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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 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