Systematic Review of Outcomes from Home-Based Primary Care Programs for Homebound Older Adults Nathan Stall, MD,* Mark Nowaczynski, PhD, MD,† and Samir K. Sinha, MD, DPhil*†‡§ [See Editorial Comments by Dr. Bruce Kinosian, pp 2433–2435]

OBJECTIVES: To describe the effect of home-based primary care for homebound older adults on individual, caregiver, and systems outcomes. DESIGN: A systematic review of home-based primary care interventions for community-dwelling older adults (aged ≥65) using the Cochrane, PubMed, and MEDLINE databases from the earliest available date through March 15, 2014. Studies were included if the house calls visitor was the ongoing primary care provider and if the intervention measured emergency department visits, hospitalizations, hospital beds days of care, long-term care admissions, or long-term care bed days of care. SETTING: Home-based primary care programs. PARTICIPANTS: Homebound community-dwelling older adults (N = 46,154). MEASUREMENTS: Emergency department visits, hospitalizations, hospital bed days of care, long-term care admissions, long-term care bed days of care, costs, program design, and individual and caregiver quality of life and satisfaction with care. RESULTS: Of 357 abstracts identified, nine met criteria for review. The nine interventions were all based in North America, with five emerging from the Veterans Affairs system. Eight of nine programs demonstrated substantial effects on at least one inclusion outcome, with seven programs affecting two outcomes. Six interventions shared three core program components: interprofessional care teams, regular interprofessional care meetings, and after-hours support. CONCLUSION: Specifically designed home-based primary care programs may substantially affect individual, caregiver and systems outcomes. Adherence to the core program components identified in this review could guide From the *Department of Medicine; †Department of Family and Community Medicine, ‡Department of Institute of Health Policy and Management, University of Toronto, Toronto, Ontario, Canada; and § Division of Geriatric Medicine and Gerontology, School of Medicine, Johns Hopkins University, Baltimore, Maryland. Address correspondence to Dr. Samir K. Sinha, Mount Sinai Hospital, Suite 475, 600 University Avenue, Toronto, ON M5G-1X5, Canada. E-mail: [email protected] DOI: 10.1111/jgs.13088

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the development and spread of these programs. J Am Geriatr Soc 62:2243–2251, 2014.

Key words: home-based primary care; house calls; homebound older adults

I

n the United States, at least 1 million individuals aged 65 and older are permanently homebound,1 with some estimating the number to be as high as 3.6 million.2 Homebound older adults have complex and often interrelated medical and social comorbidities that render them frail, making them one of the most vulnerable and marginalized populations. Because of their disabilities, office-based primary care delivery models do not serve these individuals well.3 Without easily accessible primary care, homebound older adults frequently turn to episodic alternatives such as emergency department visits and hospitalizations in times of crisis. These hospital encounters can precipitate functional decline and loss of capacity for independent living, putting these individuals at risk of permanent admission to longterm care facilities.4 Recognizing these barriers to care and adverse health trajectories, several home-based primary care (HBPC) programs have emerged internationally with the goal of providing homebound older adults with comprehensive ongoing primary care in the home.5 These programs specifically target individuals with complex chronic diseases who office-based care does not serve them well and aim to maximize independence at home, function, and overall quality of life.6,7 Since 2000, five English systematic reviews (three were also meta-analyses8–10) of HBPC programs for elderly adults have been published, with conflicting results.8–12 Some reviews reported that these programs did not affect mortality,11,12 physical and psychosocial function,11 health status,12 or healthcare use and costs,12 whereas other reviews concluded that these programs reduced mortality,8,9 admissions to long-term care facilities,8–10 and functional decline.8,10

