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Background: The current study examined potential risk factors for experiencing a decline on the interRAI Cognitive Performance Scale (CPS)., Methods: This was a retrospective cohort study using secondary data collected with the Resident Assessment Instrument for Home Care (RAI-HC) for all assessments completed in Canada between 2001 and 2020. Eligible home care clients included individuals 65+, with at least two assessments completed within 12 months, and who had a CPS score of zero at baseline (n = 146,187). A decline on the CPS was defined as any increase (i.e., worsening) on the CPS score between the two assessments., Results: The mean age of the sample was 80.6 years (standard deviation = 7.7), 67.9% were female and 44.5% were widowed. At the time of the second assessment, 25.2% experienced a decline on their CPS score. In the final multivariate model, age, having a diagnosis of Alzheimer's dementia/other type of dementia, physical inactivity, and having a caregiver at risk of experiencing burden were the most significant predictors of experiencing the outcome., Conclusions: Roughly one-quarter of Canadian home care clients experienced a cognitive decline, over an average of seven months. Since there are some modifiable risk factors for this outcome, it is important to identify and flag these factors as early as possible. Early identification of modifiable risk factors allows clinicians to create care plans that can optimize the well-being of the client and their family., (© 2024. The Author(s).)

Objectives: This study examined potential predictors of persistent depressive symptoms in a cohort of seriously ill older adults (aged 65+ years) receiving home care services., Methods: This was a retrospective cohort study using secondary data collected from the Resident Assessment Instrument for Home Care for all assessments completed between 2001 and 2020. The cohort included seriously ill individuals with depressive symptoms at baseline and who continued to have depressive symptoms on reassessment within 12 months ( n  = 8,304). Serious illness was defined as having severe health instability, a prognosis of less than 6 months, or a goal of care related to palliative care (PC) on admission to the home care program., Results: The mean age of the sample was 80.8 years (standard deviation [SD] = 7.7), 61.1% were female, and 82.1% spoke English as their primary language. The average length of time between assessments was 4.9 months (SD = 3.3). During that time, 64% of clients had persistent symptoms of depression. A multivariate logistic regression model found that language, pain, caregiver burden, and cognitive impairment were the most significant predictors of experiencing persistent depressive symptoms., Significance of Results: Persistent depressive symptoms are highly prevalent in this population and, left untreated, could contribute to the person experiencing a "bad death." Some of the risk factors for this outcome are amenable to change, making it important to continually assess and flag these factors so interventions can be implemented to optimize the person's quality of life for as long as possible.

Background: To develop and validate a prediction tool, or nomogram, for the risk of a decline in cognitive performance based on the interRAI Cognitive Performance Scale (CPS)., Methods: Retrospective, population-based, cohort study using Canadian Resident Assessment Instrument for Home Care (RAI-HC) data, collected between 2010 and 2018. Eligible home care clients, aged 18+, with at least two assessments were selected randomly for model derivation (75%) and validation (25%). All clients had a CPS score of zero (intact) or one (borderline intact) on intake into the home care program, out of a possible score of six. All individuals had to remain as home care recipients for the six months observation window in order to be included in the analysis. The primary outcome was any degree of worsening (i.e., increase) on the CPS score within six months. Using the derivation cohort, we developed a multivariable logistic regression model to predict the risk of a deterioration in the CPS score. Model performance was assessed on the validation cohort using discrimination and calibration plots., Results: We identified 39,292 eligible home care clients, with a median age of 79.0 years, 62.3% were female, 38.8% were married and 38.6% lived alone. On average, 30.3% experienced a worsening on the CPS score within the six-month window (i.e., a change from 0 or 1 to 2, 3, 4, 5, or 6). The final model had good discrimination (c-statistic of 0.65), with excellent calibration., Conclusions: The model accurately predicted the risk of deterioration on the CPS score over six months among home care clients. This type of predictive model may provide useful information to support decisions for home care clinicians who use interRAI data internationally., (© 2023. The Author(s).)

