A european study investigating patterns of transition from home care towards institutional dementia care: the protocol of a righttimeplacecare study

Verbeek et al. BMC Public Health 2012, 12:68http://www.biomedcentral.com/1471-2458/12/68 A European study investigating patterns oftransition from home care towards institutionaldementia care: the protocol of aRightTimePlaceCare study Hilde Verbeek1*, Gabriele Meyer2, Helena Leino-Kilpi3,4, Adelaida Zabalegui5, Ingalill Rahm Hallberg6, Kai Saks7,Maria Eugenia Soto8, David Challis9, Dirk Sauerland10 and Jan PH Hamers1, forthe RightTimePlaceCare Consortium Background: Health care policies in many countries aim to enable people with dementia to live in their ownhomes as long as possible. However, at some point during the disease the needs of a significant number ofpeople with dementia cannot be appropriately met at home and institutional care is required. Evidence as to bestpractice strategies enabling people with dementia to live at home as long as possible and also identifying theright time to trigger admission to a long-term nursing care facility is therefore urgently required. The current paperpresents the rationale and methods of a study generating primary data for best-practice development in thetransition from home towards institutional nursing care for people with dementia and their informal caregivers.
The study has two main objectives: 1) investigate country-specific factors influencing institutionalization and 2)investigate the circumstances of people with dementia and their informal caregivers in eight European countries.
Additionally, data for economic evaluation purposes are being collected.
Methods/design: This paper describes a prospective study, conducted in eight European countries (Estonia,Finland, France, Germany, Netherlands, Sweden, Spain, United Kingdom). A baseline assessment and follow-upmeasurement after 3 months will be performed. Two groups of people with dementia and their informalcaregivers will be included: 1) newly admitted to institutional long-term nursing care facilities; and 2) receivingprofessional long-term home care, and being at risk for institutionalization. Data will be collected on outcomes forpeople with dementia (e.g. quality of life, quality of care), informal caregivers (e.g. caregiver burden, quality of life)and costs (e.g. resource utilization). Statistical analyses consist of descriptive and multivariate regression techniquesand cross-country comparisons.
Discussion: The current study, which is part of a large European project ‘RightTimePlaceCare', generates primarydata on outcomes and costs of long-term nursing care for people with dementia and their informal caregivers,specifically focusing on the transition from home towards institutional care. Together with data collected in threeother work packages, knowledge gathered in this study will be used to inform and empower patients,professionals, policy and related decision makers to manage and improve health and social dementia care services.
Keywords: Dementia, Long-term care, Professional home care, Nursing homes * Correspondence: 1Department of Health Services Research, CAPHRI School for Public Healthand Primary Care, Maastricht University, P.O. Box 616, 6200 MD Maastricht,the NetherlandsFull list of author information is available at the end of the article 2012 Verbeek et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License ), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.
Verbeek et al. BMC Public Health 2012, 12:68 homes when already quite dependent, at later stages of Action is urgently required to prepare health care ser- dementia. This can leave families carrying a high burden vices in delivering more cost effective and higher qual- of care. Furthermore, a recent study suggests that sav- ity care for people with dementia and their informal ings on an aggregated level may be variable at the indi- caregivers. With ageing populations the number of vidual level [. Policy makers need to understand who with dementia is ever increasing with no sign yet of a pays and benefits from certain interventions, taking cure for the disease. Symptoms of dementia include a account of costs associated with patient location, disease general loss of cognitive, functional and mental cap- characteristics (e.g. dementia severity) and type of care abilities, resulting in diverse needs. Some needs require (informal/formal) health care and some are more appropriately met by Currently, there is little evidence to assist decision social care, although the boundaries between these making as to when home care or institutional care is needs are hard to delineate [Demands for health, more favorable for people with dementia and their social and nursing care arise when needs of people families. Similarly, little is known about specific charac- with dementia and their caregivers are not fulfilled, teristics of people with dementia who benefit most from usually due to insufficiencies in resources especially institutional as opposed to home-and community-based related to manage everyday activities and a lack of research . Therefore, it is unclear whether preventing social network [.
admission to an institutional long-term nursing care A common policy principle in European countries facility is the best approach for all people with dementia nowadays is to enhance resources for home- and com- and their informal caregivers. Information on best prac- munity-based care services. This is to enable people tice strategies to enable people with dementia with with dementia to remain in their own homes for as dementia to live at home as long as possible but also to long as possible, trying to delay institutionalization define the right time to trigger the admission to an However, it is questionable whether this is an institutional long-term nursing care facility is therefore beneficial policy for all people with dementia and their urgently required.