0002-8614/14/$15.00

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Experts recognize that the individual trials included in these reviews are heterogeneous, and many of the programs studied were not solely HBPC programs but rather home visit outreach programs originating from the United Kingdom and Europe.3,13 Home visit outreach programs are neither designed nor able to provide comprehensive and ongoing primary care; in this model of care, individuals receive home-based multidimensional geriatric assessments with the goal of defining needs and developing a care plan.6 An office-based healthcare provider must implement these care plans, which fails to remedy the underlying access-to-care deficiencies and may even promote further fragmentation of care. Experts have therefore hypothesized that the inclusion of studies on British and European home visit outreach programs may have produced disparate results in previous systematic reviews and meta-analyses studying HBPC for homebound older adults.13,14 Given this hypothesis, an updated systematic review was performed to evaluate the effect of comprehensive HPBC programs on several individual, caregiver, and system outcomes. The review was limited to HBPC interventions in which the house calls visitor was the ongoing primary care provider. The analysis also included newer studies that have emerged since the 2008 publication of the two most recent systematic reviews.8,12 Finally, the goal was to identify the successful operational components of HBPC programs.

METHODS Data Sources and Search Strategy A detailed literature search was conducted to identify all articles studying the effects of HBPC in communitydwelling older adults (aged ≥65). Published studies were identified through searches of PubMed, MEDLINE and the Cochrane Database from the date of database onset until March 15, 2014. The Medical Subject Headings (MeSH) and subject terms or key words “aged,” “geriatrics,” “elderly,” and “seniors” in combination with “home based primary care,” “house calls,” “home visits,” and “HBPC,” as well as “hospitalization,” “emergency service,” “longterm care” and “nursing homes” were used (Appendix 1). Reference lists of earlier systematic reviews were also checked, the reference lists from potentially relevant papers were manually searched, conference proceedings and specialty journals were searched, and experts were contacted for additional studies. The search was restricted to the English language.

Study Selection Two reviewers (NS and SS) screened abstracts to identify potentially relevant articles. Discrepancies were resolved by consensus with a third reviewer (MN). An article was considered relevant, and the full text for the publication was retrieved if it measured hospitalizations, hospital bed days of care, emergency department visits, long-term care admissions, or long-term care bed days of care as an outcome of their HBPC intervention in which the house calls visitor was the ongoing primary care provider.

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Data Extraction Articles selected for full review had information extracted on authors, country, date of publication, study design, inclusion and exclusion criteria, sample size, study population characteristics, mean age at baseline of intervention, home-based primary care intervention personnel, structure of home-based primary care intervention, duration of intervention, and number of follow-up visits after initial home-based primary care intake assessment. Information was also extracted on the effect of the intervention on hospitalizations, hospital bed days of care, emergency department visits, long-term care admissions, and long-term care bed days of care, as well as on functional status and individual and caregiver satisfaction. Finally data were extracted on cost analyses, integrated medical education programs, and any other outcomes of relevance important to individuals and caregivers.

RESULTS Identification of Eligible Trials Three hundred fifty-seven abstracts were screened, and 322 studies were excluded because of irrelevance because they were not HBPC interventions or did not measure hospitalizations, hospital bed days of care emergency department visits, long-term care admissions, or long-term care bed days of care as an outcome of their intervention, leaving 35 potentially relevant articles.3,5,8–13,15–40 Five of these articles were excluded because they were systematic reviews, and an additional 21 articles were excluded because the house calls visitor was not the ongoing primary care provider, leaving nine studies to be included for analysis (Figure 1).3,5,29–31,34–36,40

Characteristics of Studies, Individuals, and Interventions The nine included studies involved a total of 46,154 individuals aged 65 and older (Table 1). Two studies comprised the bulk of patients; one study reviewed all 20,783 veterans enrolled in the Veterans Affairs HBPC Program in fiscal year 2006,31 and the other reviewed all new veteran enrollees in fiscal years 2002 and 2007.5 Of the nine studies, five included individuals from the U.S. Veterans Affairs system,5,30,31,35,36 one included individuals from a U.S. capitated insurance program,3 one included individuals from a U.S. private not-for-profit academic hospital,34 one included individuals from an American safety-net health system,29 and one included individuals from a Canadian family practice.40 Mean age of study participants at baseline ranged from 70.4 to 87.2.

