A systematic review of different models of home and ... · Consumer-directed home care has been trialed in several countries including the Netherlands, England, Germany, France, USA

RESEARCH ARTICLE Open Access

A systematic review of different models of homeand community care services for older personsLee-Fay Low*, Melvyn Yap and Henry Brodaty

Abstract

Background: Costs and consumer preference have led to a shift from the long-term institutional care of agedolder people to home and community based care. The aim of this review is to evaluate the outcomes of casemanaged, integrated or consumer directed home and community care services for older persons, including thosewith dementia.

Methods: A systematic review was conducted of non-medical home and community care services for frail olderpersons. MEDLINE, PsycINFO, CINAHL, AgeLine, Scopus and PubMed were searched from 1994 to May 2009. Tworesearchers independently reviewed search results.

Results: Thirty five papers were included in this review. Evidence from randomized controlled trials showed thatcase management improves function and appropriate use of medications, increases use of community services andreduces nursing home admission. Evidence, mostly from non-randomized trials, showed that integrated careincreases service use; randomized trials reported that integrated care does not improve clinical outcomes. Thelowest quality evidence was for consumer directed care which appears to increase satisfaction with care andcommunity service use but has little effect on clinical outcomes. Studies were heterogeneous in methodology andresults were not consistent.

Conclusions: The outcomes of each model of care differ and correspond to the model’s focus. Combining keyelements of all three models may maximize outcomes.

BackgroundAcross the world, the proportion of older persons isprojected to grow from 6.9% of the population in 2000to a 19.3% in 2050 [1]. This expanding aged populationhas resulted in an increasing need for long-term careservices for the frail aged. Costs and consumer prefer-ence have led to a shift from the long-term institutionalcare of aged older people to home and communitybased care [2,3], a pattern that is anticipated to grow.Home and community care services (otherwise known

as domiciliary, non-medical home care or social care)aim to assist the older persons to live independently intheir homes, and to maintain or enhance their quality-of-life for as long as possible. A range of services maycontribute to this aim including home nursing, housecleaning, home maintenance, shopping, transport, daycare, social outings, home visits and allied health

(podiatry, physiotherapy, etc). Services are deliveredthrough a range of sectors including public health(national, state, county or district), social services, andprivate for profit or not-for-profit organizations. Thefunding and administrative systems through which ser-vices are delivered differ across and within countries.A common criticism of home and community services

is that they are fragmented, resulting in poor outcomesand wasted resources [4,5]. Multiple services offered bydifferent providers to increasingly disabled older personswith multiple needs often compromise coordination.This criticism led to the introduction of case manage-ment (also known as care management or case coordi-nation). This has been defined as a collaborative processof assessment, planning, facilitation and advocacy foroptions and services to meet an individual’s healthneeds, through communication and coordination ofavailable resources, to promote quality cost effectiveoutcomes [6]. Reviews have suggested that communitybased case management has clinical benefits for persons

* Correspondence: [email protected] Collaborative Research Centre, School of Psychiatry, Faculty ofMedicine, AGSM Building, University of NSW, Sydney NSW 2052 Australia

Low et al. BMC Health Services Research 2011, 11:93http://www.biomedcentral.com/1472-6963/11/93

© 2011 Low et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

mailto:[email protected]

http://creativecommons.org/licenses/by/2.0

with severe mental illness [7] and diabetes [8]. Systema-tic reviews have reported that case managementimproves outcomes for frail elderly persons and reduceshealth care utilization [9,10].However, demonstration programs showed that case

management does not necessarily produce coordinatedcare, as health and social service systems may not allowcase managers to have control over the supply or avail-ability of services [11]. As a result, integrated care hasbecome a major theme of healthcare reform in someregions and countries [12]. Integrated care has beendefined as a discrete set of techniques and organiza-tional models designed to create connectivity, alignmentand collaboration within and between the cure and caresectors at the funding, administrative and/or providerlevels [13]. The level of integration can differ - an inte-grated system could have linkages between sectors, orexplicit structures to coordinate care across sectors, orbe fully integrated such that resources are pooled frommultiple sectors to be used most efficiently and effec-tively [14]. There have been suggestions that integrationmay improve partnership processes rather than impacton services and care recipient outcomes [15]. A reviewfocusing on the features of integrated systems for olderpersons found that some integrated systems couldimprove outcomes, satisfaction and/or costs [12].Recently, consumers have been advocating for consu-

mer directed care, where consumers and their caregiversmake choices regarding the care they receive [16]. Theamount of consumer choice ranges from selecting thetype of services or selecting the service provider to hiringand supervising care staff, and from selecting how carecredits are spent to being given the cash to purchase ser-vices. Consumer directed care is conceptualized as givingconsumers greater awareness, control and responsibilityfor their health care spending, and therefore incentive toconsider both cost and quality when making healthcaredecisions [17]. Consumer directed care has been criti-cized as potentially shifting costs towards the consumer,raising barriers to needed care, and hampering consumerchoice by limited information and system restraints [18].Consumer-directed home care has been trialed in severalcountries including the Netherlands, England, Germany,France, USA and Austria [19,20]. In Austria, consumerdirected care is the only choice as the traditional modelof agency directed care is not available. Most of the eva-luations in these countries focused on satisfaction ratherthan functional outcomes or quality of care. We identi-fied no reviews focusing on the health outcomes of con-sumer-directed care.The aim of this review is to evaluate the outcomes of

case management, integrated care and consumer direc-ted home and community care services for older per-sons, including those with dementia.

MethodsLiterature searches were performed in MEDLINE, Psy-cINFO, CINAHL, AgeLine, Scopus, and PubMed usingthe key phrases ("community care” or “home care” or“community nursing” or “day care” or “respite care” or “case management” or “integrated care” or “consumerdirected care”) and ("ageing” or “aging” or “aged” or“older” or “elderly” or “dementia” or “Alzheimer$”) from1994 to May 2009. Key phrases were entered in the title,abstract and keywords fields unless this option was notavailable in which case all fields were searched.Abstracts were reviewed and articles that met follow-

ing criteria were included:

1) Written in English.2) Evaluating the delivery of case managed, inte-grated or consumer directed home and communityservices using quantitative outcomes (see below fordefinitions). Home and community services couldinclude but could not be limited exclusively to medi-cal care.3) The sample was community dwelling, with eithera majority aged 65 years and over, or with a subsam-ple of persons aged 65 and over for whom resultswere reported separately.4) The sample was not selected because they had aspecific medical illness, except for dementia.

The search yielded 34,816 unique articles. Twoauthors independently read the titles and abstracts andexcluded ineligible papers (see Figure 1). After thisexclusion process, 163 full text articles were obtainedand reviewed and 35 papers were finally included in thestudy.

34,816 unique papers were identified by searching MEDLINE, PsycINFO, CINAHL, AgeLine, Scopus, PubMed using the key phrases (“community care” or “home care” or

“community nursing” or “day care” or “respite care” or “case management” or “intergrated care” or “consumer directed care”) and (“ageing” or “aging” or “aged” or “older” or

“elderly” or “dementia” or “Alzheimer$”) from 1994 to May 2009

160 full-text papers retrieved

34,657 papers were excluded based on the title and abstract

because they were not in English, were not pertaining to case management, integrated

care or consumer directed care for persons living in the

community, or targeted persons with specific medical illness except for dementia

4 additional papers identified from reference lists of

included articles

35 papers included in this review

128 papers did not report outcome data or did not meet

inclusion criteria

Figure 1 Article selection process.


