Community-Dwelling Older Women: The Association Between Living Alone and Use of a Home Nursing Service

JAMDA xxx (2019) 1e9

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Original Study

Community-Dwelling Older Women: The Association Between Living Alone and Use of a Home Nursing Service Angela Joe PhD a, *, Marissa Dickins PhD a, b, Joanne Enticott PhD b, c, Rajna Ogrin PhD a, d, e, f, Judy Lowthian PhD a, g, h, i a

Bolton Clarke Research Institute, Bolton Clarke, Bentleigh, Victoria, Australia Southern Synergy, Department of Psychiatry at Monash Health, Southern Clinical School, Monash University, Dandenong, Victoria, Australia c Department of General Practice, School of Primary and Allied Health Care, Monash University, Notting Hill, Victoria, Australia d Department of International Business and Asian Studies, Griffith University, Gold Coast, Queensland, Australia e Biosignals for Affordable Healthcare, Royal Melbourne Institute of Technology University, Melbourne, Victoria, Australia f Austin Health Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia g School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia h Faculty of Health and Behavioural Sciences, University of Queensland, Brisbane, Queensland, Australia i Institute of Future Environments, Queensland University of Technology, Brisbane, Queensland, Australia b

a b s t r a c t Keywords: Home nursing service community health service older women living alone

Objective: To investigate the use of home nursing by community-dwelling older women to determine the nature of services required by those living alone. Design: A retrospective cohort study using routinely collected data. Setting and Participants: Women aged 55 years and older living in metropolitan Melbourne who received an episode of nursing care from a large community home-based nursing service provider between January 1, 2006 and December 31, 2015. Methods: Descriptive and inferential statistical analyses were used to examine the relationship between client- and service-related factors and use of community nursing services. The primary outcome of interest was the hours of service received in a care episode. Results: A total of 134,396 episodes of care were analyzed, in which 51,606 (38.4%) episodes involved a woman who lived alone. The median hours of care per episode to women who lived alone was almost 70% more than that for women who lived with others. Multivariable regression identified factors influencing the amount of service use: living alone status, cognitive health status, and number of required home nursing activities. After adjusting for confounding and interactions, living alone was associated with at least 13% more hours of care than is provided to those not living alone. Compared with women who lived with others, women living alone required almost double the amount of assistance with medication management and were 30% more likely to experience a deterioration in their condition or be discharged from home nursing care into an acute hospital. From 2006 to 2015, for all women there was a trend toward fewer hours of nursing service provided per episode. Conclusions and Implications: Community-dwelling older women who live alone have greater service needs and higher rates of discharge to hospital. This knowledge will help guide provision of services and strategies to prevent clinical deterioration for this population. Ó 2019 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

The proportion of adults aged 60 years or older in the population is projected to almost double, from 12% globally in 2015 to 22% in 2050.1,2 Aging is strongly associated with a decline in health3 and

This work was supported by the Lord Mayor’s Charitable FoundationdEldon & Anne Foote Trust (Innovation Grant 2016). The authors declare no conflicts of interest. * Address correspondence to Angela Joe, PhD, Bolton Clarke Research Institute, Bolton Clarke, Suite 1.01, 973 Nepean Highway, Bentleigh, VIC 3204, Australia. E-mail address: [email protected] (A. Joe). https://doi.org/10.1016/j.jamda.2019.11.007 1525-8610/Ó 2019 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

functional ability4 with increasing dependence on care provided by others. Traditionally, adult children adopt an informal caregiving role; however, with declining birth rates5 and rising childlessness among older people in economically developed countries,6e8 this option is diminishing. For people with adult offspring, involvement of more women in paid employment9 and an increasingly mobile workforce10 mean that children may not have the capacity or be living nearby to care for older parents. Such reduction in family support means there is a need for provision of formal care services. In response, many countries have government-funded aged care programs11 with a vital

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component being home care,12e16 as the majority of older people prefer to live in their own home for as long as possible.17e20 In Australia,21,22 as in many countries,22 women live longer than men, and older women are more likely to live alone. Older women who live alone are a sizeable proportion of home nursing services consumers, yet there has been limited research and a paucity of literature on their unique service needs.23 This study examines the influence of living alone on utilization of a home-based nursing service by older women. Methods This study is reported in accordance with the REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) Statement.24 This investigation is a substudy of an overarching 2-year project, titled Older Women Living Alone, aimed at optimizing the health and well-being of older women using evidence-informed co-design. We analyzed routine administrative data to (1) characterize older women using a nursing service and changes in this population over time25 and (2) investigate the nature of the services provided by the nursing organization (this study). The findings from these analyses were triangulated with a systematic review and interviews with older women to inform the codesign process.26 Design and Setting This retrospective cohort study involved secondary analysis of administrative electronic records of Bolton Clarke (formerly the Royal District Nursing Service), a large not-for-profit community nursing provider in Victoria, Australia. An episode of care is the time period during which an individual receives health care from a service provider.27 For 79% of care episodes, the services received were government-funded (Supplementary Table 1), with the remaining 21% paid for privately.28 Analyses were conducted on complete episodes that commenced and concluded within January 1, 2006 to December 31, 2015 (see Supplementary Figure 1). This study was approved by the Bolton Clarke Human Research Ethics Committee (approval number 170003). Population and Data The study population encompassed women aged
55 years living in metropolitan Melbourne and surrounds who accessed the home nursing organization for services during the study period. For each care episode, demographic information and clinical and servicerelated data were recorded. On admission to the nursing service, consent for use of the client’s deidentified data in research was sought on an opt-out basis. Demographic information included age at admission, country of birth, primary spoken language, living alone status, accommodation type, and whether there was an informal carer such as a partner or friend. Living alone status was the primary explanatory variable of interest. Clinical diagnoses were recorded using codes from the International Classification of Diseases (ICD). Both ICD-9-CM29 and ICD10-AM30,31 codes were present in the original data set; ICD-9-CM codes were mapped to ICD-10-AM codes for the purposes of data analysis. Various conditions resulting in cognitive dysfunction were grouped for analysis, namely, cognitive impairment (F06.7, R41.8, R41.3), senility (R54), Alzheimer’s disease (F00, G30), and dementia (F01, F02, F03, G31). Charlson Comorbidity Index scores,32 a measure of the severity of comorbidities, were categorized as appropriate for an older population.33 Service use data included referral source, duration of care episode, outcome of treatment, and information on service cessation. Figure 1