Methodological Quality of Trials Study quality was assessed using the Cochrane Consumers and Communication Review Group Study Quality Guide41 and Meta-analysis of Observational Studies in Epidemiology criteria.42 Using these tools, four publications did not meet evaluation criteria because these were program descriptions rather than observational trials,5,31,34,36 but

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Used the MeSH terms: "aged," "geriatrics," "elderly," "seniors"

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Searched Cochrane, PubMed and MEDLINE databases

in combination with "home based primary care," "house calls," "home visits," "HBPC" as well as "hospitalization," "emergency service," "long-term care," "nursing homes"

Retrieved 357 articles 322 articles irrelevant

Measured one of: ED visits, hospitalizations, hospital BDOC, LTC admissions, and LTC BDOC

Screened 35 studies

and House calls visitor was the ongoing primary care provider

Included 9 studies

ED = Emergency Department, BDOC = Bed Days of Care, LTC = Long-Term Care

Figure 1. Identification of the nine eligible home-based primary care (HBPC) trials.

authors of all four were successfully contacted to verify adequacy of data collection and analysis, and data from these publications were ultimately included in the systematic review.

Effects on Emergency Department Visits The analysis was based on four studies that studied emergency department encounters before and after enrollment in the HBPC intervention (Table 2).29,30,36,40 Two studies reported reductions in emergency encounters of 15%29 (no P-value reported) and 48% (P < .01).36 Two other studies reported reductions of 20.8% (P = .2)40 and 18.5% (P = .26),30 but neither of these reached statistical significance.

Effects on Hospital Admissions and Bed Days of Care The admission analysis was based on all nine studies included in the systematic review (Table 2). Seven interventions compared hospitalization before and after entry in the HBPC intervention and reported substantial reductions in hospitalizations (23% (P < .001),3 26.8% (no P-value reported),31 30% (no P-value reported),34 31% (no P-value reported),5 39.7% (P = .004),40 43.7% (P = .001),30 and 84% (P < .01)).36 The remaining two studies failed to show a positive effect of their intervention on hospitalization, with one reporting an 8% increase29 and one showing no significant difference.35 The latter study found a 22% reduction (P = .03) in hospitalizations in a subgroup of severely disabled individuals.35 This effect was significant 6 months after enrollment in the intervention but was not sustained at 12 months.

The hospital bed days of care analysis was based on four studies (Table 2).5,30,31All four of these programs reported substantial reductions in inpatient days before and after the HBPC intervention: 37.4% (P = .04), 49.9% (P = .001),30 69% (no P-value reported),31 and 62% and 59% (no P-values reported) in the 2002 and 2007 national analyses.5

Effects on Long-Term Care Admissions and Bed Days of Care The analysis was based on three studies that studied longterm care admissions before and after enrollment in the HBPC intervention (Table 2).3,5,34 These three interventions all led to substantial reductions in long-term care admissions of 10% (no P-value reported),34 20% (P = .001),3 and 25% (no P-value reported).5 Only one study analyzed long-term care bed days of care before and after entry in the HBPC intervention, reporting reductions of 88% and 89% (no P-values reported) in the 2002 and 2007 national analyses, respectively.5

Effects on Cost The analysis was based on four studies.5,29,35,36 One reported that, in fiscal year 2002, the mean total VA cost of care dropped 24%, from $38,000 to $29,000 per person.5 Another reported 1-year cost savings of more than $1 million, with fewer hospitalizations accounting for 98% of these savings.36 A third study reported that, 1 year after enrollment in the intervention, total charges per person (ambulatory and acute care) increased by $5,712,29 but $5,430 (95%) of these charges were for outpatient

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Table 1. Characteristics of the Nine Interventions Included Study