Page 2 of 15

For each included study, methodological quality wasrated on a Scale for Rating Quality of Studies [21]. Thiswas modified by eliminating the item on use of standar-dized diagnostic criteria as no medical condition wasrequired for study inclusion. The maximum total scorepossible on this scale was 15 points. Differences onquality ratings were resolved through discussion. Metho-dological quality was used as a measure of the value ofthe evidence presented, however no studies wereexcluded based on quality.Information on study design, demographics, recruit-

ment methodology, intervention description, outcomesand key results were extracted from the studies by oneauthor and checked by a second. Full text was alsoretrieved for relevant review articles. Articles weregrouped by the model of community care being evalu-ated. Case management was defined as interventionswhere a central worker provided assessment, care plan-ning, coordination of services and ongoing follow-up.Integrated care was defined as interventions where theservices were coordinated at a system level rather thanfocusing on individual consumers. Consumer directedcare was defined as interventions where consumers wereexplicitly given choice and/or control of services.Where possible, effect sizes were estimated and

described. Cohen’s d (d = (x̄1-x̄2)/SD) was used as theeffect size measure of differences between two groups.Effect sizes were defined based on published recommen-dations as small (d ≤ 0.2 or OR/HR ≥1.3 or OR/HR≤ 0.77), medium (d ≤ 0.5 or OR/HR ≥1.5 or OR/HR≤ 0.68) or large (d ≥0.8 or OR/HR ≥2.0 or OR/HR ≤0.5) [22,23].

ResultsA summary of the results of outcomes reported in twoor more papers for any model of care (case manage-ment, integrated care and consumer directed care) ispresented in Table 1. This table reports the results bymodel of care with each letter in the table representingone study, and indicating the study design and effectsize where known. Cells in the table with a greater num-ber of letters indicate greater evidence, particularly whenthe letters indicate that the studies are randomized con-trolled trials (R).

Case management (see Table 2)On average, the methodological quality for studies ofcase management was highest of all the models of homeand community care reviewed. There were seven rando-mized controlled trials (three focusing on persons withdementia), two non-randomized trials and three obser-vational studies with non-matched controls comparingcase managed care to usual non-coordinated care[24-37]. One observational study did not include a

control group [38], and one randomized trial evaluatedthe effects of a computerized system in the care man-agement process [39]. Different methods of case man-agement were evaluated such as telephone-based casemanagement [28], computer program assisted case man-agement [40] and case management in combinationwith cost subsidies [30-32]. There were usually fewdetails about the ‘usual care’ received by controls interms of the types and ease of access to services avail-able, however this probably differed by locality.As shown in Table 1, case management improves

function, improves different aspects of medication man-agement, increases use of community services andreduces nursing home admission; however this was notthe case for all studies. There were also positive resultsfor other clinical outcomes and decreasing hospitaladmissions but not consistently across studies. It wasdifficult to quantify differences in the intensity of casemanagement provided between studies; however studiesthat reported more positive outcomes did not appear tohave provided more intensive case management.

Integrated care (see Table 3)There were two randomized controlled trials and twonon-randomized trials of integrated compared to non-integrated care [41-44]. There were seven observationalstudies, six of which evaluated variants of the Programof All Inclusive Care for the Elderly (PACE) [45-51].The services received by control groups were not welldescribed in most papers, however most controlsappeared to receive non-case managed medical andhome care services.Overall, integrated care did not improve clinical out-

comes (see Table 1). Fully integrated care programs (e.g.PACE and the Kaiser Permanente Northwest) wereassociated with greater use of community and hospitalservices; however the methodological quality of thesestudies was relatively low. The higher quality rando-mized and non-randomized trials evaluated partial inte-gration models where services were formally linked andcoordinated, however these were more likely to reportsignificant effects on clinical or service use outcomes.Thus it was difficult to evaluate whether fully integratedprograms result in better outcomes than programswhere linkages are created between disparate systems.

Consumer-directed care (see Table 4)The quality of studies of consumer directed care was thelowest of the three models examined. There were threerandomized controlled trials [52-54], one non-rando-mized controlled trial [55] and two observational studies[56,57] that compared consumer-directed care to con-trol groups [55-57]. It is notable that consumer directedcare usually involves a budget for the purchase of


Page 3 of 15

services and usual care consumers may not have hadreceived a similar value of services, such that any bene-fits may not have been due to the consumer involve-ment in directing care but the facilitation of easieraccess to services. Overall the results showed that con-sumer directed care improved satisfaction with care andcommunity service use, but had little effect on clinicaloutcomes (see Table 1). Notably one study found thatreceiving consumer directed care may have increasedpsychological morbidity [54].

DiscussionIn summary, there was the most and highest quality evi-dence, including from randomized controlled trials, thatcase management improves clinical outcomes, decreasesnursing home admission and hospital use. There waspoorer quality evidence, mostly from non-randomizedtrials, that integrated care increases service use, andhigher quality evidence from randomized trials that

integrated care does not increase clinical outcomes. Thelowest quality evidence was for consumer directed care,which appears to increase satisfaction with care andcommunity service use but has little effect on consumeroutcomes. Case management decreased use of services,possibly by decreasing the need for such services, butintegrated care increased use of services, possibly byfacilitating access to needed services.These findings suggest that different models of home

and community care have differing outcomes dependingon their focus - case management focuses on consumercare, integrated care on an efficient system and consu-mer directed care on giving control to the consumer.Administrators and providers of services need to beexplicitly clear as to the focus of their service and priori-tization of outcomes. Improvement or maintenance ofphysical and mental health and functioning may bemore important than delaying mortality, or improvingsatisfaction with services. An ideal model could

Table 1 Summary of outcomes reported in two or more studies for different models of care for interventionparticipants relative to controls

Case management Integrated care Consumer directed care

Higher Nodifference

Lower Higher Nodifference

Lower Higher Nodifference

Lower

Clinical outcomes (ideallyincreased)

Function (ADLs/IADLs) R+++, N,N

R, N O R, R, N O N

Cognition R+++ N, N, O R, N N

Medication management R, O++ N N

Quality of life R R N R, N

Physical health O+ R O R, N

Social interaction or support O+ R

Clinical outcomes (ideallydecreased)

Depression, psychological health R, N R+++ R, R, N, O R N

Risk of mortality R, R, O R+++ R, R, O N

Caregiver burden/distress R, O R N

Pain N R, O

Satisfaction (ideally increased)

Satisfaction with care R R+++ R, O O, O,O

Caregiver satisfaction O+++ R O

Life satisfaction R++ O

Service use

Risk of nursing home admission R R++, R++, R+, R+

O+ R, R, N

Risk of hospital admissions R R+++, R+ N, O++,O

R,R

Risk of emergency admissions R+ R, O R++ N, O R

Community service use R+++, R++ R++, O R, O

Length of hospital stay R, O R+++ N O

R = Randomized Controlled Trial, N = Non-randomized Controlled Trial, O = Observational study (case controlled, cross-sectional, longitudinal or retrospective);+ = small, ++ = medium, +++ = large effect size; effect sizes were reported whenever possible.


Page 4 of 15

Table 2 Case management

Author(year)

Study name/Location;Study design;InterventionLength

Participant group; n (% female);Age (x̄ ± SD)

Study groups Outcomes and Results QualityRating

Gagnon(1999)

Quebec,Canada RCT 10months

≥70 years who had visited anemergency department in theprevious yearn = 427(58.1% F)x̄ = 81.6

Participants were assigned nursecase managers who operatedusing the Promotion ofAutonomy Framework. Casemanagers created andimplemented a care plan andcoordinated the work of allhealthcare and service providersinvolved in care. There wereapproximately 28 recordedtelephone contacts and 36 homevisits per person.For controls, hospital andcommunity services wereprovided separately.

