Determining if and how older patients can safely stay at home with additional services

Clinical question

How can I determine the amount of support required by my frail older patients to help them remain at home as safely as possible?

Bottom line

To determine if a patient can safely remain at home, the frequency of their need for support must be compared with the frequency of support availability to determine if there are gaps. One must then decide whether the gaps can be filled with home services or whether they require more intensive support from a retirement home or long-term care. A practical approach to determining care needs for older patients living at home can be found in the article “The ‘interval of need’ approach: how to determine if an older person can stay at home safely or be discharged from hospital safely” (http://canadiangeriatrics.ca/wp-content/uploads/2018/01/CME-Journal-Vol.-8-Issue-1-Article-3_Final.pdf).¹

Evidence

• According to Statistics Canada, more than 2.2 million Canadians received home care in 2012.²

• Of this population, 15% (331 000) had only partially met home care needs for a chronic health condition.²

• Those with unmet or partially met needs reported several adverse effects such as loneliness and higher levels of stress.²

Approach

In 1976 Isaacs and Neville coined the term interval of need, which is the length of time a person can manage without human assistance.³ The traditional way to measure care needs is to evaluate the person’s functional status, typically by assessing how he or she performs instrumental activities of daily living and other activities of daily living, and then determining the functional areas where the patient is independent or has appropriate supports and areas where the patient has unmet requirements for assistance. By identifying gaps, one can then search for home-based resources or consider the need for a more supportive environment.⁴ However, this approach does not reflect the frequency with which care is needed.

A complementary framework focuses on the intensity or frequency of support that people require for independent living (partially adapted from Isaacs and Neville³). Table 1 outlines classifications of intervals of need.⁵

Implementation

Using this approach, there are 3 initial important considerations affecting someone’s “ability” to return home or to stay at home: safety, interval of need, and interval of support.