Is integrated nursing home care cheaper than traditional care?A cost comparison

Aggie T.G. Paulus *, Arno J.A. van Raak 1, Hans J.A.M. Maarse 2

Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences,

Maastricht University, Department of Health Organization, Policy and Economics (HOPE),

P.O. Box 616, 6200 MD Maastricht, The Netherlands

Received 21 June 2007; received in revised form 23 April 2008; accepted 22 May 2008

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International Journal of Nursing Studies 45 (2008) 1764–1777

Abstract

Background: It is generally assumed that integrated care has a cost-saving potential in comparison with traditional care.

However, there is little evidence on this potential with respect to integrated nursing home care.

Aims and objectives: �To portray the costs of traditional and integrated nursing home care.�To explore the cost-saving potential

of integrated care.

Design/methods/settings/participants: Between 1999 and 2003, formal and informal caregivers of different nursing homes in

the Netherlands recorded activities performed for residents with somatic or psycho-social problems. In total, 23,380 lists were

analysed to determine the average costs of formal and informal care per activity, per type of resident and per nursing home care

type. For formal care activities, the total personnel costs per minute (in Euro) were calculated. For informal care costs, two

shadow prices were used.

Results: Compared to traditional care, integrated care had lower informal direct care costs per resident and per activity and

lower average costs per direct activity (for a set of activities performed by formal caregivers). The total average costs per resident

per day and the costs of formal direct care per resident, however, were higher as were the costs of delivering a set of indirect

activities to residents with somatic problems.

Conclusions: The general assumption that integrated care has a cost-saving potential (per resident or per individual activity)

was only partially supported by our research. Our study also raised issues which should be investigated in future research on

integrated nursing home care.

# 2008 Elsevier Ltd. All rights reserved.

Keywords: Costs; Formal care; Informal care; Integrated care; Nursing home care; Traditional care

* Corresponding author. Tel.: +31 43 3881706;

fax: +31 43 3670960.

E-mail addresses: a.paulus@beoz.unimaas.nl (A.T.G. Paulus),

a.vanraak@beoz.unimaas.nl (A.J.A. van Raak),

h.maarse@beoz.unimaas.nl (H.J.A.M. Maarse).1 Tel.: +31 43 3881699; fax: +31 43 3670960.2 Tel.: +31 43 3881571; fax: +31 43 3670960.

0020-7489/$ – see front matter # 2008 Elsevier Ltd. All rights reserved

doi:10.1016/j.ijnurstu.2008.05.005

What is already known about the topic?

� I

.

t is generally assumed that integrated care (delivered by

formal caregivers) has a cost-saving potential in compar-

ison with traditional care.

� O

nly a few studies have explored the costs of traditional

and integrated care. These studies do not include informal

care or nursing home care.

A.T.G. Paulus et al. / International Journal of Nursing Studies 45 (2008) 1764–1777 1765

What this paper adds

� T

his study indicates that the actual cost-saving potential

of integrated nursing home care (delivered by formal

caregivers) is limited.

� T

his study indicates that integrated nursing home care is

cheaper than traditional care with respect to informal care

delivery.

1. Background

In many countries, policy measures are being taken to

promote a (better) integration of health care services (Leich-

senring and Alaszewski, 2004). All measures have in com-

mon that they are aimed at stimulating functional,

organizational or financial integration in order to develop

more complete, coherent and comprehensive structures of

service delivery (Kodner and Spreeuwenberg, 2002; Leich-

senring, 2004; Mur-Veeman et al., 2008). From the perspec-

tive of patients with complex, long-term problems, ‘[t]he

result of such multi-pronged efforts to promote integration

for the benefits of these special patient groups is called

‘integrated care’.’ (Kodner and Spreeuwenberg, 2002).

There are numerous varieties of integrated care (Paulus

et al., 2002; Van Raak et al., 2003), ranging from inter-

organisational arrangements (such as a networks in which

care is provided by multiple organisations) to intra-organi-

sational arrangements in which caregivers within a single

organization focus on the development of inter-professional

relationships (Reed et al., 2005) and multi-disciplinary co-

operation (Paulus et al., 2003). Whatever the variety, the

main purpose of integrated care is to provide a level of

service that is more sensitive to the personal circumstances

and wishes of individual patients and has better results in

terms of efficiency and cost-effectiveness (WHO, 2001). The

characteristics of the patient population and the specific

challenges they face to obtain the most appropriate care

determine the level, type and combinations of the strategies

that can best be used to foster integrated care (Leutz, 1999).

Reed et al. (2005) distinguish between three integration

strategies: macro strategies (at the societal level); mezzo-

strategies (at the organizational level) and micro strategies

(at the individual service level).

In recent years, the attention for integrated care arrange-

ments in nursing homes has been growing (Reed et al., 2005,

2007; Paulus et al., 2006). Older nursing home residents with

somatic or psycho-social problems not only require long-

term care but also different types of services from a host of

formal and informal caregivers (Leichsenring, 2004). The

financial resources to deliver nursing home care, however,

are becoming more and more scarce (Spillman and Lubitz,

2002; Remsburg, 2004). Consequently, because of its

assumed cost-effectiveness, integrated nursing home care

is becoming an important policy goal in many countries.

In the Netherlands, nursing homes have translated this

goal into an integration strategy which is focused on intra-

organisational integrated care arrangements which focus on

changing the mode of service delivery. Following the ter-

minology common in this country, the strategy should result

in a replacement of ‘traditional’ nursing home care with

‘integrated’ nursing home care (Paulus et al., 2003).

Although both types of care are not completely each other’s

opposites, a typical feature of the latter type of care is that the

demand of residents dictates what is delivered (and when,

how often, how long and by whom). Generally, residents

simultaneously need services from a multitude of caregivers,

requiring integrated actions from caregivers. These services

have to be delivered in an environment in which specific

features of the home situation are copied in nursing home

care (Paulus et al., 2005, 2006) Traditional nursing home

care, on the other hand, is supply-oriented (i.e. caregivers

dictate what is delivered, when, how often, how long, et

cetera), mono-disciplinary and requires no integrated actions

from caregivers or adaptations of service delivery to a home-

like environment. In terms of the contextual framework

above, the strategy of nursing homes can be described as

one which assumes a patient-centered notion of integration

(Kodner and Spreeuwenberg, 2002) at the mezzo-level

(Reed et al., 2005) and is aimed at linking parts within a

single institution or level of care (i.e. the nursing home)

through the creation of (intra-organisational) integration

within service delivery (Leichsenring, 2004). When applied

successfully, the strategy should result in integrated nursing

home care which is not only patient-centred but also cost-

effective and more efficient compared to traditional care

(Kodner and Spreeuwenberg, 2002).

