JAMDA 15 (2014) 42e46
JAMDA journal homepage: www.jamda.com
Original Study
Development of EASY-Care, for Brief Standardized Assessment of the Health and Care Needs of Older People; With Latest Information About Cross-National Acceptability Keir E. Philip MBChB, BSc a, Vida Alizad BSc b, Alice Oates MBChB, BMedSci (Hons) c, David B. Donkin MBChB, BSc (Hons) d, Constantina Pitsillides MBChB, BMedSci (Hons) e, Stuart P. Syddall MBChB, BMedSci f, Ian Philp MD, FRCP g, * a
Royal Free Hospital, London, UK Iranian Research Center on Ageing, The University of Social Welfare and Rehabilitation Sciences, Tehran, Iran The Maudsley Hospital, London, UK d Northern General Hospital, Sheffield, UK e University of York, York, UK f Leeds Teaching Hospitals NHS Trust, Leeds, UK g Hull and East Yorkshire Hospitals NHS Trust, Hull, UK b c
a b s t r a c t Keywords: Assessment older people acceptability
Introduction: The EASY-Care system has been developed in the past 20 years in the United States and Europe as a brief standardized method for assessing the perceptions of older people about their health and care needs and priorities for a service response. More recently, it has been adapted and tested for use in poor, middle-income, and rich countries across the world. In this article we review its development and report the latest data for cross-cultural acceptability to older people and their clinicians in 6 countries across 4 continents. Method: We used a multicenter, mixed-method (quantitative and qualitative) approach to assess clinician (n ¼ 37) and patient (n ¼ 115) perspectives of acceptability of the EASY-Care Standard (2010) instrument. Data were collected between 2008 and 2012 in Iran, Colombia, India, Lesotho, Tonga, and the United Kingdom. Results: Key strengths identified included high levels of acceptability from both clinician and patient perspectives, with the tools seen as useful for identification of unmet need. Key recommendations included enhancing clarity in certain questions, ensuring it is not too long. Recommendations included minor context-specific adaptations, effective use of the screening questionnaire, and use of contextspecific interviewer prompts. Conclusions: The EASY-Care Standard has high levels of acceptability from both clinicians and patients across poor, middle-income, and rich countries and has the potential to become a global gold standard for holistic person-centered assessment. Copyright Ó 2014 - American Medical Directors Association, Inc.
The coordination of the EASY-Care International Programme has been supported by Pfizer Plc through the award of unconditional educational grants. Ian Philip is a director of the EASY-Care Foundation Ltd., which supports the work of the EASY-Care Programme and distributes profits to charity. The EASY-Care Foundation Ltd. owns the intellectual property for EASY-Care Instruments which are available free to researchers, practitioners, and volunteers involved in the care of older people. Any commercialization by third parties of use of EASY-Care Instruments is subject to a license agreement with the EASY-Care Foundation Ltd. * Address correspondence to Ian Philp, MD, FRCP, Chief Medical Officer, Hull and East Yorkshire Hospitals NHS Trust, Alderson House, Hull Royal Infirmary, Anlaby Road, Hull, HU3 2JZ, UK. E-mail address: [email protected] (I. Philp).
The world’s population is aging rapidly.1 In 1950 there were 250 million persons older than 60 in the world. It is estimated that in 2050 that number will have grown to almost 2 billion.1 This represents great successes in public health polices and economic development; however, it also creates new challenges for societies and health care provision.2 An effective and appropriate response to this demographic shift requires accurate assessment of older people and identification of health care needs and vulnerabilities. Early identification of need and preventing deterioration of current health status are the cornerstones of health policy and practice for aging populations. This approach led to the initial development of the Comprehensive Geriatric
1525-8610/$ - see front matter Copyright Ó 2014 - American Medical Directors Association, Inc. http://dx.doi.org/10.1016/j.jamda.2013.09.007
K.E. Philip et al. / JAMDA 15 (2014) 42e46
Assessment and with further evolution has led to systems, such as EASY-Care, that target individuals who are at risk of frailty and ill health, identifying opportunities to practice preventive, personcentered care. Such approaches look beyond the standard domains of clinical medical assessment, and incorporate nonmedical domains that affect health, such as quality of life and finances. Furthermore, this approach helps to centralize care, linking together the various health professionals and health-related sectors involved in a person’s care, and synergistically combines medical and social models of care.3 They provide an opportunity to facilitate, integrate, and coordinate care optimizing the use of often-limited resources.4 In this article, we describe the origins and development of the EASY-Care system, and latest data about its acceptability to older people and front-line clinicians in 6 countries across 4 continents. Origins and Development of the EASY-Care System The EASY-Care system was conceived during a research fellowship undertaken by one of the authors (IP) in the United States, under the supervision of Robert Kane, a leader in the field of geriatric assessment, with the intention of providing a brief, standardized assessment of health and care needs based on the concerns and priorities of the older person, which could be used by front-line health care practitioners in primary care settings. It would address a challenge posed by early pioneers in geriatric medicine, to identify and respond to the unmet needs of older people5 using the technology of geriatric assessment. As well as providing a holistic profile of health and care needs, the system was designed to promote a personalized response based on the priorities of the older person for support, information, or advice.3 It would also provide a summary score for overall level of independence, using a ratio scale calculated from the addition of scores from items in the assessment, weighted by the views of older people and health and care professionals about the relative contribution of each item for need for support.6 In its design, the EASY-Care assessment covers the following: B
B
B
Personal details consisting of 8 items that can be used to stratify populations for valid comparisons of health and care needs. A check list of 49 items across 7 domains of physical, mental, and social care functioning. Information to support an appropriate service response. This consists of a summary of needs identified in the assessment, stratified in relation to the older person’s priorities regarding response, the independence score, a checklist of medical conditions, and consent for information sharing.
