Home care services for older adults and developing a comprehensive model of home-based long-term care

Abstract

Background: With the increase in the aging population, the demand of this age group for care in order to have an independent life increases. Due to the complications of hospitalization and institutionalization and the desire of seniors to aging in place, home, each country needs to redesign the geriatric home care system based on its context. Objectives: The present study was conducted to develop a comprehensive formal home-based care for Iranian seniors and examine feasibility of the developed model. Methods: The current research was a multi-method study (combination of sequential explanatory type (descriptive cross sectional and then qualitative interview), scoping review, review of existing upstream policies, focused group discussion, Delphi) and was conducted in four phases. First, the current status of providing home care services to the older adults in Iran in terms of home care providers and the characteristics of caregivers and care (the type of services provided in terms of basic and instrumental activities of daily life and health services and formal care recipients) and factors affecting ADL and IADL scores were assessed through a descriptive cross sectional study. In the following, In a qualitative content analysis approach, different stakeholders involved in nursing home care were interviewed to explore challenges and expectations of standard care. Participants were chosen using a purposive sampling method. A total of 27 participants were interviewed using semi structured interviews. In the second stage, a scoping review was conducted in different databases to identify how home care is organized in different countries. In stage 3, the triangulation method (using the results of the previous phases, reviewing national upstream documents and the focus group discussion) was done to reach consensus and design the initial model for the Iranian context. In the following a Delphi study was conducted on the validation and feasibility of the developed model. Results: The quantitative study found that 51.3% of participants had family caregivers. Most participants had ADL independence (85.4%), while 22.9% and 24.3% were dependent and needed assistance with IADL, respectively. The obtained results of multiple regression analysis revealed a negative and significant association between unemployment, illiteracy, increasing age, five and more medications and ADL and IADL dependency (P < 0.05). In the qualitative study, we obtained three major themes (including lack of home care management mechanism, concern about the efficiency of home care and caregivers' job insecurity) and seven sub-themes. Determining a unique trustee for older adults’ affairs, universal coverage of long-term care insurance, empowering caregivers, providing integrated care, and monitoring it should be the priorities for public policy. Scoping review indicated that regulation makes authorities organize high-quality care. Ministries set legal frameworks, and municipalities are autonomous in determining principles and financing of services. Older adults are eligible to receive cash and in-kind benefits based on their needs or assets. Financing is done using insurance, taxes, or privately. Some countries have made quality assessment of services mandatory. In the third stage, 20 upstream documents and policies in Iran were extracted and after developing the initial model, an expert panel was held with the presence of 15 experts with experiences in the geriatric care field. The final model includes 7 basic components of governance and leadership, information management system, legislation, human resources management system, monitoring system, financing system, and finally the executive mechanism. Validation results showed that the proposed model with a CVI above 80% has high credibility from the experts' point of view and can be used as a model for providing home-based long-term care. Conclusions: The present study has presented a comprehensive model by adopting a multi-method, and organized approach and validating it using opinions of experts, trustees and geriatric experts. This model can be a guide for policymakers to provide integrated home care by professional caregivers under the supervision to ultimately improve the quality of care and the satisfaction of all involved stakeholders.