Preventing nursing home admission in dependent older adults: a randomised controlled trial of a multimodal home-based intervention

Abstract Nursing home (NH) admission remains a critical outcome in ageing and long-term care policy. Yet, many older adults prefer to age in place, even when facing complex dependency needs. To evaluate the effectiveness of a multimodal home-based care intervention in delaying or preventing willingness for NH admission among care-dependent older adults, as a key step preceding institutionalisation, and to assess its impact on health and psychosocial outcomes. An 18-month, two-arm, assessor-blinded randomised controlled trial was conducted in community settings across Catalonia (Spain), with a 15-month intervention period per participant. Eligible participants were community-dwelling adults aged ≥ 65 years with grade II or III dependency according to the Spanish Dependency Law. All used public home care services, expressed unwillingness to enter institutional care, and had support from a primary informal caregiver. Participants were randomised to standard care or to an enhanced intervention consisting of intensified home care and structured caregiver training within a person-centred framework. The primary outcome was expressed willingness to accept NH admission. Secondary outcomes were functional capacity (Modified Barthel Index), frailty (Frail-VIG), sarcopenia risk (SARC-F), falls risk (Downton Index), cognitive status (Global Deterioration Scale), and health-related quality of life (EQ-5D-3L). Assessments were performed at baseline and 3-month intervals. Time to willingness for NH admission was analysed using Fine–Gray competing-risk models, with Cox regression conducted as a sensitivity analysis. Secondary outcomes were analysed using baseline-adjusted linear mixed-effects models. 142 participants were enrolled (median age 86 years; 64.8% women). The intervention significantly reduced willingness for NH admission ( p = 0.002; HR = 0.32). No consistent intervention effects were observed across secondary outcomes, although differences favouring the intervention group emerged for cognitive status and quality of life measures at specific follow-up visits rather than reflecting sustained effects over time. A multimodal intervention combining enhanced home care with caregiver training may support ageing in place by delaying willingness for NH admission among care-dependent older adults.