illustrates the relationship between service and care activities available to clients. Service activities were grouped into 4 service types (see Supplementary Table 2). Care activities provided during a service activity were grouped into 9 care clusters (see Supplementary Table 3). For each service activity undertaken, up to 5 care activities could be recorded. Outcome The primary outcome of interest (dependent variable) was the total hours of service received within a care episode. These hours did not include travel time to where nursing care was provided. Statistical Analyses Descriptive statistics compared the characteristics of care episodes for women who lived alone with those who lived with others. Summary measures of frequencies and proportions with 95% confidence intervals (CIs) were calculated for categorical variables, and chisquared tests were conducted to test for associations. Medians were used because of skewness in the frequency distributions of continuous variables; and Wilcoxon rank sum tests were used to compare groups with non-normal distributions. Missing data were reported. Because of the size of the data set, unless otherwise stated, statistical significance was set at P < .001.34 Multilevel generalized linear mixed effects modeling was used to model service use, that is, hours of service per care episode, while adjusting for possible confounders. This method controlled for clustering of multiple episodes among clients. A negative binomial probability distribution for the outcome data was assumed as it was extremely skewed, with the variance exceeding the mean. The selection of variables and interaction terms for regression modeling was based on the literature, input from gerontological researchers and clinicians regarding clinical relevance, and on the descriptive analyses. We hypothesized that demographics (age, cultural background), issues related to the client’s health (comorbidities, the complexity of care required, episode duration), and the year of admission to care would influence the amount of service received. Univariate regression was conducted to determine the relationship between each explanatory covariate and the outcome. Collinearity, defined as a correlation coefficient greater than 0.3, between all explanatory variables was tested before multivariable regression analysis. If any 2 variables correlated above this threshold, only 1 was included for analysis. The first multivariable model included all explanatory variables. For continuous and binary variables, the P value for a regression coefficient was determined from the regression analysis. For categorical variables with more than 2 levels, a likelihood ratio test (LRT) was performed following regression modeling to calculate an overall LRT P value. A value of P  .05 was adopted to determine whether variables should be retained in the multivariable model. The best-fit model was selected based on the lowest Akaike information criterion value and a plot showing normally distributed standardized deviance residuals. Covariate interactions that we postulated may affect the outcome of interest were that age or living alone may moderate the relationship between the outcome (service use) and explanatory variables, such as cognitive dysfunction, comorbidity, or the number of care clusters. To investigate interplay between covariates, LRTs were conducted to compare the best-fit main effects model with and without individual interaction terms, with significant interactions (LRT P  .05) included in the final model. Significant interactions were as follows: living alone and number of care clusters, living alone and episode duration, and age and episode duration. A final multivariable model was

A. Joe et al. / JAMDA xxx (2019) 1e9

generated by introducing the three 2-way interaction terms into the best-fit main effects model. Results for the regression models were expressed as incidence rate ratios (IRRs) with 95% CIs. To compensate for large sample size sensitivity, the final multivariable regression models were run with 1000 bootstrapped samples drawn with replacement from the data set to ensure results were robust. Analyses were conducted using Stata, version 15.1. Results Client-Related Characteristics Of 134,396 episodes of home nursing care for females aged
55 years, 38.4% (51,606) involved a woman who lived alone (Table 1).

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Forty-four percent of older women living alone and 41.2% of older women living with others had multiple episodes of care during the 10year study period. At admission, women living alone had a median age of 83 years (interquartile range [IQR]: 78-88) whereas those living with others had a median age of 79 years (IQR: 72-86; P < .001). In care episodes for women living alone, it was more likely that English was the primary spoken language (86.5% vs 75.8% of others episodes, P < .001) and the client lived in a private residence (97.3% vs 69.6% of others episodes, P < .001). An informal carer was involved in a minimum of 53.1% to possibly as high as 75.2% of cases for women living with others, in contrast to in 24.8% of episodes for women living alone. Cognitive dysfunction was slightly more likely in women living alone (14.7% vs 12.8% of others episodes; P < .001) as

Fig. 1. Home nursing care: service activity types and care activity clusters.

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Table 1 Characteristics of 134,396 Episodes of Home Nursing Care for Women Clients Aged 55 Years or Older*, by Living Alone Status of the Client, January 1, 2006, to December 31, 2015 Characteristic

Living Alone

Living With Others

Number of episodes Number of unique clientsy Client-related information Age at admission (y), n (%, 95% CI) 55-64 65-74 75-84 85-94
95 Country of birth, n (%, 95% CI) Australia Southern and Eastern Europe Northwest Europe North Africa and the Middle Southeast Asia Southern and Central Asia Northeast Asia Oceania and Antarctica (excluding Australia) Sub-Saharan Africa Americas Other Missing values English as primary spoken language, n (%, 95% CI) No Yes Missing values Accommodation type, n (%, 95% CI) Private residencedown Private residencedrent Other, eg, residential aged care, temporary shelter Missing values Has an informal carer, n (%, 95% CI) No Yes Missing values Charlson Comorbidity Index, n (%, 95% CI) Mild (CCI 1) Moderate (CCI ¼ 2-4) Severe (CCI
5) Missing values Cognitive dysfunction, n (%, 95% CI) No Yes Home nursing care-related information Year of admission to episode, n (%z, 95% CI) 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Referral source, n (%, 95% CI) Government, community health service, or social service Self, friend, family, neighbor, landlord Subacute care service, eg, rehabilitation facility, respite care service Hospital Palliative care service Doctor (general practitioner or specialist) Residential aged care service Other Number of episodes of home nursing care during 2006-2015, median (IQR) Duration of episode (d), median (IQR) Total hours of service received per episode, median (IQR) Number of service activities undertaken per episode, median (IQR) Number of service activities undertaken per episode, by service type, median (IQR) Home visit Consultation with other health care professional, eg, client’s general practitioner, pharmacist Administrative task

