A before-after study of hospital use in two frail populations receiving different home-based services over the same time in Vancouver, Canada

Abstract

BackgroundAs individuals age, they are more likely to experience increasing frailty and more frequent use of hospital services. First, we explored whether initiating home-based primary care in a frail homebound cohort, influenced hospital use. Second, we explored whether initiating regular home care support for personal care with usual primary care, in a second somewhat less frail cohort, influenced hospital use.MethodsThis was a before-after retrospective cohort study of two frail populations in Vancouver, Canada using administrative data to assess the influence of two different services started in two different cohorts over the same time period. The participants were 246 recipients of integrated home-based primary care and 492 recipients of home care followed between July 1st, 2008 and June 30th, 2013 before and after starting their respective services. Individuals in each group were linked to their hospital emergency department visit and discharge abstract records. The main outcome measures were mean emergency department visit and hospital admission rates per 1000 patient days for 21 months before versus the period after receipt of services, and the adjusted incidence rate ratios (IRRs) on these outcomes post receipt of service.ResultsBefore versus after starting integrated home-based primary care, emergency department visit rates per 1000 patient days (95% confidence intervals) were 4.1 (3.8, 4.4) versus 3.7 (3.3, 4.1), and hospital admissions rates were 2.3 (2.1, 2.5) versus 2.2 (1.9, 2.5). Before versus after starting home care, emergency department visit rates per 1000 patient days (95% confidence intervals) were 3.0 (2.8, 3.2) versus 4.0 (3.7, 4.3) visits and hospital admissions rates were 1.3 (1.2, 1.4) versus 1.9 (1.7, 2.1). Home-based primary care IRRs were 0.91 (0.72, 1.15) and 0.99 (0.76, 1.27) and home care IRRs were 1.34 (1.15, 1.56) and 1.46 (1.22, 1.74) for emergency department visits and hospital admissions respectively.ConclusionsAfter enrollment in integrated home-based primary care, emergency department visit and hospital admission rates stabilized. After starting home care with usual primary care, emergency department visit and hospital admission rates continued to rise.

A qualitative study of health‐care experiences and challenges faced by ageing homebound adults

“…Difficulties with going out and accessing office‐based health care may be mitigated through increased provision of services such as insurance‐provided non‐emergency medical transportation (NEMT), increasing public infrastructure accessibility and increasing education about available transportation assistance services 42,43 . For individuals unable or unwilling to leave their homes, HBPC could play a major role in improving patients’ health through avoiding the cost, burden and inconvenience associated with transportation challenges, and through increasing access to health care 20‐22 …”

“…A few study participants spoke about having physicians come to their homes when they were children, nearly 60 years ago. Some participants were concerned about the effect of HBPC on health‐care system efficiency; however, technological advances, new payment models and varied HBPC models may actually improve efficiency and cost‐effectiveness 7,16,20,21,46 . Furthermore, HBPC provides an opportunity for strong, long‐term patient‐provider relationships, just as office‐based visits do, through regular home calls conducted by the patient's interdisciplinary care team 7,46 .…”

“…It is important to distinguish HBPC from Medicare home health‐care services, although both are often referred to as home‐based medical care, as Medicare home health care tends to be temporary or intermittent 7,9,15,17,18 . HBPC produces high patient satisfaction rates, lower hospitalization durations, lower readmissions, decreased emergency department visits, and lower Medicare costs with similar survival outcomes 3,7,9,16‐22 . There is currently a shortage of HBPC providers compared to the number of individuals in need 7,9,16 …”

Advance Care Planning and Decision-Making in a Home-Based Primary Care Service in a Canadian Urban Centre

“…The setting was a population of seniors receiving longitudinal home-based primary care (Home ViVE—Home Visits for Vancouver’s Elders) (11) due to their inability to access usual ambulatory primary care as a result of dementia and/or physical frailty. Care is publicly funded and provided by a team of family physicians, nurse practitioners, registered nurses, health science professionals, and office administrative support.…”

Stressors Facing Home-Based Primary Care Providers

“…In the 1980s and 1990s, the number of house calls decreased precipitously, but since that time there has been an increase in the number of house calls performed [5]. Furthermore, HBPC is not only gaining traction in the United States but has also begun to grow internationally as well [6]. Unfortunately, the number of patients that could benefit from HBPC far exceeds the number of clinicians performing house calls [2].…”