This pre-post study, registered on ClinicalTrials.gov (NCT05837728), is based on a case-only design to conduct health needs assessments, initially at the baseline and then after 5 months. The study is conducted as part of the research project “More good days at home: Advancing health-promoting practices in municipal health care services for older recipients of home care,” funded by the Norwegian Research Council (320622).

To gain in-depth insights, we use a 2-step research process. In the first step, a quantitative approach will be applied to examine changes in frailty levels in home-living older adults over 5 months. In addition, we will examine observable functional changes from t1 to t2 and how these changes correlate to frailty levels.

Following this, a qualitative approach will be used to investigate the perspectives of participants and their informal caregivers concerning the health needs assessment and its acceptability.

This study is placed in the context of the Norwegian health care system, known for its universal health care. This system ensures everyone has equal access to health care regardless of socioeconomic status or geographical location [29]. The system is based on a clearly defined division of responsibilities between the local municipalities and the central government.

The local municipalities are tasked with organizing primary, preventive, and nursing care services [29] and are committed to providing the necessary health services, such as home and personal care, free of charge to all home-living older adults [30]. These services are universally available and tailored to the specific needs of each older adult. To access these services, older adults are required to submit an application to the district office in their municipality [31]. Once the application is submitted, it will be reviewed by health care professionals in the health and welfare services office. After this phase, the health care professionals will reach out to the older adults to proceed further.

While municipalities manage the above care services, central government oversees specialist care, which includes hospital services. This clear division ensures comprehensive health care for all citizens [29]. This study takes place in a municipality in Western Norway with a population of approximately 146,011. In this population, 9874 individuals are older adults aged 75 years or older [32].

Participant recruitment was conducted in collaboration with 3 health and welfare service departments in a municipality in the western region of Norway between February 1 and June 26, 2023. Health care professionals purposively selected participants according to the eligibility criteria. During their initial phone contact with potential participants, health care professionals used their professional judgment to assess the individual’s ability to understand the research project and provide informed consent to participate.

Subsequently, health care professionals asked a designated research team member, a nurse with experience in mental health, to obtain informed consent from those who meet the initial criteria. To ensure consistency in the process, the same nurse visited all potential participants for the consent process. Potential participants were then given time to consider this information before giving their written consent.

The design of our health needs assessment package includes a cognitive assessment. This approach ensures that participants identified with cognitive impairment in the first assessment are not included in the second assessment.

We aim to enroll 40 participants in the quantitative phase of this study, in line with the agreement made with the municipality at the beginning of the project, taking into account their resource limitations. In the next phase, which uses a qualitative approach, we plan to invite all 40 participants for an interview, with the actual number of interviews conducted depending on the participants’ consent to participate. To capture diverse perspectives, we will strive to include a group of home-living older adults who differ in terms of age, gender, marital status, living situations, and health care needs.

The aforementioned sample size takes into account the limited resources available for the project, including budget constraints, personnel resources, and time limitations, while ensuring the collection of meaningful data to address the research questions.

To respond to the diverse needs of older adults, we have interprofessional teams consisting of registered nurses, physiotherapists, or occupational therapists to carry out the health needs assessments. The assessment is conducted twice at the participant’s home. To facilitate successful implementation, we provided simulation-based training and debriefings. We have also produced webinars available in Norwegian to enhance learning. The link to the webinars can be provided upon request. Our study is ongoing, so we will publish it upon completion.

The interprofessional teams will use an iPad (Apple Inc) to administer assessments covering the various factors—physical (mobility and sensory), cognitive, psychological (depression), social (loneliness), and behavioral (alcohol consumption). The collected data will be registered electronically and directly submitted to Services for Sensitive Data (Tjenester for Sensitive Data [TSD]) for secure storage and processing.

After the initial assessment, interprofessional teams will collaboratively review the results to determine whether, and to what extent, the older adult is eligible for assistance and to determine what type of support is available and appropriate for the individual [33]. Examples of such support include practical help with everyday tasks, provision of medical emergency alarms, access to walking aids, recommendations for physiotherapy sessions, referrals to hearing or vision centers, encouragement to participate in senior activity centers, and facilitating contact with primary care physicians.

After 5 months, the same interprofessional teams will conduct the second health needs assessment to determine whether the support provided at the first assessment is suitable for helping participants maintain their quality of life.

With regard to the qualitative approach, we will use 2 data collection methods in order to minimize mono-method bias [34]—in-depth individual interviews and dyadic interviews. We will use a general interview guide approach to collecting data from all the participants, which will give us the flexibility to modify or adapt questions based on responses to previous questions [35]. To maintain consistency, the topics and questions in the 2 interview methods will be identical and guided by the Theoretical Framework of Acceptability (TFA) proposed by Sekhon et al [36]. The questions will include, for example, (1) how the participant thinks and feels about the assessment, (2) what the participant thinks about the effort required to participate in this type of assessment, (3) the participant’s understanding of the assessment process, (4) what benefits or value they believe the assessment will have for them, and (5) whether they feel the assessment was conducted respectfully or not. Finally, the interviews will be audio recorded and transcribed verbatim to ensure accuracy in the data analysis.

