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. 2024 Mar 1;3(3):CD013880.
doi: 10.1002/14651858.CD013880.pub2.

Models for delivery and co-ordination of primary or secondary health care (or both) to older adults living in aged care facilities

Polina Putrik  1 , Liesl Grobler  1 , Aislinn Lalor  1   2 , Helen Ramsay  1 , Alexandra Gorelik  1 , Jonathan Karnon  3 , Deborah Parker  4 , Mark Morgan  5 , Rachelle Buchbinder  1 , Denise O'Connor  1
Affiliations

Models for delivery and co-ordination of primary or secondary health care (or both) to older adults living in aged care facilities

Polina Putrik et al. Cochrane Database Syst Rev. .

Abstract

Background: The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co-ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost-effectiveness of alternative models of providing health care to ACF residents.

Objectives: Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost-effectiveness of the alternative models.

Search methods: We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies.

Selection criteria: We included individual and cluster-randomised trials, and cost/cost-effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co-ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co-ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline-recommended care, health-related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work-related satisfaction and work-related stress of ACF staff.

Data collection and analysis: Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care.

Main results: We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co-ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low-certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I2 = 53%; 8 trials, 1263 participants; low-certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low-certainty evidence) and adherence to guideline-recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health-related quality of life of ACF residents (MD -0.016, 95% CI -0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low-certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate-certainty evidence). We did not pool the cost-effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co-ordination of care), we are uncertain of the cost-effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low.

Authors' conclusions: Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health-related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost-effectiveness of alternative models of care due to the limited, disparate data available.

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Conflict of interest statement

Polina Putrik: none

Liesl Grobler: LG is an associate editor with Cochrane EPOC but was not involved in editorial decisions for this review.

Aislinn Lalor: none

Helen Ramsay: none

Alexandra Gorelik: none

Jonathan Karnon: none

Deborah Parker: none

Mark Morgan: none

Rachelle Buchbinder: none

Denise O'Connor: DOC is an editor with Cochrane EPOC but was not involved in editorial decisions for this review.

