The Norwegian Knowledge Centre for the Health Sciences has been commissioned by the Norwegian Department of Health to produce a systematic review of the scientific evidence concerning effects of the use of personnel with special expertise in functional training and activation compared to standard care at achieving social participation and activity amongst users of municipal home care.
Summary of the results:
Social participation :
Group activities apparently reduce social isolation and loneliness amongst elderly living at home or with assisted living. Occupational therapy (at home) probably has a small but positive effect on social participation and activity of stroke patients.
Physical function :
Inter-disciplinary measures (at home) probably have a small but positive effect on the general physical function amongst elderly. Occupational therapy (at home) probably has a small, positive effect on physical function amongst stroke victims and patients with rheumatoid arthritis.
Quality of life :
Long-term interventions (case management program) probably improve the quality of life for fragile elderly living in their own homes compared to those living in care homes.
The quality of available research is too low to determine whether physiotherapy and multidisciplinary treatment for stroke victims and personal assistants for older or younger users have effect on social participation and activity.
We performed a systematic search for systematic reviews in international research databases. We selected studies that met our inclusion criteria, scored their quality and summarized the results.
We have only identified systematic reviews within rehabilitation and elderly care and have not found reviews in this context assessing mental health or drug addictions. Most included reviews have focused on measures taken in care, and not on the qualifications of the personnel. Only two of the reviews specifically referred to personnel. We identified studies on two occupations with specialized expertise in functional training and activation: occupational therapists and functional therapists. We therefore have little knowledge about other professions. In addition there are personal assistants - that have no formal competence in training function and activation. Several of the reviews included interdisciplinary measures and group therapies. We have limited information about what personnel were used in these studies.
These reviews can only partially answer our question. There is little available research on the effects of using personnel with special expertise in municipal home care. We have not found systematic reviews that evaluated these measures for the areas of mental health or alcohol and drug addictions. Concerning the elderly, group activities seem to reduce isolation and loneliness. For stroke patients, occupational therapy probably has a small positive effect on social participation and activity, but present research does not address the applicability of these results to other patients.
There is a perception that home care services for people requiring assistance should be changed from a more passive basic care to in a greater extent to encourage activity and participation. The term home care services can in a greater sense also contain measures that strengthen physical activity, social-skills training and facilitation to master activities of daily life and participation in the community. "Active care" is one of the government's five strategies to meet future challenges in the care services in the home care plan Omsorgsplan 2015. Broadening professional skills amongst personnel and further development of the present offer of activities are two important areas of focus in this process.
The Norwegian Knowledge Centre has been commissioned by the Department of Health to produce a systematic review of the scientific evidence concerning effects of the use of personnel with special expertise in functional training and activation at achieving social participation and activity amongst users of municipal home care.
We searched the following databases for systematic reviews in October 2008:
Medline, Embase, PsycInfo, British Nursing Index, Amed, Cochrane Library, CDR Databases, ISI Web of Knowledge, Svemed, Pedro and OT Seeker. Two people independently assessed the studies using inclusion and exclusion criteria for selection.
The inclusion criteria were:
Study Design: Systematic reviews
Population : All users of the municipal home care service that live at home – including assisted living domiciles.
Interventions: Use of personnel (physiotherapists, occupational therapists, assistants, etc) with competence in exercise and activation in municipal home care.
Comparison: Standard care
Outcome: Social participation and activity, levels of functioning, quality of life, user satisfaction and costs
Language: no language limitations
The exclusion criteria for the report were:
Study Design: Non-systematic reviews and systematic reviews of low quality.
Population: Patients in nursing homes and other fulltime institutional care.
We have critically reviewed relevant articles that met our inclusion criteria and have summarized the included systematic reviews in narrative and tables.
To assess the quality of the documentation we used GRADE, scoring the scientific quality as high, moderate, low or very low.
We have summarized results from nine systematic reviews. Two systematic reviews addressed younger users, four concerned the elderly in general and three concerned the elderly with special diagnoses as stroke, arthritis and Alzheimer's. The reviews referred to various interventions/personnel; personal assistants (3), group and individual interventions (1), interventions to cope with behaviour in patients with Alzheimer’s disease (1), inter-disciplinary measures (2), physiotherapy (1) and occupational therapy (2). One review investigated the effect of home carers, short-term programs for patients immediately after discharge from hospital and long-term measures for the most dependent elderly.
This summary shows that occupational therapy (at home) probably has a small, positive effect on social participation for stroke patients returning from hospital or rehabilitation, and also possibly a small effect on physical function amongst stroke victims and patients with arthritis. It is possible that the various group activities reduce isolation and loneliness amongst elderly living at home. Interdisciplinary measures (in the home) have a small, positive effect on physical function among the elderly in general. Furthermore, this review indicates that long-term interventions (case management programme) improve quality of life for the most dependent elderly who want to live at home, compared to institutional care. There are sparse data about effects on user satisfaction and cost analysis. We have only identified systematic reviews covering rehabilitation and elderly care and none assessing mental health or drugs and addiction.
Most included reviews have focused on care interventions and not on personnel, only two of the reviews were about the personnel per se . We have only identified studies of two professions with special expertise in functional training and activation: occupational and physical therapists. We therefore have little knowledge about other professions. In addition there are personal assistants, a group lacking formal competence in training function and activation. Several of the reviews included interdisciplinary measures and group exercises. The included reviews disclose little information about what personnel that were used for these interventions.’
Users of municipal home care are as such a very heterogeneous group. There are different thresholds for when a user gets to receive home care services, and the population in nursing homes and institutional care are disparate. In several of the included reviews the intervention is poorly described in the control group. There is also a lack of definition of standard care. Most of the studies have been conducted in countries outside Scandinavia. Several countries in Europe have reduced the extent of institutional care in parallel to Norway’s HVPU reform, and several included studies were performed prior to this reform. Lack of public care does not necessarily preclude social contact or activity - elderly also socialize or have activities through contacts with friends, family, organizations and volunteers.
There is little research on the effect of using personnel with special expertise in municipal home care. We have not found systematic reviews that assessed interventions for mental health or drug and addiction care. When it comes to the elderly, it appears that the group activities reduce isolation and loneliness. For stroke victims who have been discharged from hospital/rehabilitation occupational therapy probably has a small, positive effect on social participation and activity. We do not know whether this applies to other patients. Inter-disciplinary measures have a small positive effect on physical function in the elderly and occupational therapy possibly has a small, positive effect on physical function in patients with stroke and arthritis. Long-term interventions (case management programme) probably improve the quality of life for the most dependent elderly living at home compared to nursing homes.