Table 1 Characteristics and summarized outcomes

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 →.

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.

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 →.