Figures

1
1
Intervention logic model
2
2
Study flow diagram
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
5
5
6
6
Funnel plot of comparison: 1 Any alternative model of care vs usual care, outcome: 1.17 Mortality (number of deaths) adjustment for clustering in cRCTs.
7
7
Funnel plot of comparison: 1 Any alternative model of care vs usual care, outcome: 1.16 Any hospital admission (number of residents with at least one admission).
1.1
1.1. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 1: ED visits (proportion of residents with at least one ED visit)
1.2
1.2. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 2: ED visits (proportion of residents with at least one ED visit): sensitivity analysis by risk of bias
1.3
1.3. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 3: ED visits (mean number of ED visits per resident)
1.4
1.4. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 4: ED visits: logarithm of rate ratio per person‐time
1.5
1.5. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 5: Unplanned hospital admissions (proportion of residents with at least one unplanned hospital admission)
1.6
1.6. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 6: Unplanned hospital admissions (proportion of residents with at least one unplanned hospital admission): subgroup analysis by EPOC category
1.7
1.7. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 7: Unplanned hospital admissions (proportion of residents with at least one unplanned hospital admission): subgroup analysis by type of care provided
1.8
1.8. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 8: Unplanned hospital admissions (proportion of residents with at least one unplanned hospital admission): subgroup analysis by resident's condition
1.9
1.9. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 9: Unplanned hospital admissions (proportion of residents with at least one unplanned hospital admission): sensitivity analysis by risk of bias
1.10
1.10. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 10: Unplanned hospital admissions (proportion of residents with at least one unplanned hospital admission): sensitivity analysis by timing of effect
1.11
1.11. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 11: Unplanned hospital admissions (mean number of unplanned hospital admissions per resident)
1.12
1.12. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 12: Unplanned hospital admissions (logarithm of rate ratio)
1.13
1.13. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 13: Adverse events/falls (proportion of residents with a fall)
1.14
1.14. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 14: Adverse events/falls (proportion of residents with a fall): subgroup analysis by type of care provided
1.15
1.15. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 15: Adverse events/falls (proportion of residents with a fall): sensitivity analysis by risk of bias
1.16
1.16. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 16: Adverse events/falls (proportion of residents with a fall): sensitivity analysis by timing of effects
1.17
1.17. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 17: Adverse events/falls (mean number of falls per resident)
1.18
1.18. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 18: Adverse events/falls (logarithm of rate ratio)
1.19
1.19. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 19: Adverse events/injurious falls (proportion of residents with an injurious fall)
1.20
1.20. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 20: Adverse events/injurious falls (mean number of injurious falls per resident)
1.21
1.21. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 21: Adverse events/infections (proportion of residents with an infection)
1.22
1.22. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 22: Adherence to clinical guideline‐recommended care (proportion of residents with adequate antidepressant therapy)
1.23
1.23. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 23: Adherence to clinical guideline‐recommended care (proportion of residents with adequate antidepressant therapy, two intervention arms combined)
1.24
1.24. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 24: Adherence to clinical guideline‐recommended care (proportion of residents with adequate antipsychotic therapy)
1.25
1.25. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 25: Adherence to clinical guideline‐recommended care (proportion of residents with adequate antipsychotic therapy, two arms combined)
1.26