The EASY-Care system was further developed and tested within European health care systems. It was shown to provide useful data about patterns of population needs.7e9 A significant body of work has been published about its validity and reliability10e12 and costeffectiveness13e15 in European settings. In 2008, following a symposium at an international gerontology conference, a decision was made to adapt and develop the system for its potential use in other regions in the world, including poor, middleincome, and rich countries, with revised content agreed at the symposium.16 The revised version of the system, EASY-Care Standard (2010) has been evaluated in 23 acceptability and 11 full psychometric studies undertaken in 23 countries.17 Individual country studies will be reported separately. In this article, we report findings about acceptability of the system across 6 countries, the first article to report cross-national findings in the use of the EASY-Care Standard (2010).
43
Aim The aim of the study was to assess the acceptability of the EASYCare Standard (2010), from the perspectives of health care workers and patients, in 6 different centers across the world, including poor, middle-income, and rich countries. Methods We used a multicenter, mixed method (quantitative and qualitative) questionnaire-based approach to assess health care worker and patient perspectives of EASY-Care Standard (2010). Quantitative components aimed to gain a general overview of opinion, with qualitative components aiming for a more in-depth understanding of participant opinions. Data were collected using the same core methodology across 6 sites situated in Iran, Colombia, India, the United Kingdom, Lesotho, and Tonga. An overview of each site is provided later in this article. Each site had a local project coordinator familiar with the EASY-Care Standard, and working in the study area. This coordinator facilitated the study and acted as a local advisor regarding appropriated context for the data collection. At each site, health workers were trained in the use of the EASYCare Standard. They then used it, as they would in practice, to assess the care needs of older people in their respective settings. Following the assessment, both health care workers and patients completed a short questionnaire containing both qualitative and quantitative components to assess their views on the system’s acceptability. Local translators were used as required. Patient participants were opportunistically sampled at each site, had a minimum age of 60, and lived in the community (ie, not in residential care facilities). Health care workers were identified as those most likely to use the assessment in practice at the selected site. Regarding the patient evaluation, the quantitative component consisted of Likert scales assessing the degree of acceptability regarding length (time taken to complete), clarity, ability to identify needs most important to the patient, and whether the patient would recommend the tool to other older people. Qualitative data were collected using free text boxes and open questions regarding the topics aforementioned, and more generally regarding any other comments. The health care worker evaluation used Likert scales assessing the perception of usefulness in identifying unmet health and care needs; meeting care needs for patients; and finding opportunities to prevent loss of health, independence, and well-being. As with the patient questionnaire, qualitative data were collected by using open questions and free text boxes for the aforementioned areas, and any general comments. Formal written consent was gained from all participants individually, as well as the head of each study center involved. Study Sites Manizales, Colombia Data were collected from 10 health care workers and 14 patients using the system in 3 separate primary care settings: 2 urban and 1 rural clinic. Tehran, Iran Data were collected from 5 separate sites in Teheran (central, north, south, east and west), with 10 patients participating in each
44
K.E. Philip et al. / JAMDA 15 (2014) 42e46
Table 1 Quantitative Data about Acceptability Patient Feedback Colombia (n ¼ 14)
Kerala (n ¼ 10)
Lesotho (n ¼ 11)
1. How would you rate the length of EASY-Care Standard? Much less than needed 0 1 0 A little less than needed 0 1 0 About the right amount 14 8 5 A little more than needed 0 0 6 A lot more than needed 0 0 0 No answer 0 0 0 2. How clear were the questions in EASY-Care Standard? Everything was clear 14 9 6 Most things were clear 0 1 5 Some things were clear 0 0 0 Many things were unclear 0 0 0 3. How helpful is EASY-Care Standard in identifying the health and care needs that are most important to you? Very helpful 14 6 8 Somewhat helpful 0 4 3 A little helpful 0 0 0 Not helpful 0 0 0 No answer 0 0 0 4. Would you recommend EASY-Care to others? I would definitely recommend it 13 3 9 I would probably recommend it 1 7 2 I would probably not recommend it 0 0 0 I would definitely not recommend it 0 0 0 No answer 0 0 0
UK (n ¼ 24)
Tonga (n ¼ 6)
Iran (n ¼ 50)
0 1 18 4 0 1
0 0 3 3 0 0
0 0 48 0 2 0
19 5 0 0
0 6 0 0
35 15 0 0
13 9 1 1
5 1 0 0 0
38 12 0 0 0
12 7 2 0 3
0 3 3 0 0
49 0 0 1 0
Clinical feedback Colombia (n ¼ 10)
Kerala (n ¼ 2)
Lesotho (n ¼ 11)
UK (n ¼ 0)
Tonga (n ¼ 6)
Iran (n ¼ 50)
1. In your opinion, how helpful was use of EASY-Care Standard in identifying unmet health and care needs in your patients? Very helpful 10 2 4 0 10 Somewhat 0 0 0 6 5 A little helpful 0 0 0 0 0 Not helpful 0 0 0 0 0 2. In your opinion how helpful was the approach in helping you to meet the health or care needs in your patients? Very helpful 5 1 0 0 6 Somewhat 5 1 2 6 8 A little helpful 0 0 2 0 0 Not helpful 0 0 0 0 1 3. In your opinion how helpful is the approach in helping you to find opportunities to prevent loss of health, independence, and well-being in your patients? Very helpful 5 2 0 0 8 Somewhat 5 0 4 5 6 A little helpful 0 0 0 1 0 Not helpful 0 0 0 0 1
site (total n ¼ 50). Data were collected in community and nursing home settings.
