Feasibility of the INSPIRE care model: a community-based integrated care model for home-dwelling older adults

The global increase in life expectancy has led to an ageing population; particularly in Europe and Switzerland (1–4). The number of older adults, especially those aged 75 and older, is expected to rise significantly from 44 million in 2022 to 74 million by 2050 (4). However, the increase in life expectancy has not necessarily translated to an increase in healthy years due to the high prevalence of multimorbidity, ranging from 40% to 75% (5–7).
Multimorbidity poses a substantial burden on healthcare systems and is linked to adverse health outcomes, including frailty (8,9). Frailty is considered a state of vulnerability in older adults, characterized by an increased susceptibility to adverse health outcomes, functional decline, and a reduced ability to recover from stressors (10,11). There are various approaches to defining frailty, but they all agree on its multidimensional, non-linear, and dynamic nature (8,9,11). Frailty is associated with negative health outcomes, including falls, disability, hospitalization, and mortality (10,11). It also has a negative impact on the life of caregivers (10,11). Frail individuals often require care from multiple providers such as general physicians, nurses, physiotherapists, etc. However, the way in which their care is organized tends to be fragmented (12). Care fragmentation can lead to care gaps, conflicting recommendations, and unmet health and social care needs (13), which can result in unmet needs and increased healthcare costs (12,14,14–16).
Unmet needs among home-dwelling older adults can result from the unavailability or inadequacy of essential support and services (17–20). These needs encompass healthcare services (e.g. health promotion, prevention, treatment, etc.) and home support services (e.g. assistance with activities of daily living, transportation, financial management, etc.); and are associated with various adverse consequences, including lower quality of life and increased healthcare utilization (18,21–23). While the prevalence of unmet needs for healthcare services in older adults stands at 25% (24), the prevalence of unmet needs for home support ranges from 11% (22) to 55% (19) depending on the definition or assessment methodology used. Failure to meet the needs for home support services can lead to adverse outcomes, including lower quality of life, increased healthcare utilization, hospitalizations, institutionalization, and mortality (18,21–23). This underscores the importance for developing innovative solutions that facilitate a comprehensive identification of the complex health and social care needs of home-dwelling older adults, while providing the necessary multidisciplinary support to meet those needs.
Integrated care has been proposed as a solution to meet the complex needs of frail older adults and mitigate care fragmentation (25,26). Integrated care models aim to coordinate and provide multidisciplinary care to meet the needs of older adults while allowing them to stay at home (13,27). Despite recommendations to advance integrated care models in order to meet the needs of frail older adults (28) (29,30), its effectiveness remains unclear. Integrated care models are considered complex intervention with various components and challenges (13,27,31). Achieving integration requires overcoming barriers at different levels (13,27,31), and the contextual factors play a crucial role in its success (31–33). Thus, given the complex nature of integrated care models, it is recommended to first assess their feasibility in the specific context before proceeding to evaluate their effectiveness (34–36). By assessing its feasibility, potential refinements to the care model can be identified, uncertainties related to the evaluation design can be clarified, and additional barriers to its implementation can be recognized (34,37). To date, only one study has published the results of the feasibility assessment of an integrated care model for home-dwelling older adults (38). While this study reported positive enrollment and adherence, it didn't evaluate the intervention's implementation or reach. Given the challenges of engaging home-dwelling older adults for community-based programs (39), assessing reach is crucial in feasibility assessments of such interventions.
Canton Basel-Landschaft (BL) in Switzerland presents an ideal scenario to advance integrated care due to its ageing population and the introduction of a legal framework for addressing the needs of home-dwelling older adults (40,41). These determinants set a strong foundation to advance integrated care in the canton. In response to this, the Canton BL and the University of Basel partnered to create the INSPIRE (ImplemeNtation of a community-baSed care Program for home dwelling senIoR citizEns) Project. INSPIRE is multiphase project aimed to develop, implement, and evaluate a community-based integrated care model for frail home-dwelling older adults. It was designed in alignment with the recommendations of the UK Medical Research Council (MRC) Framework for the development and evaluation of complex intervention (34); and incorporates implementation science methods, as a way to unravel and facilitate its implementation and ensure their sustainability beyond the research phase. The INSPIRE project's three phases include: 1) development of the care model; 2) feasibility assessment; and 3) effectiveness evaluation.