Within the literature on integrated care, the emphasis has

been on the development and implementation of integrated

care (Van Raak et al., 2003). However, there is little evidence

on the actual cost-saving potential of integrated care (Von-

deling, 2004). Furthermore, studies with respect to nursing

home care primarily reported the costs of traditional nursing

home care activities delivered by (some) formal caregivers

(e.g. Schlenker et al., 1985; Dorr et al., 2005; Hamrick et al.,

2007). To date, results on the cost-saving potential of

integrated nursing home care, however, have not been

reported (De Bekker-Grob, 2005).

Against this background, the main purpose of this paper

is to describe the costs of an extended set of traditional and

integrated nursing home care activities and to explore the

cost-saving potential of integrated care. Because of its

explorative nature, our study also tries to indicate relevant

directions for future research on this topic. For managers,

local care providers and insurers, such an explorative ana-

lysis can indicate whether the delivery of integrated care

might be cheaper or more expensive than the delivery of

traditional nursing home care and thus whether integrated

care (and its underlying integration strategy) might be an

effective instrument to achieve a more efficient allocation of

scarce resources in nursing home care. Moreover, by focus-

ing on activities, a detailed overview can be provided on

what is delivered, by whom and for whom. This information

A.T.G. Paulus et al. / International Journal of Nursing Studies 45 (2008) 1764–17771766

is important in order to efficiently allocate nursing time and

make decisions with respect to manpower planning and

resource utilization in nursing home care (Lemonidou

et al., 1996; Weech-Maldonado et al., 2004). Finally, by

linking the cost information from our study to results from

studies in which the impact of integrated care on the quality

of care is investigated, more general information on the cost-

effectiveness of integrated care can be obtained. Such infor-

mation is generally lacking.

2. Methods

2.1. Design

Our cost study was part of a larger study (see Paulus et al.,

2003) in which also the change process and the effects of the

introduction of integrated nursing home care on the quality

of care and the quality of work were investigated. As part of

the larger study, which used a quasi-experimental design

with three measurement periods, we assembled cost data on

traditional and integrated nursing home care delivery in

different nursing homes in the Netherlands. In this

country, there are separate and combined nursing homes

for residents with somatic problems and psycho-social

problems (www.brancherapporten.minvws.nl, accessed

October 18, 2007). Older people with somatic problems

mostly have physical limitations (e.g. due to chronic illness,

heart problems or visibility impairments). They are usually

admitted to a nursing home after receiving hospital care first.

Older people with psycho-social problems usually include

people who need mental care (often besides physical care)

and who suffer from dementia or Alzheimer’s disease.

Before being admitted to a nursing home, they received

home care first or already lived in a home for older people.

The nursing homes were selected on the basis of several

criteria including a stable working environment and motiva-

tion to contribute to the research. Two homes fulfilled all of

the criteria and were therefore purposefully selected for our

cost study. Each home had separate wards for residents with

somatic problems and for residents with psycho-social

problems. Approval to conduct the study was obtained from

the relevant ethics committees in the nursing homes.

Informed consent forms were used and all participants were

informed before, during and after the research.

One of the selected nursing homes (with 121 beds and 4

wards) delivered traditional nursing home care during the

entire research period. The other nursing home (with 88 beds

in total and 3 participating wards (with 28 beds)) introduced

integrated care in March 1998 and continued to deliver this

type of care during the research period. Prior to the intro-

duction of integrated care, this nursing home also offered

traditional care.

Although both types of care were not completely each

other’s opposites, according to the care managers of the

participating homes, there were five main differences

between traditional and integrated care. First, traditional

care delivery was more supply-oriented while integrated

care was more demand-oriented. In practice, the latter

was expressed in the attention that was given by caregivers

to certain individual wishes of residents. For instance,

instead of getting out of bed at the same time each day

(in traditional care), residents could indicate the time they

preferred to get out of bed in integrated care. Secondly,

residents receiving integrated care and their informal care-

givers were engaged in daily activities such as cooking,

cleaning, doing the laundry. In traditional care they were not

and cooking took place in a central kitchen. Thirdly, for

residents receiving integrated care, there were small scale

wards with a limited number of residents (generally, a

maximum of 12 per ward). In traditional care, there were

approximately 30 residents per ward. Most of these residents

also had to share bedrooms. Fourthly, in integrated care, the

delivery of services was more integrated compared to tradi-

tional care. In practice, this was visible in the fact that nurses

also conducted certain activities (e.g. meal activities or

household activities) which were traditionally conducted

by nutrition assistants or household assistants or vice versa.

More coordination with informal caregivers was also part of

integrated care. Finally, in integrated care, to mimic the

home situation, there were more social group activities for

residents.

As part of the larger study, it was tested whether tradi-

tional and integrated nursing home care also actually dif-

fered with respect to these five characteristics. This study

(Vijgen et al., 2003) showed that there were significant

differences between both homes as regards scale, demand-

orientation, engagement of residents in daily activities, and

an integrated delivery of care services (especially as regards

residents with psycho-social problems). Although, there

were various social group arrangements, financial limita-

tions in the integrated nursing home restricted a well-

functioning club structure. In related studies, we also

showed the actual differences between traditional and inte-

grated nursing home care as regards the role of informal

caregivers (Paulus et al., 2005); the performance of activ-

ities by certain caregivers (Paulus et al., 2006) and the

frequency and duration of these activities (Paulus and Van

Raak, 2008). The most important similarities and differ-

ences between both homes are listed in Table 1. The table

shows that there are many similarities such as the average

dependency score of residents, the types of informal care-

givers involved in care delivery, visiting hours and the

average level of personnel costs for many formal caregivers.

However, the type and absolute number of roles involved in

the delivery of formal care differed to some extent. The

related implications of the latter are explored in the dis-

cussion part of this paper.

During the research period, there were waiting lists for

different types of care for older people in the Netherlands. In

2003, for instance, approximately 7000 people were on the

waiting list for nursing home care. Although there were

A.T.G. Paulus et al. / International Journal of Nursing Studies 45 (2008) 1764–1777 1767

Table 1

Features of the two nursing homes

Features Nursing home offering traditional care Nursing home offering integrated

care

Annual financial turnover

(in 2001; million Euro)

7.4 8.0 (including care offered to

homes for older persons)

Number of wards/groups 4 (2 for residents with somatic problems;

2 for residents with psycho-social problems);

all wards participated in the cost study.