Beales, 20095

Beck, 200929

Intervention Personnel

Intervention Structure

Medical director (MD), NP, RN, PA, SW, pharmacist, dietitian, OT, PT, kinesiotherapist, program director and assistant Geriatrician, geriatric NPs, RN, SW patient service assistant, practice manager

Primary care provider: MD or NP or PA Interdisciplinary team develops an individualized care plan Initial and ongoing assessments by SW, dietitians, rehabilitation therapist Weekly interdisciplinary team meetings Primary care provider: geriatrician and NP Initial in-home comprehensive geriatric assessment (geriatrician) Follow-up every 4–6 weeks (NPs) Urgent visits (NPs) Patient seen within 2 days of discharge from hospital or emergency department Initial assessment by SW with follow-up every year After-hours telephone calls (geriatrician) Weekly patient care meetings Primary care provider: NP Initial in-home comprehensive geriatric assessment (NP) Follow-up at least once a month (MD, NP or RN) Urgent home visits as needed Routine evaluations and duties (RN) After-hours telephone calls Weekly interdisciplinary conferences to discuss new patients and 90-day care plans for enrolled patients Primary care provider: MD, NP, PA Interdisciplinary team develops an individualized care plan Initial and ongoing assessments by SW and dietitians and rehabilitation therapist Weekly interdisciplinary team meetings Primary care provider: MD and NP MD performs 35% of house calls NP performs follow-up and urgent house calls (65%) If individual requires hospitalization, MD treats in a dedicated unit at affiliated hospital Primary care provider: MD Systematic screening and continuous patient care management Primary care provider: NP NP refers individuals to specialty clinics and other programs when necessary Weekly interdisciplinary team meetings to discuss concerns and review and update care plans Primary care provider: MD Initial in-home comprehensive geriatric assessment (MD and RN) Follow-up every month (RN) and every 2–3 months (MD) Urgent visits within 1 working day (RN or MD) Weekly visits for individuals who were hospitalized (MD) 89% of individuals received in-home rehabilitation (PT) After-hours telephone calls (shared by a group of family physicians from local clinics) Daily virtual team meetings and quarterly business and planning team meetings Primary care provider: MD Initial in-home comprehensive geriatric assessment (MD and RN) Follow-up every month (NP) and 3 months (MD) After-hours telephone service (MD on-call)

Chang, 200830

Medical director (MD), NP, RN, SW, pharmacist, dietitian, dental hygienist, program director

Cooper, 200731

Medical director (MD), NP, RN, PA, SW, pharmacist, dietitian, OT, PT, kinesiotherapist, program director and assistant 2 geriatricians, 2 NPs, RN, PT, OT, health assistant, program coordinator and assistant

De Jonge, 200234

Hughes, 200035 North, 200836

MD, SW, pharmacists, dietitian, OT, PT, paraprofessional aides NPs, SW, pharmacists, dietitians, OT, homemakers

Rosenberg, 201240

MD, RN, PT, office manager

Wajnberg, 20103

MD, NP, SW

MD= medical doctor; NP= nurse practitioner; RN= registered nurse; PA= physician assistant; SW= social worker; OT= occupational therapist; PT= physiotherapist.

services, and after enrollment in the program, people were more likely to visit an emergency department or be hospitalized in the study site’s healthcare system. Finally, a fourth study reported 6.8% greater costs at 6 months and 12.1% greater at 12 months.35 Similar, to the findings of the third study,29 home-based care and nursing home costs were higher after enrollment in the intervention.