Background: In the general population, sensory impairments increase markedly with age in adults over 60 years of age. We estimated the prevalence of hearing loss only (HL), vision loss only (VL), and a combined impairment (i.e., dual sensory loss or DSL) in Canadians receiving home care (HC) or long-term care (LTC)., Methods: Annual cross-sectional analyses were conducted using data collected with one of two interRAI assessments, one used for the HC setting (n = 2,667,199), and one for LTC (n = 1,538,691). Items in the assessments were used to measure three mutually exclusive outcomes: prevalence of VL only, HL only, or DSL. Trends over time for each outcome were examined using the Cochran-Armitage trend test. A negative binomial model was used to quantify the trends over time for each outcome while adjusting for age, sex and province., Results: In HC, there was a significant trend in the rate for all three outcomes (p < 0.001), with a small increase (roughly 1%) each year. In HC, HL was the most prevalent sensory loss, with a rate of roughly 25% to 29%, while in LTC, DSL was the most prevalent impairment, at roughly 25% across multiple years of data. In both settings, roughly 60% of the sample was female. Males in both HC and LTC had a higher prevalence of HL compared to females, but the differences were very small (no more than 2% in any given year). The prevalence of HL differed by province after adjusting for year, age and sex. Compared to Ontario, Yukon Territory had a 26% higher rate of HL in HC (relative rate [RR] = 1.26; 95% confidence interval [CI]:1.11, 1.43), but LTC residents in Newfoundland and Labrador had a significantly lower rate of HL (RR: 0.57; CI: 0.43, 0.76).When combined, approximately 60% of LTC residents, or HC clients, had at least one sensory impairment., Conclusions: Sensory impairments are highly prevalent in both HC and LTC, with small sex-related differences and some variation across Canadian provinces. The interRAI assessments provide clinicians with valuable information to inform care planning and can also be used to estimate the prevalence of these impairments in specific population sub-groups., (© 2022. The Author(s).)

Background: Prognostic accuracy is important throughout all stages of the illness trajectory as it has implications for the timing of important conversations and decisions around care. Physicians often tend to over-estimate prognosis and may under-recognize palliative care (PC) needs. It is therefore essential that all relevant stakeholders have as much information available to them as possible when estimating prognosis., Aims: The current study examined whether the interRAI Changes in Health, End-Stage Disease, Signs and Symptoms (CHESS) Scale is a good predictor of mortality in a known PC population and to see how it compares to the Palliative Performance Scale (PPS) in predicting 90-day mortality., Methods: This retrospective cohort study used data from 2011 to 2018 on 80,261 unique individuals receiving palliative home care and assessed with both the interRAI Palliative Care instrument and the PPS. Logistic regression models were used to evaluate the relationship between the main outcome, 90-day mortality and were then replicated for a secondary outcome examining the number of nursing visits. Comparison of survival time was examined using Kaplan-Meier survival curves., Results: The CHESS Scale was an acceptable predictor of 90-day mortality (c-statistic = 0.68; p < 0.0001) and was associated with the number of nursing days (c = 0.61; p < 0.0001) and had comparable performance to the PPS (c = 0.69; p < 0.0001). The CHESS Scale performed slightly better than the PPS in predicting 90-day mortality when combined with other interRAI PC items (c = 0.72; p < 0.0001)., Conclusion: The interRAI CHESS Scale is an additional decision-support tool available to clinicians that can be used alongside the PPS when estimating prognosis. This additional information can assist with the development of care plans, discussions, and referrals to specialist PC teams., (© 2022. The Author(s).)