1.26. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 26: Adherence to clinical guideline‐recommended care (proportion of residents with adequate antibiotic therapy)
1.27
1.27. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 27: Adherence to clinical guidelines (MAI)
1.28
1.28. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 28: Quality of life (standardised mean difference)
1.29
1.29. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 29: Quality of life (standardised mean difference): sensitivity analysis by risk of bias
1.30
1.30. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 30: Quality of life (standardised mean difference): sensitivity analysis by timing of effect
1.31
1.31. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 31: Quality of life (no meta‐analysis, calculations for individual studies)
1.32
1.32. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 32: Mortality (proportion of residents who died)
1.33
1.33. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 33: Mortality (proportion of residents who died): sensitivity analyses by risk of bias
1.34
1.34. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 34: Mortality (proportion of residents who died): sensitivity analysis by timing of effect
1.35
1.35. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 35: Any hospital admission (proportion of residents with at least one hospital admission)
1.36
1.36. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 36: Any hospital admission (proportion of residents with at least one hospital admission): sensitivity analysis by risk of bias
1.37
1.37. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 37: Any hospital admission (proportion of residents with at least one hospital admission): sensitivity by timing of effect
1.38
1.38. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 38: Any hospital admission (mean number of hospital admissions per resident)
1.39
1.39. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 39: Any hospital admission (logarithm of rate ratio)
1.40
1.40. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 40: Length of hospital stay (mean number of days per resident)
1.41
1.41. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 41: Length of hospital stay (mean number of days per resident): subgroup analysis by type of care provided
1.42
1.42. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 42: Length of hospital stay (mean number of days per resident): sensitivity analysis by risk of bias
1.43
1.43. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 43: Length of hospital stay (mean number of days per resident): sensitivity analysis by timing of effect
1.44
1.44. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 44: Length of hospital stay (mean number of days per resident): no meta‐analysis, calculations for individual studies
1.45
1.45. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 45: Length of hospital stay (mean number of days per admission/admitted resident)
1.46
1.46. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 46: Residents’ satisfaction with the health care received (mean satisfaction score)
1.47
1.47. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 47: Proportion of residents’ satisfied with the health care received
1.48
1.48. Analysis
Comparison 1: Any alternative model of care versus usual care, Outcome 48: 'Next of kin' satisfaction with the health care received
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Lin 2010 {published data only}
    1. Lin WY, Huang HY, Liu CS, Li CI, Lee SD, Lin CC, et al. A hospital-based multidisciplinary approach improves nutritional status of the elderly living in long-term care facilities in middle Taiwan. Archives of Gerontology & Geriatrics 2010;Suppl 1:S22-6. [DOI: 10.1016/S0167-4943(10)70007-8] - DOI - PubMed
Lin 2014 {published data only}
    1. Lin KH, Chen CH, Chen YY, Huang WT, Lai JS, Yu SM, et al. Bidirectional and multi-user telerehabilitation system: clinical effect on balance, functional activity, and satisfaction in patients with chronic stroke living in long-term care facilities. Sensors 2014;14(7):12451-66. [DOI: 10.3390/s140712451] - DOI - PMC - PubMed
Loeb 2005 {published data only}
    1. Loeb M, Brazil K, Lohfeld L, McGeer A, Simor A, Stevenson K, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ 2005;331(7518):669. [DOI: 10.1136/bmj.38602.586343.55] - DOI - PMC - PubMed
Loeb 2006 {published data only}
    1. Loeb M, Carusone SC, Goeree R, Walter SD, Brazil K, Krueger P, et al. Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia: a randomized controlled trial. JAMA 2006;295(21):2503-10. [DOI: 10.1001/jama.295.21.2503] - DOI - PubMed
