Creating sustainable home care services for older people

Abstract

Background: The population is ageing and recent years have revealed substantial increases in expenditure and demand for home care services. However, provision of home care is fraught with quality issues such as high staff turnover rates, inadequate staff training, a lack of coordinator support and reduced continuity of care. Consequently, ensuring the sustainability of home care services remains a critical area of concern. Objective: To evaluate the impact of a restorative home care service, for older people with varying levels of need, in relation to improving quality and sustainability. Design: Randomised controlled trial with cluster randomisation. Older people and their support workers were identified via a home care agency and cluster randomised to receive either the restorative home care service (intervention=93) or usual home care (control=93). Intervention: The restorative home care service involved goal facilitation, repetitive activity of daily living exercises, and an in-depth initial assessment for older people; experiential training for support workers; care management role and enhanced skill and competency level for the coordinator. Participants: Older people (65+ years), living in their own homes, who received assistance from a home care agency in South Auckland, New Zealand. Methods: Face-to-face interviews were conducted with older people at baseline, four and seven months. The primary outcome was change in health related quality of life measured by the Short Form 36 Health Survey. Other scale measurements were utilised to assess physical, mental and social wellbeing. Informal carer stress was assessed with the Carer Reaction Assessment. Focus groups were held with support workers at baseline and 14 months to ascertain their opinions. Coordinator perceptions were established via one-on-one interviews at 14 months. A basic comparison of costs for the two groups was undertaken. Results: Compared with usual care, restorative home care demonstrated a statistically significant improvement in health related quality of life over time for older people (P=0.05). There were no changes in other scale measurements for older people in both groups over time. Support worker turnover was 42.5 and 17.9 percent for the control and intervention group, respectively, and job satisfaction improved within the intervention group in comparison to the control group. Value adding costs increased, while, non-value adding costs were reduced. Key aspects of the intervention contributing to these findings included goal facilitation and development of personalised support plans, the coordinators enhanced input and support and the improved training for support workers. Conclusions: This study demonstrated a restorative home care service can enhance the quality of service provision to benefit both older people and support worker staff. Further amendments are addressed, such as improving support worker employment conditions and raising the eligibility criteria for home care, to ensure future sustainability.