Definition, Types and Objectives of Home Care Services
The implicit definition of home care in the studies reviewed here
appears to be any broadly defined health-related services provided in
people’s homes, as well as the remote coordination of care provided to
the recipient of such services 6-8. Content-wise, home
care can include a vast array of services ranging from specialized
medicine (for example, care provided by geriatricians, oncologists,
psychiatrists, etc.) to services to help with daily living (meal
preparation, house cleaning, etc.) and various types of care designed to
promote health, gain or maintain autonomy, or cure ailments9. The diversity and breadth of what is described as
home care in the scientific literature constitutes a significant
challenge for integrative reviews such as ours.
Beyond that general definition (or lack thereof), the literature we
analyzed can be characterized based on two main splits that we
identified. First, there is a clear divide between fixed duration
“reablement” interventions (also named restorative care in some
jurisdictions) and indefinite-duration need-based interventions. The
underlying causal hypothesis of reablement is that an intensive,
multidisciplinary, time-limited (generally under 12 weeks) service can
improve an older adult’s independence in daily activities so that no
further services are needed afterwards 10-12. Such an
approach has some good face value for specific groups (post-discharge
patients for example). However, the literature analyzed often treats
reablement as a substitute for indefinite-duration home care focused on
supporting people whose functional independence is likely on a downward
trajectory. For example, articles focused on assessing the effectiveness
of reablement interventions tend to compare the outcomes of such
interventions with “regular” long-term home care services10-17.
The second split has to do with the objectives of home care programs or
interventions we reviewed 6. The first type of
objectives are individual in focus and focus on the autonomy,
satisfaction, and health of the older adults or their family/friend
caregivers. Such objectives are frequently assessed using standardized
instruments focused on health status (i.e. SF-12 and SF-36), mental
health (i.e. 11-item CES-D Depression Scale, SPMSQ, Kessler-10 anxiety
and depression scale), quality of life (i.e. EUROQOL, WHOQOL-Bref),
functional capacities (i.e. OARS-IADL, Groningen Activity Restriction
Scale-3, Barthel Index of Activities of Daily Living), caregivers’
burden and perceived unmet needs, or idiosyncratic indicators linked
with specific interventions. The second type of objectives are societal
in focus and focus on the system-level efficiency, appropriateness of
resource allocation and the coherence between social values and
available services. Indicators of system level objectives focus more on
endpoint events (such as death or admission to hospital or nursing
home), service use intensity measured through administrative databases
(i.e. emergency room visits, number of hospitalizations, number of days
hospitalized, number of visits, continued use of home care after a given
time or number of visits), cost or cost benefits from those
interventions as well as broader policy-level discussion of the
alignment between practices and values.
Assessing Home Care
Effectiveness
Objectives and indicators
Among the 113 reviewed papers, 45 were focused on measuring or
synthesizing the effectiveness of one or multiple home care
interventions. Our first challenge when trying to synthesize the
evidence on home care intervention effectiveness revolved around the
vague operational definition of the concept of home care itself, and the
diversity in the objectives being pursued 9. The
effectiveness-focused articles we reviewed each relied on given sets of
indicators. Notably however, the rationale for those indicators were
seldom discussed in relation to the ultimate goal of the intervention
itself. For example, focusing on recipients’ quality of life versus
focusing on rates of hospitalization or number of hospital visits
suggest significantly different underlying objectives.
Shifting Goalposts
A second challenge concerns the research designs employed in the
research. Most of the effectiveness-focused studies rely on randomized
controlled trials (RCTs) and systematic reviews thereof. However, the
nature of home care interventions makes it difficult to appropriately
deploy such study designs. The vast majority of the RCTs we reviewed
compare a given home care intervention to “usual care” but fail to
define that baseline of “usual care.” In some studies, the “usual
care” provided consisted of a generous basket of services, while in
others it amounted to very little. Yet we only found three studies, all
from the United States, comparing the outcomes of providing versus not
providing home care services 18-20. Those studies all
showed clear benefits from receiving home care services. There are
obvious ethical considerations at play that might explain why few
studies explicitly compare the outcome of providing versus not providing
services to the same population. However, beyond those three studies,
when looking at the whole field it is important to contrast, on the one
hand, the significant efforts and resources invested in running RCTs
measuring the precise level of marginal benefits between two models of
home care and, on the other hand, the relative lack of interest in
demonstrating the gain of providing home care in itself.