Effects on Other Individual and Caregiver Outcomes Several studies also measured a variety of other individual and caregiver outcomes. One study reported that

participants had high levels of satisfaction with the house calls intervention, with mean scores on a 5-point scale (1 = poor to 5 = excellent) being consistently greater than 4. (Independent surveyors conducted quarterly satisfaction telephone surveys.) In addition, 94% of participants were offered influenza vaccines (72% accepted), 82% had a pneumococcal vaccination, and 58% had documented endof-life care discussions.29 Another study reported that 97.3% of participants in the HBPC intervention had documented advance directives and that 29.0% of participants were able to die at home.30 A third study found that terminally ill individuals and their caregivers receiving

20,783/0

480/0

981/985

104/0

Observationalb

Observationalb

Multisite randomized controlled trial

Observationalb

Observational

Observational

Cooper, 200731

De Jonge, 200234

Hughes, 200035

North, 200836

Rosenberg, 201240

Wajnberg, 20103 79

Bronx, New York

Victoria, British Columbia

Denver VAMC

All veterans in the U.S. HBPC program Washington Hospital Center 16 VAMCs

Marion County, Indianapolis Washington VAMC

All veterans in the U.S. HBPC program

Setting

22 months

1 year

1 year

4 years

3 years

1 year

2 years

7 years

1 year

1 year

Intervention Duration

Equivalent time before and after HBPC (median enrollment 198 days) c

1 year before and after HBPC

1 year before and after HBPC

1 year prospective comparison to control group

1 year before and after HBPC

6 months before and 12 after HBPC

6 months before and after HBPC 1 year before and after HBPC 6 months before and after HBPC

6 months before and after HBPC

Outcome Analysis

—

↓ 48% (P < .01) (166 ? 86) ↓ 20.8% (P = .2) (120 ? 95)

—

—

↓ 15% (805 ? 686) ↓ 18.5% (P = .26) (130 ? 106) —

—

—

Emergency Department Visits

VAMC = Veterans Affairs Medical Center; — = not measured. a Included two national analyses of the Department of Veterans Affairs (VA) home-based primary care (HBPC) program in 2002 and 2007. b Data extracted from a program description. c The pre-HBPC period was calculated using an equivalent number of days as the post-HBPC period (dating back from the enrollment date). d Relative reduction in proportion of participants with one or more hospitalizations or long-term care placement.

179/0

87.2

80

70.4

—

—

73.6

80

76.5

—

Mean Age of Participants

↓ 23%d (P < .001)

↓ 39.7% (P = .004) (116 ? 70)

No significant difference (but ↓ 22% in severely disabled at 6 months, P = .03) ↓ 84% (P < .01) (822 ? 135)

↓ 30%

↑ 8% (330 ? 356) ↓ 43.7% (P = .001) (126 ? 71) ↓ 26.8%

↓ 31%

—

Hospital Admissions

—

— ↓ 37.6% (P = .04) (1,700 ? 1, 061) —

↓ 20%c (P = .001)

—

—

—

—

—

—

—

—

—

—

↓ 10%

—

— ↓ 49.9% (P = .001) (1,033 ? 518) ↓ 69%

—

—

↓ 89%

↓ 88%

Long-Term Care Bed Days of Care

—

↓ 25%

—

Long-Term Care Admissions

—

↓ 59%

↓ 62%

Hospital Bed Days of Care

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248/0

183/0

Observational

Chang, 200830

468/0

2007 cohort

Observational

10,409/0

Observationala 2002 cohort

Beales, 20095

Beck, 200929

11,334/0

Design

Study

Sample Size, Intervention/ Control

Table 2. Outcomes of Nine Studies Included

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HBPC had significantly higher quality-of-life scores than those receiving regular care. Moreover, caregivers of nonterminally ill individuals receiving HBPC had better quality-of-life scores and lower levels of caregiver burden. Functional status as assessed using the Barthel Index did not differ between individuals receiving HBPC and those receiving usual care.35 A fourth study reported 90% screening rates for advance directives, pain levels, and urinary incontinence and vaccination rates of 90% for influenza and for 83% pneumococcus.36 Finally, it was reported that 46.9% of individuals who died after enrollment in an intervention were able to die at home.40