Association, and a local village in Maseru. Health care workers were those present at each site.
Cochin, Kerala, India
Results
Data were collected from 10 patients and 10 health care workers at a government-run hospital.
A summary of the quantitative data on acceptability to patients and clinicians is provided in Table 1. Further information was provided by the qualitative analysis of the comments of clinicians and patients about the system.
Vava’u, Tonga Data were from 6 patients and 6 health care workers in the Prince Wellington Hospital outpatient clinic. United Kingdom Data were collected from 32 patients. This study used a combination of questionnaires delivered by post (n ¼ 18) and by hand (n ¼ 14). Six of those delivered by post were returned not completed; hence, have not been included in the results section. This site was unable to provide formal clinician feedback. Maseru, Lesotho Data were collected from participating patients (n ¼ 11) from 3 sites: the Queen Elizabeth II Hospital, Maseru Woman Senior Citizens
Patient Responses Question1: How would you rate the length of EASY-Care Standard? B Examples of free-text responses B “Too many questions, too many parts.” (Lesotho) B “It was very thorough.” (Colombia) B “The questions are enough.” (India) Question 2: How clear were the questions in EASY-Care Standard? B Exampes of free-text responses B “ We don’t have a single word for safety, as in English.[so it is not clear]. what do you mean by safety?” (Iran)
K.E. Philip et al. / JAMDA 15 (2014) 42e46 B
“I understood everything.” (Tonga)
B
Question 3: How helpful is EASY-Care Standard in identifying the health and care needs which are most important to you? B Examples of free-text responses B “It is good to be asked what I think is important.” (Tonga) B “It’s good for identifying things I would not have known I could get help with.” (Colombia) Question 4: Would you recommend EASY-Care Standard for use with other older people that you know? B Examples of free-text responses B “It would be helpful for people.” (Colombia) B “I have friends it would help.” (Lesotho) B “I would recommend it (EASY-Care Standard). I am happy to be asked these questions and would like others to be happy.” (India) The following are further examples of free-text responses to the prompt: Write down any other comments you may have on EASYCare Standard: B
B B
B
B
“This would be good for identifying problems before they get bad. Rather than waiting for the situation to deteriorate.” (Colombia) “I don’t want to tell my life story.” (Lesotho) “It is very good to get people’s opinions on their own health. It would be good if people took more time to speak to us about our needs. So I think it (EASY-Care) is a very good idea.” (Colombia) “Male older people didn’t like questions related to cooking and doing housework because they believe that women should do cooking and house work.” (Iran) “I’m just happy to be asked so many questions and listened to.” (India)
Health Care Worker Responses Question 1: In your opinion how helpful was use of EASY-Care Standard in identifying unmet health and care needs in your patients? B Examples of free-text responses B “It’s too long. A shorter version would be better, as old people often have a short attention span. Patients would find it difficult to complete themselves. If a carer completes it might not be the patient’s opinion. Patients with deterioration of their intellect may not be aware of their needs.” (Colombia) B “EASY-Care would be a very useful tool by which to enquire about patients’ social concerns, as they were often not very forthcoming in discussing them.” (India) Question 2: In your opinion, how helpful was the approach in helping you to meet the health or care needs in your patients? B Examples of free-text responses B “Useful for issues that impact health but are not specifically clinical.” (Tonga) B “May add something as very thorough.” (Colombia) B “It provides a good opportunity to identify needs and concerns that would otherwise not be addressed.” (India) Question 3: In your opinion, how helpful is the approach in helping you to find opportunities to prevent loss of health, independence, and well-being in your patients? B Examples of free-text responses
B
B
45
“Prevention is very important, and this [assessment] should help.” (Colombia) “It [the EASY-Care system] may help identify risk.” (Lesotho) “The EASY-Care Standard allows doctors to build a better rapport with patients, as well as revealing previously unconsidered referrals, such as to psychiatry for depression, which became apparent during the questionnaire.” (India)
The following are further examples of free-text responses to the prompt: Write down any other comments about the approach: B
B
B
B
B
“We don’t have the infrastructure or relevant health professionals to meet all the needs it would identify.” (Lesotho) “EASY-Care Standard would be useful to identify the areas in developing countries that require addressing to provide better care.” (India) “Clinicians are very busy and may not have enough time to complete the whole thing.” (Lesotho) “You don’t have any questions about spiritual concept or religion.” (Iran) “You don’t have any questions about nutrition.” (Iran)
Discussion High levels of acceptability were demonstrated across all domains. Participants’ responses were highly positive regarding identifying and addressing needs, and preventing loss of health, well-being, and independence. Minor context-specific adaptations have been suggested to optimize the acceptability of the tools. These include questions regarding religion and faith-based support networks. Acceptability was highest with reference to the identification of needs in which resources were available to address them. Therefore, health care workers should be aware of what resources are available to address needs identified by the tools, and conduct the assessments accordingly. The issue of identifying issues that could not be addressed through a lack of resources had different interpretations. In Lesotho, this was stated as a criticism of the tools. However, in India this was seen as being positive, as it highlighted specific areas that need targeting. In certain contexts, the tools are perceived as taking too much time to complete. These responses largely came from individuals who, on screening, would have been shown to be less likely to benefit from the full assessment. Hence, with the appropriate use of the screening tool, this is unlikely to be an issue. Overall, clarity of the system was rated highly, although recommendations were made regarding improving specific questions. Further clarification within individual assessments for specific points or questions is most likely an issue best addressed through effective training of those delivering the assessments. Study Limitations This study has assessed only the acceptability of EASY-Care Standard 2010 in relatively small samples in a small number of countries. A number of full psychometric studies were undertaken with EASY-Care Standard in a larger range of countries between 2010 and 2013,17 and detailed results from each country will be reported soon. Although high levels of acceptability have been shown in the specific contexts assessed, optimal use of the EASY-Care Standard in novel contexts should consider further assessment of the tool’s acceptability.
