Organizational dimensions of technology-enhanced home care are intimately linked to the characteristics of the home care delivery model (e.g. eligibility, access to services, skill mix, etc.) and to the particular needs of patients in terms of care, technology, and support. The dis-cussion here is limited to home care delivery models, coordination between providers, com-munication with patients and caregivers, and ad-aptations to the home environment. A few cost-effectiveness issues will also be discussed, albeit briefly since the literature on cost-effectiveness is complex and deserves to be analyzed in greater depth in a separate report. Readers inter-ested in cost-effectiveness issues may consult a series of HSURC reports [2000, 1996a,1996b], the more recent series of studies chaired by Hollander [2002], titled the National Evaluation of the Cost-effectiveness of Home Care, the study by the University of Toronto Home Care Evaluation and Research Centre (HCERC)
[Coyte, 2002], a Cochrane systematic review [Parkes and Shepperd, 2000], a UK-based HTA agency systematic review [Elkan et al., 2000], a thorough economic evaluation [Dougherty et al., 1998], and a systematic review [Soderstrom et al., 1999].
4.1.1 Cost-effectiveness
The cost-effectiveness of home care is some-times taken for granted; since hospital costs are so high, any alternative appears less costly at first glance. For instance, the Romanow [2002, p. 171] report underscores that “there is growing evidence that investing in home care can save money while improving care and the quality of life for people who would otherwise be hospital-ized or institutionalhospital-ized in long-term care facili-ties.” However, detailed economic evaluations of home care reveal that there are broader types of costs that should be recognized, among which are the costs of hospital re-admissions, private home care, and lost income of caregivers [Soder-strom et al., 1999]. With this perspective, Gelijns and Rosenberg [1994, p. 42] argued that “em-pirical analyses that unpack the forces underly-ing technological change and its relationship to health care costs are urgently needed to strengthen the basis for future policy making.”
These authors stressed that three mechanisms of action contribute to the overall levels of utiliza-tion and costs: 1) variautiliza-tions in intensity of use (e.g. the “technological imperative”); 2) intro-duction of new or modified technologies; and 3) expansion of indications for use (i.e. more in-dividuals are treated or tested). We may expect these three mechanisms to operate in the case of home care development: it is possible that a spe-cific technology will be used when a "wait-and-see" approach would be as effective and perhaps safer, when a different technology could be im-plemented, or when the technology is not medi-cally required. In fact, much complexity arises when one wishes to know whether specific home care interventions are cost-effective compared to traditional care methods. To illustrate some of the challenges, two studies and a commentary are summarized in detail below.
Soderstrom et al. [1999] conducted a systematic review of the evidence regarding the effects of acute home care on the health of patients and caregivers, and on the social costs of managing the patient’s health conditions. Fourteen studies (inclusion criteria: publication between 1975 and early 1998, adult population, use of a control group) were first identified from MEDLINE and HEALTHSTAR databases. Only four of these studies met the internal validity criteria specified by the authors (i.e. patients were eligible for home care; comparable patients in the home care and hospital groups; adequate study size; appro-priate analytical techniques, health measures, and costing methods). Five specific health condi-tions/interventions were evaluated in these four studies: hip fracture, hip replacement, chronic obstructive pulmonary disease (COPD), hyster-ectomy, and knee replacement. Social costs were defined as the sum of three factors: 1) hospital costs savings due to shorter length of stay; 2) the added public and private costs of the home care program and other health services used; and 3) the positive or negative change in non-health system costs borne by patients and caregivers (e.g. baby-sitting, transportation). Except for hip fracture where small positive effects were found, home care had no effect on patients’ or caregiv-ers’ health compared with hospital care. Social costs under home care were unaffected for hip and knee replacement and higher for COPD and hysterectomy, while no such costs were reported for hip fracture. Overall, effects on health system costs (i.e. excluding non-health system costs) were mixed: cost savings were observed for hip fracture whereas costs were higher for hip and knee replacement. The authors thus concluded that the effects on social and health system costs vary with the condition, and that the limited evi-dence reviewed suggested that acute home care does not produce notable difference in health outcomes.