Background: Individuals receiving palliative care (PC) are generally thought to prefer to receive care and die in their homes, yet little research has assessed the quality of home- and community-based PC. This project developed a set of valid and reliable quality indicators (QIs) that can be generated using data that are already gathered with interRAI assessments-an internationally validated set of tools commonly used in North America for home care clients. The QIs can serve as decision-support measures to assist providers and decision makers in delivering optimal care to individuals and their families., Methods: The development efforts took part in multiple stages, between 2017-2021, including a workshop with clinicians and decision-makers working in PC, qualitative interviews with individuals receiving PC, families and decision makers and a modified Delphi panel, based on the RAND/ULCA appropriateness method., Results: Based on the workshop results, and qualitative interviews, a set of 27 candidate QIs were defined. They capture issues such as caregiver burden, pain, breathlessness, falls, constipation, nausea/vomiting and loneliness. These QIs were further evaluated by clinicians/decision makers working in PC, through the modified Delphi panel, and five were removed from further consideration, resulting in 22 QIs., Conclusions: Through in-depth and multiple-stakeholder consultations we developed a set of QIs generated with data already collected with interRAI assessments. These indicators provide a feasible basis for quality benchmarking and improvement systems for care providers aiming to optimize PC to individuals and their families., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Dr. A. Sinnarajah has received research grants (last 5 years) on palliative care (as principal investigator or co-investigator), from the Canadian Institutes of Health Research, MSI Foundation, Canadian Cancer Society, Applied Research in Cancer Control, College of Family Physicians of Canada, Choosing Wisely Alberta, Alberta Innovates Health Research, Alberta Cancer Foundation, Alberta Health Services, University of Calgary, Canadian Frailty Network, Alberta Health and Campus Alberta Health Outcomes and Public Health. He has an academic appointment for palliative care research with Queen’s University and Lakeridge Health (currently), and University of Calgary (last 5 years). Lastly, he is/has paid medical administrative positions with Alberta Health Services and Lakeridge Health. The remaining authors declare that no competing interests exist. We confirm that Dr. Sinnarajah has some competing interests to report (previously detailed in the online submission) and we confirm that this does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: Most individuals who typically receive palliative care (PC) tend to have cancer and a relatively short prognosis (< 6 months). People with other life-limiting illnesses can also benefit from a palliative care approach. However, little is known about those who receive palliative home care in Ontario, Canada's largest province. To address this gap, the goal of this project was to understand the needs, symptoms and potential differences between those with a shorter (< 6 months) and longer prognosis (6+ months) for individuals receiving PC in the community., Methods: A cross-sectional analysis was conducted using interRAI Palliative Care (interRAI PC) assessment data collected between 2011 and 2018. Individuals with a shorter prognosis (< 6 months; n = 48,019 or 64.1%) were compared to those with a longer prognosis (6+ months; n = 26,945) across several clinical symptoms. The standardized difference (stdiff), between proportions, was calculated to identify statistically meaningful differences between those with a shorter and longer prognosis. Values of the stdiff of 0.2 or higher (absolute value) indicated a statistically significant difference., Results: Overall, cancer was the most prevalent diagnosis (83.2%). Those with a shorter prognosis were significantly more likely to experience fatigue (75.3% vs. 59.5%; stdiff = 0.34) and shortness of breath at rest (22.1% vs. 13.4%; stdiff = 0.23). However, the two groups were similar in terms of severe pain (73.5% vs. 66.5%; stdiff = - 0.15), depressive symptoms (13.2% vs. 10.7%; stdiff = 0.08) and nausea (35.7% vs. 29.4%; stdiff = 0.13)., Conclusions: These results highlight the importance of earlier identification of individuals who could benefit from a palliative approach to their care as individuals with a longer prognosis also experience high rates of symptoms such as pain and nausea. Providing PC earlier in the illness trajectory has the potential to improve an individual's overall quality of life throughout the duration of their illness., (© 2021. The Author(s).)

Context: Breathlessness is a symptom associated with poor clinical outcomes and prognosis. Little is known about its long-term trends and associations with social factors including decline in social activities and caregiver distress., Objectives: To describe factors associated with the prevalence of clinician-reported breathlessness across Canada among cohorts receiving home care or nursing home care., Methods: A retrospective observational cohort study of cross-sectional intake assessment data from Canadian interRAI Home Care and Nursing Home data sets. In each data set, we examined covariates associated with the presence of clinician-reported breathlessness using multivariate regression., Results: Between 2007 and 2018, we identified 1,317,117 and 469,709 individuals from the home care and nursing home data sets, respectively. Over two-thirds were aged >75 and over 60% were women. Breathlessness was present at intake in 26.0% of the home care and 8.2% of the nursing home cohorts. Between 2007 and 2018, prevalence of breathlessness increased by 10% for the home care cohort, while remaining relatively constant in nursing homes. Covariates associated with increased odds of having clinician-reported breathlessness at intake in both cohorts were moderate-severe impairment with activities of daily living, being male, older age, high pain scores, signs of depression, and decline in social activities. In the home care cohort, the presence of breathlessness was associated with a greater odds of caregiver distress (odds ratio = 1.19, 95% CI: 1.18-1.20)., Conclusion: The prevalence of clinician-reported breathlessness is higher in home care than in nursing home populations, the former having risen by 10% over the decade. Prevalence of breathlessness is associated with decline in social activities and caregiver distress. Enhanced supports may be required to meet increasing patient need in the community., (Copyright © 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: The main objective was to develop a decision-support tool to assess the risk of caregiver burden, the Caregiver Risk Evaluation (CaRE) algorithm. Methods: Home care clients were assessed using the Resident Assessment Instrument for Home Care (RAI-HC). Their caregiver completed the 12-item Zarit Burden Interview (ZBI), the main dependent measure, which was linked to the RAI-HC. Results: In the sample ( n = 344), 48% were aged 85+ years and 61.6% were female. The algorithm can be collapsed into four categories (low, moderate, high, and very high risk). Relative to the low-risk group, clients in the very high-risk group had an odds ratio of 5.16 (95% confidence interval: [2.05, 12.9]) for long-term care admission, after adjusting for client age, sex, and regional health authority. Discussion: The CaRE algorithm represents a new tool to be used by home care clinicians as they proactively plan for the needs of clients and their caregivers.