Common Program Components All interventions shared several core program components. All programs described the involvement of a fully integrated interprofessional care team (Table 1). These teams comprised a variety of professionals, including geriatricians, general practitioners, nurse practitioners, community nurses, physician assistants, social workers, physiotherapists, occupational therapists, kinesiotherapists, pharmacists, dietitians, dental hygienists, program directors, and assistants. Six interventions described holding regular (at least weekly) interprofessional care meetings to review new patients and update patient care plans for existing patients.5,29–31,36,40 Four of these programs explicitly described conducting comprehensive geriatric assessments at intake to help formulate a care plan.3,29,30,40 Finally, these four programs described the availability of an afterhours urgent telephone service. (This may have been underreported because the standard of care for most primary care programs is the availability of an after-hours urgent telephone service.3,29,30,40)

DISCUSSION This systematic review found nine studies investigating healthcare use outcomes of homebound older adults served by HBPC programs. Eight (88.9%) HBPC interventions reviewed demonstrated substantial reductions in at least one of the inclusion outcomes of emergency department visits, hospitalizations, hospital beds days of care, longterm care admissions, and long-term care bed days of care; seven programs (77.8%) demonstrated reductions in at least two of these outcomes. The review also found that many of the HBPC programs reviewed positively affected several other important outcomes, including screening for common geriatric syndromes, individual and caregiver quality of life and satisfaction with care, vaccination rates, and engagement in end-of-life care discussions. This detailed systematic review identified some important operational components of successful HBPC programs. In general, robust HBPC programs involve fully integrated interprofessional care teams, regular (at least weekly) interprofessional care meetings, comprehensive geriatric assessments at intake, and an after-hours urgent telephone service. Adherence to these core program components identified could help guide the development and spread of new HBPC programs.

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It was not possible to definitively assess the overall financial effect of HBPC interventions, because only four studies included financial analyses, but two programs reported substantial cost savings.5,36 Another two reported higher costs per patient after enrollment in the program,29,35 which is troubling, because many policy-makers and program directors share a preconception that HBPC programs are financially disadvantageous, because the time-intensive nature of home visits may not be able to generate enough direct billing to support physician and administrative personnel.43 A recent independent financial analysis of an HBPC program demonstrated substantial economic benefits, with the Mount Sinai Visiting Doctors program generating 1-year revenue of $2.6 million.43 In addition, considering the current study findings that HBPC programs substantially reduce expensive admissions to acute care hospitals and skilled long-term care facilities, it would intuitively follow that these programs would result in significant cost savings from avoiding more-costly institutional care. Cost analyses from the Veterans Affairs may be limited because HBPC recipients may receive acute and long-term care services from the Veterans Health Administration and Medicare, but only the former may be accounted for. Additionally, costing data may not capture the full spectrum of community care ancillary services, including imaging, laboratory, and allied health services. Overall, the results of this systematic review are significant and highlight that HBPC for homebound older adults can positively affect several important individual, caregiver, and system outcomes. This is noteworthy, because five systematic reviews from 2008 and earlier produced mixed results.8–12 The current review is distinct from these because inclusion of HBPC programs was specifically limited to those in which the house calls visitor was the ongoing primary care provider. This ensured that the interventions reviewed were all providing comprehensive and ongoing primary care in the home. Like in other studies, the heterogeneity of studies included in previous systematic reviews was recognized, which did not limit their analysis to HBPC interventions but also included home visit outreach programs.3,13,14 The process has ultimately hindered effective systematic evaluation of the HBPC model and probably delayed the broader development, acceptance, and dissemination of effective HBPC models.14 This review had several limitations. It was attempted to perform a systematic review, but publication bias and the potential for incomplete identification of relevant studies are always considerations. Multiple databases were searched, bibliographic searches of the reviewed articles were used, and the authors of the reviewed articles were surveyed to identify additional studies. Study quality also limited this review. Only one study was a randomized controlled trial,35 whereas the remaining eight were observational, with four being program descriptions.5,31,34,36 For these four program descriptions, authors were successfully contacted to verify the adequacy of data collection and analysis. Although study quality was limited, evaluating complex multicomponent health and social interventions in randomized clinical trials may be problematic because it is difficult to recruit, standardize, blind, and randomize in this setting, and there are

