Back to the future: home-based primary care for older homebound Canadians

Defining the homebound elderly

One of the challenges of analyzing the health care needs of the homebound elderly is that this population remains imprecisely defined in the medical literature.³ The most widely accepted definition is the one used by the US Medicare program, which considers an ailing or injured individual to be homebound “if leaving the home requires considerable and taxing effort,” and if absences from the home “are infrequent, of short duration or to receive medical treatment.”⁸ However, experts recognize that even this definition might be too restrictive, as the way Medicare defines the homebound, primarily using simple physical criteria, might fail to encompass the complex interplay of medical, psychiatric, and cognitive issues, along with social frailty, that could render a person homebound.³

Research shows that compared with the overall older population, homebound elderly patients in general suffer from higher rates of metabolic, cardiovascular, cerebrovascular, and musculoskeletal diseases, as well as more cognitive impairment, dementia, and depression.³ This group also has high rates of chronic medication use,⁹ higher rates of emergency department use, and nearly twice the rate of annual hospitalizations as those who are not homebound.¹⁰

While Canadian data are unavailable, in the United States at least 1 million individuals aged 65 and older are permanently homebound,¹¹ with some researchers estimating the number to be as high as 3.6 million.³ We therefore conservatively estimate that there are at least 100 000 older homebound Canadians.

Defining the model

Historically, physicians routinely and indiscriminately delivered medical care to sick patients in patients’ homes, with housecalls accounting for 40% of all doctor-patient encounters in the 1940s.¹² Ever since, these visits have become less frequent as physicians developed an increasing reliance on technology, thus shifting health care provision to hospitals and offices, while traditional fee-for-service payment models reward high-volume and short-duration episodes of care.¹³

These traditional housecalls must be distinguished from modern home-based primary care models, which provide comprehensive ongoing primary care in the home and specifically target patients with complex chronic disease who are poorly served by office-based care.¹⁴

In order to meet the complex needs of homebound elderly patients, the provision of home-based primary care is often facilitated by organized programs that involve physician- or nurse practitioner–led interprofessional teams, frequently incorporating the support of other allied health and social care professionals.¹⁴ These home-based primary care programs have the following overall goals:

• providing access to ongoing primary medical care;

• maximizing independence and function;

• reducing emergency department and hospital admissions;

• enhancing patient safety and quality of life; and

• linking patients to supportive home-care services.^14,15

However, home-based primary care is not limited to these programs, as some independent family physicians maintain ongoing care of their homebound elderly patients through frequent housecalls.

Finally, home-based primary care models must also be distinguished from other modern home-based care models, which primarily include hospital-at-home, home visit outreach, and transitional care programs, along with skilled home-care services (Table 1).^14–19 But none of these other models is designed or able to provide ongoing comprehensive home-based primary care.

Existing research

The emergence of modern home-based care models has sparked several studies investigating the efficacy of these models. Since 2000, 5 English-language systematic reviews (3 were also meta-analyses^20–22) of home-based care models for the elderly have been published with conflicting results.^20–24 Some of these reviews reported that home visit outreach and primary care programs did not affect mortality,^23,24 physical and psychosocial function,²³ health status,²⁴ or health care use and costs.²⁴ Conversely, other reviews concluded that these programs reduced mortality,^20,21 admissions to long-term care facilities,^20–22 and functional decline.^20,22

However, experts recognize that the individual trials included in these reviews are extremely heterogeneous, and many of the programs studied did not aim to provide comprehensive and ongoing primary care. Furthermore, many programs were home visit outreach programs originating from the United Kingdom and Europe, where patients maintained their office-based primary care providers, and home visits were provided as a separate and independent intervention.^2,25 But these types of program generally fail to remedy the barriers to accessing primary care for the homebound, and promote fragmentation of care between those providing housecalls and the primary care provider. Experts have therefore hypothesized that inclusion of studies on British and European home visit outreach programs might have produced disparate results in previous systematic reviews and meta-analyses.^12,25

Learning from the United States

Several home-based primary care programs have emerged across the United States that are characterized by common principles: 1) medical housecalls are made by the ongoing primary care provider (physician or nurse practitioner); 2) the primary care provider leads an interprofessional care team; and 3) the program is available after hours for urgent issues.^7,14 Many of these programs also have access to or the capability to perform home-based laboratory and diagnostic imaging services.¹² Several leading medical centres have developed academic home-based primary care programs, with several reporting impressive outcomes such as substantial reductions in emergency department visits,²⁶ hospitalizations,^2,13,26 and long-term care admissions.²

The largest proponent and most successful provider of home-based primary care has been the Veterans Health Administration in the United States. In the mid-1990s, a concerted effort to shift the focus and delivery of veterans’ care to outpatient primary care models was pursued.¹⁵ This important transformation was made with the foresight that older veterans would be poorly served by a health care system that was becoming increasingly reliant on inpatient and acute care models. In 1995, the Veterans Affairs System established its home-based primary care programs with the firm intent to deliver longitudinal comprehensive primary care in the home.¹⁴

These programs currently care for approximately 25 000 veterans across the United States,⁷ and have demonstrated the ability to achieve good patient, caregiver, and systems-level outcomes. Emerging evidence from the Veterans Affairs System has reported considerable improvements in patient quality of life²⁷ and caregiver satisfaction,²⁷ as well as reductions in emergency department visits,¹⁵ hospitalizations,^15,28,29 readmissions,²⁷ and long-term care admissions.¹⁴

However, most existing studies from the Veterans Affairs System and elsewhere are observational in design and employ a before-and-after analysis (Table 2),^{2,13,15,26–30} and there is a need for high-quality prospective randomized trials to further support this model of care. (This is further discussed in the “Research and evaluation” section of the second part of this commentary [page 243].³¹) Additionally, it is critical that future studies carefully consider their target populations to ensure that they are selecting appropriate study participants who will actually benefit from the home-based primary care model. (This is further discussed in the “Designing effective and scalable programs” section of the second part of this commentary [page 243].³¹) This is particularly relevant because the one multisite randomized controlled trial of this model of care was only able to report significant systems benefit for the model in study participants with severe disability (P = .03).²⁷ However, it is also critical that future investigations continue to look beyond systems outcomes, as many studies have reported considerable benefit on quality of life for patients and their caregivers.^26,27

In 2006, Veterans Affairs home-based primary care programs treated 20 783 patients, and the intervention resulted in a 27% reduction in hospital admissions and a 69% reduction in inpatient days in their programs nationwide.²⁹ The home-based primary care program at the Denver Veterans Affairs Medical Center reported that in 2003 the program cared for 104 patients and reported 1-year cost savings of $1 065 513, with 98% of these savings being attributed to reductions in hospitalization.¹⁵

Recognizing the success of these programs, the most recent US health care reform legislation—the Patient Protection and Affordable Care Act of 2010—included a provision to test a remuneration incentive and operational model for home-based primary care, known as the Independence at Home program.⁷ This demonstration program is adopting the core standards that characterize other successful US programs, including using physician- or nurse practitioner–led teams who are available 24 hours a day, 7 days a week.⁷ This demonstration program aims to reduce emergency department visits and avoidable hospitalizations and readmissions, improve patient outcomes, and reduce health care costs.⁷ A similar investment in home-based primary care in Canada could better ensure the long-term sustainability of our health care system.