCNA-Johns Hopkins Dementia Care Needs Assessment; RAC-Residential Aged Care; NINCDS-ADRDA- National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer’s Disease and Related Disorders Association; NPIQ -Neuropsychiatric inventory questionnaire; NPI-NH -Neuropsychiatric inventory questionnaire fro Nursing Homes; OR-odds ratio; PIH-OA –Partners in Health Scale; QoL-quality of life; QoL-AD -Quality of Life Scale for Alzheimer’s disease; RCT-randomised control trial; SF-36-36-item Medical Outcomes Study Short Form; SIPA-System of Integrated Care for Older Persons; SMAF-functional measurement autonomy system; SMQ –Short Memory Questionnaire; SMAS – Self-Management Ability Scale; SPS-social provisions scale