Over 10-months, participants inthe intervention group werereadmitted to the emergencydepartment significantly morefrequently than controls(p = 0.041, d = 0.2).No significant differences werefound between the two groupson quality of life, satisfaction withcare, functional status, admissionto hospital, and length of hospitalstay from baseline to 10 months.

14

Vickrey(2006)

Dementia carequalityinterventiontrialCalifornia, USACluster RCT1 year

≥65 years with dementia receivingMedicare with an informalcaregivern = 408 (54.9% F)x̄ = 80.1 ± 6.6

Case managers trained to usecare management software andprovided with a care plan manualconducted assessments and 6monthly reassessments ofparticipants, designed andimplemented care plans incollaboration with caregivers,taught skills and providedongoing follow-up. Seminarswere held for primary careproviders at participating healthcare organisations.Controls received usual care.

After 18 months the proportionof guidelines adhered to wassignificnatly higher in intervention(64%) compared to controls (24%;p ≤ 0.001). Interventionparticipants had higher rates ofreceiving information or servicesfrom ≥1 community agency (RR= 1.5, 95% CI 1.0-1.9), respite care(p ≤ 0.03), home health aideservices (p ≤ 0.03), professionalcarer services (p ≤ 0.03),enrollment in a wanderingprogram (p = 0.001),cholinesterase inhibitor use(p = 0.032), health related qualityof life (p = 0.034) and health carequality (p ≤ 0.011). Interventioncaregivers had higher confidencein caring (p ≤ 0.01), caregivingmastery (p ≤ 0.01), social support(p = 0.029) and met needs forproblem behaviours (p ≤ 0.012).There were no differences incaregiver health related quality oflife.

14

Alkema(2007),Shannon(2006)

California, USARCT1 year

>65 years, enrolled in Medicarehealth plan, rated as being at riskof future healthcare service usen = 781, 823(65.3% F)x̄ = 83.3

A care manager (care advocate)operating via telephoneevaluated needs, made referralsto additional services and calledmonthly to moitor progress, offersupport and coaching, provideadditional information andassistance and follow-up toensure linkages were establised.Controls received usual careincluding Medicare managedcare.

After the 12-month intervention,the case managed care grouphad lower mortality than controls(OR = 0.45; p = 0.006). However,at 24-month follow-up, mortalitydifferences between the groupswere not significant (p = 0.198).After 12 months participants weremore likely to use primary carephysicians (OR = 2.05, 95% CI1.28-3.28), were less likely to beadmitted to hospital (OR = 0.43,95% CI 0.22-0.84) and had fewerhospital days (OR = 0.39, 95% CI0.17-0.86) compared to controls.There were no differencesbetween groups on emergencydepartment and specialist use.

13


Page 5 of 15

Table 2 Case management (Continued)

Bernabei(1998)

Rovereto, ItalyRCT1 year

≥65 yearsn = 199(70.9% F)x̄ = 81.0 ± 7.3

Participants received casemanagement and care planningfrom a community geriatricevaluation unit and generalpractitioners. Case managersconducted assessments every 2months, monitored the provisionof services, provided extra help asrequested and were available todeal with problems. Controlsreceived usual care includingnon-case managed communityservices

Over 1 year the interventiongroup improved on function(ADLs, p < 0.001, d = 6; IADLs, p< 0.05, d = 3) and depression (p< 0.05, d = 4) and declined lesson cognition (p < 0.05, d = 4),compared to the control group.Over 1 year, the interventiongroup had lower risk of admissionto a nursing home (HR = 0.81,95% CI: 0.57-1.16), acute hospital(HR = 0.74, 95% CI: 0.56-0.97), oremergency (HR = 0.64, 95% CI:0.48-0.85) compared controls.There were no differences in 1year mortality.

12

Shapiro(2002)

USARCT1 year 6months

≥60 years on waiting list toreceive social servicesn = 105(85.7% F)x̄ = 77.2

Individualized care plans weredeveloped by a geriatric nursetogether with participants andcaregivers after a thorough in-home geriatric assessment. Casemanagers coordinated thedelivery of services which wereprescribed and changed toaddress specific needs andproblems.Controls received usual care.

After 18 months, participants inthe intervention group were lesslikely to be institutionalized or diethan those in the comparisongroup (combined as a singleendpoint, OR = 0.18, p = 0.029).The intervention group hadimproved on Satisfaction withSocial Relationships (F = 2.59, p <0.05, d = 0.45), EnvironmentalMastery (F = 3.71, p < 0.01, d =0.54), and Life Satisfaction (F =3.18, p < 0.05, d = 0.53). Nostatistically significant differencewas found for depression.

12

Eloniemi-Sulkava(2001)

FinlandRCT2 years

≥65 years with dementia andcaregiversn = 100(53.0% F)x̄ = 79.4

A nurse case manager withaccess to a physician providedadvocacy, round the clockcomprehensive support,continuous and systematiccounseling, annual trainingcourses, follow-up calls, in-homevisits and assistance witharrangements for social andhealthcare services. The frequencyof contacts varied from 5 times aday to once a month.Controls received usual care.

During the first 6 months, therate of institutionalization wassignificantly lower in theintervention group than incontrols (HR = 0.12, 95% CI: 0.02-0.93) but this benefit decreasedover time (HR = 1.18, 95% CI:1.02-1.36). The estimatedprobability of staying incommunity care for 6, 12, and 24months was 0.98, 0.92, and 0.63in the intervention group and0.91, 0.81, and 0.68 in the controlgroup, respectively.

12

Miller (1999),Newcomer(1999a,1999b),Shelton(2001)

MedicareAlzheimer’sDiseaseDemonstration(MADDE)USARCT3 years

Persons diagnosed with dementiaenrolled in Medicare A and Bn = variable (see results)For Newcomer 1999a:40% Fx̄ = 79 ± 8 years

MADDE participants received casemanagement (with a ratio 1:30for Model A or 1:100 for Model B)and 80% subsidy of service costs(up to $489 for Model A or $799for model B).Controls received usual care.

After 1 year there was increaseduse of any home care service (OR= 2.77, 95% CI 2.40 - 3.0) andadult day care (OR = 2.23, 95% CI1.92-2.60) [n = 5209]Over 3 years there were nodifferences on nursing homeentry rates (n = 8095).After 3 years there were nodifferences in the change incaregiver burden or depression.[n = 5307].Over 3 years caregivers in MADDEhad a lower likelihood thancontrols of any hospitalization (OR= 0.58, 95% CI 0.35-0.97), but notof emergency department use,length of hospital stay or numberof hospitalizations (n = 412).There were no differencesbetween Model A and Model B inany of the outcomes tested.

12


Page 6 of 15


Kinney(2003)

USARCT2 years

Enrollees of Indiana’s state casemanagement program and/or theMedicaid home and community-based services waiver program forthe aged (≥65 years) and disabledn = 1006(77.5% F)x̄ = 67.7

The intervention involved twocomputer-assisted methods forindividualized care planning. TheNormative Treatment Planning(NTP) program assessed needsand prescribed services using astandard set of algorithms. TheClient Feedback System (CFS)program provided systematicfeedback on participantsatisfaction to service providers.Participants were randomlyassigned to receive none, one ortwo of the interventions.The control group had casemanagers who prepared a non-computerized care plan.