caregivers. The underlying belief is that most older Most people with dementia will be admitted to a care people, including those with complex care needs such facility at some point, since their needs cannot be met as dementia, prefer to live at home since this is a appropriately in the home situation [Although familiar environment [. Amongst expected benefits many studies have investigated predictors of institutio- are that people with dementia remain able to maintain nalization [it remains unclear if predictors are their social networks and enjoy a better quality of life country specific. Both patient (e.g. severity of cognitive ]. Cultural aspects, such as beliefs that children are and functional disability) and caregiver characteristics (e.
responsible for older adult's care, could also influence g. perceived burden, coping strategies) could play an the decision to keep people with dementia at home for important role. There is evidence that rates of institutio- as long as possible The decision to move people nalization and time to admission to a nursing home with dementia from home care to institutional care is may vary substantially among countries ]. For a complex one and is influenced by both patient and example, a recent study found that people with demen- caregiver characteristics, available resources and care tia with similar characteristics and treatment patterns had a lower risk of nursing home placement in the UK Evidence to support the timing of this decision is cur- compared with northern Scandinavian countries [ rently lacking, impeding appropriate timing of institutio- Variations in health care structure, dementia care policy, nalization. For example, knowledge of outcomes and availability of services, cultural values and funding sys- relative benefits such as quality of life and quality of tems may all contribute to these differences. However, care between home and institutional nursing care for there is little primary data across countries to under- people with dementia in various stages of the disease is stand variations in predictors of institutionalization for currently unknown. To assure more appropriate entry people with dementia.
to institutional settings, more information on serviceprovision and related outcomes on quality of life and Aims and objectives quality of care is therefore urgently needed.
This study is part of a large European research project Cost information is also important for policy makers.
called ‘RightTimePlaceCare' (RTPC), which consists of It would be dangerous to assume that a shifting balance six work packages (WPs) (see Figure . The RTPC pro- from institutional towards community care will necessa- ject aims to improve health services for European citi- rily be cost reducing . One consequence of this shift- zens with dementia and is explained elsewhere in detail ing balance is that older people are admitted to care The current study generates primary data in the Verbeek et al. BMC Public Health 2012, 12:68 WP1: Management of the Consortium (DE) * Description of Health Care Clinical Data Collection (NL) Best Practice Strategies (ES + EE) Economic Evaluation (DE) WP6: Dissemination (DE) ¦ Figure 1 Overview the European project ‘RightTimePlaceCare. * Work Package (WP) leaders are mentioned in brackets; DE = Germany; SE =Sweden; NL = Netherlands; ES = Spain; EE = Estonia; † WP2 aims to describe and analyze European health, social and welfare structures andexplores intersectorial communication; ‡ WP3 is described in the current study protocol; § WP4 aims to analyze cost-benefit ratio of services forrelevant stakeholders; WP5 aims to develop best-practice strategies and to deliver meaningful and feasible recommendations for future dementiacare; ¦. WP6 aims to develop and apply dissemination and implementation strategies of the RTPC project.
transition from professional home care towards institu- tional nursing care for people with dementia and their informal caregivers for best-practice development. It This is a prospective cohort study, conducted in eight constitutes the third WP of the RTPC study and has European countries (Estonia, Finland, France, Germany, two main objectives: Netherlands, Sweden, Spain, United Kingdom). We 1) To assess the factors influencing the institutionali- attempted to include countries from all over Europe (i.e.
zation of people with dementia at the time of admission northern, southern, eastern and western parts of Eur- to institutional long-term nursing care facility.
ope). A baseline assessment is performed between 2) To investigate the circumstances and living condi- November 2010 and December 2011 and follow-ups are tions of people with dementia receiving long-term pro- conducted after 3 months (see Table fessional home care or institutional nursing care andtheir informal caregivers. Emphasis is placed on: Setting and participants• The current study focuses on long-term care and con- a) Quality of care and quality of life of people with sists of two strata: dementia in institutional long-term care and home • Group 1: People with dementia newly admitted to institutional nursing care facilities (i.e. within one to b) Caregiver burden and quality of life of informal three months after admission) and their informal care- caregivers of people with dementia in institutional givers or next of kin; long-term care and home care.
• Group 2: People with dementia who receive profes- sional home care and are at risk of institutionalization In addition, information on direct and indirect costs (i.e. on the margins of long term care admission) and are collected.
their informal caregivers or next of kin.