Introduction: The end-of-life symptom prevalence of non-cancer patients have been described mostly in hospital and institutional settings. This study aims to describe the average symptom trajectories among non-cancer patients who are community-dwelling and used home care services at the end of life., Materials and Methods: This is a retrospective, population-based cohort study of non-cancer patients who used home care services in the last 6 months of life in Ontario, Canada, between 2007 and 2014. We linked the Resident Assessment Instrument for Home Care (RAI-HC) (standardized home care assessment tool) and the Discharge Abstract Databases (for hospital deaths). Patients were grouped into four non-cancer disease groups: cardiovascular, neurological, respiratory, and renal (not mutually exclusive). Our outcomes were the average prevalence of these outcomes, each week, across the last 6 months of life: uncontrolled moderate-severe pain as per the Pain Scale, presence of shortness of breath, mild-severe cognitive impairment as per the Cognitive Performance Scale, and presence of caregiver distress. We conducted a multivariate logistic regression to identify factors associated with having each outcome respectively, in the last 6 months., Results: A total of 20,773 non-cancer patient were included in our study, which were analyzed by disease groups: cardiovascular (n = 12,923); neurological (n = 6,935); respiratory (n = 6,357); and renal (n = 3,062). Roughly 80% of patients were > 75 years and half were female. In the last 6 months of life, moderate to severe pain was frequent in the cardiovascular (57.2%), neurological (42.7%), renal (61.0%) and respiratory (58.3%) patients. Patients with renal disease had significantly higher odds for reporting uncontrolled moderate to severe pain (odds ratio [OR] = 1.21; 95% CI: 1.08 to 1.34) than those who did not. Patients with respiratory disease reported significantly higher odds for shortness of breath (5.37; 95% CI, 5.00 to 5.80) versus those who did not. Patients with neurological disease compared to those without were 9.65 times more likely to experience impaired cognitive performance and had 56% higher odds of caregiver distress (OR = 1.56; 95% CI: 1.43 to 1.71)., Discussion: In our cohort of non-cancer patients dying in the community, pain, shortness of breath, impaired cognitive function and caregiver distress are important symptoms to manage near the end of life even in non-institutional settings., Competing Interests: The authors do not disclose any competing interests for this submission.

Purpose: To describe the trajectory of physical symptoms among cancer decedents who were receiving home care in the six months before death., Patients and Methods: An observational cohort study of cancer decedents in Ontario, Canada, who received home care services between 2007 and 2014. To be included, decedents had to use at least one home care service in the last six months of life. Outcomes were the presence of pain and several other physical symptoms at each week before death., Results: Our cohort included 27,295 cancer decedents (30,368 assessments). Forty-seven percent were female and 56% were age 75 years or older. The prevalence of all physical symptoms increased as one approached death, particularly in the last month of life. In the last weeks of life, 69% of patients reported having moderate-severe pain; however, only 20% reported that the pain was not controlled. Loss of appetite (63%), shortness of breath (59%), high health instability (50%), and self-reported poor health (44%) were also highly prevalent in the last week of life. Multivariate regression showed that caregiver distress, high health instability, social decline, uncontrolled pain, and signs of depression all worsened the odds of having a physical symptom in the last 3 months of life., Conclusion: In this large home care cancer cohort, trajectories of physical symptoms worsened close to death. While presence of moderate-severe pain was common, it was also reported as mostly controlled. Covariates, such as caregiver distress and social decline, were associated with having more physical symptoms at end of life.

