INvestigating Services Provided in the Residential care Environment for people with Dementia (INSPIRED) study - Improving quality of life for people living with dementia in residential aged care

Funded by the National Health and Medical Research Council (NHMRC) Cognitive Decline Partnership Centre (CDPC)

INSPIRED is a study within the National Health and Medical Research Council funded Cognitive Decline Partnership Centre aimed at at understanding long-term care for older people with cognitive decline in Australia. The project is led by Professor Maria Crotty and her research team of Dr Suzanne Dyer, Dr Stephanie Harrison, Dr Emmanuel Gnanamanickam, Dr Rachel Milte and Dr Enwu Liu

The INSPIRED study examines the resource use, costs and outcomes of different models of residential aged care in Australia with a focus on people living with dementia. The project provides aged care providers and health decision makers in Australia with a measure of the cost of providing quality care to people with dementia, enabling them to plan services and shape policy more effectively and efficiently.

This national study included 541 participants from 17 not-for-profit residential care facilities across four states in Australia. An important component of the study is that people with cognitive impairment and dementia were not excluded. 


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Alternative models of residential care

Internationally, models of residential aged care are changing, with more emphasis being placed on providing care in an environment that looks and feels more like a home. INSPIRED is the first Australian study to measure quality of life, medications, resource use and costs in a home-like, clustered domestic model of care compared to a more standard model of care. The cost of providing these two models was compared, as well as resident outcomes including quality of life, consumer rated quality of care, number of hospitalisations, and number of potentially inappropriate medications prescribed.

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Clustered domestic residential aged care in Australia: fewer hospitalisations and a better quality of life

Dyer SM, Liu E, Gnanamanickam ES, Milte R, Easton T, Harrison SL, Bradley C, Ratcliffe J, Crotty M (2018). Medical Journal of Australia (in press to be release 4 June). 

Psychotropic medications in older people in residential care facilities and associations with quality of life: a cross-sectional study
Harrison SL, Bradley C, Milte R, Liu E, Kouladjian O’Donnell L, Hilmer SN, Crotty M (2018). BMC Geriatrics; 18:60.

Costs of potentially inappropriate medication use in residential aged care facilities
Harrison SL, Kouladjian O’Donnell L, Milte R, Dyer SM, Gnanamanickam ES, Bradley C, Liu E, Hilmer SN, Crotty M (2018). BMC Geriatrics;  18:9. 

Associations between the Drug Burden Index, Potentially Inappropriate Medications and Quality of Life in Residential Aged Care
Harrison SL, Kouladjian O’Donnell L, Bradley C, Milte R, Dyer SM, Gnanamanickam ES, Liu E, Hilmer SN, Crotty M (2018). Drugs Aging; 35(1):83-91.


Costs of residential dementia care

The INSPIRED study provides the first estimate of the ‘whole-of-system’ costs of providing health and residential care for people living in residential aged care in Australia using individual level health and social care data. This approach to estimating costs indicates that previous, more limited cost perspectives underestimate the costs associated with caring for people living with dementia in permanent residential care.

The average annual whole-of-system cost for people living with dementia in residential care was approximately AU$88 000 per person in 2016, with the cost of residential care comprising the bulk of the total costs. The direct health care costs were comprised mainly of hospital admissions, pharmaceuticals and out-of-hospital attendances. While total costs were not significantly different between those with and without dementia, the cost of residential care was significantly higher and the cost of health care was significantly lower for people living with dementia.

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Direct health and residential care costs of people living with dementia in Australian residential aged care
Gnanamanickam ES, Dyer SM, Milte R, Harrison SL, Liu E, Easton T, Bradley C, Bilton R, Shulver W, Ratcliffe J, Whitehead C, Crotty M. (2018) International Journal of Geriatric Psychiatry; 1-8. 


Consumer rated quality of care: Consumer Choice Index-6 Dimension (CCI-6D)

With the recent introduction of consumer directed care in the Australian aged care sector, there is growing emphasis on providing people living in residential aged care with increasing levels of flexibility and choice in their care, which is hoped to lead to improved quality of life and wellbeing.

In order to better meet the needs and expectations of residents (including people with dementia) and their family members, it is essential that we understand the perspectives of residents and family members (consumers) themselves.

The 'models of residential care for older people with cognitive decline' project team has developed an Australian consumer derived measure of quality and choice in long-term aged care - the Consumer Choice Index – 6 Dimension (CCI-6D). The CCI-6D has been developed to specifically evaluate the quality of care in residential aged care homes from a consumer perspective.