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K.E. Philip et al. / JAMDA 15 (2014) 42e46
Conclusions High levels of acceptability were shown across all studies from patient and clinician perspectives. This study suggests that the EASYCare Standard assessment has potential for cross-cultural use as an international standard method of assessment. Although some contextually specific alterations should be made where appropriate, overall, the high levels of acceptability demonstrated indicate that, for the most part, the tool could be adopted in its entirety. For further information about the EASY-Care program, please visit www.easycareproject.com References 1. Department of Economic and Social Affairs Population Division, United Nations. World Population Ageing: 1950e2050. Available at: http://www.un.org/esa/ population/publications/worldageing19502050/. Accessed March 21, 2013. 2. World Health Organization. Ageing. Available at: http://www.who.int/topics/ ageing/en/. Accessed March 5, 2012. 3. Philp I. Can a medical and social assessment be combined? J R Soc Med 1997; 90:11e13. 4. The Merck Manual online. Comprehensive geriatric assessment. Available at http://www.merckmanuals.com/professional/geriatrics/approach_to_the_geria tric_patient/introduction_to_geriatrics.html. Last accessed October 13, 2013. 5. Williamson J, Stokoe IH, Gray S, et al. Old people at home. Their unreported needs. Lancet 1964;1:1117e1120. 6. Kane RL, Rockwood T, Philp I, Finch M. Differences in valuation of functional status components among consumers and professionals in Europe and the United States. J Clin Epidemiol 1998;51:657e666.
7. Wojszel ZB, Bien B, Politynska B. Ocena stanu funkcjonowania ludzi w podeslym wieku przez lekarza rodzinnego za pomoca kwestionariusza EASY-Care [Evaluation of the functioning of people in Podeslym Century by the family doctor with help of EASY-Care questionnaire]. Polski Merkuriusz Lekarski 1999;33:167e170. Polish. 8. Bath PA, Philp I, Boydell L, et al. Standardised health check data from community-dwelling elderly people: The potential for comparing populations and estimating need. Health Soc Care Community 2000;8:17e21. 9. Sousa L, Figueiredo D. Dependence and independence among old personsd realities and myths. Rev Clin Gerontol 2002;12:269e273. 10. Philp I, Lowles RV, Armstrong GK, Whitehead C. Repeatability of standardised tests of functional impairment and well-being in older people in a rehabilitation setting. Disabil Rehabil 2001;24:243e249. 11. Philp I, Newton P, McKee KJ, et al. Geriatric assessment in primary care: Formulating best practice. Br J Community Nurs 2001;6:290e295. 12. Lowles RV, Philp I. Simple measures for assessing the physical, mental and social functioning of older people. Generations Review 2001;11:12e14. 13. Melis RJ, van Eijken MI, Borm GF, et al. The design of the Dutch EASY-Care study: A randomised controlled trial on the effectiveness of a problem-based community intervention model for frail elderly people [NCT00105378]. BMC Health Serv Res 2005;5:65. 14. Melis RJF, van Eijken MIJ, Teerenstra S, et al. A randomised study of a multidisciplinary program to intervene on geriatric syndromes in frail older people who live at home (Dutch Easy-Care Study) [Clinicaltrials.gov Identifier NCT00105378]. J Gerontol A Biol Sci Med Sci 2008;63:283e290. 15. Melis RJF, van Eijken MIJ, Teerenstra S, et al. Cost effectiveness analysis of multidisciplinary program to intervene on geriatric syndromes in frail older people who live at home (Dutch EASY-Care Study). J Gerontol A Biol Sci Med Sci 2008;63:275e282. 16. Philp I. Targeted geriatric assessment in primary care e an international research collaboration. J Nutr Health Aging 2009;13(suppl 1):S27. 17. Olde-Rikkert MG, Long JF, Philp I. Development and evidence base of a new efficient assessment instrument for international use by nurses in community settings with older people. Int J Nurs Stud 2013;50:1180e1183.
