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.