System Level Integration
The first characteristic is macro-systemic. Systems that achieve more
integration seem more likely to produce desirable outcomes. Two levels
of integration can be identified in the literature we analyzed. The
first is the clinical integration of different types of health care
services and the other is the inter-sectorial integration of broader
social services and home care. The most common examples of clinical
integration in our data are processes that connect acute hospital
services and post-discharge home care services as well as ongoing
collaboration between primary care physicians and home care teams. In
our data, intersectoral integration is generally described at the
micro-level of care-coordination or multidisciplinary teams. Many
studies suggest that integration is a core element to design
high-performing home care models 32,44-47,63, but the
evidence is not unambiguous and some have found the opposite64,65.
Since a small body of highly influential seminal work in the 1990s66,67 there has been an abundance of literature on
integration of care and systems 68 the subtleties of
which are beyond the scope of this paper to discuss. However, based on
our analyses, home care models need both effective care integration and
intersectoral integration. The recipients of home care services are
often frail people with multiple needs. They will often enter and leave
acute care settings, consult with primary care and specialist physicians
as well as need housing-related support and other types of social
services. The literature we reviewed suggests that there are significant
benefits in efforts towards integration. However, the “how” part is
left under-addressed.
Care Coordination and Case
Management
The second mechanism that characterizes many of the successful
interventions we reviewed was case management and coordination. Although
there is some overlap in the concepts of integration and case
management, we treat case management separately for two reasons. First,
it is generally treated as such in the description of the home care
models we reviewed. Second, the processes involved in case management
are highly micro-individual and practical in nature. Case management is
generally described as involving a sequential set of activities (i.e.
assessment, development of individualized plans, connections with
relevant service providers, problem solving and reassessment9,18,19,32,44,45,47,48,50,51). As noted earlier, many
studies on home care interventions where case management and care
coordination played a central role resulted in positive outcomes9,18,19,28,48-51 although a few did not38,39.
Most of the home care case management roles we documented in the
research were held by nurses. The data we analyzed does not allow for an
in-depth analysis of the way case management produces its results.
However, we hypothesize that the use of formal standardized assessment
tools does not play a large role in improving outcomes. What seems more
influential is the ease of coordination and the ability to
problem-solve. We also hypothesize a significant dose-response
relationship. Case management will be most effective when the caseload
of case managers is kept to a level that allows them to properly do
their work.
Relational Continuity
The last mechanism we want to discuss is relational continuity. Most of
the literature we reviewed is written using role-based terms (the
doctor, the nurse, the care coordinator, the occupational therapist)
often without specifying how much, if any, relational continuity exists
between these individuals and the client or family. One exception is a
study by Russell, Rosati, Rosenfeld, et al. 54which directly focused on this element. It found that the level of
relational continuity varied considerably between recipients of home
care services and that it was strongly correlated with functional
capacity and risk of hospitalization. Other studies that took relational
continuity into consideration found converging results69. Conversely, studies of home care models with very
low relational continuity 70,71 identified this
feature as a weakness. For example, a study by Gray, Sedhom71 suggests that the US approach to cluster care leads
to lower satisfaction because segmenting client needs leads to very low
relational continuity. Finally, some authors 72conceive of the relational nature of the work involved in home care
provision as a defining characteristic of home care itself62,71,72. Overall, our results follow the same path.
Home care provision is acutely relational, low-tech and dependent on the
quality of the human and social relations involved. There are specific
challenges related to establishing system-level home care delivery
parameters that take this reality into account. In primary care,
relational continuity has been shown to affect mortality rates73,74 and we believe there are plausible indications
it strongly influences the quality of the care provided and their
outcomes in the home care context too.