6 (2 for residents with somatic

problems; 4 for residents with

psycho-social problems); 3

wards participated in the

cost study.

Number of residents for whom activities

were recorded

90 per measurement (on average) 24 per measurement (on average)

Average dependency score residents

(with standard deviation)a

9.78 (0.24) 9.58 (0.55)

Number of participating formal caregivers 159 per measurement (on average) 69 per measurement (on average)

Composition/types of formal caregivers

involved in care deliveryb (and their

average gross personnel costs per minute;

average of three time points; in Euro)

Licensed practical nurse (0.216), geriatric

nurse (0.178), registered nurse (0.253), ward

assistant (0.167), evening/night/weekend

manager (0.253), recreational activities

supervisor (0.213), nutrition assistant (0.190),

living room assistant (0.14), student nurse

(0.14), trainee (0.00), volunteer (0.00),

nursing assistant (0.082), nursing care

coordinator (0.238), aid (0.144), kitchen

assistant (0.164).

Licensed practical nurse

(0.210), geriatric nurse (0.191),

registered nurse (0.259),

evening/night/weekend manager

(0.253), recreational activities

supervisor (0.191),

nutrition assistant (0.188),

household assistant (0.181),

student nurse (0.124), trainee

(0.00), volunteer (0.00),

nursing assistant (0.181).

Number of forms filled in by formal caregivers 16238 (in total) 6027 (in total)

Average duration of direct care activities by

formal caregivers for somatic residents

(in minutes, with standard deviation)c

T1: 11.73 (14.02) T1: 14.49 (13.29)

T2: 14.67 (16.82) T2: 10.08 (7.25)

T3: 10.05 (4.92) T3: 9.47 (6.71)

Average duration of direct care activities by

formal caregivers for residents with

psycho-social problems (in minutes,

with standard deviation)c

T1: 14.84 (22.13) T1: 10.14 (5.40)

T2: 17.47 (19.80) T2: 10.78 (10.06)

T3: 14.98 (15.42) T3: 10.05 (5.13)

Types of informal caregivers involved in

care delivery

Mainly partners and sons/daughters, but

also brothers/sisters, other family members,

friends, neighbours.

Mainly partners and sons/

daughters, but also brothers/

sisters, other family members,

friends, neighbours.

Visiting hours Unlimited Unlimited

Number of forms filled in by informal

caregivers

794 (in total) 321 (in total)

T1, T2, T3 = First, second and third measurement point, respectively.a This feature was tested as part of the larger study (Vijgen et al., 2003).b See Paulus et al. (2006) for an elaborate description of all roles.c Based on Paulus and Van Raak (2008).

regional differences, the average waiting time was 9 months

(www.minvws.nl/dossiers/verpleeg–en-verzorgingshuizen/,

accessed October 18, 2007; www.scp.nl, accessed October

18, 2007). Due to this situation, most (potential) residents

could not really choose between nursing homes (with a

specific type of care).

2.2. Cost method and cost perspective

To determine the costs, we used the method of activity-

based costing (ABC). Since integrated care has processual

characteristics (because of continuous changes in care deliv-

ery) and incorporates many coordinating and co-operative

A.T.G. Paulus et al. / International Journal of Nursing Studies 45 (2008) 1764–17771768

activities (which can produce uncertain outcomes) and is

aimed at tailor-made care for each individual (so standar-

dized outcomes are absent), determination of the costs of

integrated care required a method which could be used

irrespective of the presence of stable, certain and standar-

dized outcomes. Of all existing cost methods, ABC was the

only method which could meet these requirements. ABC

was therefore selected to provide the best cost information to

decision-makers (Paulus et al., 2002).

ABC assumes that a product or service carries costs in

terms of the activities that it incorporates (Kaplan and

Cooper, 1998; Paulus et al., 2002). Cost-determination

therefore entails identification of the relevant activities

and resources needed to perform these activities. After

the final product or service is defined, this information is

used to identify the costs of the product or service (Kaplan

and Atkinson, 1998). Studies show that besides formal

caregivers, also informal caregivers are important resources

which contribute to activities delivered to older persons in

institutionalised settings (Whitlatch and Noelker, 1996;

Lyons and Zarit, 1999; Gaugler et al., 2004; Paulus et al.,

2005; SCP, 2005). Furthermore, since integrated care

focuses more than traditional care on the co-ordination with

informal caregivers and on a more active role of these

caregivers in daily activities, the amount of informal care

is also expected to differ between both care types (Paulus

et al., 2005). Therefore, both formal care and informal care

are part of our cost analysis. By including both types of care

as important cost features, we look at the costs from a

societal perspective (Gold et al., 1996).

2.3. Data-collection

Following the design of the larger study, we collected

data at three measurement periods between September 1999

and February 2003. At each time point, we determined the

costs of traditional and integrated care. By repeating the

same measure we could obtain more data, prevent the well-

known shortcomings of cross-sectional research and

increase the reliability of our study. Moreover, by repeating

the same measure, possible changes in the costs of integrated

care over time could be taken into account. The latter is

considered necessary because the effects of integrated care

on the costs of service delivery over time are largely

unknown (Vondeling, 2004).

Given the final service (care delivery) and the resources

(formal and informal caregivers), the bulk of the data-collec-

tion consisted of assembling information on the activities

conducted by caregivers. We used the method of self-reporting

on the basis of an a priori defined list of activities. Burke et al.

(2000, p. 124) show that for data-collection on nursing

activities in institutional settings this is an accurate method

of data-collection. They state: ‘self-reporting allows . . . to

define a list of activities precisely and to review the activity

definitions carefully with participants. By focusing on a select

list of activities, perceptual differences among participants

and the burden of continuous self-reporting are minimized’. In

this study, we also used a select list of activities. Selections

were made on the basis of a literature study (Minyard et al.,

1986; Schuster and Cloonan, 1989; Hendrikson et al., 1990;

Cardona et al., 1997), interviews with caregivers in nursing

homes throughout the country and observations in nursing

homes that offered traditional or integrated care. To test the

clearness, validity and usefulness of the list, in two of these

homes a pilot study was executed in March 2000. In each

nursing home, a random sample of formal caregivers tested the

lists during 2 days (2 � 24 h). On the basis of the comments

and suggestions of those participating in the pilot (‘expert

opinions’), two final lists were made. One list described direct

care activities (i.e. activities related to individual residents).