Unclear Causal Processes
Compounding the problem, most evaluations of a given home care
intervention provided very little, if any, details on the nature of that
intervention 17. The descriptions generally mentioned
some elements, such as numbers of home visits, intervention durations,
or types of professionals involved, but often failed to provide the
level of detail needed to understand the process involved in the
production of the outcomes being measured. This observation was also
noted in other reviews of the field 21,22.
Because of the limitations discussed above, it is generally impossible
to know whether an intervention which outperformed the baseline in a
given context might prove beneficial in another. It also makes it
impossible to determine the relative effectiveness of interventions with
similar objectives. More generally, the policy value of most of the
effectiveness studies we reviewed were limited to the time and
jurisdiction of when and where the study took place.
If It Were Easy, It Would Succeed More
Often
One observation that stands out from the quantitative evaluations of
home care interventions we reviewed is this - designing an effective
intervention is not easy. Of the 45 evaluations of home care
effectiveness, 22 were able to demonstrate the success of a given home
care model or intervention while 23 offered unconvincing or negative
results. Other reviews in the field reported similar results23.
For example, Bouman, van Rossum, Nelemans, et al.24 systematic review of seven RCTs on preventive home
visits found that those programs had no effect. Berger, Escher,
Mengle, et al. 25 systematic review of 38
articles on occupational therapy-based home care services found some
benefits for participants’ occupational performance, mixed results for
quality-of-life indicators and no effect on health care utilization. Our
analysis also included one primary study 26 covering
similar ground that found no meaningful effect from the restorative
occupational therapy intervention studied.
Turning to reablement-focused interventions in particular, one 2013
Cochrane systematic review of this approach 10 failed
to identify any high quality evidence showing that such interventions
worked. The literature we reviewed included one primary RCT13 that found a reablement intervention to be superior
to regular care, yet others 27,28 which found no
meaningful benefits. Moreover, the primary studies of reablement
services we reviewed (n=10) tended to rely on methodological choices -
such as outcome measures focused on short-term physical autonomy gains
– that likely overemphasize the benefits of such approaches12.
Luker, Worley, Stanley, et al. 29 conducted a
systematic review of 31 RCTs of home care interventions aimed at
preventing the institutionalization of older adults, and found no
meaningful benefit overall. The authors then conducted a sub-analysis of
what they described as ”complex multifactorial interventions” which
suggested that this subgroup of interventions do in fact lower
institutionalization. However, the definition and boundaries of that
subgroup of intereventions is unclear and this approach could be
interpreted as data dredging (data dredging describe the aggressive
slicing of data and use of sub-group analysis to find statistically
significant results). Four of the studies labelled by Luker, Worley,
Stanley, et al. 29 as ”complex multifactorial
interventions” are part of our own data set. Two of those30,31 found no meaningful effects and two32,33 showed positive effects. Other primary RCTs
reviewed here 34 that focused explicitly on
multifactorial interventions found no effect as compared to the control
group. Aggressive sub-analysis and potential data dredging is also
present in some primary studies focused on similar interventions35-37
We also reviewed various nurse-led assessment and coordination of care
interventions in different high-risk populations 38-40that failed to measure a meaningful effect. One study combining three
different RCTs 33 found positive impacts on mental
health in one study and no impact in the two other RCTs. Another study41 of nurse-based home care found some effects on
secondary variables (such as the incidence of falls) but no improvement
in the primary outcome measure, which was related to quality of life.
The RCTs we reviewed with interventions aimed at improving post
discharge coordination between hospitals and home care services or
providing additional home care post discharge for frail elderly patients
both failed to measure any meaningful effects 30,42.
