The need for establishing quality of indicators for community care

The need to improve care for the aging population leads specialists to search for instruments that can measure quality indicators. The latter are measurable elements of practice performance for which there is evidence or consensrts that they can be used for assessing and changing the provided quality of care (Jones. 2005). Quality indicators can be related to process, outcome, and structure of care (Joling et al., 2018). There is a debate in the literature about the most usefill types of indicators to assess quality of care. It appears that process indicators are the most sensitive in examining changes in health conditions and functioning. They can be translated to protocols to track risk factors and recommend intervention and service provision (Kajonius & Kazemi. 2016).

The most common quality indicators for older population living at home are clinical and include falls and mobility disorders, pain, weight loss, dehydration.

medications, injuries, infections, and hearing and vision loss. Given the wide variety of clinical aspects covered in this domain, these quality indicators are classified into subcategories according to need for follow up and risk assessment. However, there are other indicators that are included, such as cognition (cognitive loss and dementia) and mental health (depression and mood changes), psychosocial (social activities, loneliness), functional performance (instrumental activities of daily living and service utilization (number and length of hospitalization and use of emergency services).

Although members of the Committee of Experts did not need to examine the preferred instrument for monitoring quality of care, they were impressed by interRAI’s second-generation home care quality indicators (HC-QIs). They are derived from two of mterRAI’s widely used conununity assessments: the Community Health Assessment and the Home Care Assessment (Morris et al., 2013). The instrument consists of four gr oups of indicators:

Functional Indicators - including monitoring improvement and decline of instrumental activities of daily living, activities of daily living, cognition and communication.

Clinical Indicators - which include monitoring improvement and decline in bladder continence, follow up of falls, weight loss injuries, improvement and decline of mood, and improvement and follow up of pain.

Social Indicators - follow up of caregiver’s distress, person being alone and distressed, and whether the person used to go out and socialize, but no longer does so.

Utilization - including follow up of flu vaccinations and hospitalization and emergency care.

Committee of Experts’ recommendations on target subpopulation

Aging IDF veterans with disabilities are entitled to receive rights and benefits from the MoD for their recognized and approved disability (the exceptions are those with 100% plus disablement who receive all services with no restriction). In addition, these veterans are also entitled to receive all benefits and services provided to senior citizens. The Committee of Experts debated whether to include all aging veterans with disabilities from the age of 60. However, this possibility has been ruled out because of the excessive cost of including 27,263 veterans in this recommendation, including those with milder disablements. An alternative approach was to include all 4,507 aging veterans from the age of 60 and with 50% disablement. The number is slightly lower (4,235) because all those with 100% plus disablement are deducted since they are already entitled to comprehensive sendees without any restrictions.

The proposed package of service

Based on assessment of the current situation, the Committee of Experts’ core recommendation has been to propose a proactive health promotion package that integrates monitoring and interventions to prevent declines in veterans’ functioning and wellbeing. The package is based on Wilber et al. ’s (2002) public health and disability conceptualization which was examined in the Massachusetts Survey of Secondary Conditions. According to Wilber et al., as well as Lollar (1999) and Krause and Bell (1999), early professional work focuses on preservation of functioning among persons with disabilities instead of health promotion to prevent the development of secondary' health conditions and functional decline. Therefore, a proactive integrative health promotion package needs to be developed. which includes ongoing monitoring of medical conditions and functioning. engagement in accessing health promotion or disease prevention activities, consistent and continuous primary care and social support, and reduction of risky behaviors.

An additional recommendation is to provide aging veterans with disabilities with a psychosocial and legal assistance package. The package provides case management services to maximize their rights and benefits in the community and to integrate MoD services with other services to which they are entitled as senior citizens. The legal assistance package is based on a recent amendment to the legal capacity and guardianship law approved by the Israeli Knesset on March 29,2016. It is intended to provide aging veterans with legal and notarized services from the MoD free of charge to assist them in making informed decisions about themselves, in granting powers of attorney, and in making wills regarding property and medical care.

As proposed, the target population includes all 4,507 aging veterans from the age of 60 with 50% disablement and above. It defines needs according to age group and according to degree of disablement and types of disability to allow more refined monitoring. In addition, the population will be divided according to geriatric risk (falling, weight loss and obesity, depression, loneliness, polypharmacy) and proposed protocols.

The core goals are as follows:

• 1 Promoting and conserving functioning and quality of life of aging IDF veterans
• 2 Prevention of functional health decline in the recognized and approved disability
• 3 Improving the abilities of Division of Rehabilitation in the MoD in establishing proactive and integrative protocols on behalf of aging IDF veterans with disabilities
• 4 Improving coordmation with national health providers and social welfare agencies on behalf of health and psychosocial issues of aging IDF veterans with disabilities

Secondary goals are:

• 1 Early detection of health and psychosocial risk factors
• 2 Prevention of health and functioning decline in the interface between disability and secondary conditions relating to other disabilities and aging

• 3 Supporting family caregiving resources
• 4 Prevention of re-hospitalization and strengthening community resources
• 5 Ensuring implementation of health and psychosocial protocols and improving compliance