The Weight of The Evidence on the Cost- Effectiveness of Home Care and Integrated Care Presented to: Making a World of Difference Conference South West Community Care Access Centre Presented by: Marcus J. Hollander, PhD February 24, 2009 Hollander Analytical Services Ltd. 300-895 Fort Street Victoria, BC V8W 1H7 Tel: (250) 384-2776 Fax: (250) 389-0105 E-Mail: marcus@hollanderanalytical.com 1
Overview of the Presentation Introduction and Rationale The Veterans Affairs Canada Project Home Care as a Substitute for Residential Care Findings Regarding Home Support, Supportive Housing and Unpaid Care Integrated Models of Care Delivery Conclusions 2
Introduction and Rationale 3
Introduction Hollander Analytical Services Ltd recently completed a major study on the costeffectiveness of Continuing Care Goals: (1) Inform VAC & Ontario on approaches to service delivery to seniors; (2) Inform and contribute to wider policy discussions Approach: Two interrelated studies comparing costs and outcomes of home care, supportive housing and long term facility care 4
Study Rationale Limited previous continuum of care research Romanow Commission and Kirby Committee did not address long term home care 1999-2002 national cost-effectiveness studies did not consider supportive housing or VAC programs VAC experience: OSV experience, role of home support and VIP yet to be fully studied 5
The Veterans Affairs Canada Project 6
Two Interrelated Studies: Study 1 Case Study of the VAC Overseas Service Veteran Initiative in Halifax, Ottawa and Victoria Substitution function of home care Comparison of home and long term facility care Historical analysis & current OSVs 7
Two Interrelated Studies: Study 2 Study 2: Cost and Outcomes Study in Greater Toronto Area Broader study Include preventive and maintenance function of home care Comparison of home care, supportive housing, and long term care 8
Main Research Approaches Interviews with Veterans and their informal (unpaid) caregivers such as spouses, children, friends, etc., regarding the use of care and support services funded by VAC, for all sites of care. Diaries completed by clients and caregivers regarding out-ofpocket expenses (including payments to formal care providers) and time spent providing care services, by both paid care providers and unpaid caregivers, for all sites of care. 9
Research Questions for the Continuing Care Research Project Research Question How satisfied are VAC staff and managers with the OSV/VIP Program, what do they see as its strengths and weaknesses, and how would they rate the success of the program? To what extent have people, who originally would have only received facility care, embraced the VIP home option? What are the comparative systems costs (i.e. overall costs) for OSV clients before and after introducing the VIP home option, on a cost standardized basis? How satisfied are comparable clients in VIP, supportive housing (if applicable) and long term facility care and how do they rate their quality of life? What proportion of home care services (VIP and health services) are provided by home support services? Applied to Study 1 X X X X X Study 2 X X 10
Research Questions (cont d) Research Question Which home care and home support services are the most instrumental in keeping people out of facility care? Which factors contributed to community clients and supportive housing clients (if applicable) entering a long term care facility? What have been the positive and negative impacts on family caregivers? What is the cost-effectiveness of home care compared to long term facility care? To what extent is supportive housing an appropriate alternative to home care and long term facility care? To what extent would adding supportive housing contribute to an enhanced, and cost-effective continuum of care for VAC clients? Applied to Study Study 2 1 X X X X X X X X X X 11
Distribution of Clients and Caregivers Study Site Study 1 Study 2 Client Location Number of Clients Number of Caregivers Expected Actual Expected Actual Community 180 177 144 144 Facility 180 178 144 156 Total 360 355 288 300 Community 320 313 256 185 Facility 320 256 256 186 Supportive Housing 320 113 256 40 Total 960 682 768 411 12
