Assessment Of Services Promoting Independence And Recovery In Elders (ASPIRE)

Assessment Of Services Promoting Independence And Recovery In Elders (ASPIRE)

About ASPIRE
The primary aim of the Health of Older People Strategy (2002) is to develop an integrated approach to health and disability support services that is responsive to older people’s varied and changing needs.

Ageing-in-place services – that give older people the ability to make choices in later life about where to live, and to receive the support needed to do so – are a key component of meeting the aims of the Strategy.

In recent years, various ageing-in-place programmes have been set up around New Zealand. For such programmes, ageing-in-place is where home care meets the needs of older people who would otherwise require residential care.

The ASPIRE project was set up to evaluate the effectiveness of three of the more significant ageing-in-place programmes:

the Coordination of Services for the Elderly (COSE), Christchurch
the Promoting Independence Programme (PIP), Lower Hutt
Community FIRST (Flexible Integrated Restorative Support Team), Hamilton

ASPIRE has been a collaborative research project involving Auckland University, the Ministry of Health, and the Canterbury, Hutt Valley and Waikato district health boards.

The findings will enable us to determine the key elements that make a successful ageing-in-place service.

The three initiatives

COSE
Co-ordinated Services for the Elderly (COSE) was set up in 2000 by Canterbury DHB and Pegasus Health. Based in Christchurch, COSE is a community-based needs assessment and service co-ordination initiative. The aim was to avoid duplication in service provision. A key worker is assigned to several general practice teams and identifies resources and opportunity within communities. This offers older people a greater choice of service support and facilitates safely staying in the community. COSE represents an evolution of the current Needs Assessment Service Co-ordination (NASC). The model is a case management intervention.

PIP
The Promoting Independence Programme (PIP) was developed by the Lower Hutt Masonic Villages Trust in collaboration with Hutt Valley District Health Board, and operates in Lower Hutt. PIP is for people who would not be able to maximise their potential for recovery within the average hospital stay. Referrals to the programme are made by medical consultants, general practitioners, NASC and other similar agencies. A key worker is assigned to each older person and they initiate and co-ordinate the person’s rehabilitation process. The process also involves a team of healthcare workers including registered nurses, occupational therapists, physiotherapists and speech therapists. Older people can receive up to 8 weeks of facility based rehabilitation or, if able to receive services in the community, up to one year of rehabilitation from the time of the health event. Hand over to home care providers occurs after that period. PIP does not replace NASC, instead it integrates with current practice. The model aims to improve functional status.

Community FIRST
Community FIRST (Flexible Integrated Rehabilitation Support Team) was established in 2002 by Presbyterian Support Northern, Waikato District Health Board and the Ministry of Health, and operates in Hamilton. Community FIRST offers a different approach in the form of restorative home support, which usually involves the integration of physical activity into the routine delivery of services. It uses a multidisciplinary team (primarily registered nurse, physiotherapist and occupational therapist) and delivery is based on several levels of support depending on the needs of the older person. It offers a replacement for current home care provision. The model aims to improve functional status.

ASPIRE’s objectives

To assess the effectiveness of the ageing-in place initiatives as compared to usual care in preventing (or delaying) the time before a community-based older person requires permanent residential care
To assess the effectiveness of the ageing-in-place initiatives in improving survival in community-based older people compared to usual care
To determine the impact of the ageing-in-place initiatives on an older person’s independence and health related quality of life compared to similar measures in those receiving usual care
To establish the degree of correlation between the expected improvement in the health-related quality of life of informal caregivers attributable to the ageing-in-place initiative, compared to those receiving usual care
To identify the key elements of the ageing-in-place initiative healthcare models of community-based service delivery that lead to beneficial outcomes

The research process

The researchers conducted randomised control trials of a sample of patients using the three ageing-in-place initiatives, compared to the usual care resulting from NASC assessment.

There were 569 participants in the trial. They received care as summarised in the table below.

Table: Number of participants in the ASPIRE trial
Location	Ageing-in-place Initiative	Number in the Initiative	Number in Usual Care	Total
Christchurch	COSE	169	182	351
Hamilton	Community FIRST	56	57	113
Lower Hutt	PIP	52	53	105
Total		277	292	569

Participants in the trial:

were males and females aged 65 or over on the day of the initial assessment, or 55+ if of Maori or Pacific Island ethnicity or classified by NASC as ‘like age and interest
were assessed by NASC co-ordinators or hospital clinicians as meeting the classification of ‘high’ or ‘complex’ need (i.e. at risk of entry to residential care)
provided and were capable of providing a declaration of informed consent (or by their main caregiver)
were English-speaking or provided a family member who could act as an interpreter

Initial interviews were conducted before people participated in the trials. Interviews were repeated at three months, six months and then every six months to an average of 18 months. Interviews were conducted face-to-face or by telephone, and included assessment of function, quality of life, degree of community involvement, use of health and social services and mood assessment. Adverse events (e.g. falls, injuries and hospitalisations) were also recorded. A standardised data collection tool (InterRAI) was used.