The other list described indirect activities (i.e. activities for a

group of residents or for the entire ward). Together, both forms

listed 24 selected activities customary for nursing home care

in the Netherlands. Table 2 gives an overview of these

activities.

At each of the three measurement points, each lasting 14

consecutive days, caregivers recorded information on the

activities they conducted for (a group of) residents. To

minimize self-reporting bias and further increase the validity

and reliability of the study, those who designed the list were

present at all measurements to stimulate a proper recording

or solve any questions with respect to the list of activities.

Formal caregivers represented 15 roles, which ranged

from different types of nurses to nutrition assistants. In

traditional care, on average 159 formal caregivers per mea-

surement point recorded their activities. In integrated care,

this average was 69. Informal caregivers included partners,

brothers and sisters, sons and daughters, neighbours, friends,

and others. In traditional care, on average 242 forms were

filled in by informal caregivers per measurement point. In

integrated care this average was 115. Residents were patients

with physical or psycho-social needs who had an average

dependency score of 9 (on a scale from 1 to 12). This score

represents the care load on the nursing wards and was

measured by the SIVIS-Help Index (SIG, 1994), which is

an instrument used in nursing homes in the Netherlands.

Measured on a 12-point scale, the index measures the

resident’s functioning in daily living. The higher the score,

the higher the care load. For residents receiving traditional

care, activities were registered at the three measurement

points for 84, 89 and 98 residents, respectively. In integrated

care, these numbers were 25, 23 and 26, respectively.

Immediately or shortly after they performed an activity;

formal caregivers marked that activity on the relevant list.

They also indicated the duration of that activity (how many

minutes did the activity take?) and (and how often and) for

whom the activity had been performed. In total, 22,265 forms

from formal caregivers were subjected to data analysis.

For informal caregivers, a simplified form was developed

that listed the same 24 activities. Also informal caregivers

recorded the type, frequency and duration of activities

immediately or shortly after they performed the activity.

A.T.G. Paulus et al. / International Journal of Nursing Studies 45 (2008) 1764–1777 1769

Table 2

Recorded activities (partly based on Paulus et al., 2003, 2006)

Activities Description

Direct care activities

Morning care Getting residents out of bed, bathing, dressing, shaving, combing hair

Coffee/tea making Making and pouring out coffee and tea, doing the dishes, cleaning up

Medication Recording, distributing and helping with medication

Toileting Helping residents who need to go to the bathroom, changing

incontinence slips, emptying catheters

Afternoon care Bringing residents to bed (and sometimes getting out of bed),

dressing/undressing residents, combing hair

Extra care Giving extra attention to residents through conversations, walking

or shopping, extra pedicure or hair treatment

Evening care Bringing residents to bed, bathing, cleaning teeth and dentures

Meal activities Preparing meals, setting the table, helping residents with eating, doing the dishes

Medical care Taking care of wounds, catheterise, medical treatments, etc.

General activities Preparing and doing activities such as pottering, singing, playing

games with residents and cleaning up afterwards

Club activities Preparing and doing social activities in groups (e.g. a choir or bridge-club)

Transfer and transport Bringing residents to or back from a particular social activities

meeting ward or room for general activities or appointments

Reacting to incidents Taking care of residents in case of extra-ordinary events (e.g. a sudden

change in health, aggressive behaviour towards other residents or staff)

Additional direct activities Activities other than those mentioned above such as: buying extra food

or clothing or doing the laundry for a particular resident

Having chats with residents Socializing with residents (e.g. ordinary day to day talks during a cup

of tea) or talks by informal carers with their family member

Indirect care activities

Consultation Having consultations on and evaluating the course of matters with residents, a

group of residents, caregivers during planned or unplanned meetings

Administration Keeping and readjusting patient’s files; administration

Schooling Participating in courses, training and schooling sessions and attending

meetings relevant for keeping a specific function up to date

Handling supplies Ordering, handling and storing different (consumer) goods (such as

towels, incontinence slips, toilet paper, cleaning products)

Handling food Shopping to buy food, storing food supplies, etc.

Handling medication Ordering and preparing medicines

Cleaning Cleaning/dusting rooms, bathrooms, hallways, beds

Additional indirect activities Activities other than those mentioned above such as: making rounds on wards, etc.

Out of pocket activities Activities by informal carers such as doing the laundry, ironing or

buying make-up for their family member

They filled in a form each time they visited the nursing home

during the measurement period. Each period lasted 14 days. In

the Netherlands, such a time period covers most visits. A

recent study on nursing home care, for instance, shows that

approximately 29% of the residents in nursing homes in this

country get daily visits from informal carers. 48% on average

is visited at least once a week and 12% more than once per

week (SCP, 2005). Both homes had unlimited visiting hours.

Those who designed the list were present in the nursing homes

to stimulate a proper recording. In total, 1115 forms from

informal caregivers were subjected to data analysis.

To determine the costs of activities performed by formal

caregivers, we assembled additional data on the personnel

costs. In the Netherlands, total personnel costs include the

gross wage (including certain bonuses) and additional per-

sonnel costs. The latter costs include, among others, social

insurance premiums, pension contributions and holiday pay.

Guidelines on economic evaluation in the Netherlands indi-

cate that the gross wage plus a surcharge of 35% is a valid

estimation of the total personnel costs (Oostenbrink et al.,

2000). The percentage represents the additional personnel

costs. Using the data on gross wages that we obtained from

the nursing homes and applying the recommended guide-

lines, this allowed a specification of the gross personnel costs

per activity per minute per role (in Euro (s)). Since each

individual resident received a certain number of activities

per day, this also allowed determination of the total and

average costs per resident per day.

Following the findings of a pilot study on the valuation of

informal nursing home care (Vijgen, 2000), we decided to

A.T.G. Paulus et al. / International Journal of Nursing Studies 45 (2008) 1764–17771770

use two shadow prices to determine the costs of activities

performed by informal caregivers. The first shadow price

reflects the ‘legal worker tariff’ (lwt). This tariff represents

the lowest fee for a specific activity in case it would have

been performed by a professional (formal) caregiver. In the

Netherlands, this fee was equal to s7.941 gross per hour at

the first measurement point (Oostenbrink et al., 2000). The

second shadow price is the ‘average gross personnel costs’

(agpc). It reflects the average total personnel costs per

minute per role taking into account the relative number of

formal caregivers per role per measurement and per nursing

home. Relevant data on the number of caregivers were

provided by the nursing homes and were used to specify

the costs of informal care per activity, per minute and per

resident (in s).

