Prioritising restorative care programs in light of current age care reform

Short‐term restorative care (STRC) aims to reduce the demand for long‐term aged care services through 8 weeks of intensive, multidisciplinary services designed to enhance the independence of community‐dwelling older Australians at risk of functional decline. Evidence surrounding the effectiveness and feasibility of STRC is limited.


| INTRODUCTION
Population ageing will significantly increase the demand for community and residential aged care and acute hospital admissions, [1][2][3] with the associated health-care expenditure projected to triple by 2050. 1 Coupled with projected staffing shortages, the ageing of the population and the age-related increased number of hospitalisations will place the Australian aged care sector under significant stress.2][3] The short-term restorative care (STRC) program is an Australian Government initiative that embraces this concept by supporting 8 weeks of intensive Allied Health and Therapy (AH&T) to promote participant self-management and optimise independence. 4First introduced in 2017, there are currently 2269 STRC packages nationally with the capacity to support over 14,800 older Australians per year to improve physical and mental health. 4For the Australian Government, the national investment in STRC is a desirable alternative to the financial burden of residential aged care.
The National My Aged Care system currently supports over 1 million community-dwelling Australians, costing the government >$8 billion per annum. 5Increased spending and care needs will put the aged care sector under significant stress, with a projected staff shortage of >400,000 people by 2050. 5National aged care reform informed by the Royal Commission into Aged Care Quality and Safety sees the Australian Government moving away from the current multi-program model to a single funding stream. 5While the STRC program will be impacted by this reform, the government appreciated the program's value and intends to incorporate the concept into the incoming Support at Home Program. 5 Aligned to the irrefutable evidence that older adults are never too old, disabled or diseased to be re-abled to better health and well-being, 5 STRC gives services providers the flexibility to maximise participant AH&T engagement while in the program. 1,6,7Surprisingly, given the size of the program, no Australian studies have investigated STRC's effectiveness to re-able participants. 8,9Also for consideration, while the STRC concept embraces current evidence, government guidelines lack details, such as which services (e.g., physiotherapy and exercise physiology) to prioritise during and after the program, and the regularity of service delivery. 7,10In addition, the specified assessment tool (Modified Barthel Index) highlights disability but does not identify social and mental health well-being.With reform at hand, a detailed analysis of effective STRC service delivery will be essential to ensure future program value at both the individual and national level.The aim of the present study was to examine the effectiveness of the STRC program, inclusive of the assessment battery, service type and schedule.

| Design
The study used an observational cohort methodology to retrospectively evaluate Southern Cross Care's (SA, NT and Vic; SCC) STRC service delivery to communitydwelling older participants referred to the program following an Aged Care Assessment Team (ACAT) assessment.Thus, participants were likely to be at a lower functioning level than matched peers from the overall older people.Program effectiveness was determined via improvements from baseline to discharge in terms of physical and mental health.Information relating to the initial cause of functional decline and the number of services delivered per discipline per participant were also quantified.The University of South Australia Human Research Ethics Committee approved this study (reference number: 201429).Study participants provided written consent for the use of de-identified data before commencing SCC's STRC program.

| Setting
SCC is a supplier of residential and community aged care services and has offered STRC since 2019, with 23 packages currently available at any one time.SCC's STRC program adopts an exercise-based approach, involving a collaborative multidisciplinary team of allied health professionals and therapists, coordinated by an accredited exercise physiologist (AEP).Individual needs and

