Uittenbroek and colleagues randomized elderly patients to usual care or multi-disciplinary home-based case management. They found that a multi-disciplinary home-based team improved the quality of care for the frail or complex elderly patients, but not for those considered robust.1
One interesting finding is that among Dutch citizens 75 years or older, nearly 60% of them were considered robust; 16% were frail and 25% had complex care needs. This mirrors findings in France2 and England.3 This generation of elderly is aging well with a substantial portion healthy well into their 90s. However, 40% are frail or have complex care needs, and healthcare systems need to develop plans to deal with this group, particularly as developed countries deal with the baby boomer bulge.
One limitation not mentioned by Uittenbroek is that the control group in their study had relatively robust systems of integrated healthcare. The Dutch healthcare system includes comprehensive care for all citizens.4 It is likely that the impact of integrated care would be greater in a more fragmented healthcare system, such as in the US. Another limitation is the lack of information on other critical outcomes, such as transition to nursing homes. Keeping elderly citizens in their own home and reducing the need to move to higher levels of care could be very important. The Veterans Administration has developed a system of home-based primary care for veterans who are frail and/or have complex care needs,3 which is remarkably similar to the approach used by Uittenbroek. The VA program has been shown to improve quality of care and to reduce ER and hospitalization costs by about 12%.5 The impact of delaying transition to nursing homes has yet to be reported. Given how expensive institutional care is, minimal delays in transitioning to institutional care could produce sufficient cost reductions to render these interventions cost-effective. Nations and health systems with integrated care should watch these innovative programs closely.
Compliance with Ethical Standards
Conflict of Interest
The authors have no conflicts of interest with this article.
References
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