2.4. Data analysis

SPSS 10.0 was used to file and analyse all data. First, we

calculated the (total) average costs of formal and informal

care per resident per day (see Table 3). This average was

determined by adding up the costs at the three separate time

points. Then, this outcome was divided by three in order to

determine the mean value of the costs during the entire

period. Since an average resident received a number of

activities per day, the average costs per direct and indirect

activity (per measurement point, type of caregiver and type

of nursing home care) had to be calculated (see Tables 4 and

5). Since residents had somatic (i.e. physical) or psycho-

social problems, we distinguished between the costs per

activity for these two types of residents. The total average

costs per resident were determined by adding up the average

costs of formal direct care, formal indirect care and informal

direct care. Then the average was calculated as the mean

value of these costs during the research period. Finally, the

costs of traditional and integrated care were compared to

each other. On the basis of descriptive statistics, comparisons

were made per type of resident, per type of caregiver, per

Table 3

Costs per resident per day (in Euro (s))a

Traditional care

Residents with

somatic problems

R

ps

pr

Average costs

Formal direct care 22.30 (2.75) 19

Formal indirect care 16.18 (2.30) 12

Informal direct care (lwt) 20.51 (5.79) 19

Informal direct care (agpc) 34.26 (9.27) 32

Total average costs

Formal + informal care (lwt) 56.96 (6.28) 50

Formal + informal care (agpc) 70.15 (9.26) 63

Lwt = legal worker tariff; agpc = average gross personnel costs.a Calculated as the average of the costs at three measurement points.

activity and per set of activities (direct and indirect care). By

exploring the cost-saving potential of integrated care in this

way, our study intends to produce insights that must be tested

during future research.

3. Results

3.1. Costs per resident per day

Table 3 shows that the delivery of formal direct care to

residents receiving integrated care was more expensive

compared to traditional care. Differences ranged between

s8.00 (residents with somatic problems) and s10.00 (resi-

dents with psycho-social problems) per resident per day. For

residents with psycho-social problems, also the costs of

formal indirect care were higher in integrated care. For

residents with somatic problems, the costs of formal indirect

care were approximately s16.00 per resident in both care

types. For both types of residents, the average costs of

informal direct care were lower in integrated care.

Table 3 also shows that (based on lwt-calculations) the

total average costs per resident per day were higher in

integrated care compared to traditional care. For residents

with psycho-social problems, these costs were s50.66 for

traditional care and s64.99 for integrated care. For residents

with somatic problems, these costs were s56.96 and

s59.28, respectively. Based on agpc-calculations, however,

the total average costs of integrated care for residents with

somatic problems were slightly below those of traditional

care (s68.53 and s70.15, respectively).

In traditional care, the average costs of formal direct and

indirect care for residents with somatic problems were

higher compared to residents with psycho-social problems.

The difference in costs was about s3.50 per resident per day.

For both types of residents, the average costs of informal

direct care (determined on the basis of agpc) outweighed the

costs of formal direct care.

Integrated care

esidents with

ycho-social

oblems

Residents with

somatic problems

Residents with

psycho-social

problems

.90 (1.50) 30.97 (0.32) 29.59 (4.00)

.96 (2.10) 16.62 (2.01) 30.28 (5.19)

.45 (2.92) 13.85 (3.53) 8.23 (1.26)

.61 (5.62) 23.49 (6.11) 13.89 (1.67)

.66 (4.30) 59.28 (2.44) 64.99 (7.30)

.46 (7.38) 68.53 (4.96) 71.07 (8.54)

Standard deviation in brackets.

A.T.G. Paulus et al. / International Journal of Nursing Studies 45 (2008) 1764–1777 1771

Table 4

Average costs per activity (formal care) (in Euro (s))a

Traditional care Integrated care

Som PG Som PG

Direct care

Morning care 5.07 (0.75) 4.48 (0.12) 5.67 (0.09) 5.17 (0.51)

Coffee/tea making 5.64 (0.52) 7.32 (0.82) 4.23 (0.80) 3.38 (1.09)

Medication 1.33 (0.25) 1.02 (0.16) 0.85 (0.09) 0.81 (0.17)

Toileting 1.67 (0.22) 1.38 (0.70) 1.39 (0.06) 1.52 (0.87)

Afternoon care 3.09 (0.50) 3.17 (0.22) 2.46 (0.19) 2.72 (0.50)

Extra care 1.97 (0.19) 1.44 (0.38) 1.79 (0.26) 2.0 (0.49)

Evening care 3.59 (0.52) 3.28 (0.38) 3.68 (0.14) 3.45 (0.32)

Meal activities 1.52 (0.33) 1.90 (0.10) 1.77 (0.21) 1.8 (0.21)

Medical care 1.95 (0.54) 1.47 (0.20) 1.54 (0.21) 1.41 (0.38)

General activities 15.51 (6.87) 22.03 (3.60) 4.95 (2.38) 3.91 (0.55)

Club activities 1.56 (1.60) 6.95 (8.22) 5.32 (3.50) 6.34 (4.57)

Transfer and transport 1.38 (0.25) 0.90 (0.04) 0.96 (0.07) 1.29 (0.33)

Reacting to incidents 2.66 (0.16) 3.46 (0.75) 1.67 (0.09) 1.83 (0.30)

Additional direct activities 2.18 (0.71) 1.63 (0.80) 2.24 (1.04) 1.97 (0.52)

Average costs of set of direct care activitiesb 3.51 (0.70) 4.31 (0.67) 2.75 (2.36) 2.68 (0.24)

Indirect care

Consultation 0.84 (0.12) 0.81 (0.12) 1.25 (0.19) 0.82 (0.06)

Administration 1.70 (0.21) 1.04 (0.26) 0.91 (0.13) 0.88 (0.15)

Schooling 8.91 (5.65) 13.59 (8.03) 26.02 (17.80) 25.96 (25.64)

Handling supplies 3.10 (0.40) 2.14 (1.64) 2.36 (0.20) 3.02 (0.79)

Handling food 3.50 (0.25) 2.08 (3.60) 0.13 (0.22) –

Handling medication 5.63 (0.38) 8.23 (4.50) 5.89 (2.71) 5.07 (1.60)

Cleaning 6.97 (1.53) 6.63 (1.04) 5.67 (1.00) 7.25 (0.93)

Additional indirect activities 10.16 (1.47) 13.70 (0.97) 6.41 (2.36) 11.57 (6.30)

Average costs of set of indirect activitiesc 5.09 (0.33) 6.03 (1.34) 6.07 (1.87) 6.82 (2.60)

Som = residents with somatic problems; PG = residents with psycho-social problems.a Calculated as the average of the costs at three measurement points. Standard deviation in brackets.b Calculated as the average of the costs of 14 direct activities (since ‘chats with residents’ was not performed by formal caregivers, this activity

was not included in the calculation).c Calculated as the average of the costs of 8 indirect activities (since ‘out of pocket activities’ were not performed by formal caregivers, this

activity was not included in the calculation).