Policy Impact
Government-funded restorative care programs to reverse functional decline are under-studied and under-utilised in Australia.This study demonstrates the value of evidence-based, restorative care practice, to significantly improve participant's physical and mental well-being, and that could be adopted by other providers for widereaching national benefits.goals determine service provision, with access to AEP, occupational therapy (OT), nursing, physiotherapy, podiatry (POD), massage therapy, social work (SW), flexible respite, dietetics and Health & Wellness Promoters (H&WP).In this setting, H&WP are exercise scientists and/or experienced Certificate IV Fitness who support exercise under the guidance of the AEP.In addition to the Modified Barthel Index (MBI), SCC assesses participants using a comprehensive, holistic assessment battery (outlined below).Initially, assessment and services are delivered within the participant's homes, with the exception of social engagement services, before progressing to a SCC Health & Wellness Centre.These centres offer air-pressure-driven resistance training equipment (HUR Australia Pty Ltd, Birkdale, QLD, Australia), aerobic equipment (e.g., treadmill and recumbent cross trainer), functional exercise (e.g., Pilates reformer), hydrotherapy, group therapy (e.g., hand therapy) and one-on-one therapy (e.g., physiotherapy).Individualised progressive resistance and balance exercise programs are prescribed by AEP's, with services per week increasing as the participant's exercise tolerance increases.Transport to a Health & Wellness Centres is self-arranged or provided through SCC.If the latter, the three options include a carer-driven arrangements for those combining exercise with a social outing, an SCC volunteer-run transport services or the program's H&WP to transport the participant to the session.

| Participants
The study consisted of older South Australians commencing SCC's STRC between 19 July 2019 and 26 June 2021.ACAT-assessed individuals were eligible if (1) aged over 65 years; (2) they had functional decline that could be reversed or slowed through program participation; (3) at risk of losing independence and graduating to higher care needs; (4) not currently receiving residential care or a home care package; (5) they had not received a Transition Care program in the previous 6 months or had been hospitalised for a condition contributing to functional decline in the past 3 months; (6) not receiving end of life care; and (7) they had not accessed more than two episodes of STRC in the past 12 months. 4

| Data collection
In addition to the specific MBI, a validated battery of assessment measures was collected by an AEP on two occasions: commencement (Week 0) and upon program discharge (Week 8).

| Outcome data
• Isometric hand grip strength, the Geriatric Depression Scale-Short Form (GDS), the Geriatric Anxiety Inventory (GAI), the EuroQol EQ-5D-5L and the Short Physical Performance Battery (SPPB). 11• BMI (weight (kg)/height 2 (m 2 )) was calculated to assess body composition.To calculate BMI, standing height in metres and body mass in kilograms were determined using a portable stadiometer and validated digital scales respectively.• The 10 subitem, subjective MBI assesses dependency in activities of daily living (ADL) with a higher score of 100 indicating higher functional independence.

| Reason for referral
Multiple common themes in participants' reasons for referral were identified.The frequency of reason for referral was calculated using Microsoft Excel (2018).participant was unable to complete the GAI, one the EQ-5D-5L and one the vitality questionnaire.

| Outcome data
As shown in Table 1, a significant improvement (p < 0.001) was observed for seven of the nine outcome measures.The largest improvement was from the vitality questionnaire measure of frailty (57.9%), followed by the mental health questionnaires (GDS 52.4%; GAI 45.8%) and SPPB summary score (44.9%).Significant improvements were also found in the EQ-5D-5L index value (24.0%),MBI (17.3%) and EQ-VAS (13.6%).No change was observed BMI and grip strength (p > 0.05).

