title: In-home care for optimizing chronic disease management in the community: an evidence-based analysis.
abstract: BACKGROUND
  The emerging attention on in-home care in Canada assumes that chronic disease management will be optimized if it takes place in the community as opposed to the health care setting. Both the patient and the health care system will benefit, the latter in terms of cost savings.
  
  
  OBJECTIVE
  To compare the effectiveness of care delivered in the home (i.e., in-home care) with no home care or with usual care/care received outside of the home (e.g., health care setting).
  
  
  METHODS
  A literature search was performed on January 25, 2012, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database, for studies published from January 1, 2006, until January 25, 2012.
  
  
  METHODS
  An evidence-based analysis examined whether there is a difference in mortality, hospital utilization, health-related quality of life (HRQOL), functional status, and disease-specific clinical measures for in-home care compared with no home care for heart failure, atrial fibrillation, coronary artery disease, stroke, chronic obstructive pulmonary disease, diabetes, chronic wounds, and chronic disease / multimorbidity. Data was abstracted and analyzed in a pooled analysis using Review Manager. When needed, subgroup analysis was performed to address heterogeneity. The quality of evidence was assessed by GRADE.
  
  
  RESULTS
  The systematic literature search identified 1,277 citations from which 12 randomized controlled trials met the study criteria. Based on these, a 12% reduced risk for in-home care was shown for the outcome measure of combined events including all-cause mortality and hospitalizations (relative risk [RR]: 0.88; 95% CI: 0.80-0.97). Patients receiving in-home care had an average of 1 less unplanned hospitalization (mean difference [MD]: -1.03; 95% CI: -1.53 to -0.53) and an average of 1 less emergency department (ED) visit (MD: -1.32; 95% CI: -1.87 to -0.77). A beneficial effect of in-home care was also shown on activities of daily living (MD: -0.14; 95% CI: -0.27 to -0.01), including less difficulty dressing above the waist or below the waist, grooming, bathing/showering, toileting, and feeding. These results were based on moderate quality of evidence. Additional beneficial effects of in-home care were shown for HRQOL although this was based on low quality of evidence.
  
  
  CONCLUSIONS
  Different characterization of outcome measures across studies prevented the inclusion of all eligible studies for analysis.
  
  
  CONCLUSIONS
  In summary, education-based in-home care is effective at improving outcomes of patients with a range of heart disease severity when delivered by nurses during a single home visit or on an ongoing basis. In-home visits by occupational therapists and physical therapists targeting modification of tasks and the home environment improved functional activities for community-living adults with chronic disease.
mesh_terms: D002908:Chronic Disease / Q000401:mortality / Q000628:therapy*; D019468:Disease Management; D055317:Evidence-Based Practice; D006699:Home Care Services / Q000191:economics / Q000639:trends*; D006760:Hospitalization / Q000191:economics / Q000639:trends*; D006801:Humans; D009726:Nurses / Q000706:statistics & numerical data; D009788:Occupational Therapy / Q000706:statistics & numerical data; D009864:Ontario / Q000453:epidemiology; D010353:Patient Education as Topic; D017060:Patient Satisfaction; D059825:Physical Therapists / Q000706:statistics & numerical data; D011788:Quality of Life; D016896:Treatment Outcome