Discussion
Something is (likely) better than
nothing
The first element to emphasize here is that the literature analyzed
rarely if ever addresses the question of whether home care is beneficial
in, and of, itself (and for what purpose). As noted, we only found three
studies (all from the US) that compared the provision of some home care
services to receiving no services at all. Unsurprisingly, they all
conclude that some is better than none when it comes to home care.
As per the hierarchies of evidence in the canons of medical research,
the bulk of the research evaluating home care effectiveness relies on
comparative study designs, primarily RCTs. The strength of
well-conducted RCTs is to effectively control for many biases. However,
what we found is that, at the macro-level, the over-reliance on RCTs and
other comparative study designs in home care research have left core
questions unaddressed. For example, we did not find any evidence
allowing us to establish what services should be prioritized as core
components of a home care basket of services.
What we found, instead, is that in most jurisdictions the basket of
available home care services appears to have evolved somewhat
haphazardly over long periods of time as a mix of public, non-owned57 and private services aimed at meeting the basic
needs of some older people in the population. What needs are being
addressed (and which are ignored), which populations are covered (or
not) and what structures the accessibility of those services (capacity
to pay, poverty, age, location, etc.) does not seem to follow any
obvious pattern. It is perplexing that the core question of “what
services should be offered in priority” is left mostly unaddressed by
the literature we reviewed (with some exceptions7,58,59). It also raise ethical issues regarding
distributive justice 60.
Despite this blind spot in the literature, based on the effectiveness
data reviewed as well as some of the qualitative evidence analyzed6,61,62 and on the basis of its face value, we have
little doubt that home care provision is beneficial in itself. The next
sections expand to the systematic analysis of mechanisms associated with
effective home care in the entire body of 113 articles; here, we more
fully elaborate the three interconnected elements that appear to be
central in the design of effective and efficient home care interventions
and service delivery models – system-level integration, case
coordination/management, and relational continuity.