Background: The nutrition profile of palliative home care clients is unknown. This study describes this group and their nutrition issues and evaluates the performance of the interRAI nutrition Clinical Assessment Protocol (CAP)., Methods: This was a cross-sectional secondary analysis using Ontario interRAI Palliative Care (interRAI PC) Assessment data. The sample represents 74,963 unique Ontario home care clients assessed between 2011 and 2018. Frequencies and standardized differences (stdiffs) of nutrition characteristics were presented for cancer (n = 62,394) and noncancer (n = 12,569) diagnostic subgroups. Rates of triggering the nutrition CAP were presented by nutrition issue to evaluate its performance., Results: Of this sample, 16.7% were ≥85 years of age, 52.6% had a prognosis between 6 weeks and 6 months, and 41.4% required assistance with eating. The prevalence was higher among those with nervous/mental/behavioral disorders (72.6%) compared with those with cancer (37.6%; stdiff = 0.75). However, most nutrition issues experienced were similar (stdiff < 0.20) across diagnostic groups. Of the entire sample, 21% triggered the nutrition CAP, indicating a need for further evaluation or intervention. Yet, 73.4% of those who experienced dry mouth, 71.8% of those who required assistance with eating, and 68.4% of those who received a nutrition consult within the last 3 days did not trigger the nutrition CAP., Conclusions: Nutrition issues are prevalent in palliative home care clients, regardless of diagnosis; yet the nutrition CAP identified a small fraction of this group. There is a need to focus research and care guidelines toward life-limiting illnesses beyond cancer and address nutrition-related issues in this population., (© 2020 American Society for Parenteral and Enteral Nutrition.)

Background: Few measures exist to assess the quality of care received by home care clients, especially at the end of life. Objective: This project examined the rates across a set of quality indicators (QIs) for seriously ill home care clients. Design: This was a cross-sectional descriptive analysis of secondary data collected using a standardized assessment tool, the Resident Assessment Instrument for Home Care (RAI-HC). Setting/Subjects: The sample included RAI-HC data for 66,787 unique clients collected between January 2006 and March 2018 in six provinces. Individuals were defined as being seriously ill if they experienced a high level of health instability, had a prognosis of less than six months, and/or had palliative care as a goal of care. Measurements: We compared individuals with cancer ( n  = 21,119) with those without cancer ( n  = 47,668) on demographic characteristics, health-related outcomes, and on 11 QIs. Results: Regardless of diagnosis, home care clients experienced high rates (i.e., poor performance) on several QIs, namely the prevalence of falls (cancer = 42.4%; noncancer = 55%), daily pain (cancer = 48.3%; noncancer = 43.2%), and hospital admissions (cancer = 48%; noncancer = 46.6%). The QI rates were significantly lower (i.e., better performance) for the cancer group for three out of the 11 QIs: falls (absolute standardized difference [SD] = 0.25), caregiver distress (SD = 0.28), and delirium (SD = 0.23). Conclusions: On several potential QIs, seriously ill home care clients experience high rates, pointing to potential areas for quality improvement across Canada.

Background: Currently, there are no formalized measures for the quality of home based palliative care in Ontario. This study developed a set of potential quality indicators for seriously ill home care clients using a standardized assessment., Methods: Secondary analysis of Resident Assessment Instrument for Home Care data for Ontario completed between 2006 and 2013 was used to develop quality indicators (QIs) thought to be relevant to the needs of older (65+) seriously ill clients. QIs were developed through a review of the literature and consultation with subject matter experts in palliative care. Serious illness was defined as a prognosis of less than 6 months to live or the presence of severe health instability. The rates of the QIs were stratified across Ontario's geographic regions, and across four common life-limiting illnesses to observe variation., Results: Within the sample, 14,312 clients were considered to be seriously ill and were more likely to experience negative health outcomes such as cognitive performance (OR = 2.77; 95% CI: 2.66-2.89) and pain (OR = 1.59; 95% CI: 1.53-1.64). Twenty subject matter experts were consulted and a list of seven QIs was developed. Indicators with the highest overall rates were prevalence of falls (50%) prevalence of daily pain (47%), and prevalence of caregiver distress (42%). The range in QI rates was largest across regions for prevalence of caregiver distress (21.5%), the prevalence of falls (16.6%), and the prevalence of social isolation (13.7%). Those with some form of dementia were most likely to have a caregiver that was distressed (52.6%) or to experience a fall (53.3%)., Conclusion: Home care clients in Ontario who are seriously ill are experiencing high rates of negative health outcomes, many of which are amenable to change. The RAI-HC can be a useful tool in identifying these clients in order to better understand their needs and abilities. These results contribute significantly to the process of creating and validating a standardized set of QIs that can be generated by organizations using the RAI-HC as part of normal clinical practice.

