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Table 3 Integrated care

From: A systematic review of different models of home and community care services for older persons

Author (year) Study name/Location; Study design; Intervention Length Participant group; n (% female); Age (± SD) Study groups Outcomes and Results Quality Rating
Beéland (2006) System of Integrated Care for Older Persons (SIPA), Canada RCT 1 year 10 months (= 572 days) ≥65 years n = 1230 (71% F) = 82 Participants received care from multidisciplinary teams who delivered integrated care through the provision of health and social services and coordination of hospital and nursing home care, monitoring protocols and providing mobilized resources, including intensive home care, group homes, and a 24-hour on-call service. Controls received usual home care services including nursing, rehabilitation, physician, personal, and social services with limited time and availability and no case management. Over 22 months significantly more SIPA participants compared to controls received home health (OR = 1.72 95% CI: 1.20-2.46) and home social care (OR = 2.16, 95% CI: 1.60-2.91). There were no significant differences between the groups in mortality or admissions to emergency, hospital or nursing homes. Caregivers' satisfaction with care after 1 year was significantly higher in the intervention group than the control group. There were no significant differences on participants' satisfaction with care, chronic diseases, depression, cognition, functional limitations, daily function, and caregiver burden between the intervention and the control groups. 12.5
Hammar (2007) Finland Cluster RCT 6 months ≥65 years without dementia n = 668, 22 municipalities (74.0% F) = 81.7 Participants were assigned a home nurse and home helper who planned and integrated home care services with other service providers and hospital staff. Controls were from municipalities without case management or integration. Controls had a smaller number of diagnoses than participants. At 3-week follow-up, physical mobility significantly improved in the intervention group (p < 0.002) compared to controls but the effect was lost at 6-month follow-up. At 3-week and 6-month follow-ups, there were no significant changes between the two groups on energy, sleep, pain, emotional reactions, and social isolation. There were no differences in self-rated health, daily function, rates of mortality, institutionalization and hospitalization. 12.5
Fischer (2003) Kaiser Permanente Northwest, USA Longitudinal observational 5 years Enrollees of Social Health Maintenance Organization (SHMO) ≥65 years n = 18143 (63.7% F) = 75 Participants enrolled in the SHMO received case management and coordination to integrate the delivery of long-term care within the medical care system. Services included care coordination, home nursing visits, homemaking, transportation, adult day care and nursing home respite. Controls resided in an area where the SHMO was terminated and at baseline were younger and had fewer chronic health conditions and less utilization of acute and nursing home inpatient days compared to participants. Over 5 years, there was an increased probability of nursing home placement for the control group compared to the intervention group (OR = 1.43, 95% CI: 1.15-1.79, p = 0.002). Over 5 years there was no difference in mortality between the intervention and the control group (OR = 1.02, 95% CI: 0.87-1.20, p = 0.828). 12
Atherly (2004) Program of All Inclusive Care for the Elderly (PACE), USA Cross-sectional >55 years n = 265 (mean age not reported) Participants received care from the PACE interdisciplinary teams whom conducted comprehensive assessments and delivered preventive, primary, rehabilitative, supportive, and end-of-life care integrated into a complete health care plan. PACE also attempted to limit unnecessary hospital and nursing home use. Controls were eligible older persons who declined PACE services. Participants in the PACE group had higher satisfaction on Perceived Interpersonal Quality (p = 0.0006, d = 0.3) and Decision Making (p < 0.0001, d = 0.2) scales compared to controls. There were no differences on family satisfaction. 8.5
Bird (2007) Hospital Admission Risk Program; (HARP), Australia NRCT ≥90 days (= 227 ± 104 days) >55 years n = 316 (51.3% F) = 75.3 ± 8.5 Participants were allocated a care facilitator who linked them to all required acute and community services. They also ensured effective communication and exchange of relevant information between services including specialist medical clinics, allied health therapies and carer support services. Controls were eligible older persons who declined participation. No demographic differences were detected at baseline between controls and participants. Comparing the 12 months pre-recruitment and post-recruitment, participants in the intervention group had a 20.8% reduction in emergency visits (p < 0.001), 27.9% reduction in hospital admissions (p < 0.001), and 19.2% reduction in bed-days (p < 0.001). In the 12 months pre-recruitment and post-recruitment older persons who declined participation showed a non-significant 5.2% increase in emergency visits, 4.4% reduction in hospital admissions, and 15.3% increase in inpatient bed-days. 8