Verbeek et al. BMC Public Health 2012, 12:68 Table 1 Study design 800 People with dementia (PwD) newly admitted to a facility and their informal caregivers (IC) or next of kin (100 PwD + 100 IC per group per country) 1400 PwD receiving professional home care and their IC or next of kin (150 PwD + 150 IC per group per country) daily living, hygiene and other personal care, routine A minimum of three different long-term nursing care technical nursing procedures, patient education and facilities and three professional home care organizations counseling, psychosocial activities.
will be recruited per country, in order to achieve somevariation in the sample for recruitment of subjects. To target similar populations across countries with varying The study population consists of dyads of people with health and social care structures in long-term care, we dementia older than 65 years of age and their informal used the following care definitions: caregivers, who require formal care/help either from: Formal long-term care 1) institutional nursing care facilities. Target n in A range of services for people who need assistance on a group one is 800 dyads in total (i.e. 100 per country).
continuing basis due to chronic impairments (resulting We expect a drop-out rate of 15%. Therefore, we aim to from physical or mental disability) and a reduced degree include 115 dyads per country in this setting.
of independence and activities of daily living. This cen- 2) professional home care organizations. Target n in tral personal care component is frequently provided in group two is 1200 (i.e. 150 per country), since we conjunction with help in basic medical services such as assume that the variance in this group is higher. With wound dressing, pain management, medication, health an expected drop-out rate of 15%, we aim to include monitoring, prevention rehabilitation or services for pal- 175 dyads per country in this setting.
liative care []. This care is provided by formal care- People with Dementia givers, professional caregivers that are paid for their job.
Inclusion criteria for people with dementia consist of As such the caregiver may well possess formal profes- 1) a formal diagnosis of dementia as diagnosed by an sional education, either in health care/nursing and/or expert assessment (i.e. physician, psychiatrist, neurolo- social care.
gist, geriatrician or general practitioner depending on Institutional long-term nursing care facilities countries' specific diagnostic procedures) and recorded Nursing and personal care provided in an institution in the medical record; 2) an MMSE score of 24 or which at the same time serves as a residence of the care below and 3) the presence of an informal caregiver recipient. This should be distinguished from short-term who visits at least twice a month. The severity and care provided received in institutions, such as respite type of dementia may vary but will be recorded if care and rehabilitation. An institution is a place of col- information is available. In addition, each group has lective living where care and accommodation are pro- specific inclusion criteria. People with dementia who vided as a package by a public agency, non-profit or are newly admitted to a long-term institutional nursing private company. Residents may or may not be charged care facility (Group 1) are included if they live at least separately for care services and accommodation. In 1 month in the institution and no longer than 3 institutional nursing care, a significant part of the the months. People with dementia institutionalized only care provided is a mix of health and social services with for a limited period of time a priori (e.g. rehabilitation, the health services being largely at the level of nursing respite care) with the intention of moving back home are excluded. People with dementia who receive pro- Professional long-term home nursing care fessional home nursing care (Group 2) should be at Refers to long-term care services that can be provided to risk for institutionalization. This means that a formal patients at home by professional home-nursing organi- caregiver (e.g. registered nurse, general practitioner) zations and home-help services. This could also include judges institutionalization as probable within 3 to 6 care provided at day-care Examples of home nur- months. Reasons for being adjudged at-risk may vary sing: helping patients with basis needs in activities of across countries.
Verbeek et al. BMC Public Health 2012, 12:68 Informal caregivers gender, education, marital status, living situation, Informal care is defined as care provided by informal income, cultural background (i.e. native country, reli- caregivers, such as spouses/partners, other members of gion, ethnicity) and dementia diagnosis related the household, relatives, friends, neighbors or others, usually but not necessarily with an already existingsocial relationship to the person they provide care Measures for informal caregivers Caregivers who provide care on a voluntary basis Outcome measures for informal caregivers include qual- through an organization (such as a church group), or ity of life (EQ-5D) caregiver burden (ZBI) [ those who provide care as a career are not defined as an psychological well-being (GHQ-12) [positive and informal caregiver.
negative consequences of caregiving (CRA) []; experi- All main caregivers providing informal care for older ences on quality of care (9 items from CLINT) [] and people with dementia participating in this study are eli- an additional item ‘overall, I am satisfied with the qual- gible. The number is limited to one main informal care- ity of care provided by the organization' as rated on a 5- giver per older person with dementia, defined as the point Likert scale ranging from totally agree to totally person who is most involved in care for the people with disagree); use of personal and social resources and ser- dementia. For people in institutional nursing care, the vice use (RUD) []. Furthermore, an open-ended ques- term informal caregiver may not be completely appro- tion is addressed to gain insight in the transition priate. In this case, the next of kin/significant other is process (either ‘what is the main reason for institutiona- included, being the person who is close to the person lization?' or ‘under what circumstances do you consider with dementia (spouse, children, grand children, other institutionalization necessary?'). Sociodemographic vari- relatives or friends) and most involved in the decisions ables include age, gender, educational background, mari- about their care.
tal status, health status, number of visits per month,living situation and relation to people with dementia.
