Integrated care at home reduces unnecessary hospitalizations of community-dwelling frail older adults: a prospective controlled trial

Abstract

Background: Care of frail and dependent older adults with multiple chronic conditions is a major challenge for health care systems. The study objective was to test the efficacy of providing integrated care at home to reduce unnecessary hospitalizations, emergency room visits, institutionalization, and mortality in community dwelling frail and dependent older adults.

Methods: A prospective controlled trial was conducted, in real-life clinical practice settings, in a suburban region in Geneva, Switzerland, served by two home visiting nursing service centers. Three hundred and one community-dwelling frail and dependent people over 60 years old were allocated to previously randomized nursing teams into Control (N = 179) and Intervention (N = 122) groups: Controls received usual care by their primary care physician and home visiting nursing services, the Intervention group received an additional home evaluation by a community geriatrics unit with access to a call service and coordinated follow-up. Recruitment began in July 2009, goals were obtained in July 2012, and outcomes assessed until December 2012. Length of follow-up ranged from 5 to 41 months (mean 16.3). Primary outcome measure was the number of hospitalizations. Secondary outcomes were reasons for hospitalizations, the number and reason of emergency room visits, institutionalization, death, and place of death.

Results: The number of hospitalizations did not differ between groups however, the intervention led to lower cumulative incidence for the first hospitalization after the first year of follow-up (69.8%, CI 59.9 to 79.6 versus 87 · 6%, CI 78 · 2 to 97 · 0; p = .01). Secondary outcomes showed that the intervention compared to the control group had less frequent unnecessary hospitalizations (4.1% versus 11.7%, p = .03), lower cumulative incidence for the first emergency room visit, 8.3%, CI 2.6 to 13.9 versus 23.2%, CI 13.1 to 33.3; p = .01), and death occurred more frequently at home (44.4 versus 14.7%; p = .04). No significant differences were found for institutionalization and mortality.

Conclusions: Integrated care that included a home visiting multidisciplinary geriatric team significantly reduced unnecessary hospitalizations, emergency room visits and allowed more patients to die at home. It is an effective tool to improve coordination and access to care for frail and dependent older adults.

Trial registration: Clinical Trials.gov Identifier: NCT02084108 . Retrospectively registered on March 10^th 2014.

Keywords: Aged; Chronic disease; Community based interventions; Home care; Palliative care.

Fig. 1

Flow chart

Fig. 2

Cumulative incidences for primary and secondary outcomes. First hospitalization rate was not significant different over the three year follow-up period (global p = 0.24). However, first hospitalization rate was significantly reduced at two (p = 0.04) and three years (p = 0.01). First emergency room visit was significantly reduced over the three year follow-up period (global p = 0.03). No difference was found in institutionalization rates (global p = 0.70). Mortality was not significantly reduced (global p = 0.06) over the three year follow-up period. A significant difference appeared at two years (p = 0 · 03) with a trend at three years (p = 0 · 07) in favor of the intervention arm (see text for details)