Maintaining Independence: Predicting and Preventing Residential Care Admission in Frail Older People Discharged from Hospital

Abstract

This thesis examines influences on outcomes for frail older people in the year following their discharge from a specialist subacute geriatric assessment unit. It is a mixed methodology study comprising four phases: an exploratory retrospective cohort study, a prospective cohort study in which outcomes for the cohort are examined both quantitatively and qualitatively to develop models to predict outcome, a validation cohort for these models and finally a pilot feasibility study for an intervention to support older people in the post-discharge period. In the context of the growing ageing population, health and social care for older people is becoming a critical issue. It has been shown that older people would prefer to retain their independence and remain living in their own homes in their communities whenever possible. Those that remain in their own homes have better quality of life and lower rates of depression. The New Zealand government “Positive Ageing” strategy, and internationally the World Health Organisations “Active Ageing” policy framework support the goal of independent living for older people Frailty is an evolving concept in the field of geriatric medicine. Frail older people are a group with reduced physical and mental health, cognitive and social reserves, in whom even a minor insult may trigger a catastrophic functional decline leading to outcomes such as institutionalisation and hospital admissions. Recognition of frailty is important, as a number of interventions have been shown to improve outcomes in frail people including comprehensive geriatric assessment. My study group are frail older people in whom an acute illness has led to a loss of function requiring further hospital inpatient treatment and rehabilitation before they could be discharged. There is little existing evidence specifically regarding this group, either in terms of predicting outcomes, or interventions to support discharge and ongoing “ageing in place.” In the first phase of this study, I conducted a retrospective audit of outcomes in older people discharged from subacute geriatric care. The majority of older people were able to remain at home at one year. Predictors of residential care admission included age and function. In the second phase I conducted a prospective cohort study using both quantitative and qualitative methods to examine predictors of outcome. Predictors of residential care admission included degree of frailty, dementia, self-rated quality of life and further hospital admissions. Telephone follow-up interviews were also conducted, and those who reported their health as deteriorating had a significantly increased likelihood of entering residential care. In contrast further hospital admissions were predicted by comorbidities. Qualitative interviews were conducted with a group of older people who had entered residential care and a matched group who remained in their own homes. Key issues included burden on carers, attitudes of patients, carers and health professionals, and the impact of repeated hospital admissions. In the validation cohort, I showed that the models I developed predicted outcomes with good sensitivity. Finally, I aimed to develop an intervention based on earlier findings to support older people to remain in the community following discharge from hospital. Within the context of dynamically developing services for older people in Canterbury and New Zealand it was essential to work alongside these new developments. My intervention dovetailed with the newly evolving restorative home support system. I used regular telephone contact after discharge to identify those who reported their health as deteriorating. These people received a domiciliary visit, were discussed at a multidisciplinary team meeting and then had an individually tailored intervention. Regular telephone calls were acceptable to older people and their carers, and the majority reported a positive impact on their health. A number of feasibility issues, particularly in the interactions between my intervention and the community service were identified. In summary, this study shows that it is possible to identify older people at high risk of adverse outcomes at the time of hospital discharge, and that routine measurement of frailty would be a useful addition to inpatient geriatric care. Regular telephone contact following discharge is acceptable to older people and carers and allows identification of those whose health is deteriorating earlier than they would otherwise present to primary or secondary care. Further development and testing of post-discharge supports is warranted.