Residential care facilities providing multidisciplinary integrated care for older people achieve higher scores on 32 risk-adjusted quality of care indicators than facilities providing usual care
- Correspondence to Adeline Cooney
School of Nursing and Midwifery, National University of Ireland Galway, Aras Moyola, University Road, Galway, Ireland;
Implications for practice and research
Quality of care in residential facilities is improved when multidisciplinary integrated care is implemented; Further research should focus on identifying which elements of multidisciplinary integrated care are most effective in improving residents' quality of care and quality of life; Future studies should focus on comparing different packages of multidisciplinary integrated care with each other and on evaluating the effectiveness of such packages in different populations including older people with and without chronic illness.
Approximately 10% of Dutch older people aged 75+ live in residential care settings (Boorsma et al).These settings were established to provide ‘sheltered living’ to relatively healthy older people (Boorsma et al). However the profile of older people living in these facilities is changing. Residents are older, have multiple chronic illnesses and more complex healthcare needs (Boorsma et al). Staffing expertise and levels were not intended to meet this complexity. Boorsma et al report that family physicians, who have responsibility for medical care delivery in these settings, do not consider themselves best suited to systematically manage the needs of older people with multiple chronic illnesses. This study investigated the effects of multidisciplinary integrated care on the quality of care and quality of life of older people living in residential settings in the Netherlands. The model of multidisciplinary integrated care used in this study consisted of five elements:
A multidimensional assessment of all residents using the long-term care facility version of the Resident Assessment Instrument (RAI) was administered every 3 months. The RAI assessed an individual's physical, psychological, behavioural and social status, which guided the development of an individualised care plan. It also produced a ‘global level of care need’ score used in determining the level of care.
The care plan was adapted to the wishes of the resident;
The assessment outcomes were discussed in a multidisciplinary meeting;
The needs of residents requiring complex care were discussed with a geriatrician or psychologist;
Collated data from the outcome assessment was used to provide a report to home managers every 3 months and to benchmark against national data.
This study was a two-group, cluster randomised trial conducted in residential care facilities in the Netherlands. Randomisation to control and intervention groups was at the level of the residential care facility (ie, the cluster). Ten residential units with 340 residents with physical or cognitive impairment were randomised on a 1:1 ratio to either the intervention group who received multidisciplinary integrated care or to the control group who received usual care. The primary outcomes were quality of care and health related quality of life indicators. Process outcomes, for example the number of multidisciplinary meetings held, were also reported. Blinded outcome assessment was undertaken at baseline and 6 months later. Both intention-to-treat and per-protocol analyses were reported.
The five facilities allocated to multidisciplinary integrated care contained 201 residents and the five facilities allocated to usual care contained 139 residents. Residents within facilities allocated to multidisciplinary integrated care had significantly higher overall quality of care indicators and significantly higher scores for 11 of 32 indicators of good care in the areas of communication, delirium, behaviour, continence, pain and use of antipsychotic agents than residents within facilities allocated to usual care. Using per-protocol analyses, mortality was lower and residents were more positive about their quality of care in intervention facilities than in usual care facilities.
This study is an example of high-quality reporting of the conduct of an important trial of a complex intervention. Randomisation at the level of a group of participants rather than at the level of the individual is known as cluster randomisation and is used when it is not possible to either randomise at the individual level or to provide the intervention without contaminating participants in the control group. In this study, it would not have been possible to shield some participants from the intervention because the intervention, or at least components thereof, was targeted at the overall care provided within the facility.
Unusually, the authors report intention-to-treat and per-protocol analyses for secondary outcomes. Intention-to-treat analysis refers to the inclusion in the analysis of all participants to the group to which they were allocated originally regardless of what happened to them subsequently. Intention-to-treat analyses are considered less prone to bias than per-protocol analyses where analysis is restricted to only those who completed the trial as planned.
The authors of this study note that their study resonates with elements of care assessed in earlier studies including interdisciplinary geriatric primary care in American facilities and integrated and home-based geriatric care management. Since publication of this study, a Cochrane systematic review that includes 22 trials with 10 315 participants in six countries finds that comprehensive geriatric assessment increases the likelihood of a patient being alive and in their own home for up to 12 months.1