JAMDA journal homepage: www.jamda.com
Original Study
Development of EASY-Care, for Brief Standardized Assessment of the Health and Care Needs of Older People; With Latest Information About Cross-National Acceptability Keir E. Philip MBChB, BSc a, Vida Alizad BSc b, Alice Oates MBChB, BMedSci (Hons) c, David B. Donkin MBChB, BSc (Hons) d, Constantina Pitsillides MBChB, BMedSci (Hons) e, Stuart P. Syddall MBChB, BMedSci f, Ian Philp MD, FRCP g, * a
Royal Free Hospital, London, UK Iranian Research Center on Ageing, The University of Social Welfare and Rehabilitation Sciences, Tehran, Iran The Maudsley Hospital, London, UK d Northern General Hospital, Sheffield, UK e University of York, York, UK f Leeds Teaching Hospitals NHS Trust, Leeds, UK g Hull and East Yorkshire Hospitals NHS Trust, Hull, UK b c
a b s t r a c t Keywords: Assessment older people acceptability
Introduction: The EASY-Care system has been developed in the past 20 years in the United States and Europe as a brief standardized method for assessing the perceptions of older people about their health and care needs and priorities for a service response. More recently, it has been adapted and tested for use in poor, middle-income, and rich countries across the world. In this article we review its development and report the latest data for cross-cultural acceptability to older people and their clinicians in 6 countries across 4 continents. Method: We used a multicenter, mixed-method (quantitative and qualitative) approach to assess clinician (n ¼ 37) and patient (n ¼ 115) perspectives of acceptability of the EASY-Care Standard (2010) instrument. Data were collected between 2008 and 2012 in Iran, Colombia, India, Lesotho, Tonga, and the United Kingdom. Results: Key strengths identified included high levels of acceptability from both clinician and patient perspectives, with the tools seen as useful for identification of unmet need. Key recommendations included enhancing clarity in certain questions, ensuring it is not too long. Recommendations included minor context-specific adaptations, effective use of the screening questionnaire, and use of contextspecific interviewer prompts. Conclusions: The EASY-Care Standard has high levels of acceptability from both clinicians and patients across poor, middle-income, and rich countries and has the potential to become a global gold standard for holistic person-centered assessment. Copyright Ó 2014 - American Medical Directors Association, Inc.
The coordination of the EASY-Care International Programme has been supported by Pfizer Plc through the award of unconditional educational grants. Ian Philip is a director of the EASY-Care Foundation Ltd., which supports the work of the EASY-Care Programme and distributes profits to charity. The EASY-Care Foundation Ltd. owns the intellectual property for EASY-Care Instruments which are available free to researchers, practitioners, and volunteers involved in the care of older people. Any commercialization by third parties of use of EASY-Care Instruments is subject to a license agreement with the EASY-Care Foundation Ltd. * Address correspondence to Ian Philp, MD, FRCP, Chief Medical Officer, Hull and East Yorkshire Hospitals NHS Trust, Alderson House, Hull Royal Infirmary, Anlaby Road, Hull, HU3 2JZ, UK. E-mail address: [email protected] (I. Philp).
The world’s population is aging rapidly.1 In 1950 there were 250 million persons older than 60 in the world. It is estimated that in 2050 that number will have grown to almost 2 billion.1 This represents great successes in public health polices and economic development; however, it also creates new challenges for societies and health care provision.2 An effective and appropriate response to this demographic shift requires accurate assessment of older people and identification of health care needs and vulnerabilities. Early identification of need and preventing deterioration of current health status are the cornerstones of health policy and practice for aging populations. This approach led to the initial development of the Comprehensive Geriatric
1525-8610/$ - see front matter Copyright Ó 2014 - American Medical Directors Association, Inc. http://dx.doi.org/10.1016/j.jamda.2013.09.007
K.E. Philip et al. / JAMDA 15 (2014) 42e46
Assessment and with further evolution has led to systems, such as EASY-Care, that target individuals who are at risk of frailty and ill health, identifying opportunities to practice preventive, personcentered care. Such approaches look beyond the standard domains of clinical medical assessment, and incorporate nonmedical domains that affect health, such as quality of life and finances. Furthermore, this approach helps to centralize care, linking together the various health professionals and health-related sectors involved in a person’s care, and synergistically combines medical and social models of care.3 They provide an opportunity to facilitate, integrate, and coordinate care optimizing the use of often-limited resources.4 In this article, we describe the origins and development of the EASY-Care system, and latest data about its acceptability to older people and front-line clinicians in 6 countries across 4 continents. Origins and Development of the EASY-Care System The EASY-Care system was conceived during a research fellowship undertaken by one of the authors (IP) in the United States, under the supervision of Robert Kane, a leader in the field of geriatric assessment, with the intention of providing a brief, standardized assessment of health and care needs based on the concerns and priorities of the older person, which could be used by front-line health care practitioners in primary care settings. It would address a challenge posed by early pioneers in geriatric medicine, to identify and respond to the unmet needs of older people5 using the technology of geriatric assessment. As well as providing a holistic profile of health and care needs, the system was designed to promote a personalized response based on the priorities of the older person for support, information, or advice.3 It would also provide a summary score for overall level of independence, using a ratio scale calculated from the addition of scores from items in the assessment, weighted by the views of older people and health and care professionals about the relative contribution of each item for need for support.6 In its design, the EASY-Care assessment covers the following: B
B
B
Personal details consisting of 8 items that can be used to stratify populations for valid comparisons of health and care needs. A check list of 49 items across 7 domains of physical, mental, and social care functioning. Information to support an appropriate service response. This consists of a summary of needs identified in the assessment, stratified in relation to the older person’s priorities regarding response, the independence score, a checklist of medical conditions, and consent for information sharing.
