Effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity: a scoping review

A scoping review of intervention studies was conducted following international guidelines and recommendations [50, 51], as well as the PRISMA-ScR recommendations for reporting results of scoping reviews [52].

An exhaustive search on six databases (PubMed/Medline, Cochrane, CINAHL, Web of Science, Scopus and EMBASE) was carried out between October 2021 and April 2022. The complete search strategy used on PubMed was: (elderly OR older adults OR aged OR older) AND (multiple AND health AND conditions OR multimorbid OR multimorbidity OR non-communicable disease OR NCD OR chronic disease OR chronic condition) AND (intervention OR program OR programme OR visit* programme OR home visit* OR home visiting OR home based) AND (nurses, visiting OR home visits OR nurs* students OR human volunteers OR trained volunt*). For the rest of the databases, a similar strategy was used with the necessary adaptations (see Additional file 1). Following the PRISMA-ScR’s recommendations [52], we used the PICO approach to formulate our research question: [P] community-dwelling older adults with multimorbidity; [I] home visiting programmes; [C] usual care; [O] health-related outcomes. The question was: “What are the effects of home visiting programmes on health-related outcomes of community-dwelling older adults with chronic multimorbidity when compare to usual care?”

The following inclusion criteria were considered for study selection: (1) community-dwelling older adults (aged 60 years or older) with chronic multimorbidity; (2) interventional studies: quasi-experimental or randomised clinical trial (RCT); (3) publication in English or Spanish; (4) home visiting programmes based on individual visits. The exclusion criteria were: (1) participants were cognitively impaired; (2) the intervention was focused on a chronic condition; (3) the intervention was a single, isolated home visit. No time limit was set for the results.

In the identification phase, searching on the various databases yielded 1199 results. After checking and manually removing duplicate articles (n = 203), there were 996 records left. We then eliminated 940 studies after reading the title and abstract. In the eligibility phase, two reviewers from the research team independently assessed 56 full-text articles and conducted an additional search through their references. No new eligible articles were found, and 52 records were discarded for not meeting the eligibility criteria. Four articles were ultimately included. The flowchart shows this article selection process (see Additional file 2).

The recommendations in the Cochrane Handbook for assessing risk of bias in studies were followed [51]. Two reviewers assessed the quality of the included studies independently, and their assessments were then cross-checked by the senior researcher on the study. To assess the studies’ risk of bias, each criterion was rated as high, low or unclear (Fig. 1).

Two researchers independently extracted information from the four studies included in this review. Following international guidelines and recommendations [50, 51], a template with the following headings was created: first author's name, year of publication, study title, sample size, study location, study design, intervention characteristics, outcome measures and main findings. The data extraction method was tested with one of the included articles. Neither reviewer reported any differences or problems regarding data extraction. The method was repeated for the rest of the studies. A third experienced reviewer checked the extracted data for accuracy and integrity. A summary of the extracted data can be found in Table 1. A meta-analysis was not possible due to the heterogeneity of the interventions, assessment methods and findings reported in the studies. Therefore, a narrative synthesis of the findings was conducted based on the characteristics of the interventions, the variables studied, and the outcomes reported.

This scoping review included 4 studies with 532 community-dwelling older adults with chronic multimorbidity. All studies were randomised clinical trials (RCT) [53‐56], and involved the implementation of a home visiting programme. The interventions varied widely in terms of who conducted them (nurse case managers in collaboration with nursing students, volunteers instructed by nurses, interprofessional team, and nurses), their characteristics (follow-up calls, number of visits, duration and follow-up), sample size and reported outcomes (see Table 1). The studies were conducted from 2012 to 2018 in Hong Kong [53], Taiwan [54] and Canada [55, 56], and they were published between 2013 and 2021.

Interventions were delivered by case manager nurses (CMNs) assisted by nursing students (n = 1) [53], volunteers instructed by nurses (n = 1) [54], an interprofessional team (care coordinator (CC), nurse, physiotherapist, occupational therapist and a personal support worker) (n = 1) [55], and nurses who acted as care coordinators (n = 1) [56]. All of the people responsible for delivering the interventions in each of the studies had attended prior workshops or training programmes. The total number of older adults who participated in each study was 312 [53], 62 [54], 59 [55], and 127 [56]. The interventions lasted either 4 weeks (n = 1) [53], 2 months (n = 1) [54] or 6 months (n = 2) [55, 56]. The number of home visits carried out ranged from a minimum of 2 [56] to a maximum of 16 [55]. The duration of the visits was not reported in half of the studies [53, 55] and in the remaining two, it ranged from one to two hours [54, 56]. Three of the included studies supplemented the home visiting programme with telephone calls [53, 54, 56]. The fourth study relied only on home visits [55]. After completing the intervention, there was a follow-up in two of the four studies, ranging from 8 weeks [53] to 6 months [56].

