There is the desire amongst elderly Canadians to remain living at home, maintaining their independence. As the population ages, the health care system is faced with the challenge of allocating limited resources. Home care in Ontario is provided through Community Care Access Centres (CCAC) or Community Support Agencies (CSA). This study made comparisons among CSA clients (using the interRAI-Community Health Assessment, n=796), a sub-population of CCAC clients with lighter-care needs (n=8163) and all other CCAC clients (n=31,078), both using the Minimum Data Set-Home Care (MDS HC). The majority of clients in all groups were female, widowed, and spoke English as their primary language. CCAC clients had more health conditions than did CSA clients. Light-care CCAC clients received less hours of formal support than other CCAC clients and were less likely to have informal support caregivers who reported caregiver burden. Between 1998 and 2005, Ontario provided services to an increasingly impaired home care population, although overall impairment among home care client remained low. For the purposes of benchmarking, MDS HC data from Ontario was compared with MDS HC data from 11 European countries and was found to fall within the range of the other countries in terms of average impairment level of home care clients. Logistic regression was used to predict the likelihood of receiving CCAC services. Not being self-reliant, having decline in activities of daily living, having experienced falls, self-reporting one's health to be poor and reporting less loneliness were all correlates for CCAC service use. Implications and direction for future research were discussed.

Purpose: The purpose of this dissertation was to examine the determinants of unplanned emergency department (ED) use by home care clients, the profile of older ED patients, their transitions from the ED, as well as the determinants of post discharge outcomes among older ED patients. The goal of this dissertation was to create theoretically driven, evidence-based, and practical risk identification methods for home care and the ED. Methods: First, a multi-year, census-level cohort study was conducted on home care clients in two Canadian provinces (N=617,035). Census-level data from RAI-HC assessments were linked to census-level ED records. A needs-based decision tree model – the ED Model – informed by the Andersen Behavioural Model, was created using decision tree analyses. The final model was validated on a separate data partition and compared to the ERA Index and the CARS. Multilevel analyses were conducted to test regional variation in model performance. Disease stratified analyses were also conducted to test model generalizability across common disease classes. Regression analyses determined the effect of predisposing and enabling factors within ED Model strata. Second, a multi-site, multi-province prospective cohort study was conducted, termed the Management of Older Persons in Emergency Departments (MOPED) Study, using a clinically representative sample of 2,101 older ED patients. The interRAI ED-CA was used to assess older ED patients, and a 90-day disposition was collected. The profile of older ED patents was examined. Best-subset regression analyses identified person-level determinants of acute inpatient admission. Two needs-based decision tree models – the ALC/LTC and ED Revisit Models – were created using decision tree analyses to determine the risk of ALC designation or LTC placement, and unplanned repeat ED visits, respectively. Both models were validated on separate data partitions. Multilevel analyses were conducted to test site-level variation in the models’ performance. Results: Overall, 41.2% of home care clients had at least one unplanned emergency department visit within 6 months of an assessment. Previous ED use, cardio-respiratory symptoms, cardiac conditions, and mood symptoms featured heavily in the ED Model. The ED Model provided moderate risk differentiation and clinical utility. It achieved an area under the curve of 0.62 (95% CI: 0.61-0.62) and showed clear differentiation in Kaplan-Meier plots using validation data. Multi-level analyses showed no regional variation. The ED Model significantly outperformed the similar tools specific to primary care with respect to overall accuracy and perceived clinical utility. Predisposing and enabling characteristics provided little added differentiation beyond evaluated need. The majority of older ED patients were dependent on others for basic tasks of daily living, and many had fragile informal care or lived alone. Triage acuity generally did not differentiate chronic geriatric disabilities and conditions. Previous ED or hospital use was associated with chronic geriatric disabilities and conditions as well as informal caregiver distress. The Admission Model found that multiple factors were associated with admission to inpatient acute care, including: acuity, instability, changes in ADL function, cognition, nutrition, and anhedonia. Overall, 20.7% of older ED patients admitted to acute care were designated ALC or discharged to LTC; whereas 39.5% of older ED patients discharged home had one or more repeat ED visits within 90 days. Cognitive, functional, and informal care indicators were predictive of ALC/LTC; whereas functional status and symptoms were predictive of repeat ED use. The ALC/LTC and ED Revisit Models provided good risk differentiation, achieving AUC’s of 0.74 (95% CI: 0.69-0.79) and 0.69 (95% CI: 0.63-0.74), respectively. The ALC/LTC and ED Revisit Models showed clear differentiation in Kaplan-Meier plots. Multi-level analyses showed no site-level variation in each models’ performance. Conclusions: This dissertation produced tangible and empirically-based risk assessment models for clinical practice in home care and the ED. The models developed in this dissertation can support the targeting of preventative services as well as better communication strategies between the ED and community supportive care, primary care, and inpatient acute care. Key questions related to the prevention of the risk pathways identified in each risk assessment model remain unanswered, and should be a focus of future research.

There is the desire amongst elderly Canadians to remain living at home, maintaining their independence. As the population ages, the health care system is faced with the challenge of allocating limited resources. Home care in Ontario is provided through Community Care Access Centres (CCAC) or Community Support Agencies (CSA). This study made comparisons among CSA clients (using the interRAI-Community Health Assessment, n=796), a sub-population of CCAC clients with lighter-care needs (n=8163) and all other CCAC clients (n=31,078), both using the Minimum Data Set-Home Care (MDS HC). The majority of clients in all groups were female, widowed, and spoke English as their primary language. CCAC clients had more health conditions than did CSA clients. Light-care CCAC clients received less hours of formal support than other CCAC clients and were less likely to have informal support caregivers who reported caregiver burden. Between 1998 and 2005, Ontario provided services to an increasingly impaired home care population, although overall impairment among home care client remained low. For the purposes of benchmarking, MDS HC data from Ontario was compared with MDS HC data from 11 European countries and was found to fall within the range of the other countries in terms of average impairment level of home care clients. Logistic regression was used to predict the likelihood of receiving CCAC services. Not being self-reliant, having decline in activities of daily living, having experienced falls, self-reporting one's health to be poor and reporting less loneliness were all correlates for CCAC service use. Implications and direction for future research were discussed.