MeasuresTable summarizes all outcome measures. Variables regarding people with dementia and their informal care- Costs are measured using the RUD [It assesses givers are chosen based on recent models predicting information on resources used (e.g. frequency and dura- care demands predicting institutionalization for peo- tion of hospitalization, visits to health care professionals ple with dementia , and quality of care Mea- and type of care, medication use, use of social services) surement instruments are selected based on their for both patients and informal caregivers. In addition, psychometric properties (validity, reliability), clinical uti- the RUD investigates caregiver time, defined as time lity and appropriateness for the target settings and spent on providing basic activities of daily living (e.g.
population. If necessary, questionnaires are translated washing, dressing), instrumental activities of daily living according to a standardized backward forward transla- (i.e. cooking, handling financial affairs) and time spent tion procedure Prior to the study, permission was on supervision (e.g. preventing self-harm). It also obtained for use and translation of questionnaires.
assesses caregiver work status and whether informal car-egiving substitutes for paid work. The RUD-FOCA is Measures for people with dementia used to record direct care time in institutional nursing Outcome measures for people with dementia include cognitive status (SMMSE) independence inactivities of daily living (KATZ) , neuropsychiatric symptoms (NPI-Q) [quality of life (QoL-AD, Trained interviewers collect all data during face-to-face both self-and proxy assessment) , comorbidity interviews. All interviewers are professionals in health or (Charlson Comorbidity Index) [and medication use.
social care or medical/nursing/social care students with Furthermore, several quality of care indicators as based practical experience and at least a Bachelors degree.
on recent literature ] are assessed: nutritional status Furthermore, they received an additional training on the (one item question ‘did the patient experience a weight project, all procedures, content of the assessments and loss of 4% or more of his weight in the past year?') [ completion of questionnaires.
falls (falls and fall-related injuries during preceding 3 In order to standardize and facilitate data collection, months), pressure ulcers (presence and severity); depres- the WP3 leading centre (Maastricht University, the sive symptoms (CSDD) ; use of physical restraints (8 Netherlands) has prepared a manual as a standardized items from MAQ) ; pain (items from RAI-MDS on operating procedure (SOP). This manual has three parts: presence, frequency and location) and mortality 1) preparation for the interviews, with information on registration. Sociodemographic information includes age, selection of institutions and participants, instructions for Verbeek et al. BMC Public Health 2012, 12:68 Table 2 Measurement instruments People with dementia People withdementia Personal and social resources Quality of care indicators -nutritional status Item on weight loss -physical restraints MDS based indicators. Presence, frequency, intensity and Presence, intensity Register mortality Frequency and injuries recent falls Informal caregivers Positive and negative aspects of 24 (5 dimensions) Caregivers burden Availability of resources Psychological well-being Quality of Life informal caregivers Experiences on QoC 9 items of the CLINT open ended questions Economic evaluation * the underlined score represents the most favorable score; † at home: informal caregiver; institutional nursing care: formal caregiver; ‡ If a PwD total score is lessthan 3 on the MMSE, Qol–AD will be assessed only using proxy reports interviewers and the study pilot; 2) the interview con- each individual country. Two follow-up meetings were tent, explaining the measurement assessments used dur- scheduled (February and September 2011) for all ing the interviews; and 3) data handling, describing researchers to discuss experiences regarding recruitment procedures regarding handling and storage of data, data and data collection, taking country-specific issues into audit and data entry. The manual and all questionnaires were prepared in English and translated to the national Data are centrally managed by the RTPC coordinating languages following a strict instruction to facilitate a centre (Witten University, Germany) in close contact to standardized layout for data entry purposes.
the WP3 team who has prepared the SPSS database.