Man 2020 {published data only}
    1. Holloway EE, Constantinou M, Xie J, Fenwick EK, Finkelstein EA, Man REK, et al. Improving eye care in residential aged care facilities using the Residential Ocular Care (ROC) model: study protocol for a multicentered, prospective, customized, and cluster randomized controlled trial in Australia. Trials 2018;19(1):650. [DOI: 10.1186/s13063-018-3025-5] - DOI - PMC - PubMed
    1. Man REK, Gan ATL, Constantinou M, Fenwick EK, Holloway E, Finkelstein EA, et al. Effectiveness of an innovative and comprehensive eye care model for individuals in residential care facilities: results of the residential ocular care (ROC) multicentred randomised controlled trial. British Journal of Ophthalmology 2020;104(11):1585-90. [DOI: 10.1136/bjophthalmol-2019-315620] - DOI - PubMed
McSweeney 2012 {published data only}
    1. McSweeney K, Jeffreys A, Griffith J, Plakiotis C, Kharsas R, O'Connor DW. Specialist mental health consultation for depression in Australian aged care residents with dementia: a cluster randomized trial. International Journal of Geriatric Psychiatry 2012;27(11):1163-71. [DOI: 10.1002/gps.3762] - DOI - PubMed
Neyens 2009 {published data only}
    1. Neyens JC, Dijcks BP, Twisk J, Schols JM, Haastregt JC, den Heuvel WJ, et al. A multifactorial intervention for the prevention of falls in psychogeriatric nursing home patients, a randomised controlled trial (RCT). Age & Ageing 2009;38(2):194-9. [DOI: 10.1093/ageing/afn297] - DOI - PubMed
Pieper 2016 {published data only}
    1. Klapwijk MS, Caljouw MAA, Pieper MJC, Putter H, Steen JT, Achterberg WP. Change in quality of life after a multidisciplinary intervention for people with dementia: a cluster randomized controlled trial. International Journal of Geriatric Psychiatry 2018;33(9):1213-19. [DOI: 10.1002/gps.4912] - DOI - PubMed
    1. Pieper MJ, Achterberg WP, Francke AL, Steen JT, Scherder EJ, Kovach CR. The implementation of the serial trial intervention for pain and challenging behaviour in advanced dementia patients (STA OP!): a clustered randomized controlled trial. BMC Geriatrics 2011;11:12. [DOI: 10.1186/1471-2318-11-12] - DOI - PMC - PubMed
    1. Pieper MJ, Francke AL, Steen JT, Scherder EJ, Twisk JW, Kovach CR, et al. Effects of a stepwise multidisciplinary intervention for challenging behavior in advanced dementia: a cluster randomized controlled trial. Journal of the American Geriatrics Society 2016;64(2):261-9. [DOI: 10.1111/jgs.13868] - DOI - PubMed
    1. Pieper MJ, Francke AL, Steen JT, Scherder EJ, Twisk JW, Kovach CR, et al. [Effects of a stepwise approach to behavioural problems in dementia: a cluster randomised controlled trial] [Stapsgewijze aanpak van probleemgedrag bij dementie*: een clustergerandomiseerde gecontroleerde trial]. Nederlands Tijdschrift voor Geneeskunde 2016;160:D409. [https://www.ntvg.nl/artikelen/stapsgewijze-aanpak-van-probleemgedrag-bij...] - PubMed
    1. Pieper MJC, Achterberg WP, Steen JT, Francke AL. Implementation of a stepwise, multidisciplinary intervention for pain and challenging behaviour in dementia (STA OP!): a process evaluation. International Journal of Integrated Care 2018;18(3):15. [DOI: 10.5334/ijic.3973] - DOI - PMC - PubMed
Rubenstein 1990 {published data only}
    1. Rubenstein LZ, Robbins AS, Josephson KR, Schulman BL, Osterweil D. The value of assessing falls in an elderly population. A randomized clinical trial. Annals of Internal Medicine 1990;113(4):308-16. [DOI: 10.7326/0003-4819-113-4-308] - DOI - PubMed
Rutten 2022 {published data only}
    1. Rutten J, Buul LW, Smalbrugge M, Geerlings SE, Gerritsen DL, Natsch S, et al. An electronic health record integrated decision tool and supportive interventions to improve antibiotic prescribing for urinary tract infections in nursing homes: a cluster randomized controlled trial. Journal of the American Medical Directors Association 2022;23(3):387-93. [DOI: 10.1016/j.jamda.2021.11.010] - DOI - PubMed
    1. Rutten JJS, Buul LW, Smalbrugge M, Geerlings SE, Gerritsen DL, Natsch S, et al. Antibiotic prescribing and non-prescribing in nursing home residents with signs and symptoms ascribed to urinary tract infection (ANNA): study protocol for a cluster randomized controlled trial. BMC Geriatrics 2020;20(1):341. [DOI: 10.1186/s12877-020-01662-0] - DOI - PMC - PubMed
Stern 2014 {published data only}
    1. Stern A, Mitsakakis N, Paulden M, Alibhai S, Wong J, Tomlinson G, et al. Pressure ulcer multidisciplinary teams via telemedicine: a pragmatic cluster randomized stepped wedge trial in long term care. BMC Health Services Research 2014;14:83. [DOI: 10.1186/1472-6963-14-83] - DOI - PMC - PubMed