| Number of services
Service data were analysed among the 62 participants who completed the program.The average number of services received was 37.42 (SD = 5.79), which corresponded to approximately five AH&T services per week.The most frequently delivered services were exercise-based (54.3% of total services), delivered by AEP's (M = 9.34, SD = 2.65) and H&WP's (M = 10.97,SD = 4.23), with participants receiving an average of two to three exercise-based services per week (see Figure 2).When compared to massage therapy (M = 5.06, SD = 2.26), the third most frequent service, AEP and H&WP services were delivered 84.6% and 116.8% more regularly respectively.This study demonstrates that exercise-based STRC models can have large positive implications for communitydwelling older adults at risk of functional decline.In this project, the assessed model was effective in improving lower extremity function, mental health, frailty stage, ADL independence and health-related quality of life, all markers of well-being linked to prolonged independence.
To our knowledge, this is the first peer-reviewed evaluation of an STRC program, although previous Australian studies have examined other restorative care programs. 8,9he results of our study present an operational opportunity for other STRC providers willing to embrace a more exercise-focused program that could offer a significant cost-benefit alternative to the looming threat to aged care, the increasing need for ongoing care.
Our results show improvements directly associated with the reason participants were referred to SCC's STRC, specifically musculoskeletal declines, whereby their balance, mobility and strength all significantly improved with participation in the 8-week program.Importantly, these improvements correlate directly to the reduced need for increasing and ongoing care among older adults. 1 The average SPPB summary score of the participants increased 2.59 points (44.9%), almost double that considered a large clinically significant change in physical function (1.5). 14he substantial improvements in physical function observed also appear greater than what has been previously reported among similar cohorts participating in resistance training 15,16 or home-based reablement programs. 8,9If this model of care was embraced by all STRC providers, nationally more participants would experience substantial physical benefits.
The significant improvements in physical function observed in the study appeared consistent with the large reduction in frailty (1.58 points on a 5-point scale, as measured by the vitality questionnaire).Directly linked to Fried's frailty phenotype, 13 the vitality questionnaires measure strength, mobility, exhaustion, weight loss and low physical activity.Using this tool, 40% of participants moved from Frail to Pre-Frail (n = 26) and 13.8% (n = 9) from Pre-Frail to Not Frail over the program.More impressively, 10.6% (n = 7) of participants moved from Frail (score 3-5) to Not Frail (score 0).These improvements are substantially greater than those reported in Daryanti Saragih et al. 17 meta-analysis of RCT investigating frailty reversal with 24-week resistance band-based exercise.
A variety of significant improvements in mental health and quality of life were also reported.Of particular interest was the significant increase in the EQ-5D-5L index values (0.597 [SD = 0.201] to 0.740 [SD = 0.151]), as well as the increase in self-reported health (EQ-VAS) (70.76 [SD = 19.68] to 80.38 [SD = 15.65]).Such improvements are consistent with other multidisciplinary reablement programs, 2,8 which further supports the utilisation of multidisciplinary approaches involving exercise and allied health therapies for older adults with physical and mental health challenges.
While the optimal service frequency to achieve maximum participant outcomes was not able to be determined in this study, our results clearly demonstrate exercise prioritisation in the holistic restorative pathway provides significant functional and health benefits, potentially greater than either exercise or standard multidisciplinary reablement programs (with minimal progressive resistance training) alone.STRC offers an ability to deliver more proactive health and well-being service plans to clients with functional enhancement needs.However, while the Royal Commission recommended (#36) AH&T should be an intrinsic part of aged care services, 5 these models are not common among providers.Steward Brown 18 reported allied health is so underutilised in the aged care sector that it is described as a specialised service and accounted for only 10 service minutes per client per fortnight when compared to the 4.5 h of personal care and domestic assistance during the same period.
Although barriers to allied health service delivery may reside in staffing, provider and staff knowledge of better health pathways, and access to supportive exercise environments and programs, for STRC, it is definitely not a result of a lack of funding.With a significant day rate per client, there is ample funding to even support agency and external allied health service provision.However, aged care has traditionally prioritised care (domestic assistance and personal care) and equipment (home modification and mobility support) to support independence.This study supports the established body of evidence for the provision of allied health and exercise therapy as a pathway to independence. 2,8If reform truly wishes the older Australian to remain independent in their home, older care providers must be encouraged to change their service priorities.
The results of this study suggest that the SCC STRC model of care (focusing on exercise therapy) has widespread benefits for older clients' physical and mental well-being.This model is transferable nationally and involves a holistic person-centred approach to care planning.Essential are the utilisation of a comprehensive assessment battery to broadly define the client's objective and subjective prescription needs, a multidisciplinary approach and a focus on exercise participation.In the current study, participants completed approximately four to five services per week with over half of these exercisebased.While this may appear extensive, for the client, the provision of weekly massage as a reward may have made this more acceptable.Moreover, the program is funded to be short-term and intensive, and based on the current, best-level evidence for how to improve strength and physical function in older adults. 19,20Importantly, the intensive nature of this program was found to have no direct adverse incidents.
This study does have a number of limitations.The flexible nature of the STRC program makes it difficult to fulfil Mjøsund et al.'s 7 recommendation of explicitly describing and contrasting specific intervention characteristics.However, this can be considered a strength as it represents translational research and the ability to individualise each clients' requirements.Another limitation to this study is the absence of post-discharge data to determine whether clients maintained their progress or remained engaged in ongoing services.Future research should consider the participant perspective, assess the program's impact on clients' post-discharge health and their efforts to sustain the achieved benefits, and extend investigations to can this STRC model modify hospital presentation.Additionally, the lack of an RCT design reduces the study's strength of evidence, even though previous paralleled intervention with similar samples have demonstrated maintenance or losses in function for the control group. 15,16