Over 2 years perception of needsmet (p < 0.05, d = 0.027) andservice satisfaction (p < .05, d =0.027) improved in the NTPcompared to the control group.The CFS group had significantlyhigher satisfaction than thecontrol group (p < 0.05, d = 2.7)but not greater perception ofneeds met. There were nostatistically significant differencesin perception of needs met andsatisfaction between the groupthat used both NTP and CFS andthe control group.

11.5

Marek (2006) USANRCT1 year

≥64 yearsn = 85 (80% F)x̄ = 77.1

Participants received nurse carecoordination in addition to a localcare program, Missouri CareOptions (MCO), which includedbasic and advanced personalcare, nurse visits, homemakercare, and respite care. Carecoordinators conducted acomprehensive admissionassessment, created a care planand coordinated health and socialservices.Controls were recruited from asimilar neighborhood andreceived the basic MCO programwith limited nursing visits andwere more likely to be white.

After 12 months, the interventiongroup improved significantlymore than the control group onpain (OASIS M00420; <0.01),dyspnea (p = 0.03), and function(p = 0.01). No significantdifferences were found over timebetween groups in emotionalstability, medication management,cognition and incontinence.

9

Morales-Asencio(2008)

SpainNRCT6 months

Homebound persons requiringassistance for daily activitiesn = 258x̄ = 76.3

A case manager made homevisits, conducted assessments,established links with andcoordinated other healthinstitutions and professionals,arranged technical assistance athome, provided educationtelecare for the participants andeducation and support forcaregivers.The control group received visitsaccording to their healthdemands and at baseline hadfewer functional limitations thanparticipants.

The intervention group hadsignificantly lower scores onactivities of daily living functionand family function compared tothe control group at baseline (p= 0.021; p = 0.023 respectively).These differences no longeroccurred at six months (p =0.222; p = 0.142). Cognitive statusand instrumental activities of dailyliving were lower in theintervention than the controls atboth baseline (p = 0.042; p =0.008) and 6 months (p = 0.008; p= 0.007).

8

Gravelle(2007)

Evercare,EnglandLongitudinalobservationalstudy1 year 9months

≥65 yearsn = ~7000 Evercare practices(mean age not reported)

Participants were monitored byadvanced practice nurses whodeveloped individualized careplans with the participant, generalpractitioner and other staff.Control data were gathered fromall non-Evercare practices inEngland. At baseline, interventionpractices had significantly higherrates of admission and use ofemergency bed days and fastergrowth rates in admissions forthe general population aged ≥65.

Over 21 months, the interventionhad no significant effect on ratesof emergency admission,emergency bed days, andmortality for the whole Evercaresample or a high risk subsamplewith a history of two or moreemergency admissions in thepreceding 13 months incomparison to the control group.

7


Page 7 of 15


Onder(2007)

Aged in HomeCare Project(AdHoC),EuropeRetrospectiveobservationalstudy1 year

≥65 years and receiving homecare servicesn = 3292(73.6% F)x̄ = 82.3 ± 7.3

The case management groupcomprised participants living inFinland, Iceland, Italy, Sweden &the UK. Participants in thesecountries had case managerswho conducted assessments,dealt with problems that arose,monitored the provision ofservices, worked with geriatricevaluation units to design andimplement individualized careplans and who providedadditional services as needed.Controls lived in Czech Republic,Denmark, France, Germany, theNetherlands and Norway wherecase management was notavailable. Controls were morelikely to be women, live alone, bephysically active, had more severecognitive impairment and a lowerprevalence of daily pain and anumber of chronic diseases andunexpected weight loss thanparticipants.

During the 1-year follow-up, therisk of nursing home admissionwas significantly lower in the casemanagement group compared tocontrols (OR = 0.56, 95% CI: 0.43-0.63).

7

Bierlein(2006)

CanadaLongitudinalobservational6 months

>65 years, 22% were cognitivelyimpairedn = 179 (65% F)x̄ = 80 ± 7.38

Participants were assigned casecoordinators and had access tovarious community healthservices.There was no control group.

After 6 months, participants’scores improved on the physical(p < 0.001, d = 0.4) and mentalhealth subscales (p < 0.001, d =0.4) of the SF-8. Risk ofinstitutionalization decreasedsignificantly (p < 0.03, d = 0.1).However there was a statisticallysignificant deterioration on socialinteraction (p < 0.04, d = 0.2) andinstrumental support (p < 0.001, d= 0.3). Subjective support scores(p = 0.88) and cognitive scores (p= 0.68) did not changesignificantly.

7

Onder(2008)

AdHOCRetrospectiveobservational

≥65 years already receiving homecare servicesn = 4007(74.1% F)x̄ = 82.3 ± 7.3

See Onder, 2007 above Compared to the control group,more participants in the casemanagement group had bloodpressure measured in previous 2years (OR = 1.31, 95% CI 1.08-1.59), received influenzavaccination in the last 2 years (OR= 2.08, 95% CI: 1.81-2.39) and hadmedication reviewed in the last 6months (OR = 1.69, 95% CI: 1.42-2.01).Compared to the control group,caregivers of participants in theintervention group were morelikely to be able to continue incaring activities (OR = 0.49, 95%CI: 0.35-0.69) and were lessdissatisfied (OR = 0.47, 95% CI:0.29-0.73). There was nosignificant difference for caregiverdistress (OR = 1.04, 95% CI: 0.78-1.38).

6.5

NRCT = Non-randomized controlled trial; RCT = Randomized controlled trial.


Page 8 of 15

Table 3 Integrated care

Author(year)

Study name/Location;Study design;InterventionLength

Participant group;n (% female);Age (x̄± SD)

Study groups Outcomes and Results QualityRating

Beéland(2006)

System ofIntegrated Carefor OlderPersons (SIPA),CanadaRCT1 year 10monthsx̄ (= 572 days)

≥65 yearsn = 1230(71% F) x̄ = 82

Participants received care frommultidisciplinary teams who deliveredintegrated care through the provision ofhealth and social services andcoordination of hospital and nursinghome care, monitoring protocols andproviding mobilized resources, includingintensive home care, group homes, anda 24-hour on-call service.Controls received usual home careservices including nursing, rehabilitation,physician, personal, and social serviceswith limited time and availability and nocase management.

Over 22 months significantly more SIPAparticipants compared to controlsreceived 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 differencesbetween the groups in mortality oradmissions to emergency, hospital ornursing homes.Caregivers’ satisfaction with care after 1year was significantly higher in theintervention group than the controlgroup.There were no significant differences onparticipants’ satisfaction with care,chronic diseases, depression, cognition,functional limitations, daily function, andcaregiver burden between theintervention and the control groups.

12.5

Hammar(2007)

FinlandCluster RCT6 months

≥65 years withoutdementian = 668, 22municipalities (74.0%F)x̄ = 81.7

Participants were assigned a home nurseand home helper who planned andintegrated home care services with otherservice providers and hospital staff.Controls were from municipalitieswithout case management orintegration. Controls had a smallernumber of diagnoses than participants.

At 3-week follow-up, physical mobilitysignificantly improved in the interventiongroup (p < 0.002) compared to controlsbut the effect was lost at 6-monthfollow-up.At 3-week and 6-month follow-ups, therewere no significant changes betweenthe two groups on energy, sleep, pain,emotional reactions, and social isolation.There were no differences in self-ratedhealth, daily function, rates of mortality,institutionalization and hospitalization.

