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.