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ethical considerations regarding withholding what is arguably necessary care from vulnerable control subjects.44 Another weakness of this review is the age heterogeneity of the various interventions, with the mean age of participants ranging from 70.4 to 87.2. Although age alone does not render an individual homebound, the homebound population remains imprecisely defined in the medical literature.2 The most widely accepted definition is the one that the U.S. Medicare program uses, which considers an ailing or injured individual to be homebound “if leaving the home requires considerable and taxing effort,” and if absences from the home “are infrequent, of short duration or to receive medical treatment,”45 but this definition might be too restrictive, because the way that Medicare defines being homebound, primarily using simple physical criteria, might fail to encompass the complex interplay of medical, psychiatric, and cognitive challenges, along with social frailty, that could render a person homebound.2,3 A comprehensive review reported that homebound elderly adults have higher rates of metabolic, cardiovascular, cerebrovascular, and musculoskeletal diseases; dementia; and depression than the general elderly population.2 Given the age heterogeneity of the interventions included in the current review, as well as the lack of a consensus definition for the homebound population, it is possible that there was unmeasured heterogeneity among review subjects for characteristics such as comorbidity, frailty, cognition, and function. This points to the pressing research need to develop a consensus definition for homebound and standardized selection criteria and validated screening tools for this population.6 A final limitation was that inferences were drawn about model components associated with effectiveness of home-based primary care programs using data from this systematic review. To ensure accuracy, the authors of included studies were invited to verify the interpretations of their work. Despite these limitations, the authors feel confident in the validity of the principal finding that the existing literature demonstrates that HBPC can effectively support homebound older adults in successfully aging at home while reducing emergency department visits, hospitalizations, and long-term care admissions. Although more-robust financial analyses are required to definitively determine whether HBPC is cost effective, one could argue that, even if the model is cost neutral, this is money well spent.

CONCLUSION This systematic review has demonstrated that specifically designed HBPC programs for homebound older adults can reduce hospitalizations and long-term care admissions while improving individual and caregiver quality of life and satisfaction with care. This has been recognized elsewhere, with the most recent U.S. health-care reform legislation, the Patient Protection and Affordable Care Act of 2010, including a provision to test a remuneration incentive and operational model for HBPC, known as the Independence at Home program.46 The current review has also highlighted how much of the evidence supporting HBPC is observational and that there is a pressing need for further

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well-controlled studies of home-based primary care. In spite of this, policy-makers grappling with the needs of a rapidly aging population should recognize that HBPC could help maintain quality of life and function in older adults, as well as the overall sustainability of healthcare systems.

ACKNOWLEDGMENTS Results presented in part at the 32nd Annual Scientific Meeting of the Canadian Geriatrics Society, Quebec City, Canada, April 2012. Results presented in whole at the 20th International Association of Gerontology and Geriatrics World Congress of Gerontology and Geriatrics, Seoul, South Korea, June 2013. Conflict of Interest: Dr. Nowaczynski is Clinical Director of House Calls—a physician-led, home-based interprofessional primary and specialty care program serving frail, marginalized, and homebound older adults in Toronto, Ontario. Dr. Sinha is a consulting geriatrician for the House Calls program. Drs. Nowaczynski and Sinha are two of the four co-principle investigators of a $395,000 Ontario Ministry of Health and Long-Term Care BRIDGES grant entitled “Bridging Care for Frail Older Adults: A Study of Innovative Models Providing Integrated Home-based Primary Care in Toronto” and are two of the six co-principle investigators of a $200,000 MOHLTC Innovations Fund grant entitled “Evaluating the Effectiveness of an Integrated Home-Based Primary, Speciality and Community Care Model For Frail and Housebound Older Adults.” Author Contributions: All authors contributed to study design. Drs. N. Stall and S.K. Sinha screened abstracts for review, and resolved discrepancies by consensus with Dr. M. Nowaczynski. Dr. N. Stall performed the qualitative synthesis for eligible abstracts, and all authors contributed to the analysis and interpretation of data. Dr. N. Stall drafted the manuscript, which all authors revised. All authors approved the final version submitted for publication. Sponsor’s Role: None.