12.5

Fischer(2003)

KaiserPermanenteNorthwest, USALongitudinalobservational5 years

Enrollees of SocialHealth MaintenanceOrganization (SHMO)≥65 yearsn = 18143 (63.7% F)x̄ = 75

Participants enrolled in the SHMOreceived case management andcoordination to integrate the delivery oflong-term care within the medical caresystem. Services included carecoordination, home nursing visits,homemaking, transportation, adult daycare and nursing home respite.Controls resided in an area where theSHMO was terminated and at baselinewere younger and had fewer chronichealth conditions and less utilization ofacute and nursing home inpatient dayscompared to participants.

Over 5 years, there was an increasedprobability of nursing home placementfor the control group compared to theintervention group (OR = 1.43, 95% CI:1.15-1.79, p = 0.002).Over 5 years there was no difference inmortality between the intervention andthe control group (OR = 1.02, 95% CI:0.87-1.20, p = 0.828).

12

Atherly(2004)

Program of AllInclusive Carefor the Elderly(PACE), USACross-sectional

>55 yearsn = 265(mean age notreported)

Participants received care from the PACEinterdisciplinary teams whom conductedcomprehensive assessments anddelivered preventive, primary,rehabilitative, supportive, and end-of-lifecare integrated into a complete healthcare plan. PACE also attempted to limitunnecessary hospital and nursing homeuse.Controls were eligible older persons whodeclined PACE services.

Participants in the PACE group hadhigher satisfaction on PerceivedInterpersonal 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 familysatisfaction.

8.5


Page 9 of 15

Table 3 Integrated care (Continued)

Bird(2007)

HospitalAdmission RiskProgram;(HARP), AustraliaNRCT≥90 days (= 227± 104 days)

>55 yearsn = 316(51.3% F)x̄ = 75.3 ± 8.5

Participants were allocated a carefacilitator who linked them to allrequired acute and community services.They also ensured effectivecommunication and exchange ofrelevant information between servicesincluding specialist medical clinics, alliedhealth therapies and carer supportservices.Controls were eligible older persons whodeclined participation. No demographicdifferences were detected at baselinebetween controls and participants.

Comparing the 12 months pre-recruitment and post-recruitment,participants in the intervention grouphad a 20.8% reduction in emergencyvisits (p < 0.001), 27.9% reduction inhospital admissions (p < 0.001), and19.2% reduction in bed-days (p < 0.001).In the 12 months pre-recruitment andpost-recruitment older persons whodeclined participation showed a non-significant 5.2% increase in emergencyvisits, 4.4% reduction in hospitaladmissions, and 15.3% increase ininpatient bed-days.

8

Kane(2006)

PACE andWisconsinPartnershipProgram (WPP),USALongitudinalVariable length

≥65 yearsn = 1285(77.3% F)x̄ = 77.8

PACE group as aboveParticipants enrolled in WPP wereoffered choice of care, setting, andmanner in which their service wasdelivered and were able to keep theirprimary physician, whereas PACEenrollees were not given these choices.Enrollees in PACE were more likely to bewomen, older, non-White and eligible forMedicaid only (ie not low-income olderpersons or disabled).

Per person-month of programenrollment, the PACE group had fewerhospital 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), andpreventable emergency visits (p < 0.05)than WPP.There was no significant differencebetween the two groups in the lengthof hospital stays.

8

Brown(2002)

UKNRCT18 months

≥65 received a socialservices assessmentafter referral fromstudy general practiceN = 393(67% F)x̄ = 81 (65-99)

Intervention participants were assessedand managed by social servicedepartments (SSD) co-located withgeneral practices. SSDs met weekly withgeneral practice staff, largely for cross-referrals.Control participants resided in a countyof similar population and size whichwere managed by traditional SSDs.

There were no differences between ratesof mortality and nursing homeplacement after 18 months.In the intervention group time toassessment was shorter than controls (p= 0.039, d = 0.24), and there was anincrease in quality of life over 18 months(p = 0.08) not apparent in controls.There were no differences in changesover 18 months on daily function,mental functioning or depression.

8

Wieland(2000)

PACE, USALongitudinalUp to 8 years

>55 yearsn = 5478(71.1% F)x̄ = 78.9 ± 8.9

PACE group as aboveData were compared to the generalMedicare population of older anddisabled Americans.

Time to hospitalization for PACE was 773days (median; 95% CI: 725-814)comparable to Medicare aged andMedicare disabled populations. Annualshort-term bed use in PACE showed adecline and was comparable with thegeneral Medicare population, 2046 (in1998) versus 2014 (in 1997) respectively(no statistical test performed).

8

Weaver(2008)

All-InclusiveLong-term Care,USALongitudinalUp to 36months

Older persons veterans(≥55 years)n = 368(3.8% F)x̄ = 76.1

Three Veterans Affairs (VA) medicalcenters served as study sites, eachproviding a different program of care:The VA as sole provider program: VAprovided all care including homemakerand home health aides, adult day careand health needs.The VA and PACE partnership program:VA provided hospitalization, short-termnursing home for sub acuterehabilitation, subspecialty consultation,laboratory imaging, and pharmacyservices while PACE assumedresponsibility for primary care, adult dayhealth care, transportation, home healthcare, homemaker and other supportivecare needs.The VA as care manager program:Contracted for PACE to provide all care,veterans did not use VA healthcareservices while enrolled in PACE.

Compared to 6 months before programentry, by program discharge there was asignificant increase in adult day healthcare use in all three models (p < 0.001).In the VA as care manager model, therewas a significant increase in home careuse (p < 0.001) and nursing home use (p< 0.02), but no such increases werefound for the other two models.No statistically significant differenceswere observed in all models in hospitaladmissions per patient, total inpatientdays per patient, nursing homeadmissions per patient, nursing homedays per patient, inpatient, andoutpatient clinic use.

7


Page 10 of 15

incorporate multiple key elements - a fully integratedcare system which facilitates access to health and com-munity services, in which consumers receive case man-agement to maximize clinical outcomes and preventunnecessary institutionalization and hospital use, andwhere consumers have as much control of their owncare as they wish.The inconsistencies in results between studies are

notable - the studies reviewed here were heterogeneousin their inclusion criteria, design, sample and methodsof delivery. There was variability not just in the choiceof instruments to measure outcomes, but the outcomesthat were measured - these were based on the aim ofeach program. Most importantly, the health and socialcare systems in which the evaluations were conducteddiffer significantly - for instance the UK, Canada andAustralia offer universal health and social care, whereasin the USA the majority of care is provided by insurancecompanies also known as health maintenance organiza-tions. Successful programs would need to be skillfullyadapted for other settings. That said, the patternsobserved in these results are consistent with previousreviews of the individual models of care [9,12] suggest-ing that common lessons can be drawn from these stu-dies despite their dissimilarities.There are several limitations to this review. We did

not attempt to search the grey literature, and thus couldhave missed service evaluations. We did not considerthe cost-benefits of different models of community care.The divisions were not always clear between home andcommunity care and other services such as primaryhealth care and rehabilitation, requiring us to make

subjective decisions on the inclusion of studies. Therewere overlaps between the different models of care.Integrated care models usually included case manage-ment, and consumer-directed care usually included theassessment and individualized care plan components ofcase management. One of the consumer-care trialsexplicitly attempted to increase integration [54]. Wewere not able to examine differences in the effects ofcommunity care between subgroups such as betweenparticipants with and without caregivers, or betweenparticipants with physical disabilities or cognitiveimpairment, or both. We only identified one paper ofrestorative home care [58] and could not include thismodel in the review. The evidence for restorative homecare should be re-examined as further research is pub-lished [59].A systematic review of randomized controlled trials

provides the highest quality evidence of the efficacy ofan intervention [60]. The second highest quality evi-dence is from randomized controlled trials whereresearchers can be confident that the intervention, notunderlying differences between groups is the cause ofdifferent outcomes between groups. Examination of thestudies included in this review reveal the difficulty inconducting randomized trials of care models thatinvolve changes in care practices or whole care systems.A clustered randomized trial would be the best designto evaluate a model of care, however particularly forfully integrated care there would be substantial logisticalbarriers and high costs involved in such a study. Futureevaluations of community and home care should givedetailed descriptors of the service context, intervention

Table 3 Integrated care (Continued)

Temkin-Greener(2002)

PACE, USALongitudinalVariable length

>55 yearsn = 2263x̄ = 80

PACE group as above.Data were compared to the generalMedicare population of older anddisabled Americans.

