Effectiveness of team-managed home-based primary care - A randomized multicenter trial

Context Although home-based health care has grown over the past decade, its effectiveness remains controversial. A prior trial of Veterans Affairs (VA ) Team-Managed Home-Based Primary Care (TM/HBPC) found favorable outcomes, but the replicability of the model and generalizability of the findings are unknown. Objectives To assess the impact of TM/HBPC on functional status, health-rel ated quality of life (HR-QoL), satisfaction with care, and cost of care. Design and Setting Multisite randomized controlled trial conducted from Oct ober 1994 to September 1998 in 16 VA medical centers with HBPC programs. Participants A total of 1966 patients with a mean age of 70 years who had 2 or more activities of daily living impairments or a terminal illness, cong estive heart failure (CHF), or chronic obstructive pulmonary disease (COPD) . Intervention Home-based primary care (n=981), including a primary care mana ger, 24-hour contact for patients, prior approval of hospital readmissions, and HBPC team participation in discharge planning, vs customary VA and pri vate sector care (n=985). Main Outcome Measures Patient functional status, patient and caregiver HR-Q oL and satisfaction, caregiver burden, hospital readmissions, and costs ove r 12 months. Results Functional status as assessed by the Barthel Index did not differ f or terminal (P=.40) or nonterminal (those with severe disability or who had CHF or COPD) (P=.17) patients by treatment group. Significant improvements were seen in terminal TM/HBPC patients in HR-QoL scales of emotional role function, social function, bodily pain, mental health, vitality, and genera l health. Team-Managed HBPC nonterminal patients had significant increases of 5 to 10 points in 5 of 6 satisfaction with care scales. The caregivers o f terminal patients in the TM/HBPC group improved significantly in HR-QoL m easures except for vitality and general health. Caregivers of nonterminal p atients improved significantly in QoL measures and reported reduced caregiv er burden (P=.008). Team-Managed HBPC patients with severe disability exper ienced a 22% relative decrease (0.7 readmissions/patient for TM/HBPC group vs 0.9 readmissions/patient for control group) in hospital readmissions (P= .03) at 6 months that was not sustained at 12 months. Total mean per person costs were 6.8% higher in the TM/HBPC group at 6 months ($19 190 vs $17 97 1) and 12.1% higher at 12 months ($31 401 vs $28 008). Conclusions The TM/HBPC intervention improved most HR-QoL measures among te rminally ill patients and satisfaction among non-terminally ill patients. I t improved caregiver HR-QoL, satisfaction with care, and caregiver burden a nd reduced hospital readmissions at 6 months, but it did not substitute for other forms of care. The higher costs of TM/HBPC should be weighed against these benefits.