REFERENCES 1. Levine SA, Boal J, Boling PA. Home care. JAMA 2003;290:1203–1207. 2. Qiu WQ, Dean M, Liu T et al. Physical and mental health of homebound older adults: An overlooked population. J Am Geriatr Soc 2010;58:2423– 2428. 3. Wajnberg A, Wang KH, Aniff M et al. Hospitalizations and skilled nursing facility admissions before and after the implementation of a home-based primary care program. J Am Geriatr Soc 2010;58:1144–1147. 4. Sinha SK. Why the elderly could bankrupt Canada and how demographic imperatives will force the redesign of acute care service delivery. Healthc Pap 2011;11:46–51; discussion 86–91. 5. Beales JL, Edes T. Veteran’s Affairs Home Based Primary Care. Clin Geriatr Med 2009;25:149–154, viii–ix. 6. Stall N, Nowaczynski M, Sinha SK. Back to the future: Home-based primary care for older homebound Canadians: Part 1: Where we are now. Can Fam Physician 2013;59:237–240. 7. Stall N, Nowaczynski M, Sinha SK. Back to the future: Home-based primary care for older homebound Canadians: Part 2: Where we are going. Can Fam Physician 2013;59:243–245. 8. Huss A, Stuck AE, Rubenstein LZ et al. Multidimensional preventive home visit programs for community-dwelling older adults: A systematic review and meta-analysis of randomized controlled trials. J Gerontol A Biol Sci Med Sci 2008;63A:298–307.

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APPENDIX: SEARCH STRATEGIES Database: Ovid MEDLINE(R) Search Strategy: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

aged/or exp frail elderly/ exp Geriatrics/ elderly.mp. seniors.mp. 1 or 2 or 3 or 4 home based primary care.mp. exp House Calls/ home visits.mp. hbpc.mp. 6 or 7 or 8 or 9 hospitalization/or exp patient admission/or exp patient readmission/ Emergency Service, Hospital/ Long-Term Care/ exp Nursing Homes/ 11 or 12 or 13 or 14 5 and 10 and 15 limit 16 to (english language and “all aged (65 and over)”)

Database: The Cochrane Database (March 15, 2014) Search Strategy: #1 House Calls:ti,ab,kw OR Home Based Primary Care: ti,ab,kw OR HBPC:ti,ab,kw OR Home Visits:ti,ab,kw #2 MeSH descriptor: [Aged] explode all trees

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#3 Hospitalization:ti,ab,kw OR Patient Admission:ti,ab, kw OR Patient Readmission:ti,ab,kw OR Emergency Service:ti,ab,kw OR Long-Term Care:ti,ab,kw #4 Nursing Homes:ti,ab,kw #5 Seniors:ti,ab,kw OR Elderly:ti,ab,kw OR Geriatrics: ti,ab,kw #6 #2 or #5 #7 #3 or #4 #8 #1 and #6 and #7

2251

Database: PubMed (March 15, 2014) Search Strategy: ((“House Calls”[Mesh]) OR (hbpc)) AND (“Hospitalization”[Mesh]) OR (“Emergency Service, Hospital” [Mesh] OR “Emergency Medical Services”[Mesh]) OR (“Long-Term Care”[Mesh]) OR (“Nursing Homes” [Mesh]) AND ((“Aged”[Mesh]) OR “Geriatrics” [Mesh]) AND (English[lang] AND aged[MeSH])

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