Objectives: Hearing and vision impairment were examined across several health-related outcomes and across a set of quality indicators (QIs) in home care clients with both vision and hearing loss (or dual sensory impairment [DSI])., Method: Data collected using the Resident Assessment Instrument for Home Care (RAI-HC) were analyzed in a sample of older home care clients. The QIs represent the proportion of clients experiencing negative outcomes (e.g., falls, social isolation)., Results: The average age of clients was 82.8 years ( SD = 7.9), 20.5% had DSI and 8.5% had a diagnosis of Alzheimer's disease (AD). Clients with DSI were more likely to have a diagnosis of dementia (not AD), have functional impairments, report loneliness, and have higher rates across 20 of the 22 QIs, including communication difficulty and cognitive decline. Clients with highly impaired hearing, and any visual impairment, had the highest QI rates., Discussion: Individuals with DSI experience higher rates of adverse events across many health-related outcomes and QIs. Understanding the unique contribution of hearing and vision in this group can promote optimal quality of care.

Background: Across Ontario, home care professionals collect standardized information on each client using the Resident Assessment for Home Care (RAI-HC). However, this information is not consistently shared with those professionals who provide services in the client's home. In this pilot study, we examined the feasibility of sharing data, from the RAI-HC, between care coordinators and service providers., Methods: All participants were involved in a one-day training session on the RAI-HC. The care coordinators shared specific outputs from the RAI-HC, including the embedded health index scales, with their contracted physiotherapy and occupational therapy service providers. Two focus groups were held, one with care coordinators (n = 4) and one with contracted service providers (n = 6). They were asked for their opinions on the positive aspects of the project and areas for improvement., Results: The focus groups revealed a number of positive outcomes related to the project including the use of a falls prevention brochure and an increased level of communication between professionals. The participants also cited multiple areas for improvement related to data sharing (e.g., time constraints, data being sent in a timely fashion) and to their standard practices in the community (e.g., busy workloads, difficulties in data sharing, duplication of assessments between professionals)., Conclusions: Home care professionals were able to share select pieces of information generated from the RAI-HC system and this project enhanced the level of communication between the two groups of professionals. However, a single information session was not adequate training for the rehabilitation professionals, who do not use the RAI-HC as part of normal practice. Better education, ongoing support and timely access to the RAI-HC data are some ways to improve the usefulness of this information for busy home care providers.

Background: Home care is becoming an increasingly vital sector in the health care system yet very little is known about the characteristics of home care clients and the quality of care provided in Canada. We describe these clients and evaluate home care quality indicator rates in two regions., Methods: A cross-sectional analysis of assessments completed for older (age 65+) home care clients in both Ontario (n = 102,504) and the Winnipeg Regional Health Authority (n = 9,250) of Manitoba, using the Resident Assessment Instrument for Home Care (RAI-HC). This assessment has been mandated for use in these two regions and the indicators are generated directly from items within the assessment. The indicators are expressed as rates of negative outcomes (e.g., falls, dehydration). Client-level risk adjustment of the indicator rates was used to enable fair comparisons between the regions., Results: Clients had a mean age of 83.2 years, the majority were female (68.6%) and the regions were very similar on these demographic characteristics. Nearly all clients (92.4%) required full assistance with instrumental activities of daily living (IADLs), approximately 35% had activities of daily living (ADL) impairments, and nearly 50% had some degree of cognitive impairment, which was higher among clients in Ontario (48.8% vs. 37.0%). The highest quality indicator rates were related to clients who had ADL/rehabilitation potential but were not receiving therapy (range: 66.8%-91.6%) and the rate of cognitive decline (65.4%-76.3%). Ontario clients had higher unadjusted rates across 18 of the 22 indicators and the unadjusted differences between the two provinces ranged from 0.6% to 28.4%. For 13 of the 19 indicators that have risk adjustment, after applying the risk adjustment methodology, the difference between the adjusted rates in the two regions was reduced., Conclusions: Home care clients in these two regions are experiencing a significant level of functional and cognitive impairment, health instability and daily pain. The quality indicators provide some important insight into variations between the two regions and can serve as an important decision-support tool for flagging potential quality issues and isolating areas for improvement.

