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.