An instruction meeting took place in September 2010, Countries prepare either 1) copies of the original data before the start of recruitment when the manual and collection forms for keeping at their institutions or 2) procedures were explained by the WP3 team to all main scan the original data collection forms for generation of investigators in each country. These main investigators pdf files (or another image file). Completeness and cor- are responsible for transfer of all standardized instruc- rectness of each file will be checked immediately after tions towards interviewers in each country. At this scanning by countries. Each country will deliver either meeting the inclusion and selection criteria for study 1) the original client record files or 2) a data storage participation were discussed, based on a template pre- medium comprising the scanned files to the RTPC coor- pared by the WP3 leading centre and completed by dinating centre by secured post or express courier or Verbeek et al. BMC Public Health 2012, 12:68 even personally by a researcher. Data will be delivered People with dementia and their informal caregivers twice during the project: after baseline and follow-up participate on a voluntary basis and their informed con- assessment. Data entry will be performed centrally at sent is given by their (legal) representatives and if possi- the RTPC coordinating centre. All files will be processed with FormPro Software. Furthermore, the RTPC coordi- representative refers to either a legal authorized repre- nating centre has prepared a text file database for all sentative or, if not available, the informal caregiver of open-ended questions (in English), including medication the people with dementia who has the power to consent, classification according to the ATC coding system, to according to country specific guidelines and regulations.
ensure standardization across countries and enhance People with dementia who are not able to sign informed data quality.
consent are asked to assent Assent is defined aswillingness to participate even without full understand- ing of the complexity and the whole aims of the study.
An external audit of data plausibility and data manage- During interviews, a sense of comfort for the partici- ment will be performed in each country to ensure qual- pants, with active monitoring of willingness to partici- ity of data collection. The RTPC coordinator (GM) has pate and signs of (non)verbal dissent or distress [are developed a SOP and data audit checklist and provided provided by the interviewers. Finally, a specific SOP on training for each independent external auditor. The ethical issues encountered during data collection was audit is performed in all countries by a trained external developed by the RTPC coordinator. Each researcher is data monitoring auditor, who has a minimum qualifica- trained to follow these guidelines.
tion level of a Bachelor's degree in nursing science or arelated field of study, is not involved in the study and Statistical analysis has good English language skills. The data check covers The main objectives of the current study are to investi- at least 20% of randomly selected client record files.
gate factors influencing institutionalization and to Names of participating patients and residents remain explore circumstances and living conditions of people concealed for the auditor. Furthermore, the auditor will with dementia and their informal caregivers receiving visit at least one or two participating institutional nur- home or institutional nursing care. As this is a cohort sing care facilities and one or two participating home study with two strata, the statistical analyses will be pri- care organizations to verify their existence and contribu- marily a descriptive comparison between the two strata.
tion to participant recruitment.
First, descriptive analyses will be conducted at the levelof setting and country at baseline and follow-up. Out- Ethical considerations come measures at baseline, follow-up and the changes The Good Epidemiological Practice guidelines recom- between baseline and follow-up of the settings as well as mended by the International Epidemiological Association between the settings will be described for all countries European Federation are followed. Furthermore, each and each country separately. Therefore, crosstabulations country has obtained ethical approval from a country will be used for discrete variables and boxplots, mean/ specific legal authority for research on human beings (for medians and quartiles for continuous variables. Bivariate example a ethical committee specialized in medical or and correlation analyses will be conducted to relate nursing science) to conduct the study in accordance with (socio)demographic variables and outcome measures for the national standards and regulations in participating People with dementia and informal caregivers. Multi- countries. The specific names of each committee are as variate regression analyses are conducted per time point follows (with reference numbers if appropriate in brack- and longitudinally. To answer the first objective (factors ets): Ethics Review Committee on Human Research of influencing institutionalization), additional prospective the University of Tartu (196/T-3), Ethical Committee of regression analyses will be conducted for the subgroup the South-West Hospital District Finland (8/2010), of participants that were institutionalized during the Comite de Protection ds Personnes Sud-Ouest and study period (i.e. baseline assessment in home care Outre-Mer Toulouse (09 202 07), Nursing Science Ethi- (Group 2), follow-up in institutional care (Group 1)). A cal Committee University of Witten/Herdecke, Medical biostatistician is consulted during preparation of the sta- Ethical Committee of the Academic Hospital Maastricht/ tistical plan.
Maastricht University (MEC 10-5-044), Ethical Commit-tee of the Hospital Clinic Barcelona (2010/6031), Ethical Interpretation of findings Committee Lund University (20120/538), National The current study generates primary data on outcomes Research Ethics Service, North West 5 Research Ethics and costs of long-term nursing care for People with Committee (11/NW/0003). Prior to data collection, dementia and their informal caregivers, specifically informed consent will be obtained for all participants.
