"These findings are important because a large number of older people receive home care services and they tend to have a large burden of illness and are at risk for functional decline," said Mary Tinetti, M.D., professor of medicine at Yale School of Medicine and lead author of the study. "This restorative approach to care appears to be both effective in maintaining or improving function and symptoms, in reducing the number of home care and emergency visits and potentially saving costs."
Optimizing patient function and comfort, particularly for older, chronically ill persons with multiple illnesses, is particularly important following episodes of acute illness and hospitalizations, Tinetti said.
"Between 25 percent and 50 percent of all hospitalized older persons experience loss of function or functional independence during hospitalization," she said in the study. "According to previous studies, only a third recover to pre-hospital levels of functioning by three months."
Traditionally, home care has been aimed at treating individual diseases. There is, however, a recent mandate by the federal Center for Medicare and Medicaid Services that attention be paid to functional outcomes of patients receiving home care as well, while reducing overall costs.
"The confluence of these mandates to both constrain costs yet improve outcomes provides the opportunity to investigate innovative and cost effective clinical strategies," Tinetti said.
The study compared the outcomes of 691 patients who received restorative care vs. a similar number of patients who received usual home care. The patients were 65 years of age or older, received at least seven days of home care, had no severe cognitive impairments, and were not terminally ill, bedridden, or requiring total care. The care was delivered by one of the largest home care agencies in Connecticut. The following areas were evaluated: functional status, likelihood of remaining home, duration and intensity of the home care episode, emergency visits to a physician, emergency department visits and pain or shortness of breath.
Patients who were provided home care under the restorative care model had a greater likelihood of remaining at home (82 percent vs. 71 percent), a reduced likelihood of visiting an emergency department (10 percent vs. 20 percent), and also had better mean scores in self care and mobility.
The restorative care model was based on principles adapted from geriatric medicine, nursing, rehabilitation and goal attainment. Among key characteristics are training of nurses, therapists and home health aides in rehabilitation, geriatric medicine and goal attainment; a team approach to maximize function and comfort, and input from the patient, family and home care staff in the process of establishing and reaching these goals.
Measurement after three months included the patients’ ability to walk and transfer from a bed to a chair; to dress, bathe, eat and use the bathroom independently, as well as to prepare light meals, use transportation, do laundry and housekeeping, shop, use the telephone, and manage oral medications.
Co-authors included Dorothy Baker, William Gallo, Aman Nanda, M.D., Peter Charpentier and John O’Leary.
Journal
JAMA