51,606 28,893

82,790 48,718

P value

<.001 2641 7075 19,961 20,373 1826

(5.1, 4.9-5.3) (13.7, 13.4-14.0) (38.2, 37.7-38.6) (39.5, 39.1-39.9) (3.5, 3.4-3.7)

10,886 18,571 29,816 21,298 2219

(13.2, 12.9-13.4) (22.4, 22.1-22.7) (36.0, 35.7-36.3) (25.7, 25.4-26.0) (2.7, 2.6-2.8)

33,590 8302 5861 579 272 477 158 267 247 216 46 1591

(65.1, 64.7-65.5) (16.1, 15.8-16.4) (11.4, 11.1-11.6) (1.1, 1.0-1.2) (0.5, 0.5-0.6) (0.9, 0.8-1.0) (0.3, 0.3-0.4) (0.5, 0.5-0.6) (0.5, 0.4-0.5) (0.4, 0.4-0.5) (0.1, 0.1-0.1) (3.1, 2.9-3.2)

42,299 17,733 7936 1844 1686 1410 783 803 588 573 79 7056

(51.1, 50.7-51.4) (21.4, 21.1-21.7) (9.6, 9.4-9.8) (2.2, 2.1-2.3) (2.0, 1.9-2.1) (1.7, 1.6-1.8) (0.9, 0.9-1.0) (1.0, 0.9-1.0) (0.7, 0.7-0.8) (0.7, 0.6-0.8) (0.1, 0.1-0.1) (8.5, 8.3-8.7)

<.001

<.001 6426 (12.5, 12.2-12.7) 44,619 (86.5, 86.2-86.8) 561 (1.1, 1.0-1.2)

17,743 (21.4, 21.2-21.7) 62,775 (75.8, 75.5-76.1) 2272 (2.7, 2.6-2.9)

44,418 5761 592 835

53,637 3949 5820 19,384

<.001 (86.1, 85.8-86.4) (11.2, 10.9-11.4) (1.2, 1.1-1.2) (1.6, 1.5-1.7)

(64.8, 64.5-65.1) (4.8, 4.6-4.9) (7.0, 6.9-7.2) (23.4, 23.1-23.7) <.001

38,435 (74.5, 74.1-74.9) 12,817 (24.8, 24.5-25.2) 354 (0.7, 0.6-0.8)

20,497 (24.8, 24.5-25.1) 43,975 (53.1, 52.8-53.5) 18,318 (22.1, 21.8-22.4)

41,806 9138 505 157

62,671 17,692 1581 846

<.001 (81.0, 80.7-81.3) (17.7, 17.4-18.0) (1.0, 0.9-1.1) (0.3, 0.3-0.4)

(75.7, 75.4-76.0) (21.4, 21.1-21.6) (1.91, 1.8-2.0) (1.0, 1.0-1.1) <.001

44,030 (85.3, 85.0-85.6) 7576 (14.7, 14.4-15.0)

72,192 (87.2, 87.0-87.4) 10,598 (12.8, 12.6-13.0) <.001

5266 5189 5077 5260 5061 5610 5739 5442 5213 3749

(41.6, (40.7, (40.7, (39.9, (38.7, (39.4, (37.5, (37.0, (35.0, (33.7,

40.7-42.4) 39.9-41.6) 39.8-41.6) 39.0-40.7) 37.9-39.6) 38.6-40.2) 36.8-38.3) 36.2-37.8) 34.2-35.7) 32.8-34.6)

7397 7555 7394 7934 8002 8641 9547 9256 9687 7377

(21.4, 21.1-21.8) (15.0, 14.7-15.3) (4.9, 4.7-5.1) (30.7, 30.3-31.1) (1.9, 1.8-2.0) (16.4, 16.1-16.7) (1.0, 0.9-1.0) (8.7, 8.5-8.9) (1-5) (14-110) (4.7-25.0) (12-61)

15,550 9945 3381 32,388 5283 7903 1070 7270 2 22 5.9 15

(58.4, (59.3, (59.3, (60.1, (61.3, (60.6, (62.5, (63.0, (65.0, (66.3,

57.6-59.2) 58.4-60.1) 58.4-60.2) 59.3-61.0) 60.4-62.1) 59.8-61.4) 61.7-63.3) 62.2-63.7) 64.2-65.8) 65.4-67.2) <.001

11,065 7749 2511 15,845 997 8453 495 4491 3 42 9.8 24

(18.8, 18.5-19.0) (12.0, 11.8-12.2) (4.1, 4.0-4.2) (39.1, 38.8-39.5) (6.4, 6.2-6.5) (9.6, 9.3-9.7) (1.3, 1.2-1.4) (8.8, 8.6-9.0) (1-4) (7-67) (3.1-14.1) (8-33)

11 (3-35) 7 (3-15)

5 (2-15) 5 (2-10)

3 (1-6)

2 (1-4)

<.001 <.001 <.001 <.001 <.001 <.001 <.001

(continued on next page)

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Table 1 (continued ) Characteristic Other type of contact, eg, telephone call with client, visit client in hospital Treatment goal outcome, n (%, 95% CI) Achieved treatment goal Deterioration in condition Other, eg, change in capacity of informal support, failure to adhere to regime Missing values Planned discharge from home nursing care, n (%, 95% CI) No Yes Missing values Reason for discharge from home nursing care, n (%, 95% CI) Problem resolved, no further care required Transfer to acute care Self-care Client died Other, eg, informal care, respite care, palliative care Missing values Location after discharge from home nursing care episode, n (%, 95% CI) Home Hospital (acute care) Residential aged care accommodation Hospice Other, eg, rehabilitation facility Missing values