Socio-Demographic Characteristics of Clients Community (%) Facility (%) Supportive Housing (%) Total (%) Study 1 Male 97 90 N/A 94 85 or Older 43 67 N/A 55 Married 67 49 N/A 58 Widowed 28 44 N/A 36 Study 2 Male 100 91 48 88 85 or Older 50 68 40 55 Married 63 42 17 47 Widowed 30 47 68 43 13
Socio-Demographic Characteristics of Caregivers Community (%) Facility (%) Supportive Housing (%) Total (%) Study 1 Female 92 76 N/A 84 Spouse of Client 68 35 N/A 51 Child or Child in Law 28 57 N/A 43 75 or Older 49 32 N/A 40 Study 2 Female 90 74 80 82 Spouse of Client 61 37 28 47 Child or Child in Law 32 47 43 40 75 or Older 57 36 27 45 14
Home Care as a Substitute for Residential Care 15
Findings From Previous Studies 16
Comparative Costs of Home Care and Long Term Facility Care (Costs to Government) for the 1996/97 Fiscal Year in British Columbia All Costs ($) Overall Average Costs Community Facility IC1 9,624 25,742 IC2 16,315 31,907 IC3 24,560 40,324 Extended 34,859 44,233 Source: Hollander, M.J., & Chappell, N.L. (2007). A Comparative Analysis of Costs to Government for Home Care and Long Term Residential Care Services, Standardized for Client Care Needs. Canadian Journal on Aging. 26 (SUPPL. 1), 149-161 17
Annual Costs for Home Care and Long Term Care Clients in Saskatchewan in Fiscal 2003/04: Cost to Government for All Major Health Services Long Term Care Supervisory/Limited Personal Care $45,691 Intensive Nursing or Personal Care $44,886 Specialized Supportive and Restorative Care $43,700 Home Care Supervisory Care $9,338 Limited Personal Care $12,766 Intensive Nursing or Personal Care $16,121 Extended Care $35,358 Source: Hollander Analytical Services Ltd. (2006). Utilization and Cost Analysis for Home and Residential Care Clients Considering the Broader Health Care System. Victoria, BC: Author. 18
Comparative Cost Analysis in 2000/2001 Dollars Including Out-of- Pocket Expenses and Caregiver Time Valued at Replacement Wages Level of Care Victoria Winnipeg Community ($) Facility ($) Community ($) Facility ($) Level A: Somewhat Independent 19,759 39,255 N/A N/A Level B: Slightly Independent 30,975 45,964 27,313 47,618 Level C: Slightly Dependent 31,848 53,848 29,094 49,207 Level D: Somewhat Dependent 58,619 66,310 32,275 45,637 Level E: Largely Dependent N/A N/A 35,114 50,560 Source: Chappell, N.L., Havens, B., Hollander, M.J., Miller, J.A., and McWilliam, C. (2004). Comparative costs of home care and residential care. The Gerontologist, 44, 389-400. 19
International Findings Weissert, Lesnick, Musliner, and Foley in a 1997 American paper found that integrated systems with system wide case management, home care, long term facility care, and capitation funding, were more cost-effective (fewer admissions to long term care facilities) than less integrated approaches. Source: Weissert, W. G., Lesnick, T., Musliner, M., & Foley, K. A. (1997). Cost savings from home and community-based services: Arizona's capitated Medicaid long term care program. Journal of Health Politics, Policy & Law, 22 (6), 1329-1357. Scuvee-Moreau, Kurz, Dresse, and the NADES group in a 2002 Belgian study found that home care cost much less than long term facility care for dementia patients. Source: Scuvee-Moreau, J., Kurz, X., Dresse, A., & National Dementia Economic Study Group. (2002). The economic impact of dementia in Belgium: Results of the National Dementia Economic Study (NADES). Acta Neurologica Belgica, 102 (3), 104-113. 20
International Findings (cont d) Stuart and Weinrich in a 2001 study comparing Denmark (which has an integrated model of care and a strong reliance on home and community services) and the United States, found that from 1985 to 1997 per capita expenditures on continuing care for seniors increased by 8% in Denmark and 67% in the United States. Many of the efficiencies in Denmark were achieved by increasing home care and reducing facility beds. Source: Stuart, M., & Weinrich, M. (2001). Home- and communitybased long-term care: Lessons from Denmark. Gerontologist, 41 (4), 474-480. 21
International Findings (cont d) Landi et al., in two Italian studies (1999 and 2001), showed that an integrated home care program reduced the rate of hospitalization, the number of hospital days, and costs, in a before and after study. Source: Landi, F., Gambassi, G., Pola, R., Tabaccanti, S., Cavinato, T., Carbonin, P. U. et al. (1999). Impact of integrated home care services on hospital use. Journal of the American Geriatrics Society, 47 (12), 1430-1434.; Landi, F., Onder, G., Russo, A., Tabaccanti, S., Rollo, R., Federici, S. et al. (2001). A new model of integrated home care for the elderly: Impact on hospital use. Journal of Clinical Epidemiology, 54 (9), 968-970. For more in-depth information on the cost-effectiveness of continuing care services see the literature review on this topic prepared for Veterans Affairs Canada at www.hollanderanalytical.com 22