focusing on the transition process of professional formal Verbeek et al. BMC Public Health 2012, 12:68 home care towards institutional care. To interpret these RightTimePlaceCare ]. Together with data collected findings, data will be combined with knowledge gath- in three other work packages, RTPC aims to develop ered in the other Work Packages (WPs) of the RTPC best-practice strategies for need-tailored care while study. WP2 (leading centre Lund University, Sweden) ensuring best available outcomes for people with analyses European health care structures, social care and dementia and their informal care givers at affordable welfare systems, advocacy and informal caregiver sup- cost-benefit ratios. A RTPC Consortium and Advisory port systems for patients/consumers with dementia and board of expertise were set up, representing nursing, intersectorial communication covering the continuum of medical, health economics, social care, public policy and care from informal care, contribution from the civil other professional disciplines. Several representatives of society, public home care and the intermediate forms of the project are closely related to national political care to the long-term institutional care, including end of boards as well as to institutions and political boards of life care. WP4 (leading centre Witten/Herdecke Univer- the European Union. This will enable a widespread dis- sity, Germany) assesses costs in long-term dementia semination of results throughout disciplines, scientific care for the time period just before and just after the and non-scientific media.
admission to institutional long-term nursing care facil- The study is limited by its relatively short follow-up ities from a societal perspective. This means that all period of 3 months, due to practical restraints. To study relevant costs (direct costs, indirect costs and opportu- the transition process from professional home care nity costs) will be assessed. Finally, WP5 (leading cen- towards institutional nursing care, we examine out- tres Hospital Clinic of Barcelona, Spain and University comes for two groups of participants who are at the of Tartu, Estonia) aims to generate best practice strate- margins of care: 1) people with dementia who have gies that can be integrated into existing European health recently been admitted to an institutional nursing care and social care systems in order to enable national deci- facility and their informal caregivers; 2) people with sion makers to base their decisions on the best knowl- dementia who are at-risk for institutionalization, receiv- edge available when they reform the organisation of ing professional care at home and their informal care- dementia care. To accomplish this goal, results from givers. However, the group of participants who actually WP2 (health care structures), WP3 (primary data collec- switch from home towards institutional care during our tion) and WP4 (economic evaluation) will be integrated study period may be relatively small.
with a literature review and Delphi consensus methodol- An important strength of the current study is its over- ogy, employing a balance of care methodology, unique all size and the cross-country comparisons. Much varia- in its international configuration tion among care concepts (e.g. what constitutes anursing home?) and health care structures may exist across European countries, which in turn might affect All countries have received formal ethical approval for the outcomes and its interpretation. Since this study is part study. Baseline data collection started in November 2010 of a larger European project, we were able as one of the and is intended to end in December 2011. Monthly pro- first studies to simultaneously collect primary clinical gress reports are provided by each country as an instru- data alongside a thorough analysis of organization of ment to supervise enrolment of participants. By November health care structures, execution of an economical eva- 2011, 1757 dyads of people with dementia and their infor- luation and combine this with recent literature in order mal caregivers were included in the study (683 in the insti- to develop best-practice strategies. This knowledge will tutional care setting and 1074 in home care setting).
be used to inform and empower patients, professionals, Furthermore, 996 follow-up interviews had been con- policy and related decision makers to manage and ducted at that date. Follow-up data collection is expected improve health and social dementia care services to end in March 2012. The data audit has been completedby external independent auditors for all eight countries.
Appendix 1The RightTimePlaceCare Consortium partners are: The current study is focused on the transition of people Witten/Herdecke University (DE): Gabriele Meyer, with dementia and their informal caregivers from pro- professor (scientific coordinator, WP 1 leader), Astrid fessional home nursing care towards long-term institu- Schmitz, Anna Renom Guiteras, Dirk Sauerland, profes- tional nursing care facilities. This paper describes the sor (WP 4 & 6 leader), Dr Ansgar Wübker, Patrick research protocol to investigate factors influencing insti- tutionalization and circumstances and living conditions Consortium Members: of participants across eight European countries being Maastricht University (NL): Jan P.H. Hamers, profes- the third work package in a larger European study called sor (WP 3 leader); Basema Afram, Hanneke Beerens, Dr Verbeek et al. BMC Public Health 2012, 12:68 Michel H.C. Bleijlevens; Dr Hilde Verbeek; Dr Sandra Received: 22 December 2011 Accepted: 23 January 2012 M.G. Zwakhalen.
Published: 23 January 2012 Lund University (SE): Ingalill Rahm Hallberg, profes- sor (WP 2 leader); Ulla Melin Emilsson, professor; Dr.