Kane (2006) PACE and Wisconsin Partnership Program (WPP), USA Longitudinal Variable length ≥65 years n = 1285 (77.3% F) = 77.8 PACE group as above Participants enrolled in WPP were offered choice of care, setting, and manner in which their service was delivered and were able to keep their primary physician, whereas PACE enrollees were not given these choices. Enrollees in PACE were more likely to be women, older, non-White and eligible for Medicaid only (ie not low-income older persons or disabled). Per person-month of program enrollment, the PACE group had fewer hospital admissions (OR = 0.682, p < 0.001), preventable hospital admissions (OR = 0.589, p < 0.01), hospital days (p < 0.05), emergency visits (p < 0.001), and preventable emergency visits (p < 0.05) than WPP. There was no significant difference between the two groups in the length of hospital stays. 8
Brown (2002) UK NRCT 18 months ≥65 received a social services assessment after referral from study general practice N = 393 (67% F) = 81 (65-99) Intervention participants were assessed and managed by social service departments (SSD) co-located with general practices. SSDs met weekly with general practice staff, largely for cross-referrals. Control participants resided in a county of similar population and size which were managed by traditional SSDs. There were no differences between rates of mortality and nursing home placement after 18 months. In the intervention group time to assessment was shorter than controls (p = 0.039, d = 0.24), and there was an increase in quality of life over 18 months (p = 0.08) not apparent in controls. There were no differences in changes over 18 months on daily function, mental functioning or depression. 8
Wieland (2000) PACE, USA Longitudinal Up to 8 years >55 years n = 5478 (71.1% F) = 78.9 ± 8.9 PACE group as above Data were compared to the general Medicare population of older and disabled Americans. Time to hospitalization for PACE was 773 days (median; 95% CI: 725-814) comparable to Medicare aged and Medicare disabled populations. Annual short-term bed use in PACE showed a decline and was comparable with the general Medicare population, 2046 (in 1998) versus 2014 (in 1997) respectively (no statistical test performed). 8
Weaver (2008) All-Inclusive Long-term Care, USA Longitudinal Up to 36 months Older persons veterans (≥55 years) n = 368 (3.8% F) = 76.1 Three Veterans Affairs (VA) medical centers served as study sites, each providing a different program of care: The VA as sole provider program: VA provided all care including homemaker and home health aides, adult day care and health needs. The VA and PACE partnership program: VA provided hospitalization, short-term nursing home for sub acute rehabilitation, subspecialty consultation, laboratory imaging, and pharmacy services while PACE assumed responsibility for primary care, adult day health care, transportation, home health care, homemaker and other supportive care needs. The VA as care manager program: Contracted for PACE to provide all care, veterans did not use VA healthcare services while enrolled in PACE. Compared to 6 months before program entry, by program discharge there was a significant increase in adult day health care use in all three models (p < 0.001). In the VA as care manager model, there was a significant increase in home care use (p < 0.001) and nursing home use (p < 0.02), but no such increases were found for the other two models. No statistically significant differences were observed in all models in hospital admissions per patient, total inpatient days per patient, nursing home admissions per patient, nursing home days per patient, inpatient, and outpatient clinic use. 7
Temkin-Greener (2002) PACE, USA Longitudinal Variable length >55 years n = 2263 = 80 PACE group as above. Data were compared to the general Medicare population of older and disabled Americans. The probability of death at home for PACE participants (45.0%) was twice as great as the probability of death at home for the Medicare population of older Americans (no statistical test performed). 7
Kane (2002) WPP (as above) Case controlled ≥65 years n = 1163 78% F = 78.7 WPP described above. Controls were community options program recipients a Medicaid home and community based waiver program who receive a variety of community services designed to meet their care needs but receive their medical care from fee-for-service Medicare providers matched on age and gender from within the same county (in-area controls) and from non-WPP county (out-of-area controls). Dependency for daily self-care was lower in WPP than in area and less consistently in out-of-area controls (p ranged from 0.000 to 0.033). Over the previous 3 months fewer WPP received homemaker (p < 0.001), but more WPP received nurse, home delivered meals, special transportation, adult daycare, outpatient rehabilitation and physical therapy than both control groups (p ranged from 0.000 to 0.033). There were no differences between groups on depression, pain and unmet needs, use of medical equipment or informal care. The few differences on the 21 satisfaction items were not consistent across control groups. 7
  1. NRCT = Non-randomized controlled trial; RCT = Randomized controlled trial.