With respect to integrated care, Table 3 shows that the

delivery of formal indirect care to residents with psycho-

social problems was costlier than the delivery of the same

type of care to somatic residents. The difference in costs

was approximately s14.00 per resident per day. The

average costs of informal direct care for somatic residents

outweighed those made for residents with psycho-social

problems.

3.2. Costs per activity

3.2.1. Costs of formal care activities

Table 4 shows the average costs of 14 direct activities and

8 indirect activities executed by formal caregivers for resi-

dents with somatic or psycho-social problems.

3.2.1.1. Residents with somatic problems. For residents

with somatic problems, the average costs of the total set

of direct care activities were higher in traditional care (s3.51

on average per direct activity) than in integrated care

(s2.75). For the set of indirect activities, however, the

opposite was true. This set was more expensive for inte-

grated care (s6.07 on average per indirect activity) in

comparison to traditional care (s5.09). Table 4 also shows

that most individual traditional care activities (such as

coffee/tea making, medication, general activities and after-

noon care) were more expensive than the same activities in

integrated care.

3.2.1.2. Residents with psycho-social problems. Compar-

able to residents with somatic problems, the average costs

of the total set of direct activities conducted by formal

caregivers for residents with psycho-social problems were

lower in integrated care (s2.68 per direct activity) compared

to traditional care (s4.31 per direct activity). The average

costs of the total set of indirect activities for traditional care

were almost comparable to the same costs for integrated care

(s6.03 and s6.82, respectively).

A.T.G. Paulus et al. / International Journal of Nursing Studies 45 (2008) 1764–17771772

Table 5

Average costs per activity (informal care) (in Euro (s))a

Traditional care Integrated care

Som PG Som PG

lwt agpc lwt agpc lwt agpc lwt agpc

Direct care

Morning care 0.91 (1.57) 1.58 (2.74) 1.15 (1.35) 1.93 (2.22) – – – –

Coffee/tea making 3.31 (1.46) 5.60 (2.67) 2.24 (0.27) 3.75 (0.56) 2.26 (0.48) 3.41 (1.51) 2.21 (1.76) 3.67 (2.83)

Medication 2.02 (1.79) 3.42 (3.07) 0.66 (0.37) 1.11 (0.66) 1.02 (0.30) 1.69 (0.54) 0.32 (0.44) 0.54 (0.75)

Toileting 1.70 (0.44) 2.85 (0.79) 1.33 (0.33) 2.25 (0.63) 1.22 (2.12) 2.15 (3.72) – –

Afternoon care 1.02 (1.16) 1.74 (2.02) 1.47 (0.84) 2.49 (1.50) 6.1 (7.40) 10.4 (12.48) – –

Extra care 1.74 (0.35) 2.93 (0.66) 4.34 (1.08) 7.25 (1.74) 2.69 (2.33) 4.63 (4.00) – –

Evening care 2.17 (1.33) 3.65 (2.30) 2.24 (0.76) 3.78 (1.38) – – 0.88 (1.53) 1.55 (2.68)

Meal activities 8.98 (4.23) 15.08 (7.26) 4.72 (1.16) 7.93 (2.24) 4.32 (3.94) 7.16 (6.48) – –

General activities 5.16 (1.73) 8.56 (2.65) 7.93 (3.22) 13.31 (5.44) 5.64 (9.77) 9.23 (15.99) – –

Club activities 3.44 (4.25) 5.9 (7.44) 8.11 (8.19) 13.88 (14.2) 8.33 (7.22) 13.85 (12.0) 12.99 (3.65) 16.16 (14.4)

Transfer and transport 4.62 (0.54) 7.72 (0.76) 4.51 (1.64) 7.54 (2.68) 8.11 (8.19) 13.44 (13.8) – –

Reacting to incidents 31.48 (47.6) 51.53 (77.2) 2.14 (2.20) 3.57 (3.63) – – 7.28 (8.34) 6.9 (11.95)

Having chats with

residents

14.22 (2.01) 23.65 (3.83) 12.14 (1.02) 20.34 (2.41) 12.76 (5.88) 16.99 (15.8) 7.54 (0.43) 12.76 (0.39)

Average costs of set

of direct care

activitiesb

6.21 (4.51) 10.91 (7.34) 4.07 (1.12) 6.85 (0.91) 4.04 (1.99) 8.18 (1.29) 2.01 (1.09) 2.33 (1.17)

Indirect care

Consultation 4.70 (2.07) 7.94 (3.81) 1.96 (0.60) 3.30 (0.79) 4.19 (1.63) 7.13 (2.99) 1.48 (2.56) 2.5 (4.33)

Cleaning 0.32 (0.34) 0.55 (0.60) 1.35 (1.37) 2.31 (1.39) 1.93 (0.91) 3.26 (1.48) 2.73 (4.73) 4.62 (8.0)

Out of pocket activities 5.23 (1.14) 8.77 (7.34) 7.66 (1.35) 12.80 (2.12) – – – –

Average costs of set

of indirect

activitiesc

3.42 (1.14) 5.75 (2.13) 3.65 (0.82) 6.14 (0.21) 2.04 (0.72) 3.08 (0.85) 1.40 (2.43) 2.37 (4.11)

Som = residents with somatic problems; PG = residents with psycho-social problems; Lwt = legal worker tariff; agpc = average gross personnel

costs.a Calculated as the average of the costs at three measurement points. Standard deviation in brackets.b Calculated as the average of the costs of 13 direct activities (since medical care and additional direct activities were not performed by formal

caregivers, these activities were not included in the calculation).c Calculated as the average of the costs of 3 indirect activities (the remaining activities were not performed by informal caregivers).

3.2.2. Costs of informal care activities

Table 5 displays the average costs of 13 direct activities

and 3 indirect activities performed by informal caregivers for

residents with somatic or psycho-social problems.