Findings From VAC s Continuing Care Research Project 23
Cost-Effectiveness - Satisfaction Very high level of satisfaction with care services in all settings in both studies for clients and caregivers. Community clients generally more satisfied than facility clients. Satisfaction levels for supportive housing clients were lower than for community clients, but higher than for facility clients. Satisfaction findings are based on responses from clients who participated in the interview themselves. 24
Cost-Effectiveness Health Related Quality of Life Health related quality of life, overall, was similar for clients in all three settings. For clients with comparable care needs, facility clients reported better health related quality of life than that community and supportive housing clients. May be due to additional services VAC funds in facilities. 25
Cost-Effectiveness - Costs Home care considerably less costly than facility care. Supportive housing less costly than community care if rent factor not included, but more costly if rent factor included. 26
Comparative Cost Analysis for Community and Facility Clients (Study 1) Community Facility Care Levels Total Client and Family Contribution Replacement Wage 1 Total Costs to Government for Paid Services Overall Total 2 Levels 1 and 2 $14,411 $4,837 $19,248 Level 3 $20,194 $5,905 $26,099 Level 4 $31,083 $12,783 $43,866 Level 5 $50,297 $14,875 $65,172 Level 6 or higher $42,263 $14,581 $56,844 Overall Average $27,904 $7,963 $37,008 Level 4 $24,239 $63,008 $87,247 Level 5 $23,617 $67,675 $91,292 Level 6 $24,463 $64,594 $89,057 Level 7 $23,975 $64,811 $88,786 Level 8 $19,053 $65,296 $84,349 Level 9 $19,120 $64,203 $83,323 Overall Average $22,201 $65,175 $87,376 1 These are the total of out-of-pocket expenses and caregiver contribution costed at replacement wages. 2 These are the total of client and family contribution costed at replacement wage and costs to government. 27
Comparative Cost Analysis for Community, Facility and Supportive Housing Clients (Study 2) Community Facility Supportive Housing Care Level Total Client and Family Contribution Replacement Wage 1 Total Costs to Government for Paid Services Overall Total 2 Level 1 $11,594 $7,090 $18,684 Level 2 $14,175 $7,033 $21,208 Level 3 $18,135 $7,129 $25,264 Level 4 $22,111 $11,414 $33,525 Level 5 $74,139 $16,759 $90,898 Level 6 or higher $65,560 $12,904 $78,464 Overall Average $22,753 $8,230 $30,983 Level 3 $14,246 $83,148 $97,394 Level 4 $18,288 $87,578 $105,866 Level 5 $19,332 $85,555 $104,887 Level 6 $22,779 $82,573 $105,352 Level 7 $30,953 $83,754 $114,707 Level 8 $32,830 $83,371 $116,201 Level 9 $30,402 $83,410 $113,812 Overall Average $26,682 $84,168 $110,850 Level 1 $10,292 $4,953 $15,245 Level 2 $9,623 $7,810 $17,433 Level 3 $18,590 $8,042 $26,632 Level 4 $16,861 $10,792 $27,653 Level 5 $16,290 $10,313 $26,603 Overall Average $12,935 $7,563 $20,498 1 These are the total of out-of-pocket expenses and caregiver contribution costed at replacement wages. 2 These are the total of client and family contribution costed at replacement wage and costs to government. 28
Findings Regarding Home Support, Supportive Housing and Unpaid Care 29
Findings From Previous Studies 30
Cost-Effectiveness of the Preventive Function of Home Care and the Role of Home Support In the fall of 1994, a policy was put into place in British Columbia to cut Personal Care clients (those with the lowest care needs) who only received house cleaning from service. Most cuts were made in the first half of 1995. Different patterns of response by Health Units (HUs) to the policy. Some HUs did not cut services, some cut moderately and some cut severely. 31