The study by Chow & Wong (2014) had three arms and two intervention groups [53]. The first intervention group received home visits that alternated with telephone calls on a weekly basis for a total of four weeks (HVG). The second intervention group received solely telephone calls (PCG). Participants involved in both interventions received a pre-discharge assessment based on the Omaha System [57]. In the first intervention, the home visits were conducted by student nurses, who were supervised by a case manager nurse (CMN) only on the first visit. The students received prior information about each patient’s condition as well as six hours of training in communication, education and multimorbidity management. In the second intervention, the CMN made the first and fourth phone calls. The student nurses made the second and third calls, continuing with the interventions to meet the agreed objectives. Meanwhile, the control group (CG) received two social phone calls that lasted approximately five minutes and that were four weeks apart.

In the study by Wang et al. (2013), [54] a visiting programme was conducted to improve the medication safety of older adults in a rural area and compared to usual care. The intervention was carried out by volunteers who received 26 hours of pre-training by nurses and other members of the Primary Health Care (PHC) team, where they became proficient in the use of the Medication Safety Guide (MSG). The home visits varied in duration and content. During the first visit, the volunteer gave each participant a MSG, checked the prescribed medication and used stickers on each container to identify the shape, colour and number of pills, as well as the schedule. The second and third home visits were motivational in nature with the aim of encouraging medication adherence and safety. In addition, participants had to demonstrate what they had learned during the first visit.

In the study by Markle-Reid et al. (2021), [56] a hospital-to-home transitional care intervention comprising home visits, phone calls and accompaniment through the health system was conducted to assess its effectiveness compared to usual care. One of the inclusion criteria, in addition to age and multimorbidity, was that participants had to be positive for depressive symptoms according to the Patient Health Questionnaire (PHQ-2) [58]. The number of phone calls and home visits was not pre-set. Participants could receive monthly home visits by the nurse practitioners. Participants were called based on the number of home visits made. The home visits and phone calls included conducting a comprehensive assessment of participants’ needs, promoting multimorbidity management and medication adherence, and promoting increased social participation.

In the study conducted by Fisher et al. (2020), [55] no telephone calls were made alongside visits, and the intervention was carried out by an interprofessional team. All members conducted home visits individually. The schedule, team configuration, care plan, number of visits and who conducted the visits varied according to the budget and the participant’s needs and preferences. Each case was discussed in at least three conferences. In addition, the CCs carried out ongoing case management, which facilitated access and communication with health and social services. The CG received regular home care services.

Table 1 shows more details about the studies included in this review.

This scoping review has several limitations. The number of studies included is limited, which had an impact on the accuracy of our results. Furthermore, studies with different designs but with relevant data may have been excluded. We excluded studies that did not specify whether all their participants were older adults with chronic multimorbidity, even though they implemented home visiting programmes. On the other hand, one of the included studies evaluated a transition programme and there are already systematic reviews on the effects of this type of intervention. Nevertheless, the intervention was implemented entirely in the participants’ homes, and they all met our study’s inclusion criteria. In addition, we found differences in the way the statistical results were presented in the studies included, both within and between studies. Likewise, it is worth highlighting the studies’ heterogeneity in terms of the healthcare professionals who carried out the visits, the duration of the visits, their frequency, as well as their content. In most of the included studies, home visits are carried out alongside telephone calls; this shows the lack of studies only reporting the effects of a home visiting programme in community-dwelling older adults with chronic multimorbidity. In addition, participants in two of the included studies were recruited immediately after hospital discharge. In this respect, the acute health conditions leading to hospital admission may have influenced the results. Therefore, their comparison with the other studies should be interpreted with caution. It is also important to consider that the settings in which the studies were conducted were very diverse and with certain organisational particularities, so it is difficult to be sure whether the interventions and the results are transferable to other contexts. Similarly, the inclusion of studies that are 10 years old may detract from the relevance of the interventions evaluated in the current global context. The varying quality of the few included articles, as well as the presence of risk of bias in some of them, may limit the validity of this review’s findings.