3.2.2.1. Residents with somatic problems. For residents

with somatic problems, the average costs of the set of direct

care activities were higher in traditional care (s6.21, lwt-

calculation) compared to integrated care (s4.04). The same

was true with respect to the average costs of the set of

indirect activities (s3.42 and s2.04, respectively). Informal

caregivers in traditional care performed more activities

compared to integrated care. Morning care, evening care,

reacting to incidents and out of pocket activities were not

performed by informal caregivers in integrated care.

3.2.2.2. Residents with psycho-social problems. For resi-

dents with psycho-social problems, the average costs of the set

of direct and indirect care activities in traditional care were

higher than the same costs in integrated care. Based on lwt-

calculations, cost differences were approximately 2 euro per

direct care activity and between s1.38 and s2.25 per indirect

care activity (residents with somatic and psycho-social pro-

blems, respectively). Again, informal caregivers in traditional

care performed more activities compared to integrated care.

4. Discussion

Although further research is needed in order to test the

results, our findings indicate that integrated nursing home

care had a limited cost-saving potential. While the delivery

of informal care and (formal) direct care (per activity) were

cheaper in integrated care, the total average costs per

resident per day (including formal care and indirect care)

were higher compared to traditional care. There are a

number of possible explanations.

First, our analysis showed that the costs of indirect care

were relatively high in integrated care mainly because of one

particular activity: schooling. International studies indicate

A.T.G. Paulus et al. / International Journal of Nursing Studies 45 (2008) 1764–1777 1773

that schooling in general and interprofessional learning in

particular is a necessity for an integrated delivery of services

(Colyer, 2004). This may explain why the costs of indirect

care in integrated care were higher compared to traditional

care. Our analysis also made clear that in integrated care

fewer activities were delivered by informal caregivers.

Consequently, the costs of informal care were lower com-

pared to traditional care. The total average costs per resident

per day (including formal care), however, were higher in

integrated care. One possible explanation is substitution, i.e.

a process in which formal caregivers undertake activities

usually performed by informal caregivers. Such a process

would stimulate a shift from informal to formal care costs.

This explanation, however, is not compatible with the find-

ings from other studies on care for older people. These

suggest higher contributions by informal caregivers (e.g.

Aneshensel et al., 1995; Bass et al., 1996; Robinson, 1997;

Arno et al., 1999; Wimo et al., 2002; Van Raak et al., 2003).

It is therefore recommended to further investigate factors

which can explain cost-shifts in integrated care.

Secondly, it can be questioned whether our findings were

influenced by the fact that there was no full match between

some features of formal caregiving in both homes. Table 1

shows that, while there were matches with respect to resi-

dents and informal caregivers, the type and absolute number

of roles involved in the delivery of formal care differed to

some extent. In traditional care, there were 15 different roles.

Five of these roles (ward assistant; living room assistant,

nursing care coordinator, aid and kitchen assistant) were not

present in integrated care. The latter three roles were

involved in a majority of the activities (see Paulus et al.,

2006). In integrated care, there were 11 different roles. One

of these roles (household assistant) was not present in

traditional care and was unique for integrated care. Also

this role was involved in a majority of the activities (Paulus

et al., 2006). To what extent the presence of more and

different roles in traditional care affected the costs of direct

and indirect care is unknown. Further investigation is there-

fore recommendable. Table 1 also presents the wage levels

of formal caregivers. Although most levels were compar-

able, there were considerable differences between the wage

level of the nursing assistant in both homes (s0.082 per

minute in traditional care; s0.181 per minute in integrated

care). In a related study we showed that this assistant was

involved in more activities (and mostly to a larger extent) in

integrated care compared to traditional care (Paulus et al.,

2006). This may explain part of the higher costs per resident

which are associated with the delivery of integrated care.

Table 1 also presents the average duration of direct care

activities in both traditional and integrated care. Although

there were relatively large standard deviations, it is clear that

the average duration of these activities for residents with

psycho-social problems was considerably lower in inte-

grated care compared to traditional care. This may explain

why the average costs per direct activity were lower in

integrated care.

The fact that there was no full match between some

formal caregivers’ characteristics is a limitation of this study.

There are other methodological limitations as well. To

obtain information on (the duration of) activities, we used

the method of self-reporting. Besides the burden of report-

ing, it is sometimes argued that self-reporting may also result

in a bias: participants may not tell the truth about their

activities or record socially desirable or self-perceived rather

than actual job performances. Furthermore, conceptual dif-

ferences between participants of what constitutes an activity

may lead to under- or overestimation of the number of

activities (Burke et al., 2000). Different caregivers may also

have different perceptions of activities and record (the

duration of) activities differently (e.g. because of different

personal characteristics). This also poses questions with

respect to the reliability of the self-reporting method. Burke

et al. (2000) make clear that the reliability of the self-

reporting method would increase if the outcomes would

approximate the outcomes provided by an alternative

method (such as observations or interviews). Our research

is limited in the sense that we did not investigate this. The

duration and sample size of the research did not allow

conducting a comparable number of observations and inter-

views. Furthermore, it has to be noted that alternative

methods such as the observation method also have some

well-known shortcomings. Continuous time observations,

for instance, can result in observer-induced bias: caregivers

may change their behavior when being observed. Secondly,

observations may be costly: each caregiver has to be

observed during a certain period of time. The use of obser-

vations is therefore usually restricted to a limited number of

participants or a short observation period. Obviously, the

duration and scale of our study did not match with these

conditions. Because of this, the biases of self-reporting may

be no greater than the biases of observations, as Burke et al.

(2000) show in their study. For our cost study, the application

of the self-reporting method provided us with more than

23,000 forms with detailed information on activities, the

duration (and frequency) thereof and by whom they were

performed. Obtaining the same number and detailed level of

information (needed to determine the costs of nursing home

care and compare it to traditional care) by way of interviews

was practically and financially infeasible. Moreover, the

retrospective nature of such interviews could have resulted

in a recall bias. In conclusion: given our aims, we used the

most appropriate method to collect our data. Further valida-

tion of the a priori lists that we used for self-reporting is

recommended for future research. Future research on the

impact of certain characteristics of caregivers on the regis-

tration (and duration) of these activities and their perceptions

thereof is also recommended.

On the basis of descriptive statistics, we reported cost

differences between traditional and integrated care.