Temkin‐Greener 2018 {published data only}
    1. Temkin-Greener H, Mukamel DB, Ladd H, Ladwig S, Caprio TV, Norton SA, et al. Impact of nursing home palliative care teams on end-of-life outcomes: a randomized controlled trial. Medical Care 2018;56(1):11-8. [DOI: 10.1097/MLR.0000000000000835] - DOI - PubMed
Uy 2008 {published data only}
    1. Uy C, Kurrle SE, Cameron ID. Inpatient multidisciplinary rehabilitation after hip fracture for residents of nursing homes: a randomised trial. Australasian Journal on Ageing 2008;27(1):43-4. [DOI: 10.1111/j.1741-6612.2007.00277.x] - DOI - PubMed
Van den Block 2020 {published data only}
    1. Honinx E, Smets T, Piers R, Pasman HRW, Payne SA, Szczerbinska K, et al. Lack of effect of a multicomponent palliative care program for nursing home residents on hospital use in the last month of life and on place of death: a secondary analysis of a multicountry cluster randomized control trial. Journal of the American Medical Directors Association 2020;21(12):1973-78.e2. [DOI: 10.1016/j.jamda.2020.05.003] - DOI - PubMed
    1. Oosterveld-Vlug M, Onwuteaka-Philipsen B, Ten Koppel M, Hout H, Smets T, Pivodic, et al. Evaluating the implementation of the PACE Steps to Success Programme in long-term care facilities in seven countries according to the RE-AIM framework. Implementation Science 2019;14(1):107. [DOI: 10.1186/s13012-019-0953-8] - DOI - PMC - PubMed
    1. Smets T, Onwuteaka-Philipsen BBD, Miranda R, Pivodic L, Tanghe M, Hout H, et al. Integrating palliative care in long-term care facilities across Europe (PACE): protocol of a cluster randomized controlled trial of the 'PACE Steps to Success' intervention in seven countries. BMC Palliative Care 2018;17(1):47. [DOI: 10.1186/s12904-018-0297-1] - DOI - PMC - PubMed
    1. Van den Block L, Honinx E, Pivodic L, Miranda R, Onwuteaka-Philipsen BD, Hout H, et al, Pace trial group. Evaluation of a palliative care program for nursing homes in 7 countries: the PACE cluster-randomized clinical trial. JAMA Internal Medicine 2020;180(2):233-42. [DOI: 10.1001/jamainternmed.2019.5349] - DOI - PMC - PubMed
    1. Wichmann AB, Adang EMM, Vissers KCP, Szczerbinska K, Kylanen M, Payne S, et al. Decreased costs and retained QoL due to the 'PACE Steps to Success' intervention in LTCFs: cost-effectiveness analysis of a randomized controlled trial. BMC Medicine 2020;18(1):258. [DOI: 10.1186/s12916-020-01720-9] - DOI - PMC - PubMed
Wu 2010 {published data only}
    1. Wu MP, Lin PF, Lin KJ, Sun RS, Yu WR, Peng LN, et al. Integrated care for severely disabled long-term care facility residents: is it better? Archives of Gerontology and Geriatrics 2010;50(3):315-8. [DOI: 10.1016/j.archger.2009.05.004] - DOI - PubMed
Zwijsen 2014 {published data only}
    1. Zwijsen S, Hertogh C, Smalbrugge M, Gerritsen D, Eefsting J, Margriet Pot A. Grip on challenging behaviour: effects of a structured multidisciplinary care program for management of challenging behaviour on dementia special care units. International Psychogeriatrics 2013;25:S65‐6. [DOI: 10.1017/S1041610213002147] - DOI
    1. Zwijsen SA, Bosmans JE, Gerritsen DL, Pot AM, Hertogh CM, Smalbrugge M. The cost-effectiveness of grip on challenging behaviour: an economic evaluation of a care programme for managing challenging behaviour. International Journal of Geriatric Psychiatry 2016;31(6):567-74. [DOI: 10.1002/gps.4360] - DOI - PubMed
    1. Zwijsen SA, Gerritsen DL, Eefsting JA, Smalbrugge M, Hertogh CM, Pot AM. Coming to grips with challenging behaviour: a cluster randomised controlled trial on the effects of a new care programme for challenging behaviour on burnout, job satisfaction and job demands of care staff on dementia special care units. International Journal of Nursing Studies 2015;52(1):68-74. [DOI: 10.1016/j.ijnurstu.2014.10.003] - DOI - PubMed
    1. Zwijsen SA, Smalbrugge M, Eefsting JA, Gerritsen DL, Hertogh CM, Pot AM. Grip on challenging behavior: process evaluation of the implementation of a care program. Trials 2014;15:302. [DOI: 10.1186/1745-6215-15-302] - DOI - PMC - PubMed
    1. Zwijsen SA, Smalbrugge M, Eefsting JA, Twisk JWR, Gerritsen DL, Pot AM, et al. Coming to grips with challenging behavior: a cluster randomized controlled trial on the effects of a multidisciplinary care program for challenging behavior in dementia. Journal of the American Medical Directors Association 2014;15(7):531.e1-e10. [DOI: 10.1016/j.jamda.2014.04.007] - DOI - PubMed

