Conclusion
This review was rooted in a significant effort to identify the existing
literature so that three questions could be answered: What is home care,
what is the evidence on home care intervention effectiveness and what is
known about the causal processes involved. We eventually selected 113
documents that provided some answers to those questions. However, one
key take home message from our analysis is that home care evidence base
still contains significant blind spots. In particular, this research
only provides very limited practical or policy-oriented guidance on how
to improve or strengthen home care delivery. This hampers policymakers
and advocacy groups in their efforts to create effective system change.
There are numerous specific “narrow” services that can be provided for
older adults at home which can provide desirable outcomes for
recipients. But the systemic benefit will not be optimized by randomly
implementing some interventions based on local idiosyncratic parameters.
Rationally designing a home care delivery model implies a series of
sequential steps. The first would be to identify what system-level goals
the model should achieve and the populations it should serve. The second
step would be to identify what type of services are likely to achieve
those goals in order to establish a basket of services. Finally would
come the task of identifying the best ways and specific means to
effectively and efficiently provide those services. We want also to
stress two important elements. First, at each step, such mechanisms need
to provide enough flexibility and local contextualization to escape the
limitations of top-down, wall-to-wall approaches while ensuring
equitable coverage and service provision. Second, we want to point-out
that questions such as optimal team composition, funding model and
administrative structures can only be meaningfully discussed at the
third step of the process.
These same three steps can also be used to establish an evaluative
framework to appraise current and future home care models. First, what
are the goals being pursued and populations being served? Are those
choices aligned with societal values and system-level objectives?
Second, what basket of services is being provided? Is the basket
coherent with the goals put forward? Is the basket comprehensive enough,
and how would we know? Third, what delivery approaches and interventions
are used? Are these the most effective and efficient given available
evidence? It should be noted that the first two questions are mostly
value-driven and focused on the coherence of choices while the third is
predominantly evidence-driven.
In conclusion, it could be noted that 30% of the documents we reviewed
explicitly stated that the aging population will require stronger and
better home care models, while another 18% mentioned unmet needs that
home care could address. However, much of the knowledge needed to
implement stronger, better home care is not provided by the literature.
Future research on home care would benefit from more directly involving
decision-makers and advocates in collaborative approaches, to more fully
ensure that evidence is policy-relevant and that policymakers are not
only attuned to methodological issues but are educated in the importance
of public dialogue around the purpose and future of home care. National
and international leadership and consensus-building are needed just as
much in policy as research as we move forward to support older adults
who live at home across the globe.