title: Integrated care at home reduces unnecessary hospitalizations of community-dwelling frail older adults: a prospective controlled trial.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  Clinical Trials.gov Identifier: NCT02084108 . Retrospectively registered on March 10th2014.
authors.affiliation: Division of Primary Care Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, 1, avenue Calas, Geneva, 1206, Switzerland. l.dipollina@noshaq.ch.
authors.forename: Laura
authors.initials: L
authors.lastname: Di Pollina
authors.affiliation: Division of Primary Care Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, 1, avenue Calas, Geneva, 1206, Switzerland. idris.guessous@hcuge.ch.|Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland. idris.guessous@hcuge.ch.
authors.forename: Idris
authors.initials: I
authors.lastname: Guessous
authors.affiliation: Institution genevoise de maintien à domicile (IMAD), Carouge, Switzerland.
authors.forename: Véronique
authors.initials: V
authors.lastname: Petoud
authors.affiliation: Clinical Research Centre and Division of Clinical-Epidemiology, Department of Health and Community Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland.
authors.forename: Christophe
authors.initials: C
authors.lastname: Combescure
authors.affiliation: Association des médecins genevois (AMG), Geneva, Switzerland.
authors.forename: Bertrand
authors.initials: B
authors.lastname: Buchs
authors.affiliation: Cité générations, Onex, Switzerland.
authors.forename: Philippe
authors.initials: P
authors.lastname: Schaller
authors.affiliation: Division of Primary Care Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, 1, avenue Calas, Geneva, 1206, Switzerland.
authors.forename: Michel
authors.initials: M
authors.lastname: Kossovsky
authors.affiliation: Division of Primary Care Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, 1, avenue Calas, Geneva, 1206, Switzerland.
authors.forename: Jean-Michel
authors.initials: JM
authors.lastname: Gaspoz
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019033:Delivery of Health Care, Integrated; D005260:Female; D016330:Frail Elderly; D015577:Geriatric Assessment; D006699:Home Care Services; D017052:Hospital Mortality / Q000639:trends*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D057187:Independent Living; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013557:Switzerland / Q000453:epidemiology
keywords: Aged; Chronic disease; Community based interventions; Home care; Palliative care