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Current policies aim to promote and develop community-based support of disabled elderly persons, yet knowledge of the cost implications is insufficient. Thus, we aimed to estimate, for three disability profiles and three presence levels of the main informal carer (none, non-cohabitant, cohabitant), the cost of formal and informal support currently provided at home in Belgium. In this cross-sectional study, a sample of 5,642 disabled elderly persons living at home was established between 2010 and 2016. The administrative database of the Belgian public healthcare insurance was merged with other prospective data on social care service utilisation, informal care and disability. The total cost of formal support ranged from €725 to €1,344 (on average, per person, per month), depending on the three disability profiles identified. Twenty-five per cent of persons with the highest level of disability (important functional limitations and cognitive impairment) and helped by a cohabitant carer, had a low total cost of formal support: below €382 per month. Informal care represented the main cost component of total support costs in the three disability profiles (between 64 and 76%). To prevent the worsening of situations of disabled older persons and their informal carers, better detection of seriously disabled persons with low levels of formal support is crucial. [ABSTRACT FROM AUTHOR]

The methodological challenges to effectiveness evaluation of complex interventions has been widely discussed. Bottom-up case management for frail older person was implemented in Belgium, and indeed, it was evaluated as a complex intervention. This paper presents the methodological approach we developed to respond to four main methodological challenges regarding the evaluation of case management: (1) the standardization of the interventions, (2) stratification of the frail older population that was used to test various modalities of case management with different risks groups, (3) the building of a control group, and (4) the use of multiple outcomes in evaluating case management. To address these challenges, we developed a mixed-methods approach that (1) used multiple embedded case studies to classify case management types according to their characteristics and implementation conditions; and (2) compared subgroups of beneficiaries with specific needs (defined by Principal Component Analysis prior to cluster analysis) and a control group receiving 'usual care', to evaluate the effectiveness of case management. The beneficiaries' subgroups were matched using propensity scores and compared using generalized pairwise comparison and the hurdle model with the control group. Our results suggest that the impact of case management on patient health and the services used varies according to specific needs and categories of case management. However, these equivocal results question our methodological approach. We suggest to reconsider the evaluation approach by moving away from a viewing case management as an intervention. Rather, it should be considered as a process of interconnected actions taking place within a complex system. [ABSTRACT FROM AUTHOR]

Background/objective although informal caregivers (ICG) find caring for a relative mainly satisfying, it can be difficult at times and it can lead to a state of subjective burden characterised by -among others- fatigue and stress. The objective of this study is to analyse the relationship between perceived social support and subjective burden in providing informal care to frail older people. Methods a descriptive cross-sectional study was conducted using data from a large nationwide longitudinal effectiveness study. Pearson correlations were calculated between the variables for support and burden. Logistic regression models were applied to determine the association between being unsatisfied with support and burden, taking into account multiple confounding variables. Results of the 13,229 frail older people included in this study, 85.9% (N = 11,363) had at least one informal caregiver. Almost 60% of the primary informal caregivers manifested subjective burden, measured with the 12-item Zarit-Burden-Interview (ZBI-12). The percentage of informal caregivers that were unsatisfied with support from family and friends was on average 11.5%. Logistic regression analysis showed that being unsatisfied with support is associated with burden (OR1.85; 95%CI1.53–2.23). These results were consistent for the three groups of impairment level of the frail older persons analysed. Conclusions the association between perceived social support and subjective caregiver burden was explored in the context of caring for frail older people. ICGs who were unsatisfied with support were more likely to experience burden. Our findings underline the importance of perceived social support in relation to caregiver burden reduction. Therefore efforts to improve perceived social support are worth evaluating. [ABSTRACT FROM AUTHOR]

Background. Approximately one third of older people over 65 years fall each year. Home modifications may decrease occurrence of falls. Purpose. This study aims to determine the risk factors of falls for frail older persons and to evaluate the impact of home modifications by an occupational therapist on the occurrence of falls. Method. We conducted a longitudinal study using a quasiexperimental design to examine occurrence of falls. All participants 65 years of age and older and were assessed at baseline and 6 months after the intervention. Bivariate analysis and logistic regression models were used to study the risk factors of falls and the effect of home modifications on the incidence of falls. Findings. The main predictors of falls were vision problems, distress of informal caregiver, and insufficient informal support. Home modifications provided by an occupational therapist showed a significant reduction of falls. Implications. Informal caregivers and their health status had an impact on the fall risk of frail older persons. Home modifications by an occupational therapist reduced the fall risk of frail older persons at 6-months follow-up. [ABSTRACT FROM AUTHOR]

