The Feasibility, Effects and Costs of the 'Stay Active at Home Programme'

Many community-dwelling older adults have a highly sedentary lifestyle, especially those receiving homecare services. In the Netherlands 20% of older adults makes use of homecare. The prevalence in frail older adults is even twice as high (40%). However, once in care often a downward spiral sets in, as professionals tend to meet their clients' needs by task completion rather than by stimulating self-management and active engagement in tasks to contribute to active ageing. Thereby they deprive older adults of their opportunities to engage in a routine range of movements necessary for maintaining underlying capability resulting in further deconditioning and functional decline.

To prevent these negative consequences the behaviour of healthcare professionals has to change from 'doing things for older adults' to 'engaging older adults' in daily life in order to improve physical activity among older adults by reducing their sedentary time. This innovative care philosophy is also known as Function Focused Care (FFC), restorative care or reablement. These terms can be used interchangeably, but we will refer to it as FFC throughout this project proposal. In the US the research group of Resnick and colleagues conducted various studies in inpatient and residential care facilities. They have shown that FFC succeeds in increasing physical activity. Furthermore, FFC has shown to result in physical (e.g. daily functioning, muscle strength, balance) and psychological benefits (e.g. mood, behavioural symptoms) and reduces the risk for adverse outcomes (e.g. falls, delirium). Resnick et al. have little experience in homecare settings, but there is an emerging body of evidence, especially in Norway, New Zealand and Australia, that FFC has also potential for community-based care showing beneficial effects with regard to daily functioning, self-perceived activity performance and satisfaction, health-related quality of life, healthcare utilisation/costs, and even mortality. Experiences and results of FFC in Dutch community-dwelling older adults are lacking.

Promising programmes in one particular care setting are not automatically replicable in other settings due to cultural or organisational differences. Consequently, available programmes need to be adapted to the local circumstances before they can be successfully implemented in another setting. However, making changes requires careful planning and execution to prevent a loss of effectiveness by affecting the original programme's theory or removing core components of the programme. Therefore, the investigators have followed so far the first two phases of the framework of the Medical Research Council in preparing the use of FFC in Dutch community-dwelling older adults receiving homecare services:

• Phase I (2013- first half of 2016): The investigators systematically adapted in co-creation with international FFC experts and a Dutch panel of relevant stakeholders the initial FFC philosophy and conducted a pilot study. Throughout the adaptation process healthcare professionals, policy makers, managers and scientists were involved at various times to ensure that all interests are considered and respected. Although not the primary target population (i.e. homecare professionals), the project idea was also intensively discussed with a panel of older adults. The final result of this adaptation process was the 'Stay Active at Home' programme (in Dutch: 'Blijf Actief Thuis'). During the pilot, data about its feasibility was collected from healthcare professionals and older adults.
• Phase II (second half of 2016 - first half of 2017): The investigators conducted a second pilot study, a so-called 'early trial' prior to the currently proposed trial, as part of the ZonMw project BASIC CARE REVISITED (ZonMw #520002003). This early trial provided relevant information regarding: a) the implementation of specific intervention components; b) key components of the chosen methodology (e.g. outcome measures); c) rates of recruitment and retention; and d) the expected effect size. This information is highly relevant with regard to finalising the intervention and designing a subsequent main trial.

In conclusion, 'Stay Active at Home' is systematically developed for the Dutch homecare setting based on international evidence in close collaboration with Dutch stakeholders (i.e. older adults, healthcare professionals, policy makers and managers). The initial feasibility of the programme and the proposed study design are evaluated in two pilot studies prior to the grant period. In order to determine the (cost-) effectiveness of 'Stay Active at Home' prior to dissemination and implementation of the programme in the Dutch homecare setting this cluster randomised controlled trial has to be conducted. Alongside the trial an extensive process evaluation will be conducted.