Living Alone 2 (0-4) 33,483 11,121 7000 2

(64.9, 64.5-65.3) (21.5, 21.2-21.9) (13.6, 13.3-13.9) (0.0, 0.0-0.0)

Living With Others

P value

1 (0-3)

<.001 <.001

58,588 13,320 10,856 26

(70.8, (16.1, (13.1, (0.03,

70.5-71.1) 15.8-16.3) 12.9-13.3) 0.02-0.05)

17,376 (33.7, 33.3-34.1) 34,228 (66.3, 65.9-66.7) 2 (0.0, 0.0-0.0)

23,197 (28.0, 27.7-28.3) 59,568 (72.0, 71.6-72.2) 25 (0.0, 0.0-0.0)

15,807 13,358 6092 653 15,694 2

(30.6, 30.2-31.0) (25.9, 25.5-26.3) (11.8, 11.5-12.1) (1.3, 1.2-1.4) (30.4, 30.0-30.8) (0.0, 0.0-0.0)

26,060 16,224 8598 3429 28,454 25

(31.5, 31.2-31.8) (19.6, 19.3-19.9) (10.4, 10.2-10.6) (4.1, 4.0-4.3) (34.4, 34.0-34.7) (0.0, 0.0-0.0)

33,193 13,023 1668 439 3281 2

(64.3, 63.9-64.7) (25.2, 24.9-25.6) (3.2, 3.1-3.4) (0.9, 0.8-0.9) (6.4, 6.2-6.6) (0.0, 0.0-0.0)

58,474 16,338 2029 1328 4595 26

(70.6, 70.3-70.9) (19.7, 19.5-20.0) (2.5, 2.3-2.6) (1.6, 1.5-1.7) (5.6, 5.4-5.7) (0.0, 0.0-0.0)

<.001

<.001

<.001

CCI, Charlson Comorbidity Index. *The number of unique clients was 70,348. Of these, 40,530 women (30.2%) had 1 episode only during the study period; 29,818 women (69.8%) had multiple episodes. y Of the clients who had multiple episodes of care, 7263 women switched between living alone and living with others during this period; thus, the same client may be in both the “living alone” and “living with others” categories. The client’s living arrangement (living alone or living with others) at each episode was recorded. Statistical analyses were conducted at the episode level. z Percentages were calculated across the row.

was a mild level of comorbidities (81.0% vs 75.7% of others episodes). Home CareeRelated Characteristics The median episode duration for women living alone was 42 days (IQR: 14-110) compared with 22 days (IQR: 7-67; P < .001) for those living with others (Table 2). More service activities were likely to be carried out in an episode for women living alone (median: 24; IQR: 1261) than for women living with others (median: 15; IQR: 8-33; P < .001), with the median hours of care per episode for women living alone being 70% greater than that for their counterparts living with others (median: 9.8 hours; IQR: 4.7-25.0 vs others episode, median: 5.9 hours; IQR: 3.1-14.1). The number of home visits per episode to women living alone (median: 11; IQR: 3-35) was double that for women living with others (median: 5; IQR: 2-15; P < .001). Women living alone were more likely to experience a deterioration in their condition (21.5% vs 16.1%; P < .001) or be discharged from home nursing care to a hospital (25.2% vs 19.7%; P < .001) than women living with others. Women living alone required a greater diversity of care activities, with almost a quarter of episodes for women living alone (21.2% vs 12.8% of others episodes; P < .001) requiring activities from 7 to 9 care clusters (Table 2). Episodes for women living alone were more likely to involve assistance with medication (43.2% vs 29.8% of others episodes; P < .001). Furthermore, women living alone received more home visits for medication management, with a median of 20 (IQR:4-30) medication-related tasks per month compared with 13 (IQR: 2-28; P < .001) required by women living with others. Predictors of Increased Use of Home Nursing Services Generalized linear mixed effects modeling regression revealed 8 explanatory variables and three 2-way interaction terms that were significantly associated with the hours of service per episode of care

(Table 3). The 4 dominant main effects were as follows: living alone, cognitive dysfunction, the number of care clusters under which care activities were provided in visits at home, and the year of admission to an episode of care. Without adjustment for confounding factors and interactions, univariate modeling indicated that, compared to episodes where the client was living with others, living alone was likely to increase the hours of care by 75% (IRR: 1.75, 95% CI: 1.72-1.78; P < .001). A multivariable model that included interaction effects (model 2) demonstrated that in the context of other factors influencing utilization of home nursing care, living alone was likely to result in 13% more hours of service in an episode (95% CI: 1.11-1.15; P < .001) contingent on the number of care clusters required in visits at home. This will be elaborated on below. The influence of living alone on care utilization also appeared to be dependent on the duration of the episode. However, we noted in model 2 that the IRRs for the interaction terms (Living alone  Episode duration) and (Age  Episode duration) had almost no effect on the hours of care per episode. Although these terms contributed to fitting a better multivariable model, for interpretative purposes we regarded these interaction effects as negligible.35 Episodes where the client had a cognitive dysfunction were estimated to result in 19% more service use (95% CI: 1.17-1.21; P < .001) compared to those where individuals were without a recorded cognitive condition. The explanatory factor showing the greatest influence on service utilization was if a diverse range of care activities was required to support the client to live at home. Compared with activities from only 1 to 3 care clusters, if care tasks had to be undertaken from 7 to 9 care clusters, there was an estimated 7-fold increase in the hours of care per episode (IRR: 6.98, 95% CI: 6.84-7.12; P < .001). Furthermore, this increase in care time was dependent on the living arrangement of the client. If the episode involved a woman living alone, there was a predicted additional 45% more hours of care required (IRR: 1.45, 95% CI: 1.41-1.50; P < .001) on top of the 7-fold increase.

