Development of a Care Delivery Model for High-Need Older Adults in the Community

Abstract

Background High-need older adults have multiple needs and require different types of care services. Care coordinators in community care centers in Taiwan, however, often experience difficulties in providing sufficient care services because of the inadequate capacity of case management. Objective The aim of this study was to develop a realistic care delivery model for the care coordinators to manage the care of high-need, community-dwelling older adults. Methods Focus-group interviews concerning elements and process for establishing a care delivery model were conducted with 12 care management experts in two groups: the practical work group (three registered nurses and three social workers) and the care management group (three care managers and three care management supervisors). The interviews were video-recorded and subjected to content analysis. Results A five-stage care delivery model was formulated: case screening, case assessment, care plan, care delivery, and follow-up evaluation. Six types of high-need older adults were identified: those living with disability, solitude, dementia, depression, elder abuse, and poverty. A list of categorized care services, including care resources, social welfare resources, and caregiver resources, was then used as a guide for case management and care delivery. Discussion The developed model—consisting a classification of services for different types of high-need older adults—serves as a guide for care coordinators in community care centers to make better decisions on service linkages, resource management, and care plan monitoring.

Prevalence and demographic characteristics of high‐need community‐dwelling older adults in Taiwan

“…In agreement with Hsu et al. (2019), this study operationalised the ‘high‐need older adult’ as ‘an older individual who requires social well‐being and resources through long‐term, professional interventions for supporting his/her daily life, and for whom these requirements are needed because of the result of unfavourable factors, such as poor physical or mental states or social environments’.…”

Effectiveness of a Care Delivery Model for High-Need Older Adults in Communities

“…In the intervention group, the HCOACDM was implemented for 6 months. The HCOACDM involved case screening, comprehensive assessment, and care coordination (Hsu et al, 2019). After a screening using the HCOASS, the high-need older adults received in-home assessments of functional and cognitive status, quality of life, and current resource utilization by a care coordinator.…”

“…Aging individuals have increasing and multidimensional physical, psychological, and social care needs (Gobbens et al, 2010; Verver et al, 2018). High-need older adults are those aged 65 and older and who are frail, marginal, and with different conditions; therefore, they often have complex health and social care needs and thus require multiple care services (Hsu et al, 2019). The health care and social services, however, are often provided individually by various providers without sufficient integration and communication, which results in fragmented, uncoordinated, and discontinuous care (Kristensson et al, 2010; Tinetti et al, 2012; Wallace et al, 2015).…”

“…Care delivery models deploying care coordinators appear to be promising, with evidence suggesting that care coordinators have beneficial effects on helping older adults living in the community overcome barriers to needed medical, social, and psychological services and support (Hudon et al, 2017; Scharlach et al, 2015) and to improve health and functional outcomes (Popejoy, 2015). In this regard, a High-Need Community-Dwelling Older Adults Care Delivery Model (HCOACDM) was developed (Hsu et al, 2019) in Taiwan based on a care coordination model suggested by the World Health Organization (WHO, 2016). The HCOACDM addressed the importance of care coordination.…”

“…Such individualized and person-centered care was recognized as crucial to holistic care delivery (Morgan & Yoder, 2012). The HCOACDM aimed to coordinate health care and social services and was developed to improve the high-need community-dwelling older adults’ quality of care and service use (Hsu et al, 2019); its effectiveness, however, has not yet been validated.…”