Although the cost information we provided was far more

detailed compared to most cost studies, we did not use

statistical methods to test the significance of these differ-

A.T.G. Paulus et al. / International Journal of Nursing Studies 45 (2008) 1764–17771774

ences. Instead we described these differences because we

wanted to explore the cost-saving potential of integrated

care. Since so little is known about the costs of this type of

care (while many stakeholders and scholars automatically

assume that it has a cost-saving potential), we wanted to

open part of the current black box. Our study indicates that

(irrespective of significance testing), providing an answer to

the question ‘is integrated care cheaper or not?’ is not that

simple. Integrated care can be cheaper or more expensive at

the same time, depending on the types of costs, activities and

residents included. Since there is no general agreement on

this, our study intended to produce insights which can be

used during future research. For future cost comparisons, it

is recommendable to actually test the cost-saving potential

provided that particular methodological challenges have

been met. By definition, integrated nursing home care is

aimed at small scale arrangements. Comparisons with tradi-

tional care (with large scale arrangements) therefore always

have to deal with the problem of ‘numbers’ (see Table 1

which illustrates this problem in our study with respect to the

number of residents and formal caregivers included in this

study). Furthermore, due to its demand-orientation and

underlying integration strategy, integrated care delivery

(and the associated roles and informal–formal care relation-

ships) develops and changes continually in response to the

demands from users. Comparisons with a more ‘static’ usual

care arrangement can therefore present formidable metho-

dological challenges. In our cost study, we tried to capture

the ‘dynamics’ of integrated care delivery by repeating the

same measure at different time points and using the out-

comes to determine the mean value of the costs. In this way,

we tried to present a more realistic picture of the costs. It is

recommended to further explore these and related metho-

dological challenges in future research.

On the basis of 23,380 lists on which a range of formal and

informal caregivers reported the activities they conducted

during 42 days, we investigated the costs of traditional and

integrated nursing home care in the Netherlands. Most of these

activities are routine activities in nursing home care in many

countries (Paulus et al., 2006). Moreover, our finding that

integrated care has a limited cost-saving potential (especially

for formal care) is comparable with the results from interna-

tional studies such as Wan et al. (2001), Newhouse et al.

(2003) and Segal et al. (2004). These features indicate some

potential for generalization. It has to be noted, however, that

there also studies which indicate that integrated care leads to

cost savings (Bernabei et al., 1998; Hernandez et al., 2003;

Johri et al., 2003; Gross et al., 2004; Leung et al., 2004). Here

the problem arises that these studies refer to different types of

integrated care for older persons, various integration strategies

and a variety of costs. Integrated nursing home care as defined

in our research is not part of these studies. In this sense, our

study is quite unique.

Our findings suggest that integrated care leads to cost

savings in some care delivery activities (such as informal care

activities and a set of formal direct care activities) and to

additional costs in others (such as certain formal indirect care

activities and the average total costs per resident). For the

practice and development of care delivery, these findings

suggest that integrated care can principally be a viable option

in case decision-makers can control the costs of indirect care

as well as the costs per resident. Controlling the costs of

schooling and training for formal caregivers (as part of indirect

care) and choosing an efficient size of the group of residents to

which integrated care has to be delivered seem particularly

important in this respect. Otherwise, decision-makers should

take into account that the introduction of integrated care leads

to shifts and/or increases in the costs rather than to cost

savings. In that case, integrated care seems a viable option

only as long as these costs are evenly matched with the

relevant benefits. As Kodner and Kyriacou (2000) indicate,

fully integrated models of care may improve the delivery of

health and social care for older people. Possible benefits

include better patient outcomes and improvements in the

quality of care or the quality of work (Weech-Maldonado

et al., 2006). Our study is limited in the sense that we did not

assess these or other potential benefits of integrated care.

However, as we explained in the methods section of our paper,

our cost study was part of a larger study in which other

researchers investigated the impact of integrated care on

the quality of work and the quality of care. The findings of

the latter study are reported in Vijgen and Boumans (2003).

The authors indicate that especially particular elements of the

quality of care, as experienced by the family members of

residents who received integrated nursing home care, were

higher in comparison to traditional care. Elements include the

living environment, possibilities for residents to relax, treat-

ment of residents and involvement of family members in

decisions on care delivery. The effects on the quality of work

are reported in Boumans et al. (2008). This study shows that

the effects of integrated nursing home care on quality of work

are limited. Our findings and recommendations, combined

with these outcomes, provide a first step in providing infor-

mation that can be used for the development of more cost-

effective care arrangements for older people in nursing homes.

5. Conclusions

The general assumption that integrated care has a cost-

saving potential (per resident or per individual activity) was

only partially supported by our research. Only with respect

to informal care delivery and a set of formal direct care

activities, integrated care was cheaper in comparison with

traditional care. For the practice of care delivery this means

that there may be reasons not to be overly positive about the

cost-saving potential of integrated care. If only because of

this, cost savings should not serve as the sole reason to

promote or implement integrated care. After all, it is always

quality which should come first.

Further researchon integratednursinghomecare isneeded.

Our study indicated that, besides in-depth analyses of the

A.T.G. Paulus et al. / International Journal of Nursing Studies 45 (2008) 1764–1777 1775

associated costs (including informal care), also the benefits

and underlying integration strategy should be investigated.

Additionally, the factors which can explain possible cost shifts

(such as changing informal–formal care relationships and the

presence of different roles) should be included in future

research. Finally, research on the development of methods

which can capture the dynamic and (methodologically) chal-

lenging features of integrated care is recommendable.

Funding

We obtained financial sources of support from the Dutch

Ministry of Health; The Province of Limburg; VGZ Insurers;

the Boncura Foundation/Care Group ‘Noord-Limburg’; the

Foundation Stimulating Scientific Research on Nursing

Home Care. The resources allowed us to conduct our

research. These financial supporters did not have any role

in determining the study design; the collection, analysis and

interpretation of the data; the writing of the report or the

decision to submit this paper for publication.

Ethical approval

Approval to conduct the study was obtained from the

relevant ethics committees in the nursing homes. Informed

consent forms were used and all participants were informed

before, during and after the research. [The nursing homes did

not use a reference number].

Acknowledgements

The authors would like to thank Femke Keijzer for her

contribution to the data-collection. Furthermore we are

grateful for the financial sources of support that we obtained

from the Dutch Ministry of Health; The Province of Lim-

burg; VGZ Insurers; the Boncura Foundation/Care Group

‘Noord-Limburg’; the Foundation Stimulating Scientific

Research on Nursing Home Care. We are also grateful for

the suggestions and comments provided by the reviewers.

Conflict of interest

None of the authors has been engaged in any relationship

that could have inappropriately influenced this work. There

is no conflict of interest.

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