There can be cases where a specific home care intervention is considered appropriate from a public policy perspective, despite an overall in-crease in costs. For instance, Dougherty et al.
[1998] examined the health and cost effects of using home care to treat newly-diagnosed Type I diabetic children, rather than traditional hospital care. Sixty-three children were randomized into
two groups and followed for 24 months. Chil-dren in the home care group (n=32) were dis-charged from hospital after their metabolic con-dition stabilized, and insulin adjustments and teaching were done in their homes by a trained nurse. Social costs (i.e. net change in costs for the health system and parents) were $48 higher under home care. According to the authors, “the increased cost of health care services with home care ($768) was largely offset by parental cost savings ($720).” This evaluation focused on pe-diatric home care, an area where parental in-volvement as caregivers is usually high, and where the benefits of discharging children from hospital are obvious (e.g. to reduce the risk of nosocomial infections). The results of this evaluation suggest that criteria other than strict cost-effectiveness should be used to decide whether to implement a home care program or not; among others, these criteria include feasibil-ity, quality of care, and comprehensiveness of the program.
A commentary on home care published in the fall 2000 issue of Healthcare Papers by Thomp-son [2000, p. 61] sheds light on how decisions to provide different types of home care services (or not) can be grounded on evidence about their cost-effectiveness. The author suggests that evi-dence about effectiveness of home care can be examined adequately only by distinguishing the goals of diverse home care interventions. The goal of “curative” care is “to restore functioning that has been temporarily lost, or limit the loss of functioning caused by sudden insult to good health.” If clinical outcomes of care are as good at home as in hospital, then the policy issue is one of cost-minimization, or cost-substitution. If the outcomes are better in one of these locations of care, then the issue is one of cost-effectiveness: “Do the better outcomes justify the additional cost, compared to other opportuni-ties to use those resources?” The goal of “pre-ventive” care is to prevent deterioration in client functioning. According to Thompson [2000, p. 62], “the burden of proof is heavier for pre-ventive home care, because establishing equal outcomes is not sufficient, as preventive home care is not a substitute, but an add-on.” The goal of “supportive” care is to “maintain the client at as high a level of independent living as possible,
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for as long as possible”. This goal can be achieved through home care, nursing homes, and assisted living. Caregivers’ health can also be maintained through supportive housing, institu-tional respite care, and support groups. Thus, to identify whether supportive care is cost-effective, client and caregiver outcomes should be compared for each alternative.
Thompson argues that several studies support the conclusion that outcomes of curative home care are as good or better than hospital care. This au-thor stresses that recent economic evalu-ations have highlighted the need to achieve substitution for demonstrating cost-effectiveness; otherwise, there are no cost savings. Substituting home care for hospital care requires effective discharge planning and close integration between hospital and home care providers. An HSURC [1996a]
report argued that several US randomized trials failed to demonstrate the cost-effectiveness of supportive home care in the 1980s, since a ma-jority of clients in supportive home care demon-stration projects were in fact receiving preven-tive care, for which the alternapreven-tive was no care.
According to Weissert [1985; Weissert et al., 1997, cited in Thompson, 2000], supportive home care can be cost-effective only with true single entry and accurate targeting of clients at risk of nursing home admission. Integration is required between nursing homes and home care programs so that priority clients are admitted first. According to Thompson, preventive home care has not yet been clearly and unequivocally proven cost-effective. In the cases where better outcomes have been identified, this has con-cerned high-risk populations of elderly after dis-charge from the hospital [HSURC, 1996b]. Inte-gration between hospitals and CLSCs is again the key here. Nonetheless, a more recent study by HSURC [2000] cast doubts on the cost-effectiveness of preventive home care. Retro-spective analysis of administrative records indi-cated that seniors receiving preventive home care were 50% more likely to lose their inde-pendence or die than those not receiving such service. The average total health services costs for preventive home care recipients were triple those for non-recipients. Residents of seniors’
housing were 63% less likely to lose their inde-pendence and 40% less likely to die, and had
about the same total health services costs as non-residents. Seniors’ housing thus appears more ef-fective and less costly than preventive home care, perhaps due to increased socialization and decreased use of other services. However, the authors themselves acknowledged several limita-tions in this study (for example, the selection bias inherent to the use of administrative data to compare groups, the use of crude outcome measures, and the fact that costs were limited to those borne by the health system). Policy-makers should wait until replications of these results are published and augmented with clinical data be-fore acting upon such findings.