References to studies excluded from this review

Abernethy 2006 {published data only}
    1. Abernethy AP, Currow DC, Hunt R, Williams H, Roder-Allen G, Rowett D, et al. A pragmatic 2 x 2 x 2 factorial cluster randomized controlled trial of educational outreach visiting and case conferencing in palliative care-methodology of the Palliative Care Trial [ISRCTN 81117481]. Contemporary Clinical Trials 2006;27:83-100. - PubMed
Aiken 2006 {published data only}
    1. Aiken L S, Butner J, Lockhart C A, Volk-Craft B E, Hamilton G, Williams FG. Outcome evaluation of a randomized trial of the PhoenixCare intervention: program of case management and coordinated care for the seriously chronically ill. Journal of Palliative Medicine 2006;9:111-26. - PubMed
Allen 1986 {published data only}
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Allen 2011 {published data only}
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Allen 2012a {published data only}
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Anderson 2008 {published data only}
    1. Anderson AA. CONNECT for quality: a study to reduce falls in nursing homes. https://clinicaltrials.gov/show/NCT00636675 2008.
Anderson 2012 {published data only}
    1. Anderson RA, Corazzini K, Porter K, Daily K, McDaniel RR Jr, Colon-Emeric C. CONNECT for quality: protocol of a cluster randomized controlled trial to improve fall prevention in nursing homes. Implementation Science 2012;7:11. - PMC - PubMed
Bakker 2011 {published data only}
    1. Bakker TJ, Duivenvoorden HJ, Lee J, Olde Rikkert MG, Beekman AT, Ribbe MW. Integrative psychotherapeutic nursing home program to reduce multiple psychiatric symptoms of cognitively impaired patients and caregiver burden: randomized controlled trial. American Journal of Geriatric Psychiatry 2011;19:507-20. - PubMed
Bavelaar 2022 {published data only}
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Beland 2006 {published data only}
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Bergh 2016 {published data only}
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Bloomfield 2022 {published data only}
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Bond 1989 {published data only}
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Bond 1989a {published data only}
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Bond 1990 {published data only}
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Boockvar 2015 {published data only}
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Boockvar 2018 {published data only}
    1. Boockvar K. Nursing assistant intervention to prevent delirium in nursing homes. https://clinicaltrials.gov/ct2/show/NCT02994979 2018.
Borbasi 2011 {published data only}
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Boumans 2005 {published data only}
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Boumans 2008 {published data only}
    1. Boumans NP, Berkhout AJ, Vijgen SM, Nijhuis FJ, Vasse RM. The effects of integrated care on quality of work in nursing homes: a quasi-experiment. International Journal of Nursing Studies 2008;45:1122-36. - PubMed
Bower 2011 {published data only}
    1. Bower P, Cartwright M, Hirani SP, Barlow J, Hendy J, Knapp M, et al. A comprehensive evaluation of the impact of telemonitoring in patients with long-term conditions and social care needs: protocol for the whole systems demonstrator cluster randomised trial. BMC Health Services Research 2011;11:184. - PMC - PubMed
Bruhmann 2019 {published data only}
    1. Bruhmann BA, Reese C, Kaier K, Ott M, Maurer C, Kunert S, et al. A complex health services intervention to improve medical care in long-term care homes: study protocol of the controlled coordinated medical care (CoCare) study. BMC Health Services Research 2019;19:332. - PMC - PubMed
Callegari 2022 {published data only}
    1. Callegari E, Benth J S, Selbaek G, Gronnerod C, Bergh S. The effect of the NorGeP-NH on quality of life and drug prescriptions in Norwegian nursing homes: a randomized controlled trial. Pharmacy 2022;10(1):32. - PMC - PubMed
Camacho 2018 {published data only}
    1. Camacho EM, Davies LM, Hann M, Small N, Bower P, Chew-Graham C, et al. Long-term clinical and cost-effectiveness of collaborative care (versus usual care) for people with mental-physical multimorbidity: cluster-randomised trial. British Journal of Psychiatry 2018;213:456-63. - PMC - PubMed
Cameron 2020 {published data only}
    1. Cameron ID, Dyer SM, Panagoda CE, Murray GR, Hill KD, Cumming RG, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews 2020, Issue 1. - PMC - PubMed
Carpenter 2021 {published data only}
    1. Carpenter JG, Hanson LC, Hodgson N, Murray A, Hippe DS, Polissar NL, et al. Implementing primary palliative care in post-acute nursing home care: protocol for an embedded pilot pragmatic trial. Contemporary Clinical Trials Communications 2021;23:100822. - PMC - PubMed
Carpenter 2021a {published data only}
    1. Carpenter J. Implementation of a telehealth palliative care model for persons with dementia. ClinicalTrials.gov: https://clinicaltrials.gov/ct2/show/NCT05001620 2021.
Cassel 2016 {published data only}
    1. Cassel S. A comparison of traditional face-to-face and tele-dysphagia instructional methods in geriatric TBI and CVA populations. Archives of Physical Medicine and Rehabilitation 2016;97:e16‐7.
Catic 2014 {published data only}