Low, Fletcher, Gresham, et al. 43 found no
convincing link between the need for home care services, the wait time
required to obtain said services, or even the amount of services
allocated. They also found no link between the services received and
outcomes measured, such as quality of life indicators.
This list of negative results provides half the portrait; as we stated
earlier, nearly half of the effectiveness-focused literature we reviewed
found significantly better outcomes for the intervention under study.
What we want to emphasize with this summary of non-effects is that one
should not underestimate the challenges related to the design and
implementation of an effective and efficient home care intervention.
Insights on What Seems to
Work
Three characteristics of home care interventions stand out in the
subsample of research studies which found positive results:
intersectoral integration, care coordination and relational continuity.
Regarding integration, Bernabei, Landi, Gambassi, et al.44 RCT of a multidisciplinary, integrated social and
health care intervention, among frail older adults in northern Italy,
found it improved functionality and mental health and lowered hospital
or nursing home admission and costs per recipient. Likewise, Landi,
Gambassi, Pola, et al. 45 quasi-experimental
study on the effectiveness of another multidisciplinary, integrated
social and health care intervention (also in in northern Italy), found
it lowered hospital admissions and costs. Beland and colleagues32,46 led the development and pilot testing of SIPA,
an integrated care intervention for vulnerable community-dwelling older
adults in Québec (Canada). The SIPA model involves community-based
multidisciplinary teams responsible for the full spectrum of care
provision, and led to improved accessibility, satisfaction and lower
per-recipient costs. Stewart, Georgiou, Westbrook 47systematic summary of the results from the broader PRISMA research
program, a different model also from Québec (Canada), identified 45
journal articles and two books authored or co-authored by the team that,
overall, support the effectiveness of integrated models of home care on
client satisfaction and limiting functional decline.
In the same way, multiple studies on the effectiveness of care
coordination in home care showed positive results. Onder, Liperoti,
Soldato, et al. 48 large-scale retrospective
cohort study of multiple European case-management programs found those
to effectively lower nursing home admissions. Scharlach, Graham,
Berridge 19 evaluation of an integrated assessment and
care coordination model suggests an improvement in clients’ satisfaction
and autonomy. Markle‐Reid, Weir, Browne, et al.49 RCT on the benefit of proactively providing older
people with home care nursing, health promotion and care coordination in
Ontario (Canada), found positive effects on mental health for similar
costs. Melis, van Eijken, Teerenstra, et al. 9ran a RCT in the Netherlands demonstrating improved client mental health
associated with a nurse-centred home care assessment and management
intervention. Morales-Asencio, Gonzalo-Jiménez, Martin-Santos, et
al. 50 Spanish, quasi-experimental study showed that
their nurse-led case management intervention had a positive impact on
functional capacity and caregiver burden. Bass, Judge, Lynn Snow,
et al. 51 surmised that in the United States, a
Veteran Health Administration’s care-coordination program focused on
caregiver needs lowered their level of unmet needs, strain and
depression. Parsons, Senior, Kerse, et al. 21’s
meta-analysis of RCTs of three different care management models in New
Zealand highlighted an association between those models and lower
long-term care admissions and the incidence of death. Lastly, Shapiro,
Taylor 18’s US-based RCT of a nurse-led assessment and
case-management intervention also found improved satisfaction, lowered
institutionalization and deaths.
The third characteristic we want to discuss here is relational
continuity. Relational continuity is an ongoing therapeutic relationship
between a service recipient and a professional 52. In
comparison with integration and care coordination, there is far less
hard evidence that links continuity with positive outcomes in the
documents we reviewed. Three effectiveness-focused studies identified
continuity as a characteristic associated with desirable outcomes49,53,54 while two other more analytical articles55,56 discuss its importance in high-performing home
care models. However, 34 of the documents we reviewed (30%) mention
continuity – most often relational continuity, with informational
continuity as a more secondary focus – as a desirable feature of home
care interventions and a core process leading to high quality services.
The next section on the main insights and policy-level lessons that can
be learned from the 113 documents analyzed here.