Objectives To examine the effects of home care interventions for frail older people in delaying permanent institutionalization during 6 months of follow-up. Design Longitudinal quasi-experimental research study, part of a larger study called Protocol 3. Setting Community care in Belgium. Participants Frail older adults who received interventions (n = 4,607) and a comparison group of older adults who did not (n = 3,633). Organizations delivering the interventions included participants provided they were aged 65 and older, frail, and at risk of institutionalization. A comparison group was established consisting of frail older adults not receiving any interventions. Intervention Home care interventions were identified as single component (occupational therapy ( OT), psychological support, night care, day care) or multicomponent. The latter included case management ( CM) in combination with OT and psychological support or physiotherapy, with rehabilitation services, or with OT alone. Measurements The inter RAI Home Care ( HC) was completed at baseline and every 6 months. Data from a national database were used to establish a comparison group. Relative risks of institutionalization and death were calculated using Poisson regression for each type of intervention. Results A subgroup analysis revealed that 1,999 older people had mild impairment, and 2,608 had moderate to severe impairment. Interventions providing only OT and interventions providing CM with rehabilitation services were effective in both subpopulations. Conclusion This research broadens the understanding of the effects of different types of community care interventions on the delay of institutionalization of frail older people. This information can help policy-makers to plan interventions to avoid early institutionalization. [ABSTRACT FROM AUTHOR]

Background: Case management is a type of intervention expected to improve the quality of care and therefore the quality of life of frail, community-dwelling older people while delaying institutionalisation in nursing homes. However, the heterogeneity, multidimensionality and complexity of these interventions make their evaluation by the means of classical approaches inadequate. Our objective was twofold: (i) to propose a tool allowing for the identification of the key components that explain the success of case management for this population and (ii) to propose a typology based on the results of this tool. Methods: The process started with a multiple embedded case study design in order to identify the key components of case management. Based on the results of this first step, data were collected among 22 case management interventions, in order to evaluate their expected effectiveness. Finally, multiple correspondence analyses was conducted to propose a typology of case management. The overall approach was informed by Wagner's Chronic Care Model and the theory of complexity. Results: The study identified a total of 23 interacting key components. Based on the clustering of response patterns of the 22 case management projects included in our study, three types of case management programmes were evidenced, situated on a continuum from a more "socially-oriented" type towards a more "clinically-oriented" type of case management. The type of feedback provided to the general practitioner about both the global geriatric assessment and the result of the intervention turned out to be the most discriminant component between the types. Conclusion: The study design allowed to produce a tool that can be used to distinguish between different types of case management interventions and further evaluate their effect on frail older people in terms of the delaying institutionalisation, functional and cognitive status, quality of life and societal costs. [ABSTRACT FROM AUTHOR]