The EASY-Care system was further developed and tested within European health care systems. It was shown to provide useful data about patterns of population needs.7e9 A significant body of work has been published about its validity and reliability10e12 and costeffectiveness13e15 in European settings. In 2008, following a symposium at an international gerontology conference, a decision was made to adapt and develop the system for its potential use in other regions in the world, including poor, middleincome, and rich countries, with revised content agreed at the symposium.16 The revised version of the system, EASY-Care Standard (2010) has been evaluated in 23 acceptability and 11 full psychometric studies undertaken in 23 countries.17 Individual country studies will be reported separately. In this article, we report findings about acceptability of the system across 6 countries, the first article to report cross-national findings in the use of the EASY-Care Standard (2010).
43
Aim The aim of the study was to assess the acceptability of the EASYCare Standard (2010), from the perspectives of health care workers and patients, in 6 different centers across the world, including poor, middle-income, and rich countries. Methods We used a multicenter, mixed method (quantitative and qualitative) questionnaire-based approach to assess health care worker and patient perspectives of EASY-Care Standard (2010). Quantitative components aimed to gain a general overview of opinion, with qualitative components aiming for a more in-depth understanding of participant opinions. Data were collected using the same core methodology across 6 sites situated in Iran, Colombia, India, the United Kingdom, Lesotho, and Tonga. An overview of each site is provided later in this article. Each site had a local project coordinator familiar with the EASY-Care Standard, and working in the study area. This coordinator facilitated the study and acted as a local advisor regarding appropriated context for the data collection. At each site, health workers were trained in the use of the EASYCare Standard. They then used it, as they would in practice, to assess the care needs of older people in their respective settings. Following the assessment, both health care workers and patients completed a short questionnaire containing both qualitative and quantitative components to assess their views on the system’s acceptability. Local translators were used as required. Patient participants were opportunistically sampled at each site, had a minimum age of 60, and lived in the community (ie, not in residential care facilities). Health care workers were identified as those most likely to use the assessment in practice at the selected site. Regarding the patient evaluation, the quantitative component consisted of Likert scales assessing the degree of acceptability regarding length (time taken to complete), clarity, ability to identify needs most important to the patient, and whether the patient would recommend the tool to other older people. Qualitative data were collected using free text boxes and open questions regarding the topics aforementioned, and more generally regarding any other comments. The health care worker evaluation used Likert scales assessing the perception of usefulness in identifying unmet health and care needs; meeting care needs for patients; and finding opportunities to prevent loss of health, independence, and well-being. As with the patient questionnaire, qualitative data were collected by using open questions and free text boxes for the aforementioned areas, and any general comments. Formal written consent was gained from all participants individually, as well as the head of each study center involved. Study Sites Manizales, Colombia Data were collected from 10 health care workers and 14 patients using the system in 3 separate primary care settings: 2 urban and 1 rural clinic. Tehran, Iran Data were collected from 5 separate sites in Teheran (central, north, south, east and west), with 10 patients participating in each
44
K.E. Philip et al. / JAMDA 15 (2014) 42e46
Table 1 Quantitative Data about Acceptability Patient Feedback Colombia (n ¼ 14)
Kerala (n ¼ 10)
Lesotho (n ¼ 11)
1. How would you rate the length of EASY-Care Standard? Much less than needed 0 1 0 A little less than needed 0 1 0 About the right amount 14 8 5 A little more than needed 0 0 6 A lot more than needed 0 0 0 No answer 0 0 0 2. How clear were the questions in EASY-Care Standard? Everything was clear 14 9 6 Most things were clear 0 1 5 Some things were clear 0 0 0 Many things were unclear 0 0 0 3. How helpful is EASY-Care Standard in identifying the health and care needs that are most important to you? Very helpful 14 6 8 Somewhat helpful 0 4 3 A little helpful 0 0 0 Not helpful 0 0 0 No answer 0 0 0 4. Would you recommend EASY-Care to others? I would definitely recommend it 13 3 9 I would probably recommend it 1 7 2 I would probably not recommend it 0 0 0 I would definitely not recommend it 0 0 0 No answer 0 0 0
UK (n ¼ 24)
Tonga (n ¼ 6)
Iran (n ¼ 50)
0 1 18 4 0 1
0 0 3 3 0 0
0 0 48 0 2 0
19 5 0 0
0 6 0 0
35 15 0 0
13 9 1 1
5 1 0 0 0
38 12 0 0 0
12 7 2 0 3
0 3 3 0 0
49 0 0 1 0
Clinical feedback Colombia (n ¼ 10)
Kerala (n ¼ 2)
Lesotho (n ¼ 11)
UK (n ¼ 0)
Tonga (n ¼ 6)
Iran (n ¼ 50)
1. In your opinion, how helpful was use of EASY-Care Standard in identifying unmet health and care needs in your patients? Very helpful 10 2 4 0 10 Somewhat 0 0 0 6 5 A little helpful 0 0 0 0 0 Not helpful 0 0 0 0 0 2. In your opinion how helpful was the approach in helping you to meet the health or care needs in your patients? Very helpful 5 1 0 0 6 Somewhat 5 1 2 6 8 A little helpful 0 0 2 0 0 Not helpful 0 0 0 0 1 3. In your opinion how helpful is the approach in helping you to find opportunities to prevent loss of health, independence, and well-being in your patients? Very helpful 5 2 0 0 8 Somewhat 5 0 4 5 6 A little helpful 0 0 0 1 0 Not helpful 0 0 0 0 1
site (total n ¼ 50). Data were collected in community and nursing home settings.