The probability of death at home forPACE participants (45.0%) was twice asgreat as the probability of death athome for the Medicare population ofolder Americans (no statistical testperformed).

7

Kane(2002)

WPP (as above)Case controlled

≥65 yearsn = 116378% Fx̄ = 78.7

WPP described above.Controls were community optionsprogram recipients a Medicaid homeand community based waiver programwho receive a variety of communityservices designed to meet their careneeds but receive their medical carefrom fee-for-service Medicare providersmatched on age and gender from withinthe same county (in-area controls) andfrom non-WPP county (out-of-areacontrols).

Dependency for daily self-care was lowerin WPP than in area and less consistentlyin out-of-area controls (p ranged from0.000 to 0.033). Over the previous 3months fewer WPP received homemaker(p < 0.001), but more WPP receivednurse, home delivered meals, specialtransportation, adult daycare, outpatientrehabilitation and physical therapy thanboth control groups (p ranged from0.000 to 0.033).There were no differences betweengroups on depression, pain and unmetneeds, use of medical equipment orinformal care.The few differences on the 21satisfaction items were not consistentacross control groups.

7



Page 11 of 15

Table 4 Consumer-directed care

Author(year)

Study name/Location; Studydesign;InterventionLength

Participant group;n (% female);Age (x̄± SD)

Intervention;Control

Outcomes and Results QualityRating

Meng (2005) MedicarePrimary andConsumerDirected CareDemonstrationUSARCT12 months

≥65 years, enrolled in Medicare A &B, ≥2 ADL or ≥3 IADL limitations andbeen hospitalized, in residential careor received home health care in last12 months or ≥2 emergency visits inpast 6 monthsn = 1394(70% F)x̄ = 80 ± 8 years

3 intervention groups:1. Voucher group could choosehow to spend ≤$200 p/month,advised and financiallymanaged by voucher specialist2. Disease management healthpromotion nurse taughtdisease management skills,implemented behaviourchange strategies, andfacilitated conferences withprimary care physicians3. Combination of 1 and 2Controls received usualMedicare benefits.

The voucher group increasedthe probability of usingpersonal assistance services (p= 0.002) as did thecombination group (p < 0.001).The combination group alsoincreased the probability of useof skilled home health care (p= 0.03).

10

Wiener(2007)

Washington,USACross-sectional

Medicaid beneficiaries receivinghome and community servicesn = 513(72.9% F)≥65 years: 55%

Participants in the consumer-directed care group wereresponsible for hiring, orienting,supervising, and findingreplacements for their paidcaregivers.Participants in the agency-directed care group includedthose residing in assisted livingand residential aged care.

In subsample of participants≥65 years, thosereceivingconsumer-directed serviceswere more satisfied with paidpersonal assistance comparedto those receiving agency-directed care (p < 0.05).

9

Glendinning(2008)

IndividualBudgets PilotProgramUKRCT6 months

Social service recipients, subsampleof persons ≥65 yearsn = 26366% FMean age not given

Intervention participants wereassigned an individual budgetbased on a needs assessmentwhich could be spent on largerange of services andequipment including hiringfamily and relatives. They wereassisted by a care coordinator.The 13 sites also attemptedwith varying success tointegrate resources fromseveral funding streams.Controls received standardsocial care.

At 6 months, there were nosignificant differences betewenindividual budget recipientsand controls on quality of life,self or informant-rated health orcare needs. Indivdiual budgetrecipients were significantlymore likely to score above thecutoff on a screening tool forpsychological morbidity (45%)than controls (29%; p < 0.05).

Carlson(2006)

Cash andCounselingUSARCT (evaluationonly at 9months)

Medicaid beneficiaries - subsamplesaged ≥65 years in Arkansas and NewJersey and ≥60 years in FloridaN = 2353Mean age not given

Intervention group couldchoose how to spendallowance from broad range ofequipment and servicesincluding hiring relatives -advised by a consultant(counselor).Control group receivedMedicaid benefits as usual.

Arkanses and New Jerseyintervention participants hadsignificantly higher hours ofpaid care (p < ≤ 0.001), lowerhours of unpaid care (p =0.036; p = 0.034) and weremore satisfied with the way thepaid caregiver provided care,with overall care arrangementsand way of spending life (all p<.001) than controls. In NewJersey intervention particpantswre more likely to have madean equipment purchase orhome or vehicle modification(p = 0.039) and had lower ratesof falls (p = 0.009)anddevelopment or worsening ofcontractors (p = 0.002).There were no differencesbetween groups on bedsoredevelopment and rates ofuninary tract infections.In Florida there were fewdifferences between groupswhich may be because only39% had received theallowance by the evaluation.

8


Page 12 of 15

and care received by controls, and should measure abroad range of outcomes clinical and service outcomes.

ConclusionsThis is the first systematic review comparing differentmodels of non-medical home and community servicesfor older persons. Each model impacts on different out-comes which relate to the focus of the model. Instead ofasking which model is the best at improving outcomes,we should be asking how to combine the successful fea-tures of all three models to maximize outcomes.

AcknowledgementsThe study was funded by the Dementia Collaborative Research Centre atUniversity of New South Wales as part of the Australian Government’sInitiative, Dementia: A National Health Priority. Dr Low was supported byNHMRC grant #455377 and Mr. Yap and Prof Brodaty were supported by theDementia Collaborative Research Centre at University of New South Wales aspart of the Australian Government’s Initiative, Dementia: A National HealthPriority. Prof Brodaty was also supported by Prince of Wales Hospital. Thefunding bodies had no role in study design, collection, analysis orinterpretation of the data, writing of the manuscript or the decision tosubmit the manuscript for publication.

Authors’ contributionsLFL and HB conceptualized the review. LFL and MY conducted the searchand data compilation. All authors contributed to writing the paper andinterpretation, and read and approved the final manuscript.

Competing interestsThe authors declare that they have no competing interests.

Received: 20 July 2010 Accepted: 9 May 2011 Published: 9 May 2011

References1. Gavrilov LA, Heuveline P: Aging of Population. In The Encyclopedia of

Population. Volume 1. Edited by: Demeny P, McNicoll G. New York:McMillan; 2006:32-37.

2. Australian Institute of Health and Welfare: Aged care packages in thecommunity 2006-07: a statistical overview. In Aged Care Statistics Series.Volume 27. Canberra: Australian Institute of Health and Welfare; 2008.

3. Department of Work and Pensions: Opportunity for all: Indicators update2007. London: Department of Work and Pensions, UK; 2007.

4. Fine M: The fragmented structure of community support services: acommunity case study. Kensington: University of NSW Social PolicyResearch Centre; 1993.