Summary of key findings

The key findings are:

All three services reduced the risk of mortality compared with usual services in their respective regions
All three services reduced the risk of entry to residential care in comparison with usual care
Caregiver stress levels did not appear to rise in the intervention groups in comparison to usual care, despite older people with high and complex needs continuing to live at home
An improvement in the independence levels of older people (as measured by Activities of Daily Living) was noted in the Community FIRST initiative, compared to usual care. No change was noted in function in the COSE or PIP initiatives in comparison to usual care

Predictive modelling using the same data set identified a number of factors that increase the likelihood of older people being hospitalised or entering residential care. Factors associated with increased risk of residential care included functional decline, social isolation, negative mood, caregiver stress, inadequate meals or dehydration. Factors associated with increased risk of hospitalisation included a lack of medication review, negative mood and previous hospitalisation.

An incidental finding was that the current Support Needs Level Assessment process used by NASCs to determine need, and the resulting allocation of services, was highly variable across the three district health boards involved in the project.

Summary of key conclusions

The sample sizes for two of the initiatives were smaller than planned for a number of reasons, mainly due to difficulty recruiting participants. This meant that some of the results were not statistically significant. However, clear trends are apparent in all the results, both across the services and in comparison with the usual services.

When considered in the context of other research internationally, the ASPIRE trials demonstrate that such initiatives can be effective in keeping older people living in the community longer.

Where to from here

A discussion document will be released in mid October. The discussion document will highlight key elements of new models of care to support older people to stay in their own homes or the community.

The Ministry of Health will hold bilateral meetings with the organisations involved in service delivery and development across the older people sector during late October and November 2006.

Detailed summary of key findings

All three services reduced the risk of mortality compared with usual services in their respective regions, although the small sample size impacted on the statistical significance of the findings. Mortality risk was reduced by 28% for those enrolled in Community FIRST, 14% in PIP and 10% in COSE.
All three services reduced the risk of entry to residential care in comparison with usual care. The COSE programme reduced the risk by 43%, Community FIRST by 33% and PIP by 16%. The lower sample size for Community FIRST and PIP impacted on the statistical significance of the findings for these interventions.
Caregiver stress levels did not appear to rise in the intervention groups in comparison to usual care, despite older people with high and complex needs continuing to live at home.
An improvement in the independence levels of older people (as measured by Activities of Daily Living) in the Community FIRST initiative was noted, in comparison to usual care. No change was noted in function in the COSE or PIP initiatives in comparison to usual care.
An incidental finding of the research was that the current Support Needs Level Assessment process used by NASCs to determine need, and thus the allocation of services, was highly variable across the three District Health Boards. Older people in Christchurch were assessed as requiring residential care with a lower level of disability than those living in Hamilton and Lower Hutt. The MDS-HC (InterRAI) assessment tool used by the research team appeared to provide a more rigorous and standardised method of assessment. The variation in needs assessment explains some of the variation between the outcomes achieved for the different services in the three regions.
Predictive modelling of the likelihood of older people being hospitalised or entering residential care was also undertaken using the complete data set. The results of this modelling show that:

If a functional decline occurs in older people, the older person is 11 times more likely to enter residential care;
An older person is almost twice as likely to enter residential care if they are socially isolated;
If an older person reports having a negative mood, they are over twice as likely to be admitted to residential care;
For every one unit increase on the Caregiver Reaction Assessment (which measures caregiver stress), there is a 7% increased risk of residential care entry;
When an older person has inadequate meals or experiences dehydration, they are over twice and 1.7 times more likely to be admitted to residential care, respectively;
Older people with delirium are 3.6 times more likely to enter residential care;
A lack of medication review (almost twice as likely), negative mood (1.5 times more likely) and previous hospitalisation (1.8 times more likely) are all correlated with increased risk of hospitalisation.

The ASPIRE report also included the results from in-depth interviews with a sub-sample (131 people) from the same study population. The research was undertaken as part of a PhD thesis known as OPERA and was not part of the original scope of ASPIRE. Given the shortage of widely accepted quality of life indicators appropriate for older people in New Zealand, this research will contribute towards the development of these measures.
The OPERA findings show that having the ability to make their own decisions and to be able to cope at home are very important to older people, as is their place of residence.
The OPERA study explored the process by which people entered residential care. While many older people felt they had made the decision to enter residential care themselves, in most cases the family and NASC services thought that the family had been the main decision makers.
Nearly half of those who had entered residential care were ‘sad’ or ‘very sad’ about the decision. By contrast three quarters of those living in their own homes were ‘happy’ or ‘very happy’ with their place of residence.

Related information

Media Release (26 Sept) Key Findings of Research Trial to Improve Outcomes for Older People Released