Association, and a local village in Maseru. Health care workers were those present at each site.
Cochin, Kerala, India
Results
Data were collected from 10 patients and 10 health care workers at a government-run hospital.
A summary of the quantitative data on acceptability to patients and clinicians is provided in Table 1. Further information was provided by the qualitative analysis of the comments of clinicians and patients about the system.
Vava’u, Tonga Data were from 6 patients and 6 health care workers in the Prince Wellington Hospital outpatient clinic. United Kingdom Data were collected from 32 patients. This study used a combination of questionnaires delivered by post (n ¼ 18) and by hand (n ¼ 14). Six of those delivered by post were returned not completed; hence, have not been included in the results section. This site was unable to provide formal clinician feedback. Maseru, Lesotho Data were collected from participating patients (n ¼ 11) from 3 sites: the Queen Elizabeth II Hospital, Maseru Woman Senior Citizens
Patient Responses Question1: How would you rate the length of EASY-Care Standard? B Examples of free-text responses B “Too many questions, too many parts.” (Lesotho) B “It was very thorough.” (Colombia) B “The questions are enough.” (India) Question 2: How clear were the questions in EASY-Care Standard? B Exampes of free-text responses B “ We don’t have a single word for safety, as in English.[so it is not clear]. what do you mean by safety?” (Iran)
K.E. Philip et al. / JAMDA 15 (2014) 42e46 B
“I understood everything.” (Tonga)
B
Question 3: How helpful is EASY-Care Standard in identifying the health and care needs which are most important to you? B Examples of free-text responses B “It is good to be asked what I think is important.” (Tonga) B “It’s good for identifying things I would not have known I could get help with.” (Colombia) Question 4: Would you recommend EASY-Care Standard for use with other older people that you know? B Examples of free-text responses B “It would be helpful for people.” (Colombia) B “I have friends it would help.” (Lesotho) B “I would recommend it (EASY-Care Standard). I am happy to be asked these questions and would like others to be happy.” (India) The following are further examples of free-text responses to the prompt: Write down any other comments you may have on EASYCare Standard: B
B B
B
B
“This would be good for identifying problems before they get bad. Rather than waiting for the situation to deteriorate.” (Colombia) “I don’t want to tell my life story.” (Lesotho) “It is very good to get people’s opinions on their own health. It would be good if people took more time to speak to us about our needs. So I think it (EASY-Care) is a very good idea.” (Colombia) “Male older people didn’t like questions related to cooking and doing housework because they believe that women should do cooking and house work.” (Iran) “I’m just happy to be asked so many questions and listened to.” (India)
Health Care Worker Responses Question 1: In your opinion how helpful was use of EASY-Care Standard in identifying unmet health and care needs in your patients? B Examples of free-text responses B “It’s too long. A shorter version would be better, as old people often have a short attention span. Patients would find it difficult to complete themselves. If a carer completes it might not be the patient’s opinion. Patients with deterioration of their intellect may not be aware of their needs.” (Colombia) B “EASY-Care would be a very useful tool by which to enquire about patients’ social concerns, as they were often not very forthcoming in discussing them.” (India) Question 2: In your opinion, how helpful was the approach in helping you to meet the health or care needs in your patients? B Examples of free-text responses B “Useful for issues that impact health but are not specifically clinical.” (Tonga) B “May add something as very thorough.” (Colombia) B “It provides a good opportunity to identify needs and concerns that would otherwise not be addressed.” (India) Question 3: In your opinion, how helpful is the approach in helping you to find opportunities to prevent loss of health, independence, and well-being in your patients? B Examples of free-text responses
B
B
45
“Prevention is very important, and this [assessment] should help.” (Colombia) “It [the EASY-Care system] may help identify risk.” (Lesotho) “The EASY-Care Standard allows doctors to build a better rapport with patients, as well as revealing previously unconsidered referrals, such as to psychiatry for depression, which became apparent during the questionnaire.” (India)
The following are further examples of free-text responses to the prompt: Write down any other comments about the approach: B
B
B
B
B
“We don’t have the infrastructure or relevant health professionals to meet all the needs it would identify.” (Lesotho) “EASY-Care Standard would be useful to identify the areas in developing countries that require addressing to provide better care.” (India) “Clinicians are very busy and may not have enough time to complete the whole thing.” (Lesotho) “You don’t have any questions about spiritual concept or religion.” (Iran) “You don’t have any questions about nutrition.” (Iran)
Discussion High levels of acceptability were demonstrated across all domains. Participants’ responses were highly positive regarding identifying and addressing needs, and preventing loss of health, well-being, and independence. Minor context-specific adaptations have been suggested to optimize the acceptability of the tools. These include questions regarding religion and faith-based support networks. Acceptability was highest with reference to the identification of needs in which resources were available to address them. Therefore, health care workers should be aware of what resources are available to address needs identified by the tools, and conduct the assessments accordingly. The issue of identifying issues that could not be addressed through a lack of resources had different interpretations. In Lesotho, this was stated as a criticism of the tools. However, in India this was seen as being positive, as it highlighted specific areas that need targeting. In certain contexts, the tools are perceived as taking too much time to complete. These responses largely came from individuals who, on screening, would have been shown to be less likely to benefit from the full assessment. Hence, with the appropriate use of the screening tool, this is unlikely to be an issue. Overall, clarity of the system was rated highly, although recommendations were made regarding improving specific questions. Further clarification within individual assessments for specific points or questions is most likely an issue best addressed through effective training of those delivering the assessments. Study Limitations This study has assessed only the acceptability of EASY-Care Standard 2010 in relatively small samples in a small number of countries. A number of full psychometric studies were undertaken with EASY-Care Standard in a larger range of countries between 2010 and 2013,17 and detailed results from each country will be reported soon. Although high levels of acceptability have been shown in the specific contexts assessed, optimal use of the EASY-Care Standard in novel contexts should consider further assessment of the tool’s acceptability.