5. Clarfield AM, Bergman H, Kane R: Fragmentation of Care for Frail OlderPeople; an International Problem. Experience from Three Countries:Israel, Canada, and the United States. J Am Geriatr Soc 2001,49(12):1714-1721.

6. Glossary/FAQ’s. [http://www.cmsa.org/Consumer/GlossaryFAQs/tabid/102/Default.aspx].

7. Mueser KT, Bond GR, Drake RE, Resnick SG: Models of community care forsevere mental illness: A review of research on case management.Schizophr Bull 1998, 24(1):37-74.

8. Norris SL, Nichols PJ, Caspersen CJ, Glasgow RE, Engelgau MM, Jack L Jr,Isham G, Snyder SR, Carande-Kulis VG, Garfield S, Briss P, McCulloch D: Theeffectiveness of disease and case management for people withdiabetes: A systematic review. Am J Prev Med 2002, 22(4 SUPPL 1):15-38.

9. Eklund K, Wilhelmson K: Outcomes of coordinated and integratedinterventions targeting frail elderly people: a systematic review of

Table 4 Consumer-directed care (Continued)

Giannini(2007)

Bologna, ItalyNRCT2 years

Older persons needing help in ≥2ADLs or severely chronically ill andMMSE <24/30n = 121x̄ = 83.7 ± 6.4 years

The primary caregiver receivedvouchers to buy 4 to 24 hoursper day of home careattendance from healthproviders.Controls had recently beendischarged from hospital andreceived usual assistance fromPublic Health and Social CareServices.

Mortality was lower in theconsumer-directed care groupthan in controls at 6 and 24months (p < 0.05).At 24 months, there were nostatistically significantdifferences between thechanges in the two groups ondaily function, cognition, clinicalburden of medical conditions,severity of cognitiveimpairment, behavioral andpsychological symptoms,caregiver burden, depression,number of drug used andquality of life.

7/

Benjamin(2000)

USACross-sectional

Adults (>18 years) in the CaliforniaManagement and InformationPayrolling Systemn = 1095(72.9% F)51.2% were≥65 years

The consumer-directed grouprecruited and hired their ownproviders, and trained,supervised, and replaced themas needed. Participants used upto 283 hours of services permonth including personal care,household, paramedical,protective supervision andmedical transportation.Participants were placed in theagency-based group andreceieved services from homecare agencies if judgedinappropriate for consumerdirection.

Participants in the consumer-directed group reported betteroutcomes than the agency-based group on sense ofsecurity, (p < 0.001), unmetactivities of daily living needs (p< 0.05), and service satisfaction(technical quality, p < 0.001;service impact, p < 0.001;general satisfaction, p < 0.001;interpersonal manner, p <0.001).The groups did not differ inphysical and psychological risk(p = 0.142), unmet instrumentalactivities of daily living needs (p= 0.199), and providershortcomings (p = 0.984).

6.5



Page 13 of 15

http://www.ncbi.nlm.nih.gov/pubmed/11844008?dopt=Abstract



http://www.cmsa.org/Consumer/GlossaryFAQs/tabid/102/Default.aspx

http://www.cmsa.org/Consumer/GlossaryFAQs/tabid/102/Default.aspx








randomised controlled trials. Health & Social Care in the Community 2009,17(5):447-458.

10. Hutt R, Rosen R, McCauley J: Case-managing Long-term Conditions: whatimpact does it have in the treatment of older people? London: King’sFund; 2004.

11. Dant T, Gearing B: Keyworkers for Elderly People in the Community: CaseManagers and Care Co-ordinators. J Soc Policy 1990, 19(03):331-360.

12. MacAdam M: Frameworks of integrated care for he elderly: a systematicreview. Ontario: Canadian Policy Research Networks; 2008.

13. Kodner DL, Spreeuwenberg C: Integrated care: logic, meaning, implicationsand applications. International Journal of Integrated Care 2002, 2.

14. Leutz WN: Five Laws for Integrating Medical and Social Services: Lessonsfrom the United States and the United Kingdom. The Milbank Quarterly1999, 77(1):77-110.

15. Kodner DL: Whole-system approaches to health and social carepartnerships for the frail elderly: an exploration of North Americanmodels and lessons. Health and Social Care in the Community 2006,14(5):384-390.

16. Tilley J, Rees G: Consumer-Directed care: A way to empower consumers?Canberra: Alzheimer’s Australia; 200711.

17. American Association of Health Plans: Consumer-directed health plans:explornig an innovative coverate option, issues brief. Washington, DC:AAHP; 2003.

18. Axtell-Thompson LM: Consumer Directed Health Care: Ethical Limits toChoice and Responsibility. J Med Philos 2005, 30(2):207-226.

19. Tilly J, Wiener JM: Consumer-directed home and community servicesprograms in eight states: Policy issues for older people andgovernment. J Aging Soc Policy 2001, 12(4):1-26.

20. Tilly J, Wiener JM, Cuellar AE: Consumer-directed home- and community-based services programs in five countries: Policy issues for older peopleand government. Generations 2000, 24(3):74-83.

21. Brodaty H, Burns K: Non-pharmacological Management of Apathy inDementia: a Systematic Review. Am J Geriatr Psychiatry , in revision.

22. Cohen J: Statistical power for the behavioral sciences. Hillsdale, NewJersey: Lawrence Erlbaum Associates, Publishers;, 2 1988.

23. Bedard PL, Krzyzanowska MK, Pintilie M, Tannock IF: Statistical Power ofNegative Randomized Controlled Trials Presented at American Societyfor Clinical Oncology Annual Meetings. Journal of Clinical Oncology 2007,25(23):3482-3487.

24. Shapiro A, Taylor M: Effects of a community-based early interventionprogram on the subjective well-being, institutionalization, and mortalityof low-income elders. Gerontologist 2002, 42(3):334-341.

25. Bernabei R, Landi F, Gambassi G, Sgadari A, Zuccala G, Mor V,Rubenstein LZ, Carbonin P: Randomised trial of impact of model ofintegrated care and case management for older people living in thecommunity. BMJ 1998, 316(7141):1348-1351.

26. Eloniemi-Sulkava U, Notkola IL, Hentinen M, Kivela SL, Sivenius J, Sulkava R:Effects of supporting community-living demented patients and theircaregivers: a randomized trial. J Am Geriatr Soc 2001, 49(10):1282-1287.

27. Gagnon AJ, Schein C, McVey L, Bergman H: Randomized controlled trial ofnurse case management of frail older people. J Am Geriatr Soc 1999,47(9):1118-1124.

28. Alkema GE, Wilber KH, Shannon GR, Allen D: Reduced mortality: Theunexpected impact of a telephone-based care managementintervention for older adults in managed care. Health Services Research2007, 42(4):1632-1650.

29. Shannon GR, Wilber KH, Allen D: Reductions in costly healthcare serviceutilization: Findings from the care advocate program. J Am Geriatr Soc2006, 54(7):1102-1107.

30. Newcomer R, Yordi C, DuNah R, Fox P, Wilkinson A: Effects of theMedicare Alzheimer’s Disease Demonstration on caregiver burden anddepression. Health Services Research 1999, 34(3):669-689.

31. Miller R, Newcomer R, Fox P: Effects of the Medicare Alzheimer’s DiseaseDemonstration on nursing home entry. Health Services Research 1999,34(3):691-714.

32. Newcomer R, Spitalny M, Fox P, Yordi C: Effects of the MedicareAlzheimer’s Disease Demonstration on the use of community-basedservices. Health Services Research 1999, 34(3):645-667.

