Aging Clin. Exp. Res . 7: 247-250, 1995

A randomized trial of multidisciplinary in-homecare for frail elderly patients awaiting hospitaldischargeA.L. MelinSerafen Primary Health Care Center, Stockholm , Sweden

Multidisciplinary clinical programs for frail el­derly people have emerged since the 1980's inthe form of in-hospital and post-hospital geriatricassessment units , and physician-led home healthcare teams (1-3). The present work was occa­sioned by a crisis of bed availability in the hospitalsof Stockholm, Sweden, which occurred due to re­tention of large numbers of frail elderly patients oth­erwise ready for discharge. We developed a physi­cian-led primary home care intervention programfor chronically ill, dependent patients after short­term hospital care . In collaboration with homeservices assistance , a multidisciplinary team as ­sessed each patient's needs for medical , function­al and social care in the home. This service wascompared with usual hospital and post-hospitalcare in terms of 6-month health outcomes andcost, in a prospective, randomized controlled trialdescribed in greater detail elsewhere (4-6).

The study was conducted from May 1988 toOctobe r 1990. Patients awaiting hospital discharge ,but at risk for long-stay hospital care were recruit­ed in St. Gorans , a county general hospital. Pa­tients were required to be medically stable , butchronically ill , and dependent in 1-5 Katz ADLs.Demented and aphasic patients, and those fromservice hotels, were excluded. Over 23 months ,745 inpatients were screened, with 255 meetingthe study criteria. Consenting patients were ran­domly assigned either to receive "team " (N=150) or"standard" care (N=99) . Following randomization,"team" subjects were discharged home to the careof the team, comprised of the project and teamphysicians, a secretary, district nurse , physiother­apist, occupational therapist , and nurse assistant."Standard" care could consist of continued treat­ment in an acute or long-stay hospital , followed by

standard district nurse-administered care at home.At randomization , team and control patients

were found very comparable in most assessedcharacteristics , including age , gender, and otherdemographic and functional measures (Table 1).Team patients had significantly more medical di­agnoses at baseline (p=0 .003). Both team andcontrol patients were moderately impaired in cog­nition and basic ADLs. Patients in each groupwere taking over 4 prescribed medications (4, 5).

By six months , 27% of team and 26% of con­trol patients had died (NS). Survivors in bothgroups tended to recover in terms of basic and in­strumental ADLs , cognitive status, mobility , andsocial act ivities (4). From randomization to 6­month follow-up , team patients had improvedsignificantly more than controls in instrumentalADLs and outdoor mobility status (Table 2). Also,changes in the number of active diagnoses andmedications favored team patients.

Analysis of service utilization and associatedcosts demonstrated that surviving team patientsused less long-term institutional care (p<O .OOl)and more home care (p=O.OOl), than survivingcontrols (Table 3). Further, among survivors , totalhealth-care costs were significantly less for theteam group , with a reduction of 20 .2% (5).

Among decedents , team patients spent moredays at home (p<O.OOl) and used less inpatientand more outpatient care than controls (Table4) . Total costs did not differ significantly.

In summary, this multidisciplinary in-home teamcare program was found to be cost-effective for se­lected elderly , chronically ill , dependent hospitalpatients . We determined that these patients canlive a fairly normal life at home in spite of theirhealth problems and daily assistance needs. The

Key words : Geriatric assessment, health-care outcomes , random ized controlled trials.

Correspondence: Anna Lisa Melin, M.D., Serafen Primary Health Care Center, Hantverkargatan 2, 11283 Stockholm, Sweden.

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A.L. Melin

Table 1 - Baseline characteristics of team and control patients.

Parameter

Age

Male

Widowed/living alone

Children

Education :E 7 years

Katz ADLs (range: 0, 6)

Instrumental ADLs (r: 6, 30)

Folstein MMSE (r: 0, 30)

Indoor walking (r: 1, 5)

Social activities (r: 0, 21)

Social contacts (r: 0, 21)

Medicaldiagnoses (#)

Prescription drugs (#)

Primary cardiovascular disease

Primary circulatory disease

Percent or Mean ± SEM

Team (N=150) Control (N=99)

81.3 ± 7.8 80.7 ± 7.7

31% 30%

76% 68%

57% 58%

61% 66%

2.4 ± 0.1 2.3 ± 0.1

6.0 6.0

22.2 ± 0.4 22.3 ± 0.5

3.2 ± 0.1 3.0 ± 0.1

5.7 ± 0.5 5.2 ± 0.6

5.6 ± 0.3 5.9 ± 0.5

4.5 ± 0.1 3.9 ± 0.1

4.4 ± 0.2 4.3 ± 0.2

23% 21%

19% 28%

p value

0.47

0.86

0.13

0.93

0.43

0.48

0.41

0.17

0.48

0.75

0.003

0.78

0.76

0.16

ADL: activities of daily living (7); MMSE: Folstein Mini-mental State Exam (8); walking ability (9). Higher scores reflect greater health/independence.