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Table 2 Characteristics of Care Activities Provided During Home Visits to Women Clients Aged 55 Years or Older, by Living Alone Status of the Client, January 1, 2006 to December 31, 2015 Characteristic

Living Alone (n ¼ 51,606 Episodes)

Per episode, number of care clusters under which care activities were provided, n (%, 95% CI) 1-3 9865 (19.1, 18.8-19.5) 4-6 29,868 (57.9, 57.5-58.3) 7-9 10,949 (21.2, 20.9-21.6) Missing values 924 (1.8, 1.7-1.9) Per episode, number of times per month a care activity was undertaken, by care cluster Medication, median (IQR) 20.0 (4.3-29.5) (n ¼ 22,294 episodes*; 43.2% of episodes involving women living alone) Monitoring and surveillance, median (IQR) 10.1 (5.4-22.8) (n ¼ 45,692*, 88.5%) Nursing care, median (IQR) 7.6 (2.8-12.4) (n ¼ 38,764*, 75.1%) Counseling and support, median (IQR) 4.1 (1.6-8.7) (n ¼ 36,250*, 70.2%) Personal care, median (IQR) 2.8 (0.6-7.6) (n ¼ 3929*, 7.6%) Assessment, median (IQR) 1.9 (0.9-4.3) (n ¼ 46,623*, 90.3%) Care coordination, median (IQR) 1.4 (0.6-3.2) (n ¼ 26,786*, 51.9%) Education, median (IQR) 1.3 (0.5-3.3) (n ¼ 26,919*, 52.2%) Other, median (IQR) 0.9 (0.3-3.6) (n ¼ 7964*, 15.4%)

Living With Others (n ¼ 82,790 Episodes)

P value <.001

22,857 47,318 10,580 2035

(27.6, 27.3-27.9) (57.2, 56.8-57.5) (12.8, 12.6-13.0) (2.5, 2.4-2.6)

12.8 (1.9-28.4) (n ¼ 24,657 episodes*; 29.8% of episodes involving women living with others) 9.1 (4.3-19.0) (n ¼ 70,308*, 84.9%) 9.5 (4.3-15.6) (n ¼ 59,987*, 72.5%) 4.2 (1.5-8.7) (n ¼ 52,571*, 63.5%) 3.4 (0.8-7.6) (n ¼ 5130*, 6.2%) 2.6 (1.1-6.1) (n ¼ 67,516*, 81.6%) 1.5 (0.7-4.2) (n ¼ 33,935*, 41.0%) 1.9 (0.7-5.1) (n ¼ 41,079*, 49.6%) 1.3 (0.4-4.5) (n ¼ 9631*, 11.6%)

<.001

<.001 <.001 .14 <.001 <.001 <.001 <.001 <.001

*The analysis included only those episodes where a care activity was undertaken from the care cluster. For example, if no assistance with medication was required in an episode, that episode was omitted from the calculation of frequency of medication-related activities per month.

Of particular interest is that the year of admission to care was a strong predictor of the number of hours of service per episode. Across the 10-year study period, regression modeling showed a downward trend in service use per episode. To validate this finding, we analyzed our data for the hours of service per episode stratified by the client’s living arrangement and admission year (Figure 2). For episodes involving women living alone, service utilization was consistent from 2006 to 2011, with the hours of service per episode decreasing from 2012 to 2015. Where women living with others were provided with care, a steady downward trend in nursing utilization from 2006 to 2015 was observed. Discussion In more than a third of episodes involving women using a home nursing service, the woman lived alone. After adjusting for other factors, living alone was associated with 13% greater need for home nursing care, and even more than this if complex care was required. Compared with episodes where the client lived with others, care episodes for clients living alone involved admission of older women. This suggests that women living alone may be a more physiologically robust group. Hubbard and Rockwood36 postulate that childless women, who have been spared the demands of childbearing and child rearing, are less frail in older age. Consistent with research indicating that older women have the capacity to live alone with no or little help in the community,37 our findings show that many women live independently to an older age before accumulated health deficits necessitate home nursing care. Importantly, in episodes where the client was living alone, the woman was 30% more likely to deteriorate clinically, and to require hospitalization. The support and nursing care required by women living alone at an older age, coupled with higher rates of clinical deterioration, may signal the start of a decline and, in the absence of an in-house carer, an acceleration in health care needs that may proceed faster than for women living with others. In the context of population aging and increasing

numbers of people wishing to age in place,2 these findings provide important information for future planning. Further investigation is warranted into the strategies that could help prevent this decline by women living alone to support optimal outcomes for their wish to age in place. Our results are in line with recent research that show women living alone are more likely to be moderate- or high-volume users of home support services.38 Several factors, which included cognitive dysfunction and living alone, influenced the amount of home nursing care required. This is consistent with previous studies noting that the risk factors contributing to loss of independence in communitydwelling older adults are diverse and involve physical function, psychological factors, and social circumstances.39,40 The impetus for this study was to investigate how living alone influences the need for home-based nursing for women. The predominant factor affecting the extent of home nursing usage was the number of care clusters provided to the client as part of their care episode, rather than living alone. However, these 2 factors interacted and although, overall, as the number of care clusters increased, that is, as the complexity of care grew, there was a corresponding increase in hours of care per episode for all women, this increase was greater if the episode involved a woman who lived alone. Our observation that a sizeable proportion of episodes involved a diverse range of home visit activities is consistent with similar findings by Rahman and colleagues,38 who reported that 10 or more home service types were used by approximately a third of older women requiring complex nursing care. Of note was the higher proportion of episodes for women living alone, compared with those for women living with others, that involved care activities from many care clusters. This reflects the more complex care needs of women living alone, likely a result of declining health. Cognitive impairment has been linked previously to increases in home care service usage.41 We estimated 19% higher nursing care utilization in the presence of cognitive dysfunction. Our findings also show a higher proportion of episodes for women living alone,

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7

Table 3 Living Alone as a Predictor of Increased Use of Home Nursing Care by Women Aged 55 Years or Older: Regression Models for the Hours of Service Received Per Episode of Care, January 1, 2006, to December 31, 2015 Explanatory Variable