33. Marek KD, Popejoy L, Petroski G, Rantz M: Nurse care coordination incommunity-based long-term care. Journal of Nursing Scholarship 2006,38(1):80-86.

34. Morales-Asencio JM, Gonzalo-Jiménez E, Martin-Santos FJ, Morilla-Herrera JC, Celdráan-Mañas M, Carrasco AM, García-Arrabal JJ, Toral-López I:Effectiveness of a nurse-led case management home care model inPrimary Health Care. A quasi-experimental, controlled, multi-centrestudy. BMC Health Services Research 2008, 8.

35. Gravelle H, Dusheiko M, Sheaff R, Sargent P, Boaden R, Pickard S, Parker S,Roland M: Impact of case management (Evercare) on frail elderlypatients: Controlled before and after analysis of quantitative outcomedata. BMJ: British Medical Journal 2007, 334(7583):31.

36. Onder G, Liperoti R, Bernabei R, Landi F: Case management, preventivestrategies, and caregiver attitudes among older adults in home care:results of the ADHOC study. Journal of the American Medical DirectorsAssociation 2008, 9(5):337-341.

37. Onder G, Liperoti R, Soldato M, Carpenter I, Steel K, Bernabei R, Landi F:Case management and risk of nursing home admission for older adultsin home care: results of the AgeD in HOme Care Study. J Am Geriatr Soc2007, 55(3):439-444.

38. Bierlein C, Hadjistavropoulos H, Bourgault-Fagnou M, Sagan M: A six-monthprofile of community case coordinated older adults. Can J Nurs Res 2006,38(3):32-50.

39. Kinney ED, Kennedy J, Cook CA, Freedman JA, Lane KA, Hui SL: Arandomized trial of two quality improvement strategies implemented ina statewide public community-based, long-term care program. Med Care2003, 41(9):1048-1057.

40. Vickrey BG, Mittman BS, Connor KI, Pearson ML, Della Penna RD, Ganiats TG,DeMonte RW Jr, Chodosh J, Cui X, Vassar S, Duan N, Lee M: The Effect of aDisease Management Intervention on Quality and Outcomes ofDementia Care: A Randomized, Controlled Trial. Ann Intern Med 2006,145(10):713-726.

41. Beland F, Bergman H, Lebel P, Dallaire L, Fletcher J, Contandriopoulos AP,Tousignant P: Integrated services for frail elders (SIPA): A trial of a modelfor Canada. Canadian Journal on Aging 2006, 25(1):5-42.

42. Hammar T, Perala ML, Rissanen P: The effects of integrated home careand discharge practice on functional ability and health-related quality oflife: a cluster-randomised trial among home care patients. InternationalJournal of Integrated Care 2007, 7:1-12.

43. Bird SR, Kurowski W, Dickman GK, Kronborg I: Integrated care facilitationfor older patients with complex health care needs reduces hospitaldemand. Australian health review: a publication of the Australian HospitalAssociation 2007, 31(3).

44. Brown L, Tucker C, Domokos T: Evaluating the impact of integratedhealth and social care teams on older people living in the community.Health and Social Care in the Community 2003, 11(2):85-94.

45. Fischer LR, Green CA, Goodman MJ, Brody KK, Aickin M, Wei F, Phelps LW,Leutz W: Community-based care and risk of nursing home placement.Med Care 2003, 41(12):1407-1416.

46. Atherly A, Kane RL, Smith MA: Older adults’ satisfaction withintegrated capitated health and long-term care. Gerontologist 2004,44(3):348-357.

47. Kane RL, Homyak P, Bershadsky B, Flood S: Variations on a theme calledPACE. Journals of Gerontology - Series A Biological Sciences and MedicalSciences 2006, 61(7):689-693.

48. Weaver FM, Hickey EC, Hughes SL, Parker V, Fortunato D, Rose J, Cohen S,Robbins L, Orr W, Priefer B, Wieland D, Baskins J: Providing all-inclusivecare for frail elderly veterans: Evaluation of three models of care. J AmGeriatr Soc 2008, 56(2):345-353.

49. Wieland D, Lamb VL, Sutton SR, Boland R, Clark M, Friedman S, Brummel-Smith K, Eleazer GP: Hospitalization in the Program of All-Inclusive Carefor the Elderly (PACE): Rates, concomitants, and predictors. J Am GeriatrSoc 2000, 48(11):1373-1380.

50. Temkin-Greener H, Mukamel DB: Predicting place of death in the programof all-inclusive care for the elderly (PACE): Participant versus programcharacteristics. J Am Geriatr Soc 2002, 50(1):125-135.

51. Kane RL, Homyak P, Bershadsky B, Lum YS: Consumer responses to theWisconsin Partnership Program for Elderly Persons: a variation on thePACE Model. Journals of Gerontology Series A-Biological Sciences & MedicalSciences 2002, 57(4):M250-258.

52. Meng H, Friedman B, Wamsley BR, Mukamel D, Eggert GM: Effect of aconsumer-directed voucher and a disease-management-health-promotion nurse intervention on home care use. Gerontologist 2005,45(2):167-176.


Page 14 of 15











































































53. Carlson BL, Foster L, Dale SB, Brown R: Effects of Cash and Counseling onPersonal Care and Well-Being. Health Services Research 2007,42(1p2):467-487.

54. Glendinning C, Challis D, Fernández JL, Jacobs S, Jones K, Knapp M,Manthorpe J, Moran N, Netten A, Stevens M, Wilberforce M: Evaluation ofthe Individual Budgets Pilot Programme. London: Individual BudgetsEvaluation Network; 2008.

55. Giannini R, Petazzoni E, Savorani G, Galletti L, Piscaglia F, Licastro F,Bolondi L, Cucinotta D: Outcomes from a program of home careattendance in very frail elderly subjects. Arch Gerontol Geriatr 2007,44(2):95-103.

56. Wiener JM, Anderson WL, Khatutsky G: Are consumer-directed home carebeneficiaries satisfied? Evidence from Washington State. Gerontologist2007, 47(6):763-774.

57. Benjamin AE, Matthias R, Franke TM: Comparing consumer-directed andagency models for providing supportive services at home. Health ServicesResearch 2000, 35(1 II):351-366.

58. Tinetti ME, Baker D, Gallo WT, Nanda A, Charpentier P, O’Leary J: Evaluationof restorative care vs usual care for older adults receiving an acuteepisode of home care. JAMA 2002, 287(16):2098-2105.

59. Lewin G, Vandermeulen S: A non-randomised controlled trial of theHome Independence Program (HIP): An Australian restorativeprogramme for older home-care clients. Health and Social Care in theCommunity 2010, 18(1):91-99.

60. National Medical and Health Research Council: A guide to thedevelopment, implementation and evaluation of clinical practiceguidelines. Canberra: Commonwealth of Australia; 1999.

Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/11/93/prepub

doi:10.1186/1472-6963-11-93Cite this article as: Low et al.: A systematic review of different modelsof home and community care services for older persons. BMC HealthServices Research 2011 11:93.

Submit your next manuscript to BioMed Centraland take full advantage of:

• Convenient online submission

• Thorough peer review

• No space constraints or color figure charges

• Immediate publication on acceptance

• Inclusion in PubMed, CAS, Scopus and Google Scholar

• Research which is freely available for redistribution

Submit your manuscript at www.biomedcentral.com/submit


Page 15 of 15















http://www.biomedcentral.com/1472-6963/11/93/prepub

Documents

A systematic review of different models of home and ... · Consumer-directed home care has been trialed in several countries including the Netherlands, England, Germany, France, USA