In summary, the extent to which home care in-terventions are cost-effective is not clear. How-ever, this is not a sufficient reason to cut home care services. According to Béland and Bergman [2000], a high proportion of those with health needs do not have sufficient access to home care and continuing care. For instance, a study by Trahan et al. [2000, cited in Béland and Berg-man, 2000] showed that CLSCs were providing nursing care at home to 31.2% of day surgery patients and to 85% of post-hospitalized patients, while homemaking services were delivered al-most exclusively by families: CLSCs provided homemaking services to 3.7% of day surgery patients and to 18.8% of post-hospitalized patients. This suggests that home care services may not be deployed to the fullest extent in Québec, and that families are providing a significant portion of care and support. Thus, well-designed evaluations are needed to clarify the cost-effectiveness of specific home care interventions and how costs are being shifted from the health system to the patients and their families.
4.1.2 Integrated health care delivery models
The 1990s saw the emergence of integrated health care delivery systems in North America and Western Europe, assuming diverse forms while aiming to improve the quality of care through patient-centered coordination among care providers. The majority of home care is provided by nurses, while family physicians are more involved in patient follow-up. The
objec-tives of nursing care delivery systems are to as-sess the patient, identify the nursing needs, and provide the nursing care until the patient is dis-charged from the program [Lyon, 1993]. An in-tegrated home care delivery system facilitates a closer collaboration between nurses, physicians, other professionals, and home helpers. The pur-pose of client-centered case management is to assist the patient through a complex, often frag-mented and confusing health care system, while system-centered case management serves ration-ing and priority-settration-ing functions as well. Tradi-tional models of home care are likely to be al-tered by integrated service delivery systems, in which home care has closer links with other lev-els of care, such as hospitals or nursing homes, in a care continuum [Handy, 1995].
Continuity of care is paramount in such systems.
Based on a survey of children whose routine source of care was a community health clinic, O’Malley and Forrest [1996] found that continu-ity of care was associated with a two-fold in-crease in the odds of receiving age-appropriate preventive services. Based on interviews with patients, another study found that the factors as-sociated with a continuous care relationship were patient familiarity with the physician, physician knowledge of the patient, patient satisfaction with care received, and patient confidence in the physician [Gabel et al., 1993]. Personal attrib-utes of the physician, friendship with the physi-cian, ease of communication, and professional growth of the physician were also associated with this relationship. The availability of the physician and the location of practice were rea-sons to start consulting a physician.
Integrated service delivery systems are also thought to be cost-effective compared to tradi-tional delivery models. A Randomized Control Trial (RCT) demonstrated that an integrated mo-del of service mo-delivery, based on interdiscipli-nary care-management and blended modalities of service, enhanced quality of life and was a cost-effective method of providing care for ter-minally ill AIDS patients at home [Huba et al., 1998]. According to a cohort study [Forrest and Starfield, 1996], the use of an identified primary
care source during the first visit (first-contact care) was associated with reductions in ambula-tory episode-of-care expenditures of over 50%.
Nonetheless, Okun [1995] has argued that technology-enhanced home care program devel-opment has largely preceded research on safety and effectiveness. Outcomes research in this area has been given the challenge of determining the effects of home care attributable to such diverse factors as the illness itself, the home setting, pro-fessional care received, and social support. For instance, in a retrospective analysis of discharges for congestive heart failure and total hip replacement recorded by six home health agencies (in New Hampshire, USA), O’Sullivan and Volicer [1997] observed that variability in likelihood of meeting care goals is much better predicted by patient characteristics (e.g. diagno-sis, age, functional limitations, prognodiagno-sis, reha-bilitation potential, presence of an able and will-ing caregiver) than by utilization of home care services.