    1. Catic AG, Mattison MLP, Bakaev I, Morgan M, Monti SM, Lipsitz L. ECHO-AGE: an innovative model of geriatric care for long-term care residents with dementia and behavioral issues. Journal of the American Medical Directors Association 2014;15:938‐42. - PubMed
Challis 2004 {published data only}
    1. Challis D, Clarkson P, Williamson J, Hughes J, Venables D, Burns A, et al. The value of specialist clinical assessment of older people prior to entry to care homes. Age and Ageing 2004;33:25-34. - PubMed
Challis 2014 {published data only}
    1. Challis D, Tucker S, Wilberforce M, Brand C, Abendstern M, Stewart K, et al. National trends and local delivery in old age mental health services: towards an evidence base. A mixed-methodology study of the balance of care approach, community mental health teams and specialist mental health outreach to care homes. NIHR Journals Library 2014;2:na. - PubMed
Chenoweth 2009 {published data only}
    1. Chenoweth L, King MT, Jeon YH, Brodaty H, Stein-Parbury J, Norman R, et al. Caring for Aged Dementia Care Resident Study (CADRES) of person-centred care, dementia-care mapping, and usual care in dementia: a cluster-randomised trial. Lancet Neurology 2009;8:317-25. - PubMed
Chi 2004 {published data only}
    1. Chi YC, Chuang KY, Wu SC, Huang KC, Wu CL. The assessment of a hospital-based care management model for long-term care services. Journal of Nursing Research 2004;12:317-26. - PubMed
Christian 2020 {published data only}
    1. Christian N, King-Mallory R, Blackwelder R. Evaluating the effects on hospital encounters after implementing after-hours telemedicine visits in a senior living facility. In: Journal of the American Medical Directors Association. Vol. 21. 2020:B20.
Clarkson 2011 {published data only}
    1. Clarkson P, Brand C, Hughes J, Challis D. Integrating assessments of older people: examining evidence and impact from a randomised controlled trial. Age and Ageing 2011;40:388-91. - PubMed
Connolly 2018 {published data only}
    1. Connolly MJ, Broad JB, Bish T, Zhang X, Bramley D, Kerse N, et al. Reducing emergency presentations from long-term care: a before-and-after study of a multidisciplinary team intervention. Maturitas 2018;117:45-50. - PubMed
Davidson 2022 {published data only}
    1. Davidson G. Preventing medication-related problems in care transitions to skilled nursing facilities. https://ClinicalTrials.gov/show/NCT05241951 2022.
Dobke 2008 {published data only}
    1. Dobke MK, Bhavsar D, Gosman A, De Neve J, De Neve B. Pilot trial of telemedicine as a decision aid for patients with chronic wounds. Telemedicine Journal and e-Health 2008;14:245-9. - PubMed
Dozeman 2011 {published data only}
    1. Dozeman E, Schaik DJ, Marwijk HW, Stek ML, Beekman AT, Horst HE. Feasibility and effectiveness of activity-scheduling as a guided self-help intervention for the prevention of depression and anxiety in residents in homes for the elderly: a pragmatic randomized controlled trial. International Psychogeriatrics 2011;23:969-78. - PubMed
Duffy 2010 {published data only}
    1. Duffy JR, Hoskins LM, Dudley-Brown S. Improving outcomes for older adults with heart failure: a randomized trial using a theory-guided nursing intervention. Journal of Nursing Care Quality 2010;25:56-64. - PubMed
Eckermann 2019 {published data only}
    1. Eckermann S, Phillipson L, Fleming R. Re-design of aged care environments is key to improved care quality and cost effective reform of aged and health system care. Applied Health Economics & Health Policy 2019;17:127-30. - PubMed
ElBestawi 2018 {published data only}
    1. ElBestawi MR, Kohm C. Decreasing preventable emergency department transfers for long-term care residents using PREVIEW-ED©. Healthcare Management Forum 2018;31:137-41. - PubMed
Fan 2018 {published data only}
    1. Fan L, Lukin B, Zhao J, Sun J, Dingle K, Purtill R, et al. Cost analysis of improving emergency care for aged care residents under a Hospital in the Nursing Home program in Australia. PLOS One 2018;13:e0199879. - PMC - PubMed
Farin‐Glattacker 2017 {published data only}
    1. Farin-Glattacker E. Extended coordinated medical care in long term care homes. https://trialsearch.who.int/Trial2.aspx?TrialID=DRKS00012703 2017.
Feng 2018 {published data only}
    1. Feng H, Li H, Xiao LD, Ullah S, Mao P, Yang Y, et al. Aged care clinical mentoring model of change in nursing homes in China: study protocol for a cluster randomized controlled trial. BMC Health Services Research 2018;18:816. - PMC - PubMed
Fick 2000 {published data only}
    1. Fick DM, Clark WF, Riley P, Cunningham B, Malakoff F. Advanced practice nursing care management model for elders in a managed care environment. Journal of Care Management 2000;6(1):28-49.
Finnema 2005 {published data only}
    1. Finnema E, Droes RM, Ettema T, Ooms M, Ader H, Ribbe M, et al. The effect of integrated emotion-oriented care versus usual care on elderly persons with dementia in the nursing home and on nursing assistants: a randomized clinical trial. International Journal of Geriatric Psychiatry 2005;20:330-43. - PubMed
Frisoni 1998 {published data only}
    1. Frisoni GB, Gozzetti A, Bignamini V, Vellas BJ, Berger AK, Bianchetti A, et al. Special care units for dementia in nursing homes: a controlled study of effectiveness. Archives of Gerontology and Geriatrics 1998;27:215‐24.
Fukahori 2016 {published data only}
    1. Fukahori, C. Development of an integrated care pathway (ICP) for end-of-life care in long term care facilities in Japan. http://www.who.int/trialsearch/Trial2.aspx?TrialID=JPRN-UMIN000022579 (https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R0000...) 2016.
