Improving integration of care through nurses’ assessment of complexity in older people receiving community-based care: the ImPaCt study

Background: Care for older people is more complex as they live longer with more multimorbidity and bio-psychosocial factors that require health professionals to identify needs to facilitate a holistic and safe approach to home-based care.

Approach: This presentation aims to enhance understanding of care complexity in older adults and its implications for healthcare providers. The ImPaCt study was a randomized controlled trial (RCT) conducted to determine the effectiveness of the PCI on decisions regarding complexity in a regional Australian community nursing setting between 1st July 2019 and 30th September 2020. The study aimed to examine the effectiveness of adding the Patient (Client) Complexity Instrument (PCI) to nurses’ clinical judgment to enhance detection of care complexity (primary outcome) and subsequent resource allocation (secondary outcome) for the care of the older person compared to usual assessment alone. Nurses working in a regional community nursing service were included in the study. Surveys conducted with the nurses pre and post the RCT contributed to the process evaluation.

The study was designed to address the gaps of the lack of decision support tools for assessing care complexity in older individuals living at home by testing a structured assessment approach using a decision-support tool in a clinical setting. By using a complexity detection tool to support decision-making of health professionals, new person-centered models of care could ensure that the right care is delivered at the right time and in the person’s preferred location.

Results: Client assessments were randomized into one of two groups (i) usual-assessment and (ii) usual assessment plus PCI. Randomization resulted in 53 participants in the usual-assessment group (control) and 52 in the PCI group (intervention). The addition of the PCI to usual-care did not enhance complexity detection compared to usual assessment (x2 = 1.144, p=0.564). However, for older people initially assessed with low levels of complexity, the PCI indicated a need for additional clinical care time (x2= 17.94, p < .001). Nurses also reported increased confidence in resource allocation for future care.

Implications: This trial represents a significant step in detecting care complexity and improving timely care delivery in Australia. Future research is essential for measuring the effectiveness of standardized complexity assessments, which aim to enhance care quality and decision-making efficiency. In the context of workforce shortages and aged care reforms, this research will be crucial for developing effective care strategies.

By improving complexity detection, healthcare professionals can make timely, informed decisions with clients, facilitate efficient referrals, and implement effective risk mitigation strategies, potentially reducing hospitalizations. Thus, contributing to a holistic model of care.

While the concept of care complexity is well-recognized, this study contributes significantly by offering methods for detection and clarity on contributing factors. This understanding supports a value-based care approach, fostering shared decision-making with older adults to ensure access to appropriate services at the right time and place.

Finally, the study highlights the inherent unpredictability in care complexity, emphasizing the “worry factor” tied to clinical judgment among caregivers. This nuance is critical for navigating the complexities of effective care delivery.