Evaluation of restorative care vs usual care for older adults receiving an acute episode of home care.

摘要

CONTEXT: Illness and hospitalization often trigger functional decline among older persons. Home care services implemented for functional decline provide an opportunity to intervene to improve outcomes. OBJECTIVE: To compare functional status and the likelihood of remaining at home for persons receiving restorative care vs usual home care. DESIGN AND SETTING: Intervention using prospective individual matching conducted between November 1, 1998, and April 30, 2000. Six offices of a home care agency in Connecticut were used. One branch office served as the restorative care unit and the other 5 served as usual care offices. PARTICIPANTS: Patients receiving home care through the restorative care office who were 65 years or older; in receipt of Medicare-covered home care lasting at least 7 days; with absence of severe cognitive impairment; and not terminal, bedridden, or requiring total care were matched with patients from 1 of the usual care offices. The matching factors included age, sex, race, baseline self-care function, cognitive status, whether hospitalization preceded the home care episode, and date of the home care episode. Of the 712 eligible restorative care patients, 691 (97%) were matched with a usual care patient. INTERVENTION: Restorative care, provided by the home care agency nursing, therapy, and home health aide staff, was based on principles from geriatric medicine, nursing, rehabilitation, and goal attainment. MAIN OUTCOME MEASURES: Remaining at home, functional status at completion of the home care episode, and duration and intensity of home care episode. RESULTS: Compared with usual care, and after adjusting for baseline characteristics and other factors, restorative care was associated with a greater likelihood of remaining at home (82% vs 71%; odds ratio [OR], 1.99; 95% confidence interval [CI], 1.47-2.69) and a reduced likelihood of visiting an emergency department (10% vs 20%; OR, 0.44; 95% CI, 0.32-0.61). Home care episodes were shorter (mean [SD], 24.8 [26.8] days vs 34.3 [44.2] days; S = -17 821; P<.001). Restorative care patients had better mean (SD) scores than usual care patients in self-care (11.0 [2.1] vs 10.7 [2.5]; P =.07 after adjustment), home management (9.5 [2.9] vs 9.2 [3.0]; P =.05 after adjustment), and mobility (3.3 [0.8] vs 3.2 [0.9]; P =.02 after adjustment). CONCLUSIONS: This trial suggests that reorganizing the structure and goals of home care can enhance health outcomes of older patients without increasing health care utilization.