Introduction: The aim is to present the evaluation of effectiveness of case management interventions, designed from the bottom-up, which have been implemented in Belgium since 2010 to support dependent elderly people at home. This type of intervention is an integrated care process which combines prevention, evaluation, custom designed multidisciplinary care plan, coordination of services and follow-up. Mixed methods are necessary for covering the indispensable steps of the analysis of effectiveness which includes the specific description of the interventions, the identification of the target populations, the building of a control group, the tracking of pertinent indicators, and the choice of a quantitative approach bearing in mind the implementation process of the interventions. Methods: The quantitative analysis of effectiveness has been guided by the results of the implementation analysis, a qualitative approach which provides the description of essential components of the interventions. Two quantitative databases are available for the beneficiaries and the control group (not benefiting from interventions and recruited by home care organisations, thus reflecting “usual care”): (1) a prospective data collection through a validated comprehensive geriatric instrument (the interRAI Home Care instrument) including clinical variables and data related to the informal caregivers, and (2) the administrative database of the reimbursed health care consumption (routinely recorded by the health care insurance). The different types of dependency are defined through a clustering analysis grouping beneficiaries according to functional and cognitive limitations. Thereafter, each P3 beneficiary is matched by using a propensity score method with one individual of the control group having similar health characteristics and similar levels of presence of informal caregiver (without, non-cohabitant, cohabitant). Finally, the different variables for assessing effectiveness are tested between beneficiaries and the control group. Results: Case management interventions are grouped according to three criteria: (1) the feedback to a general practitioner, (2) the psychological support, and (3) the intensity of the intervention. Beneficiaries are divided into five dependency types (low limitations; important IADL limitations; important ADL and IADL limitations; significant cognitive and functional deficiencies; and people cumulating significant cognitive, functional and behavioural problems). The results are presented for each of the above subgroups in the form of a “dashboard” including the different essential indicators for the evaluation of the impact of the intervention: indicators of health care consumption (i.e. nursing care at home, visits to a medical specialist), indicators identifying the stress on the health system (i.e. unexpected hospitalisation, visits to emergency service) and clinical outcomes (i.e. functional, cognitive, and depressive status, quality of life, informal caregiver’s perceived burden). Discussion: The analysis of the data collected through the questionnaires filled out by both the care recipients and their main informal caregivers linked to the administrative database of health care consumption provides a comprehensive evaluation of the effectiveness of a complex intervention. Both clinical and use of resources outcomes are analyzed for the dyads of care recipients/informal caregivers and allow for comprehensively and accurately describing the consequences of case management interventions according to various types of situations at home. [ABSTRACT FROM AUTHOR]

Aim and background. Although many systematic reviews have been conducted over the last decade to assess the overall effectiveness of case management to achieve desirable outcomes for community-dwelling frail older persons, there is little evidence that the expected results are indeed achieved in terms of delaying unwanted institutionalisation, stabilising functional status, lower overall healthcare cost, reduce informal caregiver burden and improve quality of life. One of the reasons provided is the method of data pooling used in the meta-analyses in these reviews, by aggregating the information, despite the extreme heterogeneity of the case management interventions, i.e. components, activities and context. The aim of the systematic review was to provide one or more theories about why and how case management interventions were successful (or not) in their given contexts and for whom? Methods. A realist approach was used in order to define the mechanisms by which the case management interventions were linked to frail older persons' outcomes in a given context. Therefore, we performed firstly a qualitative scoping, in order to 'map the area' and build a tentative theoretical framework. In a second step, we conducted a systematic review in MEDLINE, EMBASE, CINAHL, ISI Web of Knowledge, PsychInfo in Spring 2013. Reference list of selected papers were hand-searched. During an iterative process of discussion with a multidisciplinary team and further diving into the extracted information from the selected articles, we build and tested a theoretical framework of successful case management. As a result of the iterative research strategy and discussions, 87 papers were included in the analysis. A first theoretical framework was proposed, guided by D'Amour's framework of collaborative professional care and linked to the outcomes of case management interventions studied. Four domains were identified: impact of the components of the interventions, impact of the characteristics of the target population, impact of the technologies or tools used and impact of the organisational strategies. Discussion. This review strategy yielded interesting and robust evidence about key components of case management interventions which can explain the success of failure of a case management intervention to achieve its goals, in a given context. [ABSTRACT FROM AUTHOR]

Background / Objective: In the international literature, case management is often found to be a valuable way of organizing home care services and providing continuity of care. However, not many studies have provided evidence that case management can be effective in delaying institutionalization of older persons. The Belgian federal government is interested in funding home care projects that attain this goal. Twenty two case management projects will be analyzed during a 4-year period to reach a policy decision. Methods: Professional caregivers are asked to fill out the comprehensive geriatric assessment interRAI Home Care (HC) and an ad-hoc economic questionnaire describing the social services use and the time of informal care Informal caregivers also fill out the Zarit Burden scale 12 items and older persons fill out the WHOQOL-8. After descriptive statistics, the study population is stratified according to impairment levels (ADL, depression and cognition). Multivariate analyses are performed to identify significant associations and the effect of case management on the delay of institutionalization. Results: The study population consists of frail older persons in 21 case management projects (n=8534, average age: 79.7 median age 81.0, 67.6% women. The total of older persons in case management projects is 5004. This population shows moderate to high ADL impairment (47% CI(0.45 - 0.48)), moderate to high cognitive problems (27% CI(0.25 - 0.27)) and daily depression symptoms (27% CI(.25 - .28). These clients will be compared to a population not receiving any case management. Conclusion: This research will show the effect of case management combined with home care interventions in order to delay institutionalization of older persons. This information can help home care providers to adapt their services into a more integrated form of care model where case management will bring different types of services together. The results will also help policy makers to decide whether case management should be funded or not. [ABSTRACT FROM AUTHOR]