Access to services is another important issue when considering home care delivery models.
Through an analysis of three American databases containing renal dialysis patients, Kendix [1995]
found a negative association between the number of facilities per square mile and the probability of provision of home services. In Québec, hospi-tals are increasingly providing ambulatory care services [AHQ, 1997] and specific home care programs (e.g. IV therapy, parenteral nutrition).
Each hospital seeks to implement a model of care that remains flexible, as technology is changing rapidly. One might expect CLSCs to be less involved in home care when such services are offered by local hospitals, since hospitals control patient flow (Lehoux et al., 2001b].
However, if a specific service is to be offered jointly by a hospital and a CLSC, communica-tion and coordinacommunica-tion between organizacommunica-tions will be crucial. In our prevailing health care system, there are few organizational or financial incen-tives for consolidating collaboration between CLSCs and hospitals. For ex-ample, there is no specific budget to hire liaison agents, and no in-formation system that can be used to transfer pa-
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tient information from hospitals to CLSCs, or vice-versa [Lehoux et al., 2001b]. Low levels of mutual understanding will tend to impede the development of solid collaboration.
4.1.3 Physician involvement in home care
Since the implementation of Medicare in Can-ada, physicians have not been largely involved in the provision of home care. As highlighted by an issue of the Canadian Family Physician [Laberge et al., 2000, p. 2022-9], several disincentives limit the number of house calls by physicians.
Eaton [2000], in the editorial of this journal is-sue, lists ten reasons and/or preconceptions about why doctors do not make house calls.
First, this could be related to a lack of role mod-els for younger physicians due to a shortage of family physicians in several regions (this short-age forcing them to decrease the provision of house calls in favor of other medical services).
Second, diagnostic support in the home envi-ronment is limited, and physicians may be less comfortable performing examinations and estab-lishing diagnoses without the tools that are easily available in clinics or hospitals. Third, some pa-tients can be inconsiderate to physicians by not respecting schedules or by being excessively demanding. Fourth, physicians may be worried about lack of hygiene and concerned about spreading disease to themselves or others. Fifth, getting to a patient’s house (e.g., finding the way) can be difficult and frustrating. Sixth, phy-sicians may be put off by having to attend lengthy meetings of interdisciplinary teams common in home care. Seventh, fear of assault and litigation may also limit physicians making house calls. Eighth, some physicians may feel overwhelmed by the complexity of geriatric care (in particular, end-of-life care) and fear intense family entanglements. Ninth, house calls may be perceived as an inefficient use of time. Tenth, fi-nancial compensation for making house calls is insufficient, given that several Canadian gov-ernment agencies do not pay for travel time.
Some of these arguments may seem weak or un-founded. Nonetheless, physicians are given the choice of providing or not providing home care, and their decision may depend on all sorts of
ob-jective and subob-jective considerations which should be recognized by home care managers and policy-makers. A recent survey, adminis-tered to family physicians in the Québec city re-gion (response rate: 487/696=70%), confirmed that physician involvement in home care was low: Laberge et al. [2000] found that 58.1% of their respondents were making house calls to a clientele consisting mainly of elderly patients (87.6%). Forty-two percent of these physicians saw fewer than five patients per week, close to one-third (31%) spent 2 hours or less per week on house calls, and close to two-thirds (64%) devoted 15 to 30 minutes to these visits. Only 22% of their patients were also receiving home care services from a CLSC. Finally, a minority of physicians (19.5%) had participated in multid-isciplinary meetings at the CLSC. In summary, although home care patients can see their family physicians when they need medical advice, the overall role of physicians in home care remains limited, as does their collaboration with CLSCs.
4.1.4 Working in home care
Several observers have described the differences between nursing responsibilities in home care and typical hospital-based nursing duties. Brown [1996] has stressed that a new generation of ad-vanced practice nurses is required to provide cost-effective, quality home care. Nurses with
Several observers have described the differences between nursing responsibilities in home care and typical hospital-based nursing duties. Brown [1996] has stressed that a new generation of ad-vanced practice nurses is required to provide cost-effective, quality home care. Nurses with