| Objective:To construct a scientific,objective,standardized and feasible comprehensive evaluation index system suitable for the assessment of long-term care needs for community-dwelling elderly people and to form an assessment tool on this basis.To carry out empirical research on the assessment tool to construct a hierarchical standards.To apply the hierarchical standards to determine the long-term care services for community-dwelling elderly people at different care levels and to preliminarily verify its feasibility in providing guidance for home-and community-based long-term care services for the elderly in community.Methods:Part one:The establishment of the evaluation index system of longterm care needs assessment for community-dwelling elderly people.A systematic literature review of the existing long-term care assessment tools was carried out to extract the common evaluation indicators as the main source of the evaluation index system,and an evaluation system framework was initially constructed based on the evidence and the theoretical framework.A qualitative study was conducted to interview the elderly in community and their main caregivers using descriptive qualitative research methods.The content analysis method was used to analyze the data,aiming to explore the care and support needs related to their physical and/or mental conditions faced by the older adults living at home,and deduced the results based on the theoretical framework to enrich the framework of the evaluation system.Further,the Delphi method was conducted to modify,delete or add the evaluation indications according to the opinions of experts to form the final evaluation system.Part two:Formation and quality evaluation of the long-term care needs assessment tool for community-dwelling elderly people.Based on the established evaluation index system of long-term care needs assessment for community-dwelling elderly people,the official version of long-term care needs assessment tool for community-dwelling elderly people was formed on the basis of the pilot study.A cross-sectional formal survey using face-to-face interview with older people receiving long-term care(or their proxies)was conducted,and multi-stage stratified cluster sampling was used to carry out this survey.The item analysis,reliability and validity was analyzed to screen item and evaluate the reliability and validity of the questionnaire.Part three:The construction of the hierarchical standard of long-term care needs assessment for community-dwelling elderly people.Combined with the subjective weight obtained by the analytic hierarchy process and the objective weight obtained by the entropy method,the comprehensive weight of each evaluation indicator was obtained.Further,appropriate comprehensive evaluation methods were used to explore the hierarchical standard of long-term care needs assessment for community-dwelling elderly people,including quartile equal division method,cluster analysis method and weighted rank sum ratio method.The advantages and disadvantages of the three classification methods were compared,and the appropriate classification scheme was selected to determine the grading cutoff value and then verify it.Part four:The long-term care services for community-dwelling elderly people with different care levels based on the hierarchical standard.A comprehensive literature review and policy analysis were undertaken to identify the relevant literature and policy documents related to the home-and community-based long-term care services for disabled community-dwelling elderly people,and the content framework of the long-term care services was established on this basis.Further guided by the theoretical basis and the content framework,a Kano attribute questionnaire for the long-term care needs for community-dwelling elderly people was formed.A cross-sectional study was conducted to determine the contents of long-term care services for communitydwelling elderly people with different care levels based on the hierarchical standard.The ABC classification method was further used to analyze the main health problems faced by the elderly at different levels of care,combined with the content of long-term care services with different care levels,to preliminarily verify the feasibility of the hierarchical standard in providing guidance for home-and communitybased long-term care services for the elderly in community.Results:Part one:Two first-level indicators,15 second-level indicators and 51 third-level indicators were selected based on the evidence from the literature review and the theoretical framework.A total of 22 communitydwelling elderly people and their caregivers were included in the qualitative study.Three themes and 11 sub-themes were extracted according to the interview data and the theoretical framework of this study.Three first-level indicators,13 second-level indicators,and 58 third-level indicators was determined to enrich the framework of the evaluation system.A total of 20 experts from 9 cities were invited to participate in the consultation,and the experts were engaged in geriatric nursing,geriatric medicine,geriatric rehabilitation and geriatric services and management.Two rounds of consultation were conducted,with the response rates of 90%and 94.4%,opinion response rates of 94.4%and 29.4%,expert authority coefficients of 0.94 and 0.95,respectively.The coefficient of variation of each index was<0.15,and the Kendall’s coefficients of the overall index and all levels of index were between 