Unadjusted IRR (95% CI)

Main effects Living alone No 1.00 (Ref) Yes 1.75 (1.72-1.78) Age at admission (y) 55-64 1.00 (Ref) 65-74 1.08 (1.05-1.11) 75-84 1.34 (1.31-1.39) 85-94 1.47 (1.43-1.52)
95 1.31 (1.24-1.38) English as primary language No 1.00 (Ref) Yes 1.14 (1.12-1.17) Charlson Comorbidity Index Mild (CCI 1) 1.00 (Ref) Moderate (CCI ¼ 2-4) 1.15 (1.13-1.17) Severe (CCI
5) 1.23 (1.16-1.30) Cognitive dysfunction No 1.00 (Ref) Yes 1.58 (1.55-1.61) Year of admission to episode 2006 1.00 (Ref) 2007 1.01 (0.98-1.04) 2008 0.98 (0.95-1.01) 2009 0.95 (0.92-0.98) 2010 0.92 (0.89-0.95) 2011 0.89 (0.86-0.91) 2012 0.85 (0.82-0.87) 2013 0.75 (0.73-0.77) 2014 0.71 (0.69-0.73) 2015 0.53 (0.52-0.55) Number of care clusters under which care activities were provided in home visits 1-3 1.00 (Ref) 4-6 3.04 (3.01-3.08) 7-9 15.38 (15.13-15.63) Episode duration (d) 1.0044 (1.0044-1.0045) Interaction terms Living alone  Number of care cluster types in home visits Living alone [yes]  4-6 care clusters in home visits Living alone [yes]  7-9 care clusters in home visits Living alone  Episode duration (d) Living alone [yes]  Episode duration Age  Episode duration (d) Age 65-74 y  Episode duration Age 75-84 y  Episode duration Age 85-94 y  Episode duration Age
95 y  Episode duration

P value

<.001 <.001y <.001 <.001 <.001 <.001

<.001 <.001y <.001 <.001

<.001 <.001y .48 .24 .001 <.001 <.001 <.001 <.001 <.001 <.001 <.001y

<.001 <.001 <.001

Model 1: Main Effects Adjusted IRR (95% CI)*

1.00 (Ref) 1.20 (1.19-1.21) 1.00 1.01 1.05 1.10 1.12

(Ref) (0.99-1.03) (1.03-1.06) (1.08-1.12) (1.09-1.15)

1.00 (Ref) 1.09 (1.08-1.10) 1.00 (Ref) 1.06 (1.04-1.07) 1.07 (1.04-1.11) 1.00 (Ref) 1.19 (1.17-1.20) 1.00 0.97 0.95 0.89 0.90 0.88 0.81 0.81 0.78 0.70

(Ref) (0.95-0.99) (0.93-0.97) (0.88-0.91) (0.89-0.92) (0.86-0.90) (0.80-0.83) (0.79-0.82) (0.77-0.80) (0.69-0.72)

1.00 (Ref) 2.83 (2.80-2.86) 8.32 (8.17-8.48) 1.0026 (1.0025-1.0026)

P value

<.001 <.001y .18 <.001 <.001 <.001

<.001 <.001y <.001 <.001

<.001 <.001y .009 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001y

<.001 <.001 <.001

Model 2: Adding Interaction Effects Adjusted IRR (95% CI)*

1.00 (Ref) 1.13 (1.11-1.15) 1.00 1.00 1.03 1.04 1.00

(Ref) (0.97-1.02) (1.00-1.05) (1.01-1.06) (0.96-1.04)

1.00 (Ref) 1.09 (1.07-1.10) 1.00 (Ref) 1.06 (1.04-1.07) 1.08 (1.04-1.12) 1.00 (Ref) 1.19 (1.17-1.21) 1.00 0.97 0.95 0.89 0.90 0.88 0.81 0.81 0.78 0.70

(Ref) (0.95-0.99) (0.93-0.96) (0.87-0.91) (0.88-0.92) (0.86-0.90) (0.80-0.83) (0.79-0.82) (0.77-0.80) (0.69-0.72)

P value

<.001 <.001y .90 .005 .002 .90

<.001 <.001y <.001 <.001

<.001 <.001y .012 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001y

1.00 (Ref) 2.62 (2.58-2.65) 6.98 (6.80-7.16) 1.0030 (1.0028-1.0032)

<.001 <.001 <.001

1.21 (1.18-1.24)

<.001y <.001

1.45 (1.40-1.51)

<.001

0.9987 (0.9986-0.9988)

<.001y <.001

1.00016 (0.99992-1.00039)

<.001y .20

1.000197 (0.999983-1.000410)

.07

1.0006 (1.0004-1.0008)

<.001

1.0012 (1.0008-1.0016)

<.001

CCI, Charlson Comorbidity Index; Ref, reference category. *In model 1, the IRR was adjusted for all 8 main effect variables listed in Table 3; for model 2, IRR was also adjusted for three 2-way interaction terms. Both multivariable models were run with 1000 bootstrapped samples drawn with replacement from the data set. y Overall likelihood ratio test P value.

compared with those for women living with others, where the client had a diagnosed cognitive impairment. For these individuals with cognitive impairment to remain living independently, they are largely reliant on having an informal carer,42 and as cognitive decline progresses it is likely that women living alone transition from their home to higher-acuity care earlier than women living with others. The need for medication management support was significantly more likely for women living alone than for those living with others.

The combination of cognitive dysfunction, multimorbidity, and polypharmacy is increasing as we become more adept at medically managing concurrent chronic conditions.43 As such, it is not unexpected that older people may need assistance with managing increasingly complex drug regimens. Those living alone and receiving help with their medication had almost double the number of home visits for this purpose than women living with others, making assistance with medication a principal task undertaken by nurses caring for women living alone.