Galik 2021 {published data only}
    1. Galik EM, Resnick B, Holmes SD, Vigne E, Lynch K, Ellis J, et al. A cluster randomized controlled trial testing the impact of function and behavior focused care for nursing home residents with dementia. Journal of the American Medical Directors Association 2021;22(7):1421. - PMC - PubMed
Garland 2022 {published data only}
    1. Garland A, Keller H, Quail P, Boscart V, Heyer M, Ramsey C, et al. BABEL (Better tArgeting, Better outcomes for frail ELderly patients) advance care planning: a comprehensive approach to advance care planning in nursing homes: a cluster randomised trial. Age & Ageing 2022;51(3):1-10. - PMC - PubMed
Garrard 1990 {published data only}
    1. Garrard J, Kane R L, Radosevich DM, Skay CL, Arnold S, Kepferle L, et al. Impact of geriatric nurse practitioners on nursing-home residents' functional status, satisfaction, and discharge outcomes. Medical Care 1990;28:271‐83. - PubMed
Gotze 2022 {published data only}
    1. Gotze K, Bausewein C, Feddersen B, Fuchs A, Hot A, Hummers E, et al. Effectiveness of a complex regional advance care planning intervention to improve care consistency with care preferences: study protocol for a multi-center, cluster-randomized controlled trial focusing on nursing home residents (BEVOR trial). Trials 2022;23(1):770. - PMC - PubMed
Hakkaart‐van 2013 {published data only}
    1. Hakkaart-van Roijen L, Bakker TJ, Al M, Lee J, Duivenvoorden HJ, Ribbe MW, et al. Economic evaluation alongside a single RCT of an integrative psychotherapeutic nursing home programme. BMC Health Services Research 2013;13:370. - PMC - PubMed
Holmkjaer 2021 {published data only}
    1. Holmkjaer P, Holm A, Overbeck G, Rozing MP. A cluster-randomized trial of a complex intervention to encourage deprescribing antidepressants in nursing home residents with dementia: a study protocol. Trials 2022;23(1):410. [DOI: 10.1186/s13063-022-06368-9] - DOI - PMC - PubMed
Huizing 2009 {published data only}
    1. Huizing AR, Hamers JP, Gulpers MJ, Berger MP. A cluster-randomized trial of an educational intervention to reduce the use of physical restraints with psychogeriatric nursing home residents. Journal of the American Geriatrics Society 2009;57:1139-48. - PubMed
Jeon 2015 {published data only}
    1. Jeon YH, Simpson JM, Li Z, Cunich MM, Thomas TH, Chenoweth L, et al. Cluster randomized controlled trial of an aged care specific leadership and management program to improve work environment, staff turnover, and care quality. Journal of the American Medical Directors Association 2015;16:629.e19-28. - PubMed
Junius‐Walker 2021 {published data only}
    1. Junius-Walker U, Krause O, Thurmann P, Bernhard S, Fuchs A, Sparenberg L, et al. Drug safety for nursing-home residents-findings of a pragmatic, cluster-randomized, controlled intervention trial in 44 nursing homes. Deutsches Arzteblatt International 2021;118(42):705-12. - PMC - PubMed
Kane 1989 {published data only}
    1. Kane RL, Garrard J, Skay CL, Radosevich DM, Buchanan JL, McDermott SM, et al. Effects of a geriatric nurse practitioner on process and outcome of nursing home care. American Journal of Public Health 1989;79:1271‐7. - PMC - PubMed
Kane 2017 {published data only}
    1. Kane RL, Huckfeldt P, Tappen R, Engstrom G, Rojido C, Newman D, et al. Effects of an intervention to reduce hospitalizations from nursing homes: a randomized implementation trial of the INTERACT program. JAMA Internal Medicine 2017;177:1257-64. - PMC - PubMed
Kennedy 2015 {published data only}
    1. Kennedy CC, Ioannidis G, Thabane L, Adachi JD, Marr S, Giangregorio LM, et al. Successful knowledge translation intervention in long-term care: final results from the vitamin D and osteoporosis study (ViDOS) pilot cluster randomized controlled trial. Trials 2015;16:214. - PMC - PubMed
Konno 2014 {published data only}
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Kosari 2021 {published data only}
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References to studies awaiting assessment

Bagaragaza 2021 {published data only}
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Bath 2001 {published data only}
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Palmer 2020 {published data only}
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Sillies 2022 {published data only}
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Umpierrez 2021 {published data only}
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References to ongoing studies

Brucken 2022 {published data only}
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Choi 2020 {published data only}
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Dantoine 2019 {published data only}
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Muller 2020 {published data only}
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Papaioannou 2021 {published data only}
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Sourdet 2018 {published data only}
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Tchalla 2019 {published data only}
    1. Evaluation of the impact of a telemedicine device (DTM) on the prevention of emergency department visits and hospitalisations of nursing home residents aged polypathological (GERONTACCESS). Ongoing study. November 2015. Contact author for more information.
Tesky 2019 {published data only}
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