| CONCLUSIONS
SCC's STRC model has broad scoping physical and mental health benefits, which translates to enhanced independence among community-dwelling older Australians at risk of functional decline.The implementation of an exercise-based STRC framework across Australia, such as described here, could substantially offset the projected increase in demand for community and long-term aged care services.With community aged care reform underway, the promise of financial and staff sector stress, consideration of alternatives to usual care is imperative.This study offers a transferable, evidence-based model of care that could be embraced by all providers with STRC packages, which significantly alters the trajectory of disability among older Australians.To address this, future research should examine longer term outcomes for SCC's STRC clients and incorporate cost-effectiveness analyses to better determine the health budget implications from this evidence-based model of care.
-eight low-functioning participants were referred to SCC's STRC program between 19 July 2019 and 26 June 2021; 62 of these met the eligibility criteria, and entered and completed the program.A CONSORT diagram of participants' movement into and out of the program is given as Figure 1.Of the referred group, five participants declined to commence, and one was not eligible.Eighty-two participants undertook the initial assessment and were admitted into the program.Thirteen dropped out, eight gave no reason, and four accepted a Home Care Package and one moved into permanent care making them ineligible to continue.Three participants required program leave greater than 7 days, making them ineligible, two due to hospitalisation and one due to a short-term residential respite stay.Four participants were discharged early due to COVID-19 concerns (n = 2), medical complications (n = 1) and death (n = 1).At baseline, participants (n = 62) averaged 83.1 years of age (SD = 6.96), and more than two-thirds were female (69.7%).The ACAT referrer identified multiple contributors to declining function.The most common reasons were a loss of balance/fall risk (n = 43), decreased strength (n = 33), impaired mobility/gait (n = 32), reduced independence (n = 23) and musculoskeletal conditions/ pain (n = 23).Due to cognitive decline, at baseline one F I G U R E 1 Consort diagram of participant movements into and out of Southern Cross Care's (SCC) short-term restorative care (STRC) program.ACAT, Aged Services Assessment Team.

aZF I G U R E 2
scores and p-values were calculated using Wilcoxon signed-rank tests or related samples sign tests depending on the distribution of differences.Mean number of services participants received from each discipline.Error bars represent standard deviation.AEP, accredited exercise physiologist; H&WP, Health & Wellness Promoter; OT, occupational therapist; Physio, physiotherapist; SW, social work. 12 entered into Microsoft Excel (2018) and then imported into SPSS Inc., Chicago, IL, USA for analysis.Raw data were examined for multivariate normality, monotonicity and homoscedasticity.
2.5.2 | Number of servicesTo identify service regularity and priority, the number of AH&T services received weekly per discipline per participant was Changes in outcome measures from baseline to discharge.
T A B L E 1Abbreviations: BMI, body mass index; Diff, difference; EQ-VAS, EQ Visual Analogue Scale; GAI, Geriatric Anxiety Inventory; GDS, Geriatric Depression Scale; M, mean; MBI, Modified Barthel Index; SD, standard deviation; SPPB Sum, Senior Physical Performance Battery summary score.