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A. Joe et al. / JAMDA xxx (2019) 1e9

Fig. 2. Hours of service received for episodes of home nursing care for women aged 55 years or older living alone and living with others, January 1, 2006, to December 31, 2015. Boxplot showing median, interquartile range, and minimum and maximum values (outliers are not shown) for total hours of service per episode against the year of admission.

A finding of interest was that during our 10-year study period, there was a downward trend in the hours of care per episode. A steady decrease in service utilization was observed in episodes with women living with others. This may be due to increased dependence on informal carers to contribute to the care delivered by home-visiting nurses. In episodes involving women living alone, the median hours of care per episode was consistent across 2006 to 2011, even showing a slight increase. However, from 2012 onward, fewer hours were provided per episode to these clients. This could be related to changed funding arrangements for aged care and warrants further investigation. The major strengths of this study were the use of prospectively and routinely collected data; the large amount of information available to increase the power of the study, which enabled accurate determination of trends; and the minimal data cleaning required. However, some limitations must be taken into consideration. A high percentage of episodes for women living with others did not have accommodation type recorded (23.4%) or information on whether the client had an informal carer (22.1%). These data were collected for the purposes of service provision rather than research; therefore, incomplete or misreported information is not unexpected. However, given the comprehensiveness of the data, the authors believe that inaccuracies in the data set were likely to be minimal. Caution should be taken when generalizing the findings of this study as the information analyzed was obtained from 1 (albeit large) metropolitan service provider. Furthermore, culturally and linguistically diverse women may be disinclined to use home nursing services and thus may be underrepresented in our data set. A future avenue for research is the home nursing needs of older men living alone. The trajectory of ageing in men has traditionally differed from that of women,36 and in some aspects of older age, men living alone may be more vulnerable. Compared with women, men appear to have lower physiological reserves in old age, resulting in

higher mortality.36 Furthermore, older men living alone are at higher risk of social isolation and mental ill health than older women.44e47

Conclusions and Implications This study quantifies that for community-dwelling older women, living alone increases the need for home nursing services. Notably, women living alone need more support with medication management and require more home visits per episode of care. Women living alone were also more likely to experience a decline in their condition and be discharged from home nursing care into a hospital. In providing home-based care for women living alone, vigilant monitoring for clinical deterioration and timely interventions to minimize or delay declining health and hospitalization are critical in supporting women to maintain independent living. Future work is needed to identify how home nursing services can better meet the needs of the growing number of older people with complex needs in an effective, feasible, and sustainable way.

Acknowledgments The authors acknowledge Ms Erika Van Der Spuy, Bolton Clarke, for her assistance with data extraction and for sharing her knowledge on the meaning and relationship between data elements. We also thank Dr Wei Wang, Cabrini Institute, for her statistical support.

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26. Ogrin R, Lowthian JA, Johnstone G, et al. Older women living alone: Co-creating health and social care services (Symposium). Papers presented at: 51st Australian Association of Gerontology Conference; Melbourne, Australia; November 21-23, 2018. 27. Australian Institute of Health and Welfare. Episode of care definition. Available at: https://meteor.aihw.gov.au/content/index.phtml/itemId/268978. Accessed March 10, 2019. 28. Aged Care Financing Authority. Annual report on the funding and financing of the aged care sectord2017. Available at: https://www.gen-agedcaredata.gov. au/Resources/2017_acfa_annual_report. Accessed May 6, 2019. 29. National Center for Health Statistics. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). 2015. Available at: https:// www.cdc.gov/nchs/icd/icd9cm.htm. Accessed May 30, 2019. 30. Australian Consortium for Classification Development. ICD-10-AM/ACHI/ACS. 2019. Available at: https://www.accd.net.au/Icd10.aspx. Accessed May 30, 2019. 31. Roberts RF, Innes KC, Walker SM. Introducing ICD-10-AM in Australian hospitals. Med J Aust 1998;169:S32eS35. 32. Sundararajan V, Henderson T, Perry C, et al. New ICD-10 version of the Charlson Comorbidity Index predicted in-hospital mortality. J Clin Epidemiol 2004;57:1288e1294. 33. Buntinx F, Niclaes L, Suetens C, et al. Evaluation of Charlson’s Comorbidity Index in elderly living in nursing homes. J Clin Epidemiol 2002;55: 1144e1147. 34. Palesch YY. Some common misperceptions about P values. Stroke 2014;45: e244ee246. 35. Martinez HDR. Analyzing interactions of fitted models. 2015. Available at: https://cran.r-project.org/web/packages/phia/vignettes/phia.pdf. Accessed September 29, 2019. 36. Hubbard RE, Rockwood K. Frailty in older women. Maturitas 2011;69: 203e207. 37. Foster P, Neville S. Women over the age of 85 years who live alone: A descriptive study. Nurs Prax N Z 2010;26:4e13. 38. Rahman M, Efird JT, Kendig H, et al. Patterns of home and community care use among older participants in the Australian Longitudinal Study of Women’s Health. Eur J Ageing 2019;81:39e47. 39. Beswick AD, Rees K, Dieppe P, et al. Complex interventions to improve physical function and maintain independent living in elderly people: A systematic review and meta-analysis. Lancet 2008;371:725e735. 40. Stuck AE, Walthert JM, Nikolaus T, et al. Risk factors for functional status decline in community-living elderly people: A systematic literature review. Soc Sci Med 1999;48:445e469. 41. Sandberg L, Nilsson I, Rosenberg L, et al. Home care services for older clients with and without cognitive impairment in Sweden. Health Soc Care Community 2019;27:139e150. 42. Brodaty H, Donkin M. Family caregivers of people with dementia. Dialogues Clin Neurosci 2009;11:217e228. 43. Morin L, Johnell K, Laroche M-L, et al. The epidemiology of polypharmacy in older adults: Register-based prospective cohort study. Clin Epidemiol 2018;10: 289e298. 44. McLaughlin D, Vagenas D, Pachana N, et al. Gender differences in social network size and satisfaction in adults in their 70s. J Health Psychol 2010;15: 671e679. 45. Zebhauser A, Hofmann-Xu L, Baumert J, et al. How much does it hurt to be lonely? Mental and physical differences between older men and women in the KORA-Age Study. Int J Geriatr Psychiatry 2014;29:245e252. 46. Byles J, Vo K, Thomas L, et al. Partner status and mental and physical health of independently living men aged 70 years and older. Australas J Ageing 2016;35: 143e146. 47. Bergland AMG, Tveit B, Gonzalez MT. Experiences of older men living alone: A qualitative study. Issues Ment Health Nurs 2016;37:113e120.

