Factors Associated With Care Trajectory Following Acute Functional Decline in Older Home Nursing Care Patients: A Prospective Observational Study

Abstract

Health policies and previous research highlight the importance of early identification and treatment of clinical deterioration in older patients to prevent frailty, higher levels of care, and mortality. This study explores older home nursing care patients’ care trajectories and factors associated with clinical response (type and level of intervention) from the health care services, final level of community care and death within 3 months after an incidence of acute functional decline. This observational study with a prospective, descriptive design includes a sample of 135 older home nursing care patients with acute functional decline. Demographic, health-related, and clinical characteristics were analyzed and prediction models for care trajectories were fitted using Bayesian generalized mixed models. Age ranged from 65 to 100, with a median age of 85. Hospital admission were registered for 13.33% ( T1) and 8.77% ( T2) of the participants. Nine patients (6.7%) were transferred to a higher level of community care, and 11 patients (8.1%) died. Frequent transitions between levels of care characterized care trajectories for patients experiencing more severe functional decline. Age, living in a private home, and increased Modified Early Warning Scores (MEWS) were associated with level of clinical responses throughout the care trajectory. Living in a private home was associated with the patients’ final level of community care. Female gender, hospital admission, and increased MEWS scores were associated with death. Health care personnel must be vigilant when MEWS scores rise even slightly, as this might be an indication of acute functional decline with possible increased risk of mortality.

Clinical Leadership – An Important Precondition for the Success of Proactive and Interdisciplinary Follow-up of Frail Older Recipients of Home Healthcare

“…18 The study provided some indications of the importance of achieving more proactive care which includes interdisciplinary collaboration. We found, in line with Jeppestøl et al 16 that a more structured working mode regarding observations and decision making was recognized as being important by the informants. However, both organizational and individual-level factors impeded such a structured working mode being developed.…”

“…However, studies in the proceeding years up to the present day have documented a constant increase in the number of older people living at home with multimorbidity, functional decline, and polypharmacy. 3,16 At the same time, there has been little change in the organization of HHC. 43 There has been an increase in the number of employees, but there is still a lack of geriatric care competence.…”

“…13 Several screening and assessment tools are used in HHC, but to our knowledge, they are mainly employed reactively when symptoms of decline have become pronounced through nutritional status and assessments of acute illness. 15,16 Although designed and validated for acute hospital settings, early warning scores are recommended as a clinical decisionmaking tool in outpatient settings in Norway 15, 16 Jeppestøl et al 16 found that RNs and GPs considered modified early warning scores as potentially useful in HHC settings, but this tool had not been adapted for use in HHC settings or for the older patients. Therefore, in 2013, a group of RNs, GPs and researchers developed a new tool for the context of older patients receiving HHC.…”

Early warning scores and trigger recommendations must be used with care in older home nursing care patients: Results from an observational study

“…Despite radically different contexts, early warning score (EWS) tools are recommended in both hospital and community care settings to detect early clinical deterioration and to support clinical decisions in cases of clinical deterioration (NICE, 2007 ; The Norwegian Directorate of Health, 2020 ). The implementation of various EWS in home nursing care, care homes and skilled nursing homes is ongoing, and research exploring how EWSs are used and how they impact clinical practice is increasing (Ammitzbøll & Maarslet, 2015 ; Barker et al, 2020 ; Brangan et al, 2018 ; Hodgson et al, 2022 ; Jeppestøl et al, 2022a ). Normal and pathological physiological changes are well known to occur with aging (Chester & Rudolph, 2011 ; Churpek et al, 2015 ), and older peoples' vital signs often deviate from standard reference values.…”

“…Suspicion of acute functional decline initiates a process in which healthcare professionals must assess the likelihood of acute illness (Hébert, 1997 ). Health professionals decide whether referral for medical service is needed and how quickly it must occur by comparing the changes in functional abilities and vital signs to the patient's normal and stable habitual state, taking the rapidity of the changes into account (Jeppestøl et al, 2022a ; Hodgson et al, 2022 ).…”