Table 2 - Functional and medical status, and care satisfaction: mean differences from entry to six-month follow-up in team and con­trol groups.

Parameter Mean Difference ± SEM p value

Team (N=110) Control (N=73)

Katz ADLs 1.8 ± 0.2 1.6 ± 0.3 0.48

Instrumental ADLs 4.9 ± 0.6 3.2 ± 0.7 0.04

Folstein MMSE 1.4 ± 0.4 1.7 ± 0.5 0.65

Indoor walking 0.7 ± 0.1 0.8 ± 0.2 0.95

Outdoor walking 1.1±0.2 0.6 ± 0.1 0.03

Social activities 6.7 ± 0.8 7.1 ± 0.8 0.75

Social contacts 1.3 ± 0.5 1.1 ± 0.7 0.83

Medicaldiagnoses (#) -0.5 ± 0.1 0.4 ± 0.2 0.001

Prescription drugs (#) 0.0 ± 0.1 0.4 ± 0.2 0.05

Satisfaction with care (range: 1-5) 0.3 ± 0.1 0.4 ± 0.1 0.99

Note: Higher satisfaction score reflects greater satisfaction with care; indoor/outdoor walking, see reference 9.

248 Aging Clin. Exp. Res., Vol. 7, No.3

In-home care trial

Table 3 - Institutional and home-care services utilization and associated costs (in thousands of u.s. dollarsF for survivors during 6­month follow-up, by group.

Level of Care Team (N=110) Control (N=73) p value (cost)

Mean ± SO Per capita cost Mean ± SO Per capita cost

Institutional (days) (days)

Short-term 24±32 9.3 25±27 9.5 0.50

Long-term 16±42 3.6 49±62 10.8 <0.001

Rehab. hasp. 2±17 0.5 3±16 0.6 0.87

Outpatient Care

Per capita home-care and clinic visits 220.6 5.4 123.7 3.6 =0.001

Other costs/ 0.6 0.5 =0.01

Team-care-' implementation 0.7

Total costs 20 4 25 =0.02

One U.S. dollar = 6.453 Swedish crowns (1989 exchange rate).Other costs include home medications, durable equipment and prosthetics, transportation, and reimbursement of informal caregivers.Implementation costs include team staff salaries and weekly meetings.Column does not total due to rounding error.

Table 4 - Institutional and outpatient services utilization and associated costs (in U.S. dollars)1 for decedents during 6-month follow­up, by group.

Level of Care Team (N=40) Control (N=26) p value (cost)

Mean± SO

Institutional

Short-term

Long-term

Rehab. hosp.

Outpatient care

Per capita cost

(days)

22±19

4±12

1±4

Mean ± SO

(days)

149.9

7.4

5.4

Per capita cost

24±33

25±46

o

179.9

53.6

0.93

0.18

Per capita home-care and clinic visits

Other costs/

Total costs

31.8

4.2

5.7

2.0

<0.001

=0.01

0.53

lOne U.S. dollar ~ 6.453 Swedish crowns (1989 exchange rate).2 Other costs include home medications, durable equipment and prosthetics, transportation, and reimbursement of informal caregivers.3 Column total includes team implementation costs.4 Column does not total due to rounding error.

team care approach results in a decreased numberof long-term care hospital days, more days athome, and less total per capita cost. For soci­ety, the total cost of health services can be de­creased marginally, but significantly.

ACKNOWLEDGEMENTSThis study was supported by grants from the Foundation

Aldre Centrum of the Stockholm County Council, and Cen­trala Stockholms Sjukvardsomrade, Stockholm City Council.The author would like to thank Lars Olov Bygren, M.O., Umea,for his helpful review of an earlier version of this manuscript, and

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A.L. Melin

Elisabeth Berg, B.Sc., Stockholm, who reviewed the statisticalprocedures.

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4. Melin AL., Bygren L.O.: Efficacy of rehabilitation of elderly

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primary health care patients after short-stayhospitaltreatment.Med. Care 30: 1004-1015, 1992.

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