Effectiveness of team-managed home-based primary care: a randomized multicenter trial.
BACKGROUND
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.


OBJECTIVE
To assess the impact of TM/HBPC on functional status, health-related quality of life (HR-QoL), satisfaction with care, and cost of care.


METHODS
Multisite randomized controlled trial conducted from October 1994 to September 1998 in 16 VA medical centers with HBPC programs.


METHODS
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, congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD). Intervention Home-based primary care (n=981), including a primary care manager, 24-hour contact for patients, prior approval of hospital readmissions, and HBPC team participation in discharge planning, vs customary VA and private sector care (n=985).


METHODS
Patient functional status, patient and caregiver HR-QoL and satisfaction, caregiver burden, hospital readmissions, and costs over 12 months.


RESULTS
Functional status as assessed by the Barthel Index did not differ for 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 general health. Team-Managed HBPC nonterminal patients had significant increases of 5 to 10 points in 5 of 6 satisfaction with care scales. The caregivers of terminal patients in the TM/HBPC group improved significantly in HR-QoL measures except for vitality and general health. Caregivers of nonterminal patients improved significantly in QoL measures and reported reduced caregiver burden (P=.008). Team-Managed HBPC patients with severe disability experienced 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 ($19190 vs $17971) and 12.1% higher at 12 months ($31401 vs $28008).


CONCLUSIONS
The TM/HBPC intervention improved most HR-QoL measures among terminally ill patients and satisfaction among non-terminally ill patients. It improved caregiver HR-QoL, satisfaction with care, and caregiver burden and 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.
Hughes
S L
SL
Cooperative Studies Program Coordinating Center, Edward A. Hines Jr Veterans Affairs Hospital, Hines, Ill, USA. shughes@uic.edu
Weaver
F M
FM
Giobbie-Hurder
A
A
Manheim
L
L
Henderson
W
W
Kubal
J D
JD
Ulasevich
A
A
Cummings
J
J
D000203:Activities of Daily Living; D000368:Aged; D005260:Female; D017048:Health Care Costs; D006333:Heart Failure; D006699:Home Care Services / Q000191:economics / Q000458:organization & administration*; D006760:Hospitalization / Q000706:statistics & numerical data; D006787:Hospitals, Veterans / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D008173:Lung Diseases, Obstructive; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010346:Patient Care Management; D010348:Patient Care Team; D017060:Patient Satisfaction; D011320:Primary Health Care / Q000191:economics / Q000458:organization & administration*; D011788:Quality of Life; D018709:Statistics, Nonparametric; D019452:Terminally Ill; D014481:United States