Purpose: The purpose of this dissertation was to examine the determinants of unplanned emergency department (ED) use by home care clients, the profile of older ED patients, their transitions from the ED, as well as the determinants of post discharge outcomes among older ED patients. The goal of this dissertation was to create theoretically driven, evidence-based, and practical risk identification methods for home care and the ED. Methods: First, a multi-year, census-level cohort study was conducted on home care clients in two Canadian provinces (N=617,035). Census-level data from RAI-HC assessments were linked to census-level ED records. A needs-based decision tree model – the ED Model – informed by the Andersen Behavioural Model, was created using decision tree analyses. The final model was validated on a separate data partition and compared to the ERA Index and the CARS. Multilevel analyses were conducted to test regional variation in model performance. Disease stratified analyses were also conducted to test model generalizability across common disease classes. Regression analyses determined the effect of predisposing and enabling factors within ED Model strata. Second, a multi-site, multi-province prospective cohort study was conducted, termed the Management of Older Persons in Emergency Departments (MOPED) Study, using a clinically representative sample of 2,101 older ED patients. The interRAI ED-CA was used to assess older ED patients, and a 90-day disposition was collected. The profile of older ED patents was examined. Best-subset regression analyses identified person-level determinants of acute inpatient admission. Two needs-based decision tree models – the ALC/LTC and ED Revisit Models – were created using decision tree analyses to determine the risk of ALC designation or LTC placement, and unplanned repeat ED visits, respectively. Both models were validated on separate data partitions. Multilevel analyses were conducted to test site-level variation in the models’ performance. Results: Overall, 41.2% of home care clients had at least one unplanned emergency department visit within 6 months of an assessment. Previous ED use, cardio-respiratory symptoms, cardiac conditions, and mood symptoms featured heavily in the ED Model. The ED Model provided moderate risk differentiation and clinical utility. It achieved an area under the curve of 0.62 (95% CI: 0.61-0.62) and showed clear differentiation in Kaplan-Meier plots using validation data. Multi-level analyses showed no regional variation. The ED Model significantly outperformed the similar tools specific to primary care with respect to overall accuracy and perceived clinical utility. Predisposing and enabling characteristics provided little added differentiation beyond evaluated need. The majority of older ED patients were dependent on others for basic tasks of daily living, and many had fragile informal care or lived alone. Triage acuity generally did not differentiate chronic geriatric disabilities and conditions. Previous ED or hospital use was associated with chronic geriatric disabilities and conditions as well as informal caregiver distress. The Admission Model found that multiple factors were associated with admission to inpatient acute care, including: acuity, instability, changes in ADL function, cognition, nutrition, and anhedonia. Overall, 20.7% of older ED patients admitted to acute care were designated ALC or discharged to LTC; whereas 39.5% of older ED patients discharged home had one or more repeat ED visits within 90 days. Cognitive, functional, and informal care indicators were predictive of ALC/LTC; whereas functional status and symptoms were predictive of repeat ED use. The ALC/LTC and ED Revisit Models provided good risk differentiation, achieving AUC’s of 0.74 (95% CI: 0.69-0.79) and 0.69 (95% CI: 0.63-0.74), respectively. The ALC/LTC and ED Revisit Models showed clear differentiation in Kaplan-Meier plots. Multi-level analyses showed no site-level variation in each models’ performance. Conclusions: This dissertation produced tangible and empirically-based risk assessment models for clinical practice in home care and the ED. The models developed in this dissertation can support the targeting of preventative services as well as better communication strategies between the ED and community supportive care, primary care, and inpatient acute care. Key questions related to the prevention of the risk pathways identified in each risk assessment model remain unanswered, and should be a focus of future research.

Objectives: Research on life stressors and adverse life events has a long tradition. Few studies have addressed this topic in connection to very old people. Life stressors, especially major life stressors (MLSs) experienced by clients of home care services in the community have rarely been the subject of studies. Considering this gap, we investigated the prevalence of MLSs in home care clients. We examined the effects that MLSs have on their mood and health status as well as the impact of clients’ social resources on MLSs and their outcomes. Method: We used assessment data from 2,884 home care clients in six European countries. The methodological basis was the comprehensive and standardized interRAI Home Care Assessment (interRAI HC). Results: Fifteen point four percent of the sample—that consisted of women and men with an average age of 82.89 years–experienced an MLS in the last 6 months before the assessment. They were more depressed than persons without these experiences, and their health status indicated a higher level of instability and deterioration. At reassessment after 6 months, the situation changed. Despite the fact that both outcomes of the MLSs, depression and health status became worse in the reassessment-sample, home care clients without MLS were more affected by the worsening, especially that of depression. The expected buffering impact of social resources was low. Discussion: Although this study worked with limited information on MLSs, it could contribute to closing various knowledge gaps. The study shows that the MLSs represent a prevalent problem in a population of home care clients and that this problem has negative consequences for their mood and the stability of their health status. Furthermore, this research took up the situation of very old and vulnerable adults, who have previously rarely been considered in studies on major critical life events and stressors. Conclusion and Research Perspective: Future research on MLSs has to take up the issue of the time passage between the MLS and the impact on health and well-being of individuals dependent on care. It has to determine immediate as well as later consequences and identify those factors that are appropriate to reduce the MLS-effects on very old people dependent on care.