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Conclusions High levels of acceptability were shown across all studies from patient and clinician perspectives. This study suggests that the EASYCare Standard assessment has potential for cross-cultural use as an international standard method of assessment. Although some contextually specific alterations should be made where appropriate, overall, the high levels of acceptability demonstrated indicate that, for the most part, the tool could be adopted in its entirety. For further information about the EASY-Care program, please visit www.easycareproject.com References 1. Department of Economic and Social Affairs Population Division, United Nations. World Population Ageing: 1950e2050. Available at: http://www.un.org/esa/ population/publications/worldageing19502050/. Accessed March 21, 2013. 2. World Health Organization. Ageing. Available at: http://www.who.int/topics/ ageing/en/. Accessed March 5, 2012. 3. Philp I. Can a medical and social assessment be combined? J R Soc Med 1997; 90:11e13. 4. The Merck Manual online. Comprehensive geriatric assessment. Available at http://www.merckmanuals.com/professional/geriatrics/approach_to_the_geria tric_patient/introduction_to_geriatrics.html. Last accessed October 13, 2013. 5. Williamson J, Stokoe IH, Gray S, et al. Old people at home. Their unreported needs. Lancet 1964;1:1117e1120. 6. Kane RL, Rockwood T, Philp I, Finch M. Differences in valuation of functional status components among consumers and professionals in Europe and the United States. J Clin Epidemiol 1998;51:657e666.
7. Wojszel ZB, Bien B, Politynska B. Ocena stanu funkcjonowania ludzi w podeslym wieku przez lekarza rodzinnego za pomoca kwestionariusza EASY-Care [Evaluation of the functioning of people in Podeslym Century by the family doctor with help of EASY-Care questionnaire]. Polski Merkuriusz Lekarski 1999;33:167e170. Polish. 8. Bath PA, Philp I, Boydell L, et al. Standardised health check data from community-dwelling elderly people: The potential for comparing populations and estimating need. Health Soc Care Community 2000;8:17e21. 9. Sousa L, Figueiredo D. Dependence and independence among old personsd realities and myths. Rev Clin Gerontol 2002;12:269e273. 10. Philp I, Lowles RV, Armstrong GK, Whitehead C. Repeatability of standardised tests of functional impairment and well-being in older people in a rehabilitation setting. Disabil Rehabil 2001;24:243e249. 11. Philp I, Newton P, McKee KJ, et al. Geriatric assessment in primary care: Formulating best practice. Br J Community Nurs 2001;6:290e295. 12. Lowles RV, Philp I. Simple measures for assessing the physical, mental and social functioning of older people. Generations Review 2001;11:12e14. 13. Melis RJ, van Eijken MI, Borm GF, et al. The design of the Dutch EASY-Care study: A randomised controlled trial on the effectiveness of a problem-based community intervention model for frail elderly people [NCT00105378]. BMC Health Serv Res 2005;5:65. 14. Melis RJF, van Eijken MIJ, Teerenstra S, et al. A randomised study of a multidisciplinary program to intervene on geriatric syndromes in frail older people who live at home (Dutch Easy-Care Study) [Clinicaltrials.gov Identifier NCT00105378]. J Gerontol A Biol Sci Med Sci 2008;63:283e290. 15. Melis RJF, van Eijken MIJ, Teerenstra S, et al. Cost effectiveness analysis of multidisciplinary program to intervene on geriatric syndromes in frail older people who live at home (Dutch EASY-Care Study). J Gerontol A Biol Sci Med Sci 2008;63:275e282. 16. Philp I. Targeted geriatric assessment in primary care e an international research collaboration. J Nutr Health Aging 2009;13(suppl 1):S27. 17. Olde-Rikkert MG, Long JF, Philp I. Development and evidence base of a new efficient assessment instrument for international use by nurses in community settings with older people. Int J Nurs Stud 2013;50:1180e1183.