Background: Canadian palliative care (PC) philosophy seeks to support individuals in a person-centered and sensitive manner. Unfortunately, philosophy does not necessarily translate into practice and this divide may leave patients without appropriate care at the end of life, causing distress for some families. The primary goal of the study was to identify key factors affecting perceptions of quality PC from the perspective of informal caregivers and decision makers (e.g., program managers) and to understand how their experiences within the health care system may have influenced their perceptions. Methods: Nine caregivers and 11 decision makers from Yukon Territory, British Columbia, Alberta, Ontario, & Nova Scotia shared their experiences in PC via interview or focus group. Audio recordings were transcribed verbatim and qualitatively analyzed for themes. Results: Three themes emerged, including the Caregiver as Anchor, Bewildering System, and Patient, Caregiver, and Family-Centered Care. While these results resembled other studies on caregivers and individuals receiving PC, the present study also uncovered systemic concerns. There was agreement between the two participant groups across most subthemes, however only caregivers reported feelings of being trapped by the health care system and a general lack of respect from health care professionals. Additionally, caregivers stressed the importance of preserving some sort of normalcy in daily life despite the individual's illness. Conclusions: Caregivers are critical. The health care system expects them to help a great deal, but they often do not feel supported or respected and the system is lacking the capacity and resources to meet their needs while they are grieving loss and struggling to meet demands. [ABSTRACT FROM AUTHOR]

Purpose: Understanding the end-of-life psychosocial needs of cancer patients at home is a knowledge gap. This study describes the trajectory of psychosocial symptoms in the last 6 months of life among cancer decedents who were receiving home care.Methods: Observational population-based cohort study of cancer decedents who were receiving home care services between 2007 and 2014. Decedents had to have at least one home care assessment in the last 6 months of life for inclusion. Outcomes were the presence of psychosocial symptoms (i.e., anxiety, loneliness, depression, social decline, caregiver distress, and cognitive decline) at each week before death.Results: Our cohort included 27,295 unique cancer decedents (30,368 assessments), of which 58% died in hospital. Fifty-six percent were older than 74, and 47% were female. The prevalence of all symptoms increased approaching death, except loneliness. Social decline (48%-78%) was the most prevalent psychosocial symptom, though loneliness was reported in less than 10% of the cohort. Caregiver distress rose over time from 15%-27%. A third of the cohort reported issues with cognitive impairment. Multivariate regression showed that physical symptoms such as uncontrolled pain, impairment in independent activities of daily living, and a high level of health instability all significantly worsened the odds of having a psychosocial symptom in the last 3 months of life.Conclusion: In this large home care cancer cohort, trajectories of psychosocial symptoms worsened close to death. Physical symptoms, such as uncontrolled pain, were associated with having worse psychosocial symptoms at end of life. [ABSTRACT FROM AUTHOR]

Objectives: The objective of the current study was to understand the added effects of having a sensory impairment (vision and/or hearing impairment) in combination with cognitive impairment with respect to health-related outcomes among older adults (65+ years old) receiving home care or residing in a long-term care (LTC) facility in Ontario, Canada. Methods: Cross-sectional analyses were conducted using existing data collected with one of two interRAI assessments, one for home care (n = 291,824) and one for LTC (n = 110,578). Items in the assessments were used to identify clients with single sensory impairments (e.g., vision only [VI], hearing only [HI]), dual sensory impairment (DSI; i.e., vision and hearing) and those with cognitive impairment (CI). We defined seven mutually exclusive groups based on the presence of single or combined impairments. Results: The rate of people having all three impairments (i.e., CI+DSI) was 21.3% in home care and 29.2% in LTC. Across the seven groups, individuals with all three impairments were the most likely to report loneliness, to have a reduction in social engagement, and to experience reduced independence in their activities of daily living (ADLs) and instrumental ADLs (IADLs). Communication challenges were highly prevalent in this group, at 38.0% in home care and 49.2% in LTC. In both care settings, communication difficulties were more common in the CI+DSI group versus the CI-alone group. Conclusions: The presence of combined sensory and cognitive impairments is high among older adults in these two care settings and having all three impairments is associated with higher rates of negative outcomes than the rates for those having CI alone. There is a rising imperative for all health care professionals to recognize the potential presence of hearing, vision and cognitive impairments in those for whom they provide care, to ensure that basic screening occurs and to use those results to inform care plans. [ABSTRACT FROM AUTHOR]

The onset of depressive symptoms is common in home care clients and their caregivers. Understanding the experience of the informal caregiver can assist clinicians in providing services to maximize the well-being of both the client and their caregivers. The objectives of this article are to examine risk factors for the development of depressive symptoms. A longitudinal analysis design was completed for clients with 2+ assessments. The development of depressive symptoms was defined as a Depression Rating Scale score of 3+ on re-assessment. The results—overall, 10.7% of clients experienced new depressive symptoms and clients with a caregiver who was feeling distressed, angry, or depressed were 45% more likely to develop symptoms. [ABSTRACT FROM AUTHOR]

