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Not an enchanted place

I have come back again to where I belong; not an enchanted place, but the walls are strong.
Dorothy H. Rath

I was once asked to take on a new patient by her husband. He came expecting to be turned down because he had been told by others that his request was unreasonable. His once-well wife needed to be in a chronic care setting, but she wanted to live at home. And he wanted her at home too. He needed a physician to organize her home care. I agreed to take her on in my practice, and we started to put together a plan.

There is no broadly accepted definition of home care. The Canadian Home Care Association defines it as an array of services, provided in the home and the community, encompassing health promotion and teaching, curative intervention, end-of-life care, rehabilitation, support, maintenance, social adaptation and integration, and support for informal (family) caregivers. A broad range of activities, to be sure. To confuse matters further, home care often integrates the delivery of health care services in the home with community services (eg, Meals on Wheels, day programs, respite care facilities, transportation services).¹

Home care is not legislated through the Canada Health Act, but government-funded programs exist in all provinces and territories. Most home care services are delivered by provincial, territorial, and, in some areas, municipal governments.² The services covered, the delivery methods, and the funding of these services across the provinces and territories varies.³ In particular, population density makes a difference in provision of services. Although 98% of Canada’s geography is rural or remote, these areas tend to have fewer health care resources and community supports compared with urban areas.⁴

In this issue, we focus on 2 innovative aspects of home care: telehomecare and home-based intermediate care. Telehomecare refers to the use of information and communications technologies to enable effective delivery and management of health services like medical diagnosis, treatment, consultation, or health maintenance between a patient’s home and a health care provider. Telehomecare has been identified as a best practice in the delivery of health care in rural and remote settings.⁴ Although studies have demonstrated improved accessibility, quality of care, and quality of life with the use of telehomecare, there has been little uptake in primary care.⁵ Liddy and colleagues (page 58) explore the use of this technology in monitoring patients with chronic illnesses in a semirural primary care setting. Although this pilot study showed that patients, informal caregivers, and health care providers were satisfied with the technology and found it useful, further studies looking at clinical outcomes are needed.

The term intermediate care is often used to refer to the range of services designed to facilitate transition from hospital to home. These services are generally beyond the scope of the traditional primary care team, but do not require the full resources of a hospital.⁶ It is thought that providing these services in the home might be a cost-effective alternative to hospital care and might also reduce the demand on hospital beds. Deri Armstrong et al (page 66) assess the actual costs of a home-based intermediate care program in a large Canadian city, compared with historical controls. The researchers found that there were no cost-savings associated with this program. There were, however, several confounding factors that might have contributed to this result. More research is needed to determine if home-based intermediate care in Canadais cost-effective and provides similar or improved clinical outcomes to hospital-based care.

What happened with my patient? We were able to put together an excellent health care team that enabled her to have hospital-level chronic care services in her home. The process required time, coordination, and lots of patience. She had several good years at home with her husband until she died of complications related to aspiration. Her husband is grateful for the extra time they had together.

Unfortunately, I would find it difficult to duplicate this level of home care for another patient. We were able to provide these services because of several important factors: my patient had a gold-plated insurance plan, lived across from a teaching hospital, and, most important, had a husband who was determined to bring his wife home. An enchanted place? No. Strong walls? Yes.

	References

TOP References

 

1. Health Canada. Home care case management: invitational roundtable, March 3–4, 2005. Summary of proceedings. Ottawa, ON: Health Canada; 2005. Available from: www.hc-sc.gc.ca/hcs-sss/pubs/home-domicile/2005-cas-mgmt-gest/index_e.html. Accessed 2007 Dec 3.
2. Health Canada. Home and community care. Ottawa, ON: Health Canada; 2006. Available from: www.hc-sc.gc.ca/hcs-sss/home-domicile/commun/index_e.html. Accessed 2007 Dec 3.
3. Preto N, Mitchell I. Ethical issues in home care. Ottawa, ON: Health Canada; 2004. Available from: www.hc-sc.gc.ca/hcs-sss/pubs/home-domicile/2004-ethi-homedomicile/index_e.html. Accessed 2007 Dec 3.
4. Canadian Home Care Association. The delivery of home care services in rural and remote communities in Canada. Ottawa, ON: Canadian Home Care Association; 2006.
5. Health Canada. eHealth resources. Ottawa, ON: Health Canada;; 2006. Available from: www.hc-sc.gc.ca/hcs-sss/ehealth-esante/res/thesaurus/index_e.html. Accessed 2007 Dec 3.
6. Melis RJF, Olde Rikkert MGM, Parker SG, van Eijken MIJ. What is intermediate care? BMJ 2004;329:360-1. DOI:10.1136/bmj.329.7462.360.[Free Full Text]

Related articles in CFP:

Telehomecare for patients with multiple chronic illnesses: Pilot study

Clare Liddy, Joanne J. Dusseault, Simone Dahrouge, William Hogg, Jacques Lemelin, and Jennie Humber
CFP 2008 54: 58-65. [Abstract] [Full Text]  

Home-based intermediate care program vs hospitalization: Cost comparison study

Catherine Deri Armstrong, William E. Hogg, Jacques Lemelin, Simone Dahrouge, Carmel Martin, Gary S. Viner, and Raphael Saginur
CFP 2008 54: 66-73. [Abstract] [Full Text]  

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