Phase 1 concluded with the development of the INSPIRE care model, a community-based integrated care model with four core components: frailty screening, multidimensional assessment, development of a care plan and coordination, and follow-up. While this dissertation draws on secondary data used for the development of the care model, its primary focus lies on the feasibility evaluation of the INSPIRE care model. Consequently, the main objectives of this PhD focus on three key aspects. First, by using an ecological approach, we aimed to determine the prevalence of and identify the factors associated with perceived unmet needs for home support in home-dwelling older adults, in order to get a better understanding of the vulnerable home-dwelling older population. Second, we recognized the inherent challenges in reaching home-dwelling older adults, and therefore we wanted to contribute evidence on how to reach this population by using implementation strategies selected by following an implementation mapping approach. Last, due to the complexity of integrated care models, we wanted to determine the feasibility of the INSPIRE community-based integrated care model for frail home-dwelling older adults using implementation science methods. This care model was implemented and tested in an Information and Advice Center (IAC) of a care region of Canton Basel-Landschaft.
Chapter 1 provides an in-depth examination of population demographics concerning ageing. It introduces essential concepts like multimorbidity, frailty, and unmet needs before delving into integrated care, implementation science, and providing a concise overview of the INSPIRE Project in Canton Basel-Landschaft. Chapter 2 describes the aims of this dissertation.
Chapter 3 focuses on analysing the prevalence of unmet needs for home support in home-dwelling older adults and the factors at the macro-, meso-, and micro- levels associated with them (42). Using an ecological approach and data from the INSPIRE Population Survey (43) we found a prevalence of unmet needs for home support of 4.3% (42), which was lower than previous studies (19,20). This was likely due to differing definitions and the methods used to assess them. Key factors associated with the perception of unmet needs for home support included: receiving other government support (macro), using transportation services (meso), and experiencing depression or abandonment (micro), increasing odds of unmet needs. Conversely, having private health insurance (macro), higher education, good self-perceived health, and informal care (micro) reduced odds of unmet needs. These findings coincided with previous studies that have demonstrated that socio-economic disparities at different levels can shape the perception of unmet needs for home support among home-dwelling older adults (19,22,44–47).
Chapter 4 elucidates our approach for identifying implementation strategies to reach home-dwelling older adults in order to allow them to receive the services of the new IAC of a care region in Canton BL. Guided by the implementation mapping approach (48), we identified seven implementation strategies (49) that were organized in bundles and delivered by the IAC manager to community care providers, home-dwelling older adults, and their caregivers. Despite using this approach, the reach of the target population was estimated at 5.4%, somewhat lower comparing to other studies in Canada and the US (50,51). Moreover, our analysis revealed that most IAC visitors were either self-referred or referred by their caregivers, with minimal referrals from community care providers. Factors such as low fidelity in delivering the implementation strategies selected and low coverage partially explained the low reach observed. However, we considered that other factors such as the time needed for the IAC to establish itself in the community (32,52), and the absence of formal collaborative structures could have also impacted the observed results (32).
Chapter 5 describes the results of the feasibility evaluation of the INSPIRE care model implemented in the IAC of a care region of Canton Basel-Landschaft. This study was conducted using a convergent parallel mixed-methods design. We collected quantitative and qualitative data in order to assess the acceptability, fidelity, feasibility, and reach of the INSPIRE care model core components from the perspective of older adults, informal caregivers, IAC staff and community care providers. Our analysis revealed that while frailty screening and multidimensional assessment were two core components delivered with high fidelity levels (100% and 75%, respectively) and widely accepted by older adults, informal caregivers and IAC staff, the implementation of the other two core components encountered significant challenges. We observed a poor fidelity for care planning and coordination (42%), accompanied by acceptability issues among community care providers. Similarly, our results revealed that follow-up (10%) had the lowest fidelity score, associated with some feasibility issues (e.g. lack of time of the IAC staff). Our findings aligned with other studies that had underscored the inherent challenges in collaborating with other care providers, potentially acting as a barrier to the successful implementation of integrated care (31,32,53,54).
Chapter 6 provides a comprehensive synthesis of the findings reported in Chapters 3 through 5; offering a thoughtful interpretation within the framework of existing literature. It also addresses the methodological strengths and potential limitations of this PhD project. This chapter also includes reflections on the implications of this research for fellow researchers, policy developers, and practitioners.
In summary, the increasing aging population and the challenges of multimorbidity and frailty demand innovative solutions. The INSPIRE Project in Canton Basel-Landschaft aims to address these challenges with the implementation of a community-based integrated care model. The insights from this research offer valuable guidance for researchers, practitioners, and policymakers. Our findings revealed the impact of socio-economic disparities on unmet needs, even in high-income countries, demonstrating that more efforts are needed to facilitate the access of vulnerable older adults to the support needed. They also emphasize the necessity of community-wide collaboration in order to effectively reach home-dwelling older adults. Additionally, our research highlights the challenges in implementing integrated care within the community, and the importance of investing time and efforts to improve the collaboration between healthcare and social care professionals. We believe that our findings have valuable implications for improving care for frail older adults and advancing the implementation of integrated care models in community-settings.