Knapp M, Comas-Herrera A, Somani A, Banerjee S: Dementia. International Staffan Karlsson.
comparisons. Summary report for the National Audit Office London: Personal University of Manchester (UK): David Challis, profes- Social Services Research Unit, London School of Economics and PoliticalScience and the Institute of Psychiatry, King's College; 2007.
sor; Caroline Sutcliffe; Dr David Jolley; Anthony Crook; van Bilsen PM, Hamers JP, Groot W, Spreeuwenberg C: University of Turku (FI): Helena Leino-Kilpi, profes- BMC Health Serv Res sor; Jaana Koskenniemi, Riitta Suhonen, professor; Matti Moise P, Schwarzinger M, Um M: Dementia care in 9 OECD countries: A Viitanen, professor; Seija Arve, adj professor; Minna Comparative Analysis Paris: OECD; 2004.
Stolt; Dr. Maija Hupli; OECD: The OECD Health Project. Long-term Care for Older People Paris: University of Tartu (EE): Kai Saks, professor (WP 5 Organisation for Economic Cooperation and Development; 2005.
Gibson MJ, Gregory SR, Pandya SM: Long-term care in developed nations: a leader); Ene-Margit Tiit, professor; Jelena Leibur; Katrin brief overview Washington: AARP; 2003.
Raamat; Angelika Armolik; Teija Tuula Marjatta Toivari; Tucker S, Hughes J, Burns A, Challis D: Fundació Privada Clinic per la Recerca Biomedica, Aging MentHealth 2008, 12:81-91.
Hospital Clinic of Barcelona (ES): Dr Adelaida Zabalegui Luppa M, Luck T, Brahler E: Konig HH. Riedel-Heller SG: Prediction of (WP 5 leader); Dr Montserrat Navarro; Dr Esther Cab- institutionalisation in dementia. A systematic review. Dement Geriatr Cogn rera (Tecnocampus Mataró).
Disord 2008, 26:65-78.
Nikmat AW, Hawthorne G, Al-Mashoor Gerontôpole, University of Toulouse (FR): Dr Maria Int Psychogeriatr 2011, Soto; Agathe Milhet; Dr Sandrine Sourdet; Sophie Gill- ette; Bruno Vellas, professor.
Schneekloth U, Whal H: Möglichkeiten und Grenzen selbständigerLebensführung in stationären Einrichtungen (MuG IV) - Demenz, Angehörigeund Freiwillige, Versorgungssituation sowie Beispielen für "Good Practice"München: Bundesministerium für Familie, Senioren, Frauen und Jugend; ATC: Anatomical Therapeutic Chemical classification system; CLINT: Client Vickland V, Werner J, Morris T, McDonnell G, Draper B, Low LF, Brodaty H: interview questionnaire; CRA: Caregiver Reaction Assessment; CSDD: Cornell Who pays and who benefits? How different models of shared responsibilities Scale for Depression in Dementia; EQ5D: EuroQuol, 5 dimensions; GHQ-12: between formal and informal carers influence projections of costs of dementia General Health Questionnaire, 12 item version; IC: Informal Caregivers; KATZ: management. BMC Public Health 2011, 11:793.
Katz Index of Independence in Activities in Daily Living; MAQ: Maastricht Quentin W, Riedel-Heller SG, Luppa M, Rudolph A, Konig HH: Attitude Questionnaire; MMSE: Mini-Mental State Examination; MR: Medical Record; NPI-Q: Neuropsychiatric Inventory - Questionnaire; PwD: People with Acta Psychiatr Scand 2010, 121:243-259.
Dementia; Quol-AD: Quality of Life in Alzheimer's Disease; RTPC: Association A: Alzheimer's disease facts and figures. Alzheimers Dement RightTimePlaceCare; RUD: Resource Utilization in Dementia; SOP: Standard Operating Procedure; WP: Work Package; ZBI: Zarit Burden Interview.
Gaugler JE, Yu F, Krichbaum K, Wyman Med Care 2009, 47:191-198.
Feldman HH, Pirttila T, Dartigues JF, Everitt B, Van Baelen B, Schwalen S, The RightTimePlaceCare study is supported by a grant from the European Commission within the 7th Framework Program (project 242153).
Int J Geriatr Psychiatry 2009, 24:479-488.
Ribbe MW, Ljunggren G, Steel K, Topinkova E, Hawes C, Ikegami N, 1Department of Health Services Research, CAPHRI School for Public Health Henrard JC, Jonnson PV: and Primary Care, Maastricht University, P.O. Box 616, 6200 MD Maastricht, Age Ageing 1997, 26(Suppl 2):3-12.
the Netherlands. 2School of Nursing Science, Faculty of Health, Witten/ Brodaty H, Mittelman M, Gibson L, Seeher K, Burns Herdecke University, Witten, Germany. 3Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland. 4South-West Hospital District of Finland, Turku, Finland. 5Fundacíó Privada Clinic per la Recerca Am J Geriatr Psychiatry 2009, 17:734-743.