Objectives: Dual sensory impairment (DSI) is a combination of vision and hearing impairments that represents a unique disability affecting all aspects of a person’s life. The rates of DSI are expected to increase due to population aging, yet little is known about DSI among older adults (65+). The prevalence of DSI and client characteristics were examined among two groups, namely, older adults receiving home care services or those residing in a long-term care (LTC) facility in four countries (Canada, US, Finland, Belgium). Methods: Existing data, using an interRAI assessment, were analyzed to compare older adults with DSI to all others across demographic characteristics, functional and psychosocial outcomes. Results: In home care, the prevalence of DSI across the four countries ranged from 13.4% to 24.6%; in LTC facilities, it ranged from 9.7% to 33.9%. Clients with DSI were more likely to be 85+, have moderate/severe cognitive impairment, impairments in activities of daily living, and have communication difficulties. Among residents of LTC facilities, individuals with DSI were more likely to be 85+ and more likely have a diagnosis of Alzheimer’s disease. Having DSI increased the likelihood of depression in both care settings, but after adjusting for other factors, it remained significant only in the home care sample. Conclusions: While the prevalence of DSI cross nationally is similar to that of other illnesses such as diabetes, depression, and Alzheimer’s disease, we have a limited understanding of its affects among older adults. Raising awareness of this unique disability is imperative to insure that individuals receive the necessary rehabilitation and supportive services to improve their level of independence and quality of life. [ABSTRACT FROM AUTHOR]

Depression can be a disabling and debilitating condition among older adults (aged 65+). This study examined risk factors for symptoms of depression in a large sample of older home care clients (n = 218,850) in Ontario, Canada, using existing data collected with the Resident Assessment Instrument for Home Care (RAI-HC). The RAI-HC has been mandated across the province since 2002. The most important predictors of depression were lower self-rated health (odds ratio [OR] = 3.4), cognitive impairment (OR = 2.9), dual sensory impairment (OR = 1.2), and a primary language other than English or French (OR = 1.5). This suggests that not only physical health but also sensory impairments and communication difficulties increase the risk for depression among home care recipients. [ABSTRACT FROM AUTHOR]

Individuals with heart failure experience complex symptoms and have a poor prognosis, comparable to those with cancer. However, people with heart failure are less likely to be recognized as needing palliative care. We compared seriously ill home care clients with cancer versus those with heart failure to explore differences between them using existing data from the Resident Assessment Instrument for Home Care (RAI-HC). The sample included 1,475 older adults (65+) in Ontario who had a prognosis of less than 6 months or severe health instability. Clients with heart failure were significantly older (p< .0001) and experienced significantly higher rates of impairment in activities of daily living (p= .005), cognitive impairment (p< .0001), and severe health instability (p< .0001), but were significantly less likely to have a prognosis of less than 6 months (p< .0001). Home care clients with heart failure have needs similar to those with cancer yet are typically not identified as having a terminal prognosis. [ABSTRACT FROM AUTHOR]

Background: Adults with vision and hearing loss, or dual sensory loss (DSL), present with a wide range of needs and abilities. This creates many challenges when attempting to set the most appropriate and equitable funding levels. Case-mix (CM) funding models represent one method for understanding client characteristics that correlate with resource intensity. Methods: A CM model was developed based on a derivation sample (n = 182) and tested with a replication sample (n = 135) of adults aged 18+ with known DSL who were living in the community. All items within the CM model came from a standardized, multidimensional assessment, the interRAI Community Health Assessment and the Deafblind Supplement. The main outcome was a summary of formal and informal service costs which included intervenor and interpreter support, in-home nursing, personal support and rehabilitation services. Informal costs were estimated based on a wage rate of half that for a professional service provider ($10/hour). Decision-tree analysis was used to create groups with homogeneous resource utilization. Results: The resulting CM model had 9 terminal nodes. The CM index (CMI) showed a 35-fold range for total costs. In both the derivation and replication sample, 4 groups (out of a total of 18 or 22.2%) had a coefficient of variation value that exceeded the overall level of variation. Explained variance in the derivation sample was 67.7% for total costs versus 28.2% in the replication sample. A strong correlation was observed between the CMI values in the two samples (r = 0.82; p = 0.006). Conclusions: The derived CM funding model for adults with DSL differentiates resource intensity across 9 main groups and in both datasets there is evidence that these CM groups appropriately identify clients based on need for formal and informal support. [ABSTRACT FROM AUTHOR]