Older people in retirement villages: unidentified need & intervention research

We believe that older retirement village ('village') residents may have multiple unmet need and high healthcare utilisation, and targeted intervention will decrease long term care entry & acute hospitalisation. We will evaluate an integrated care package to increase care coordination results for NZ. The trial will have three phases. Phase 1: Residents will complete a questionnaire about their health and functional items. The main purpose is to describe the health and functional needs of residents. Phase 2: All participants will be followed for three-six years from the survey date using Ministry of Health routinely collected data on healthcare usage. Survey interviews will be repeated at 12, 24 and 48 months. The main purpose of this phase is to describe trajectories of health-care service utilisation and identify resident clusters by baseline characteristics and trajectories. Phase 3 (randomised controlled trial) : Based on results from BRIGHT (ACTRN12609000648224) and ARCHIP (ACTRN12614000499684) study criteria we will select a sub-sample of residents (about 40%) ‘at high risk’ of health and functional decline from phase 1’s sample. A multidisciplinary team (MDT) led by gerontology nurse specialist (GNS) will (in the intervention group of residents) complete a comprehensive geriatric assessment develop/ implement an intervention plan in collaboration with the older person & their nominated support person(s), geriatrician, village staff, physiotherapist, occupational therapist & clinical pharmacist (with standard clinical application of the STOPP/START criteria). This will necessitate an initial consultation with between the GNS and the older person and their nominated support person (if the older person desires) of approximately 1 hours' duration. Treatment goals will be developed, and the GNS & MDT will record interventions in a computerized log and in the participant's hospital-based clinical record (with letters to the general practitioner). GNS will meet regularly with MDT: GPs will be invited to attend - if unable the GNS will liaise in writing and in-person. Intervention duration (not <6 months - duration decided by GNS/MDT/GP by consensus and based on perception of clinical need - this is likely to involve regular consultations between the GNS and the older person) approximately every 3 months (though this will vary from person to person) in order to monitor clinical progress - again with record of consultation and recommended interventions in a computerized log and in the participant's hospital-based clinical record (with letters to the general practitioner) will be person-specific be followed by open-ended clinical GNS support from the hospital based GNS service - as dictated by standard clinical need. The General Practitioner will continue to have overall charge of the participant's care and will be free to accept/modify/reject MDT/GNS recommendations (as per ARCHIP). The intervention will be tested by cluster-RCT of usual care vs. intervention. The ‘high risk’ intervention and control groups will have assessments repeated at the end of first and second years.