Original Study| Volume 21, ISSUE 6, P843-850.e5, June 2020

Download started.


Impact of Prior Home Care on Length of Stay in Residential Care for Australians With Dementia

Published:January 31, 2020DOI:



      To assess the impact of home care on length-of-stay within residential care.


      A retrospective observational data-linkage study.

      Setting and Participants

      In total there were 3151 participants from the 45 and Up Study in New South Wales, Australia with dementia who entered residential care between 2010 and 2014.


      Survey data collected from 2006‒2009 were linked to administrative data for 2006‒2016. The highest level of home care a person accessed prior to residential care was defined as no home care, home support, low-level home care, and high-level home care. Multinomial logistic regression and Cox proportional hazards were used to investigate differences in activities of daily living, behavioral, and complex healthcare scales at entering residential care; and length-of-stay in residential care.


      People with prior high-level home care entered residential care needing higher assistance compared with the no home care group: activities of daily living [odds ratio (OR) 3.41, 95% confidence interval (CI) 2.14‒5.44], behavior (OR 2.61, 95% CI 1.69‒4.03), and complex healthcare (OR 2.02, 95% CI 1.06‒3.84). They had a higher death rate, meaning shorter length-of-stay in residential care (<2 years after entry: hazard ratio 1.12; 95% CI 0.89‒1.42; 2-4 years: hazard ratio 1.49; 95% CI 1.01‒2.21). Those using low-level home care were less likely to enter residential care needing high assistance compared to the no home care group (activities of daily living: OR 0.61, 95% CI 0.45‒0.81; behavioral: OR 0.72, 95% CI 0.54‒0.95; complex healthcare: OR 0.51, 95% CI 0.33‒0.77). There was no difference between the home support and no home care groups.


      High-level home care prior to residential care may help those with dementia stay at home for longer, but the low-level care group entered residential care at low assistance levels, possibly signaling lack of informal care and barriers in accessing higher-level home care.


      Better transition options from low-level home care, including more timely availability of high-level care packages, may help people with dementia remain at home longer.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Gnanamanickam E.S.
        • Dyer S.M.
        • Milte R.
        • et al.
        Direct health and residential care costs of people living with dementia in Australian residential aged care.
        Int J Geriatr Psychiatry. 2018; 33: 859-866
        • Lehnert T.
        • Heuchert M.
        • Hussain K.
        • König H.-H.
        Stated preferences for long-term care: A literature review.
        Ageing Soc. 2018; 39: 1873-1913
        • Australian Institute of Health and Welfare
        The desire to age in place among older Australians. AIHW bulletin.
        (Available at:)
        • Howe A.L.
        Recent developments in aged care policy in Australia.
        J Aging Soc Policy. 2002; 13: 101-116
        • Australian Government Department of Health
        Aged care reform.
        (Available at:)
        Date: 2019
        Date accessed: January 29, 2019
      1. Australian Institute of Health and Welfare. Pathways to permanent residential aged care in Australia: A Pathways in Aged Care (PIAC) analysis of people’s aged care program use before first entry to permanent residential aged care in 2013–2014. Cat. no. AGE 81. Canberra: AIHW; 2017

        • Jorm R.
        • Walter R.
        • Lujic S.
        • et al.
        Home and community care services: A major opportunity for preventive health care.
        BMC Geriatr. 2010; 10: 26
      2. Australian Government Department of Health and Ageing, Home Care Packages Program, Canberra. Available at:, Accessed July 20, 2019