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Appendix

Supplementary Table 1 Government-Funded Aged Care Programs Available in Victoria, Australia, During the 10-Year Study Period From January 1, 2006, to December 31, 2015

Approximately one percent of home nursing care clients opt out of research. Data on episodes of care during 2006 to 2015 where the client has agreed to their informaon being used for research purposes (n = 353325)

Episodes where the client’s living arrangement (living alone or living with others) was not recorded were excluded (n = 33720)

From 1992 up to 31 July 2013 Community Aged Care Packages (CACP) program The provision of a range of home-based services (excluding home nursing assistance and allied health services) designed to help older people with complex daily care needs stay in their own homes, as an alternative to residential types of care. CACP was fully funded by the Australian Commonwealth Government. CACP was transitioned into the Home Care Packages Program (HCPP) on August 1, 2013. From August 1, 2013, to present day

Episodes with an admission date before Jan 1, 2006 or aer Dec 31, 2015 (n = 10841), or with a discharge date aer Dec 31, 2015 (n = 11970) were excluded

Episodes where the gender of the client was male (n = 140547) or was not recorded (n = 602) were excluded

Episodes where the client’s age at admission was <55 years were excluded (n = 21249)

Episodes included in the current study (n = 134396) Home nursing care was provided to 70348 unique women aged ≥55 years; episodes commenced and concluded during the period Jan 1, 2006 to Dec 31, 2015.

Supplementary Figure 1. Flow diagram showing the selection of episodes for analysis.

Home Care Packages Program (HCPP) Commenced from a merger of the 3 programs: CACP, Extended Aged Care at Home (EACH) packages, and Extended Aged Care at Home Dementia (EACHD) packages. The Home Care Packages Program is fully funded by the Australian Commonwealth Government and provides long-term support for older people who want to stay living at home. There are 4 levels of services [level 1 (basic care needs) to level 4 (high care needs)], which include personal care, support services and nursing, allied health, and clinical services. All new Home Care Packages from August 1, 2013, had to be delivered on a consumerdirected care basis, which provides clients with more choice and flexibility when choosing home care services. From July 1, 2015, it was mandatory for all Home Care Packages (new and old packages) to be delivered on consumer directed care basis. From 1985 to June 30, 2016, for Victoria Home and Community Care (HACC) program The provision of a large range of services (including allied health and home nursing services) to support people of all ages at home. HACC was introduced in 1985 and was jointly funded in Victoria by the Australian Commonwealth Government and the State Government of Victoria, until the program concluded on June 30, 2016.

A. Joe et al. / JAMDA xxx (2019) 1e9 Supplementary Table 2 Service Activity Types There are 168 service activities consisting of a face-to-face home visit or other clientrelated activities. These service activities were grouped into 4 service activity types. Listed below are examples of the service activities in each service activity category. Service Activity Type

Examples of Service Activities in This Category

Visit at home

“Visit at home” represents a single service activity, which is a face-to-face home visit where care was provided Communication with specialist clinic Consultationdcommunity pharmacist Consultationdgeneral practitioner/practice nurse Consultation between enrolled nurse and registered nurse Case conference Consultationdnurse practitioner Consultation with clinical nurse consultant Care coordination (coordinated Veterans’ Care clients) Client survey Staff orientation Client documentation Guardianship activities Report writing Auditing of client record Telehealth monitoring coordination Referral to other service Visit to patient in hospital Client attended center or clinic Visit at school, work, or other venue Visit to local medical officer or other service provider Telephone calldclient at general practitioner setting Telephone call to clientdheat stress prevention Telephone call to carer Support visit to family only

Consultation with other health care professional

Administrative task

Other type of contact

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Supplementary Table 3 Care Activity Clusters There are 117 care activities, each being a specific task undertaken in a service activity. Up to 5 care activities can be recorded per service activity. The 117 care activities were grouped into 9 care activity clusters. Listed below are examples of the care activities in each cluster. Care Activity Cluster

Examples of Care Activities in This Cluster

Medication

Home medicines review Medicinesdwriting orders [Nurse Practitioner] Educationdmedication Insulin titrationdpeople with diabetes Medication/preparationdInsulin Medication/preparationdother Injectable Medication support Symptom control/pain management ‘Monitoring and surveillance’ represents a single care activity where the client is observed and evaluated to detect any decline in their health Clinical care Technical CaredWound Technical CaredBlood collection Technical CaredCentral line access/care Technical CaredUrinary Catheter Management Technical CaredCompression Bandaging Diagnosticsdorder investigations [Nurse Practitioner] Peritoneal Dialysis Counseling Counseling and support “Personal care” represents a single care activity in which assistance with personal care was provided, for example, help with showering Assessmentdadmission (general assessment) Assessmentdcontinence Assessmentddiabetes Assessmentdpain Assessmentdpalliative care AssessmentdMini Nutritional Assessment Assessmentdwound Falls risk screening Active servicedservice coordination Client care coordination and collaboration Consultation only (other staff) Secondary consultation General practitioner management plansddocumentation EducationdContinence EducationdDiabetes EducationdPalliative care EducationdWound EducationdBushfire and heatwave EducationdStomal therapy EducationdOther Family conference Advocacy Domestic assistance Assistance with nutrition Social support Transport Team care arrangementsddocumentation Use of professional on-site interpreter

Monitoring and surveillance

Nursing care

Counseling and support Personal care

Assessment

Care co-ordination

Education

Other