The selection of measures was informed by a comprehensive review of existing literature, consultation with experts, and input from stakeholders involved in the project. Many of the measures have been validated in different contexts, including the Norwegian context. The study also includes novel scales that will be tested for validity within this particular sample of home-living older adults. The measures in the study are described below, and an overview is given in Table 1.

This study has two primary outcome measures: (1) identifying changes in frailty levels of home-living older adults over a period of 5 months and (2) assessing any observed changes in functions from t1 to t2 and how these changes relate to the level of frailty.

In addition to the primary outcome measures, this study will also evaluate the feasibility of the health needs assessment. Emphasis will be placed on the acceptability of the assessment among older adults and their informal caregivers, as well as the practicality of implementation in relation to time and resource constraints.

In this study, older adult participants were not involved in developing the study design or objectives. The study design and objectives were developed by the researchers of this study in collaboration with the local municipality stakeholders. The Service User Association for Older Adults in Norway (Pensjonistforbundet) contributed insights to the grant application, which was successfully funded by the Research Council of Norway. Furthermore, details about the study design and recruitment procedures were provided to health care professionals prior to data collection.

Ethics approval was obtained from the Regional Committees for Medicine and Health Research Ethics (REK) of West Norway on November 15, 2022 (523455). The project was subsequently approved by the Norwegian Agency for Shared Services in Education and Research (SIKT) on January 19, 2023 (100847), which ensures that adequate safeguards are in place to protect the privacy of participants and to maintain the confidentiality of data. This study will be conducted in accordance with the Declaration of Helsinki guidelines [71] from REK and the Data Protection Impact Assessment (DPIA). It will also be conducted under the principle of informed consent. Prior to data collection, all the participants who agreed to participate in the study will sign a consent form, which includes a description of the study, its objectives, and participants’ involvement and rights. Participation in the study is entirely voluntary and participants can withdraw at any time. Additionally, participants are entitled to access the information documented about them and to make necessary corrections to any errors discovered.

Studies have documented that frail older adults have an elevated risk of negative health outcomes [13,14]. Early assessment of frailty in older adults is, therefore, crucial, and is recommended. Despite its recognized importance, assessing frailty is not considered a standard clinical practice in many health care systems [18], including in Norway [72]. This situation is understandable as such an assessment often requires significant resources, which many health care facilities lack [73].

Our study is carefully designed to reflect real-world applications and settings, with a particular focus on municipal health care in Norway, where health care professionals tend to have heavy workloads. These conditions pose a challenge to incorporating additional tasks, such as a frailty assessment, into routine health needs assessments. As mentioned earlier, older adults typically turn to their local municipality for home care services and health care professionals make home visits to assess their care needs. This assessment process uses the standardized tool (The Norwegian Information System for the Nursing and Care Sector [Individbasert pleie- og omsorgsstatistikk; IPLOS]), which was developed to optimize care needs assessments in Norway [33]. Despite being a standardized tool, IPLOS has been criticized for being too subjective, as assessments appear to vary widely among health care professionals [74].

In response to these challenges, we aim to refine the health needs assessment process to improve objectivity and consistency, and to highlight the critical needs to incorporate frailty assessments into routine municipal care practices. The path begins with selecting appropriate measurement tools that are meaningful and practical, and training interprofessional teams to implement them. Part of this training process includes the task of conducting assessments and discussing the results to make informed decisions.

Beyond integrating assessments, our study aims to shed light on the dynamic nature of frailty and provide a deeper understanding of the factors that impact its progression. This insight could potentially help older adults and their informal caregivers to manage frailty. Additionally, it can better prepare health care professionals to develop and implement strategies aimed at delaying and mitigating the progression of frailty.

This study has several strengths. First, it deepens our understanding of frailty as a complex condition and highlights how levels of frailty and related functional changes can differ. Moreover, because the study is designed to reflect the real-world settings and applications, it can help improve health care practices in the municipal sector. The involvement of local stakeholders in the municipality from the planning to the implementation phase ensures that the study remains relevant and applicable, thereby facilitating the translation of knowledge into practice. Additionally, the inclusion of home-living older adults’ and their informal caregivers’ perspectives can help facilitate improvement in the feasibility of the assessment.

As with other studies, this study has its limitations, particularly with regard to the relatively small sample size and the absence of a control group. This could lead to misinterpretation of the observed changes, either in the support or services for participants, other confounding factors, or due to a habituation effect over the 5-month period. Consequently, this limitation may also potentially impact the internal validity of the study, as well as the construct validity of the study [75]. To address this challenge, we will carefully compare our findings with those of previous studies investigating similar approaches to aiding the interpretation of outcomes.

Despite its inherent limitations, this study will serve as an important first step in developing a more systematic health needs assessment for home-living older adults and the development of health promotion strategies that can improve these older adults’ quality of life.

Nonetheless, the results should be interpreted with caution due to the absence of a control group, the limited sample size, and the potential underrepresentation of all home-living older adults. These limitations suggest that the results indicate possible correlations and patterns, rather than confirming a definite relationship or establishing specific cause-and-effect relationships.