For most of history medical care has been provided in the home, in most cases by family members or neighbors and in more dire situations by physicians. With the rise of the modern hospital in the early part of the twentieth century, together with the increasing mobility offered by the automobile, patients began to come to physicians rather than the other way round. In the United States, for example, a precipitous drop in the number of home visits after World War II occurred, from 40 percent of all patients encounters in 1930 to no more than 10 percent by 1950. By 1980 house calls made up only 0.6 percent of such contacts. In Canada and the United Kingdom, especially in large cities, the practice of home visiting has also declined.
However, for a significant minority of older persons, care today should still be provided in the patient's home. One may divide up the kinds of care broadly between acute and ongoing (long-term) services.
Home-based services ("hospitals without walls" as the most extreme example) have evolved since the early 1980s in response to two pressures: the first financial, the second relating to quality of care and patient choice. In some cases (for example the provision of intravenous antibiotics for the treatment of pneumonia), at least in the United States, it is often although not always cheaper to look after such patients in their own homes. In addition, the acute hospital can be a dangerous place for patients, especially the frail elderly. Thus there is the approach by many jurisdictions toward the transferring of hospital care back to the community as well as the frequently heard complaint that elders are being discharged home "quicker and sicker."
That being said, this kind of hospital-at-home acute care system requires careful and frequent monitoring of the patient, and at least daily visits by a physician and usually more than once daily visits from nurses. In the case of home rehabilitation (for example, stroke or fracture of the hip) physiotherapists and occupational therapists may also be involved in home visiting.
Midway between this acute kind of home care and long-term home care for the chronically ill sits the traditional medical home visit usually supplied by a physician, although sometimes a nurse may be involved. Here the main purpose of the visit is assessment, either of an acute illness or for examination of patient function within the home as part of the process of comprehensive geriatric assessment. Many experts in geriatric medicine believe there is no better place than the senior's home to examine the four principal domains of geriatric assessment: functional ability, physical health, psychological health, and socio-environmental factors.
The very act of entering the older person's domain instantly provides the visitor with a wealth of data. The physician (or other assessor) can quickly take in the family constellation and other support systems, as well as the safety of the physical environment. The physician can examine the medications that the patient says that she is taking and might even find others that have not been reported. Can the patient get in and out of her home or does her arthritis preclude the use of stairs and render her a shut-in? The patient's nutritional status can sometimes be determined by merely opening the refrigerator door.
The third model of visiting involves the care of the chronically ill for ongoing care in their own homes. Most older people, in the face of chronic, severe, and even terminal illness prefer to be looked after and to stay in their own homes as long as possible. Family members usually concur and many are willing to take on the load ("informal care"). However, such caregivers require the support of a formal network in order to avoid the inevitable burnout that can accompany such a "thirty-six hour day" (as has been so well described in caring for the Alzheimer's patient).
A well-organized and publicly funded system is best for the provision of such ongoing care. Various models exist and organization, use of personnel, and funding mechanisms will differ from country to country and may even differ within countries. For example, while Canada's health care system is supervised and regulated by the federal government, each province maintains responsibility for the day-to-day functioning of its health care system. Thus home care plans differ from province to province. An interesting experimental model in the province of Quebec involves an attempt to integrate home, hospital, and long-term services.
In the United Kingdom there is a split between the nationally run National Health Service and the "district" that is responsible for social services. Thus once can find various models of home care throughout the United Kingdom.
In Israel, the National Insurance Institute (Social Security) provides homemaker services to more than 90,000 of Israel's 600,000 seniors for a maximum of sixteen hours weekly in a nationally run program. The four sick funds (similar in function to nonprofit health maintenance organizations) provide medical and nursing care, but not always in coordination with the homemaker program.
Other countries provide different models of service. An excellent review of the literature can be found in an annotated bibliography from the World Health Organization.
Hospice care is an excellent example of the use of medical and nursing home visits. The patient qualifying for such care will have a terminal disease and usually less than three to six months to live (although it is notoriously difficult to make such accurate predictions). Such home care utilizes a multidisciplinary care team made up of a physician, nurse, and social worker. Other professions are called in as required.
The "elderly" are a very heterogeneous group including both vigorous and frail people found at any age from 65 to 120. The "youngold" (65–84) and even the vigorous "old-old" (85+) senior may well utilize health services in the usual way and not require home visits.
However, for the frail, the chronically ill, the housebound, and especially the terminally ill older person, care should be provided at home whenever possible. A well-organized health and social service system can help provide such care, keep health care costs within reasonable limits, and, above all, contribute to a higher quality of life and satisfaction for such people.
A. MARK CLARFIELD SUSAN GOLD HOWARD BERGMAN
BERGMAN, H.; BELAND, F.; LEBEL, P.; CONTANDRIOPOULOS, A. P.; TOUSIGNANT, P.; BRUNELLE, Y.; KAUFMAN, T.; LEIBOVICH, E.; RODRIGUEZ, R.; and CLARFIELD, A. M. "Care of the Frail Elderly in Canada: Fragmentation or Integration?" Canadian Medical Association Journal 157 (1997): 1272–1273.
KOREN M. J. "Home Health Care." In The Merck Manual of Geriatrics, 2d ed. Edited by W. B. Abrams, M. H. Beers, R. Berkow, and A. J. Fletcher. Whitehouse Station, N.J.: Merck Research Laboratories, 1995. Pages 303–313.
MEYER, G. S., and GIBBON, R. V. "House Calls to the Elderly—A Vanishing Practice Among Physicians." New England Journal of Medicine 337 (1997): 1815–1820.
MORGANSTIN, B.; GERA, R.; and SCHMELZER, M. Long-Term Care Insurance in Israel, 1999. Jerusalem: National Insurance Institute, 1999.
PUSHPANGODAN, M., and BURNS, E. "Caring for Older People." British Medical Journal 313 (1996): 805–808.
SOROCHAN, M. "Home Care in Canada." Caring 14 (January 1995): 12–19.
TENNSTEDT, S. L.; CRAWFORD, S. L.; and MCKINLAY, J. B. "Is Family Care on the Decline? A Longitudinal Investigation of Formal Long-Term Services for Informal Care." Milbank Quarterly 71, no. 4 (1993): 601–624.
World Health Organization. Home-Based and Long-Term Care: Annotated Bibliography. Geneva: World Health Organization, 1999.
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