Biomedica, Hospital Clinic of Barcelona, Barcelona, Spain. 6Lund University, The RightTimePlaceCare Project. Lund, Sweden. 7Department of Internal Medicine, University of Tartu, Tartu, European Communities: Health Statistics. Key data on health 2002 Luxembourg: Estonia. 8Department of Geriatric Medicine, Toulouse University Hospital, Office for Official Publications of the European Communities; 2002.
Toulouse, France. 9Personal and Social Services Research Unit, Faculty of Teperi J, Porter ME, Vuorenkoski L, Baron JF: The Finnish Health Care System: Medical and Human Sciences, University of Manchester, Manchester, UK.
A Value-Based Perspective. Helsinki: Sitra Reports 82 2009.
10Faculty of Management and Economics, Witten/Herdecke University, Du Moulin MF, van Haastregt JC, Hamers Witten, Germany.
Patient Educ Couns 2010, 78:288-296.
Authors' contributions Mapi: Linguistic validation of a Patient Reported Outcomes Measure Lyon: HV, GM and JH conceived the study protocol and its final design, with Mapi Research Institute; 2005.
participation of HLK, AZ, IRH, KS, MES, DC and DS. DS was responsible for Molloy DW, Alemayehu E, Roberts R: the economical evaluation. HV drafted the manuscript and all authors commented on and approved of the final version of the manuscript.
Am J Psychiatry 1991, 148:102-105.
Folstein MF, Folstein SE, McHugh PR: A practical method for grading the Competing interests cognitive status of patients for the clinician. J of Psychiatr Res 1975, The authors declare that they have no competing interests.
Verbeek et al. BMC Public Health 2012, 12:68 Katz J Am Geriatr Soc 1983, 31:721-727.
Cummings JL, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA,Gornbein Neurology 1994, 44:2308-2314.
Kaufer DI, Cummings JL, Ketchel P, Smith V, MacMillan A, Shelley T,Lopez OL, DeKosky ST: J Neuropsychiatry Clin Neurosci 2000,12:233-239.
Logsdon RG, Gibbons LE, McCurry SM, Teri L: Psychosom Med 2002, 64:510-519.
Charlson ME, Pompei P, Ales KL, MacKenzie J Chronic Dis 1987, 40:373-383.
Wallace JI, Schwartz RS, LaCroix AZ, Uhlmann RF, Pearlman J AmGeriatr Soc 1995, 43:329-337.
Alexopoulos GS, Abrams RC, Young RC, Shamoian CA: Biol Psychiatry 1988, 23:271-284.
Hamers JP, Meyer G, Kopke S, Lindenmann R, Groven R, Huizing AR:Int JNurs Stud 2009, 46:248-255.
interRAI: RAI for Nursing Home Care (RAI 2.1) Utrecht: InterRAI Corporation;2002.
Brazier J, Jones N, Kind P: Qual Life Res1993, 2:169-180.
Zarit SH, Reever KE, Bach-Peterson J: Gerontologist 1980, 20:649-655.
Goldberg DP, Gater R, Sartorius N, Ustun TB, Piccinelli M, Gureje O, Rutter C:Psychol Med 1997, 27:191-197.
Given CW, Given B, Stommel M, Collins C, King S, Franklin S: Res Nurs Health 1992, 15:271-283.
Vaarama M: Care-related quality of life in old age. Eur J Ageing 2009,6:113-125.
Wimo A, Wetterholm AL, Mastey V, Winblad B: Evaluation of the resourceutilization and caregiver time in Anti-dementia drug trials-a quantitativebattery. In The Health Economics of Dementia. Edited by: Wimo A, JonssonB, Karlsson G, Winblad B. London: John Wiley and Sons; 1998:465-499.
Luttenberger K, Graessel E: Int Psychogeriatr 2010, 22:1291-1300.
Slaughter S, Cole D, Jennings E, Reimer MA: Nurs Ethics 2007,14:27-40.
Pre-publication historyThe pre-publication history for this paper can be accessed here: doi:10.1186/1471-2458-12-68Cite this article as: Verbeek et al.: A European study investigatingpatterns of transition from home care towards institutional dementiacare: the protocol of a RightTimePlaceCare study. BMC Public Health2012 12:68.
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Source: http://rtpc.progressima.eu/fileadmin/rtpc/public_website/publications/RTPC_study_protocol_Full_Article.pdf

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