        • Thomas K.S.
        The relationship between older Americans act in-home services and low-care residents in nursing homes.
        J Aging Heal. 2014; 26: 1-27
        • Kaye H.S.
        • LaPlante M.P.
        • Harrington C.
        Do noninstitutional long-term care services reduce medicaid spending?.
        Health Aff. 2009; 28: 262-272
        • Muramatsu N.
        • Yin H.
        • Campbell R.T.
        • et al.
        Risk of nursing home admission among older Americans: Does states' spending on home- and community-based services matter?.
        J Gerontol B Psychol Sci Soc Sci. 2007; 62: S169-S178
        • Guo J.
        • Konetzka R.T.
        • Manning W.G.
        The causal effects of home care use on institutional long-term care utilization and expenditures.
        Health Econ. 2015; 24: 4-17
        • Spillman B.
        Does Home Care Prevent or Defer Nursing Home Use? Washington DC.
        (Available at:)
        • Australian Institute of Health and Welfare (AIHW)
        Pathways in aged care: Do people follow recommendations?.
        AIHW, Canberra2011
        • Barczyk D.
        • Kredler M.
        Evaluating long-term-care policy options, taking the family seriously.
        Rev Econ Stud. 2018; 85: 766-809
        • Aged Care Financing Authority
        Fifth report on the Funding and Financing of the Aged Care Sector (July 2017)–Short form report.
        (Available at:)
        • Karmel R.
        • Gibson D.
        • Anderson P.
        • et al.
        Care trajectories through community and residential aged care services: Disease effects.
        Ageing Soc. 2012; 32: 1428-1445
        • Jorgensen M.
        • Siette J.
        • Georgiou A.
        • et al.
        Modeling the association between home care service use and entry into residential aged care: A cohort study using routinely collected data.
        J Am Med Dir Assoc. 2018; 19: 117-121.e3
        • Banks E.
        Cohort profile: The 45 and up study.
        Int J Epidemiol. 2008; 37: 941-947
        • Waller M.
        • Mishra G.D.
        • Dobson A.J.
        Estimating the prevalence of dementia using multiple linked administrative health records and capture-recapture methodology.
        Emerg Themes Epidemiol. 2017; 14: 1-9
        • Harvey L.
        • Mitchell R.
        • Brodaty H.
        • et al.
        Differing trends in fall-related fracture and non-fracture injuries in older people with and without dementia.
        Arch Gerontol Geriatr. 2016; 67: 61-67
        • Australian Government Department of Health
        Aged Care Funding Instrument (ACFI) user guide.
        (Available at:)
        • Katz S.
        • Downs T.D.
        • Cash H.R.
        • Grotz R.C.
        Progress in development of the index of ADL.
        Gerontologist. 1970; 10: 20-30
        • Mackinnon A.J.
        • Henderson A.S.
        • Scott R.
        • et al.
        The psychogeriatric assessment scales: A multidimensional alternative to categorical diagnoses of dementia and depression in the elderly.
        Psychol Med. 1995; 25: 447-460
        • Alexopoulos G.S.
        • Abrams R.C.
        • Young R.C.
        • Shamoian C.A.
        Cornell scale for depression in dementia.
        Biol Psychiatry. 1988; 23: 271-284
        • Andersen R.M.
        Revisiting the Behavioral Model and Access to Medical Care: Does It Matter?.
        J Health Soc Behav. 1995; 36: 1-10
        • Ridgeway G.
        • McCaffrey D.F.
        • Morral A.R.
        • et al.
        Toolkit for Weighting and Analysis of Nonequivalent Groups: A Tutorial for the R Twang Package. Santa Monica.
        RAND Corporation, CA2014 (Available at:)
        Date: 2014
        Date accessed: July 18, 2019
        • Temple J.B.
        • Jukic M.
        • Dow B.
        Informal care relationships and residential aged care recommendations: Evidence from administrative data.
        BMC Geriatr. 2017; 17: 1-9
        • Australian Institute of Health and Welfare (AIHW)
        Aged Care Packages in the Community 2008/09: A Statistical Overview. Canberra.
        (Available at:)
        • Australian Government Department of Health
        Home care packages program: Data report–1st Qtr 2018/2019.
        (Available at:)
        • Visvanathan R.
        • Amare A.T.
        • Wesselingh S.
        • et al.
        Prolonged wait time prior to entry to home care packages increases the risk of mortality and transition to permanent residential aged care services: Findings from the Registry of Older South Australians (ROSA).
        J Nutr Health Aging. 2018; 23: 271-280
        • McCaffrey D.F.
        • Ridgeway G.
        • Morral A.R.
        Propensity score estimation with boosted regression for evaluating causal effects in observational studies.
        Psychol Methods. 2004; 9: 403-425
        • Curtis L.H.
        • Hammill B.G.
        • Eisenstein E.L.
        • et al.
        Using inverse probability-weighted estimators in comparative effectiveness analyses with observational databases.
        Med Care. 2007; 45: 103-107
        • Wilkinson T.
        • Ly A.
        • Schnier C.
        • et al.
        Identifying dementia cases with routinely collected health data: A systematic review.
        Alzheimer Dement. 2018; 14: 1038-1051
        • Mealing N.
        • Banks E.
        • Jorm L.
        • et al.
        Investigation of relative risk estimates from studies of the same population with contrasting response rates and designs.
        BMC Med Res Methodol. 2010; 10: 26