The tool has been validated and correlates as expected with other related measures of resident quality of life and quality of care.

To develop the tool, qualitative interviews were conducted with residents of aged care homes, including people with dementia and their family members to ascertain what characteristics of residential aged care are important to them for good quality care.

The CCI-6D measures six key characteristics of quality care which were derived from these interviews. The CCI-6D can be used by aged care organisations to properly evaluate the success of innovations to improve care from their consumers’ perspectives.


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Evaluating the quality of care in long-term facilities from a consumer perspective: development and construct validity of the Consumer Choice Index - Six Dimension Instrument 

Milte R, Ratcliffe J, Bradley C, Shulver W, Crotty M. (2017). Ageing and Society; 1-23.

Quality in residential care from the perspective of people living with dementia: the importance of personhood 
Milte R, Shulver W, Killington M, Bradley C, Ratcliffe J, Crotty M. (2016). Archives of Gerontology and Geriatrics; 63: 9-17.

What characteristics of nursing homes are most valued by consumers? A discrete choice experiment with residents and family members
Milte R, Ratcliffe J, Chen G, Crotty M. (2017) Value in Health; Dec 6: 1-7.


Additional findings from INSPIRED

The extensive data collected for the INSPIRED study has enabled additional analyses of various aspects of residential aged care. The listed publications from INSPIRED examine facets such as medications, food and dining, economic analyses, Consumer Directed Care and quality of life measures.

The SACRED Trial:

People living with dementia fall more frequently than those without cognitive impairment, and a common debilitating consequence of falls is hip fracture.

The SACRED trial (Southern Adelaide Co-ordinated Regional Hip and Debility Rehabilitation Programme) evaluated the efficacy and cost effectiveness of providing a 4 week rehabilitation program into residential aged care homes following residents’ discharge from hospital post-surgery to repair a hip fracture.


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Patterns of medication prescription by dementia diagnosis in Australian nursing home residents: a cross-sectional study
Liu E, Dyer SM, Whitehead C, Kouladjian O’Donnell L, Gnanamanickam ES, Harrison SL, Milte R, Crotty M. (2018) Journal of Pharmacy Practice (In press).

Taste, choice and timing: investigating resident and carer preferences for meals in aged care homes
Milte M, Ratclife J, Chen G, Miller M, Crotty M. (2018) Nursing and Health Sciences; 20:116-124.

Introducing consumer directed care in residential care settings for older people in Australia: views of a citizens’ jury
Laver K, Gnanamanickam E, Whitehead C, Kurrle S, Corlis M, Ratcliffe J, Shulver W, Crotty M. (2018) Journal of Health Services Research and Policy;

Struggling to maintain individuality - describing the experience of food in institutional long-term care for people with cognitive impairment
Milte R, Shulver W, Killington M, Bradley C, Miller M, Crotty M. (2017) Archives of Gerontology and Geriatrics; 72: 52-58.

Where' the evidence? A systematic review of economic analyses of residential aged care infrastructure
Easton T, Milte R, Crotty M, Ratcliffe J. (2017) BMC Health Services; 17:226.

Association of Cardiovascular System medications with cognitive function and dementia in older adults living in nursing homes in Australia
Liu E, Dyer S, O'Donnell L, Milte R, Bradley C, Harrison S, Gnanamanuckam E, Whitehead C, Crotty M. (2017) Journal of Geriatric Cardiology; 16(6): 407-415.

An empirical comparison of the 5Q-5D-5L, DEMQOL-U and DEMQOL-Proxy-U in a post-hospitalisation population of frail older people living in residential aged care
Ratcliffe J, Flint T, Easton T, Killington M, Cameron I, Davies O, Whitehead C, Kurrle S, Miller M, Liu E, Crotty M. (2017) Appied Health Economics and Health Policy; 15(3): 399-412.

An empirical comparison of the measurement properties of the EQ-5D-5L, DEMQOL-U and DEMQOL-Proxy-U for older people in residential care
Easton T, Milte R, Crotty M, Ratcliffe J (2017) Quality of Life Research; 15(3)399-412.

Advancing aged care: a systematic review of economic evaluations of workforce structures and care processes in a residential care setting
Easton T, Milte R, Crotty M, Ratcliffe J. (2016) Cost Effectiveness and Resource Allocation; 14: 12.

The chaotic journey: recovering from hip fracture in a nursing home
Killington M, Walker R, Crotty M. (2016) Archives of Gerontology and Geriatrics; 67: 106-112.