Frail Elderly Homecare Clients: The Costs and Effects of Adding Nursing Health Promotion and Preventive Care to Personal Support Services

Key Implications for Decision Makers

This is the first Canadian randomized trial with a full economic evaluation that gives evidence for the effectiveness and efficiency of having a nurse provide health promotion and preventive care to a general population of elderly homecare clients and their caregivers. It assessed the effects and expense of adding nursing health promotion and preventive care to usual homecare services in a national system of health and social insurance.

  • This study provides scientific support for re-investment of professional nursing services in health promotion and preventive care for chronic and vulnerable elderly homecare populations.
  • Providing seniors with nursing health promotion, compared to providing professional services on a reactive and on-demand basis, results in better overall mental health functioning, a reduction in depressive symptoms, and an enhanced level of perceived social support without increasing the overall costs of healthcare.
  • Health promotion by nurses results in a clinically important improvement in caregivers' level of social functioning (23.7 percent) versus 5.9 percent in the usual care group, and a reduction in depressive symptoms (1.5 percent) versus a 7.7 percent increase in the usual care group.
  • The maintenance and promotion of mental health in seniors should be identified explicitly as a role for homecare. Homecare programs should have sufficient resources to overcome barriers to service access and provide effective care and support for clients with mental health issues, even if those clients do not have physical limitations.
  • Organizations should provide a variety of professional development opportunities to support nurses in effectively developing strategies for promoting health, including assessing mental health status in seniors within the homecare sector.
  • Organizational models of care delivery should allow for a flexible, client-centred approach and support nurses' ability to develop continuous, uninterrupted, and meaningful relationships with elderly homecare clients and their caregivers. Nursing organizations should provide ongoing opportunities for discussion, education, and reflection to reinforce the importance of best practices.
  • Support for elderly caregivers of clients with chronic health problems should be seen as an essential component of a publicly funded homecare program. A national public homecare program should provide a continuum of services, including health promotion and prevention and curative, rehabilitative, and palliative services.

Executive Summary

This randomized controlled trial in a homecare program in southern Ontario, Canada was designed to assess the effects and expense of adding nursing health promotion and preventive care to usual homecare services in a national system of health and social insurance. The findings of this study have implications for elderly homecare clients and their caregivers and for decision makers who determine how to allocate scarce homecare resources.

The study sample was comprised of elderly persons and their informal caregivers [5] referred to the community care access centre of Halton from an acute-care hospital, the community, and other institutional settings. Clients were eligible to participate in the study if they met the following criteria: (1) were 75 years of age and older; (2) were newly referred to and eligible for personal support services [6] through the community care access centre of Halton; (3) communicated in English (client and/or caregiver); and (4) expected to receive treatment and/or reside in the Halton region for the six months of the study. It was not necessary for a subject to have a family caregiver to participate in the study. Clients were considered ineligible for the study if they were newly referred to the community care access centre for nursing services.

Of 288 eligible and consenting subjects who were randomly allocated to receive the nursing intervention or not, 242 (or 84 percent) completed the study. The subjects who completed the study were similar to those who did not, with the exception of gender: more completers were female. The study sample consisted of 242 seniors (75 years and older) eligible for personal support services through the homecare program. A nurse telephoned or visited 84.7 percent of those frail elderly participants who were randomly allocated to the nursing group at baseline. Subjects randomized to the nursing group received an average of 3.94 home visits and 1.81 telephone contacts over the six-month follow-up.

At six months, results showed that having nurses provide seniors with health promotion, compared to providing professional services on a reactive and on-demand basis, results in better overall mental health functioning, a reduction in depressive symptoms, and an enhanced level of perceived social support at no additional expense from a societal perspective. This is the first randomized controlled trial in a Canadian homecare setting that used a comprehensive cost assessment. It demonstrates that nursing health promotion, provided to a general population of frail seniors, 25.6 percent of whom are depressed and 93.4 percent of whom are functionally limited, enhances quality of life while not increasing the overall costs of healthcare, thus making the intervention highly feasible. The results provide scientific support for re-investment of professional nursing services in health promotion and preventive care for chronic and vulnerable elderly homecare populations.

Of 288 eligible and consenting subjects randomly allocated at baseline to receive the nursing intervention or not, 171 (or 59.3 percent) had an available and consenting caregiver. Of 171 caregivers, 116 (or 67.8 percent) were retained in the six-month follow-up period. Caregivers who completed the study were similar to those who were lost to follow-up, with the exception of use of prescription medications; caregivers who completed the study reported taking a higher mean number of prescription medications daily (4.22) compared to those lost to follow up (3.6). A nurse telephoned or visited 65.1 percent of the available caregivers (n=86) of those elderly participants who were randomly allocated to the nursing group at baseline. Caregivers of subjects randomized to the nursing group received an average of 1.47 home visits and 0.92 telephone contacts over the six-month follow-up.

At six months, results showed that providing caregivers with nursing health promotion results in a clinically important improvement in social functioning (23.7 percent) versus 5.9 percent in the usual care group, and a reduction in depressive symptoms (1.5 percent) versus a 7.7 percent increase in the usual care group, at no additional expense from a societal perspective. In this group of caregivers, 40.7 percent were 75 years and older, 16.7 percent were depressed, 35.3 percent were functionally limited related to their physical health, and 60.3 percent were limited in terms of social functioning. The study findings also suggest that many caregivers are elderly themselves, and so face significant issues related to later life themselves. Decision makers and the public need to recognize and support the role of caregivers of elderly homecare clients with chronic health needs.

The overall conclusion from this study is that proactive health promotion and preventive care from nurses results in measurable gains in quality of life for frail elderly homecare clients eligible for personal support services and their informal caregivers at no additional expense from a societal perspective. The most notable improvement at the six-month follow-up was in mental health.