Purpose/objectives: The Belgian National Institute for Health and Disability Insurance (NIHDI) is interested in delaying institutionalization of older persons. Informal caregivers play an important role in maintaining the health, well-being, functional performance and quality of life of older people living at home. The aim of this paper is to identify whether innovative projects in home care are statistically associated with decreasing the informal caregiver's perceived burden. Background/Methods: The study uses the interRAI HC instrument and a shorter version of the original 22-Zarit Burden Interview. In this ongoing study we have a population of 4346 frail older persons who have an informal caregiver and who are benefiting from innovative projects in home care. Through multivariate logistic regression researchers analyze the effect of the projects in the burden of caregivers. This method enables researchers to take into account factors such as the older person's cognitive functioning, ADL performance, depressive symptoms, as well as the informal caregivers' characteristics. Conclusions: This research will provide knowledge on perceived burden and will show whether some types of interventions may have a positive effect on decreasing the burden in giving care. This is important information for home care agencies but also useful information for policy makers at a societal level. [ABSTRACT FROM AUTHOR]

Background/objective: although informal caregivers (ICG) find caring for a relative mainly satisfying, it can be difficult at times and it can lead to a state of subjective burden characterised by -among others- fatigue and stress. The objective of this study is to analyse the relationship between perceived social support and subjective burden in providing informal care to frail older people., Methods: a descriptive cross-sectional study was conducted using data from a large nationwide longitudinal effectiveness study. Pearson correlations were calculated between the variables for support and burden. Logistic regression models were applied to determine the association between being unsatisfied with support and burden, taking into account multiple confounding variables., Results: of the 13,229 frail older people included in this study, 85.9% (N = 11,363) had at least one informal caregiver. Almost 60% of the primary informal caregivers manifested subjective burden, measured with the 12-item Zarit-Burden-Interview (ZBI-12). The percentage of informal caregivers that were unsatisfied with support from family and friends was on average 11.5%. Logistic regression analysis showed that being unsatisfied with support is associated with burden (OR1.85; 95%CI1.53-2.23). These results were consistent for the three groups of impairment level of the frail older persons analysed., Conclusions: the association between perceived social support and subjective caregiver burden was explored in the context of caring for frail older people. ICGs who were unsatisfied with support were more likely to experience burden. Our findings underline the importance of perceived social support in relation to caregiver burden reduction. Therefore efforts to improve perceived social support are worth evaluating., (© The Author(s) 2019. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: To examine the effects of home care interventions for frail older people in delaying permanent institutionalization during 6 months of follow-up., Design: Longitudinal quasi-experimental research study, part of a larger study called Protocol 3., Setting: Community care in Belgium., Participants: Frail older adults who received interventions (n = 4,607) and a comparison group of older adults who did not (n = 3,633). Organizations delivering the interventions included participants provided they were aged 65 and older, frail, and at risk of institutionalization. A comparison group was established consisting of frail older adults not receiving any interventions., Intervention: Home care interventions were identified as single component (occupational therapy (OT), psychological support, night care, day care) or multicomponent. The latter included case management (CM) in combination with OT and psychological support or physiotherapy, with rehabilitation services, or with OT alone., Measurements: The interRAI Home Care (HC) was completed at baseline and every 6 months. Data from a national database were used to establish a comparison group. Relative risks of institutionalization and death were calculated using Poisson regression for each type of intervention., Results: A subgroup analysis revealed that 1,999 older people had mild impairment, and 2,608 had moderate to severe impairment. Interventions providing only OT and interventions providing CM with rehabilitation services were effective in both subpopulations., Conclusion: This research broadens the understanding of the effects of different types of community care interventions on the delay of institutionalization of frail older people. This information can help policy-makers to plan interventions to avoid early institutionalization., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)