0.277 and 0.441(all the p-values were<0.01).Based on the consultations,the final evaluation system was formed,including 3 firstlevel indicators,12 second-level indicators and 49 third-level indicators.Part two:The method of critical ratio,discrete trend,correlation coefficient and exploratory factor analysis were used to jointly screen the items of questionnaire in the formal survey.After excluding 2 items,it showed that the remaining items of questionnaire had good discrimination,sensitivity,representativeness and independence.The results of reliability analysis showed that the test-retest reliability of the total questionnaire and each sub-questionnaire ranged from 0.901 to 0.957,and the inter-rater reliability ranged from 0.859 to 0.932.The Spearman-Brown ranged from 0.934 to 0.986,the Guttman halfcoefficient ranged from 0.910 to 0.985,and the Cronbach’s coefficient ranged from 0.870 to 0.967.The results of content validity showed that the I-CVI was 0.83-1.00,the S-CVI/UA of the questionnaire was 0.915,and the S-CVI/ave was 0.986.The results of exploratory factor analysis showed that the actual dimensions of each sub-questionnaire were basically the same as the preset dimensions after adjustment,the variance contribution rate of each factor was above 10%,and the cumulative variance contribution rate was above 70%.The loading values on the factors were all>0.6,and the loading values on other common factors were small.The results of confirmatory factor analysis showed that the factor models of each sub-questionnaire and the total questionnaire fitted well with the measured data,and the basic fit index,overall fit index and internal structure fit index all met the requirements(some were the revised results).Part three:The categories divided by the three grading methods showed that the mean difference between any two groups was statistically significant,and the correlation coefficients among the three grading methods were between 0.844 and 0.915(P<0.01).The correlation results between the three grading methods and ADLs showed that the correlation coefficients with BADLs grading were between 0.736 and 0.782,and the correlation coefficients with IADLs grading were between 0.668 and 0.698(P<0.01).The grading result of cluster analysis method was selected as the best choice,and the grading cutoff value was determined.483 samples were used to verify the grading cutoff value again,and the results showed that the mean difference between any two groups was statistically significant.Finally,the hierarchical standard was divided into four levels,the higher the level,the greater the intensity or difficulty of care required.Part four:The content framework of long-term care services for community-dwelling elderly people was established,including 35 items in five categories:life care,medical care,safety care,functional maintenance,and spiritual comfort.The content framework was transformed into a Kano attribute questionnaire for the long-term care needs for community-dwelling elderly people.After testing,the content validity of the questionnaire was 0.896,the Cronbach α coefficient of the forward question was 0.918,and the Cronbach α coefficient of the reverse question was 0.932.The results of the service demand survey showed that there were 13,16,18 and 21 service items belonging to the effective demand of community-dwelling elderly people at different care levels.On this basis,the Kano attributes and service demand orders of long-term care service items for community-dwelling elderly people were defined.The Pareto chart showed that there were 12 items,18 items,24 items,and 30 items with the cumulative ratio of health care problems for the elderly in 1-4 levels of care ranging from 0 to 80%,respectively,and the cumulative proportions were 78.86%,78.61%,79.74%,78.02%and 78.94%.Conclusion:1.The construction process of the evaluation index system was rigorous,the indicators were systematic and comprehensive,and the research methods and results were scientific and reliable.The long-term care needs assessment tool for community-dwelling elderly people based on the evaluation index system was standardized,scientific,and reliable,with high feasibility,and good reliability and validity.2.This study explored three grading methods for assessing the longterm care needs for community-dwelling elderly people.The results suggested that the three grading models were scientific and reliable,and can comprehensively,specifically and accurately distinguish the care levels of community-dwelling elderly people.Finally,the cluster analysis was selected to determine the four-level grading standard and the grading cut-off value.After verification,the grading results were scientific,stable and reliable,and can be promoted and applied as a grading assessment tool in many fields involving long-term care for the elderly.3.The Kano attribute questionnaire developed for the long-term care services for community-dwelling elderly people in our study was comprehensive and had good reliability and validity.With the increase of care levels,the care services showed a trend of increasing effective demand and changed dynamically.The comparative analysis found that the content of long-term care services and health care problems for community-dwelling elderly people in different care levels could reflect each other,suggesting that the hierarchical standard had good guidance for service demand.21 figures,73 tables,165 references... |
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