Comparative Costs Per Person Average Costs of Care Before and After Cuts for Health Units With and Without Cuts Period Year Prior to Cuts ($) First Year After Cuts ($) Second Year After Cuts ($) Third Year After Cuts ($) All Cuts 5,252 6,688 9,654 11,903 Costs No Cuts 4,535 5,963 6,771 7,808 Source: Hollander, M.J. (2001). Evaluation of the Maintenance and Preventive Model of Home Care. Victoria: Hollander Analytical Services Ltd. A recent study by Markle-Reid also found that modest amounts of home support services may reduce hospital and LTC facility costs. [Source: Markle-Reid, M., Browne, G., Weir, R., Gafni, A., Roberts, J., & Henderson, S. (2008). Seniors at risk: The association between the six-month use of publicly funded home support services and quality of life and use of health services for older people. Canadian Journal on Aging, 27 (2), 207-224.] 32
A Cost Breakdown for 1996/97 Intermediate Care 3 Clients: Home Support Costs in Context Type of Service 1996/97 Cohort $ % Physician Services 1,367 5.6 Hospital Services 7,936 32.3 Professional Home Care 773 3.1 Home Support 11,988 48.8 Other 2,498 10.2 Total 24,560 100 Source: Hollander, M.J. (2001). Substudy 1: Final Report of the Study on the Comparative Cost Analysis of Home Care and Residential Care Services. Victoria, British Columbia: National Evaluation of the Cost-Effectiveness of Home Care. Home support has constituted over 90% of the costs of home based care in British Columbia. 33
Findings From VAC s Continuing Care Research Project 34
Main Services Used by Community Clients in Study 1 Main Services Used by Community Clients in Study 2 Main Services Used by Supportive Housing Clients Role of Home Support in Care Delivery Service Percent (%) Housekeeping 87 Home Adaptations 61 Grounds Maintenance 53 Personal Care 35 Housekeeping 98 Grounds Maintenance 69 Home Adaptations 63 Transportation for Medically Related Issues 44 Grounds Maintenance 100 Housekeeping 90 Home Adaptations 84 Transportation for Medically Related Issues 54 in Study 2 Social Transportation 50 35
Supportive Housing Mixture of clients with intermediate level care needs, lower level care needs, and financial needs (provincial policy states that 40% of units need to be for low income individuals). Appears to be of benefit to single and lower income individuals. Beneficial for spouses - if husband dies spouses are in familiar and supportive environment. 36
Supportive Housing (cont d) Based on Study 2 of the CCRP, supportive housing and other similar options such as assisted living, could provide a valuable complement to VAC s continuum of care. 37
Main Factors Enabling Community Clients to Remain at Home Study 1 Study 2 Factor Percent (%) Availability of Informal Care 57 Client Health 32 Client Control 23 Availability of Formal Care 20 Availability of Home Support Services 16 Availability of Informal Care 44 Client Health 44 Client Choice (to remain at home) 28 Client Control 26 Financial Independence 25 38
Main Factors Affecting the Decision to Have the Client Move Into a Facility Study 1 Study 2 Factor Percent (%) Client s cognitive health care needs increased 40 Client s physical health care needs increased 38 Informal caregiver unable to provide adequate 34 support Client s overall health care needs increased 31 Concerns regarding client s safety (e.g., wandering, falls) 20 Client s physical health care needs increased 37 Informal caregiver unable to provide adequate 34 support Client s cognitive health care needs increased 27 Client ready to go into a facility 27 Client s overall health care needs increased 21 39
Main Factors Affecting the Decision to Move Into Supportive Housing Factor Percent (%) Client preferred to be in supportive housing 49 Client better off financially 44 Client s health needs increased 25 No support from an informal caregiver 20 Client and family wanted to be closer together 19 40
Main Benefits and Disadvantages of Providing Care (Study 1) Benefits of Caregiving Disadvantages of Caregiving Opportunity to Show Care and Love (e.g., opportunity to give back) Client is Well Looked After (e.g., client s needs are appropriately met) Caregiver Has Peace of Mind (e.g., because client is in a facility) Emotional Aspects (e.g., caregiving is emotionally draining, tiring) Commitment and Responsibility (e.g., time constraints) Caregiver Feels Tied Down (e.g., decreased social life) Community (%) Facility (%) 62 46 12 30 4 26 49 46 29 23 59 6 41
Main Benefits and Disadvantages of Providing Care (Study 2) Benefits of Caregiving Opportunity to Show Care and Love (e.g., opportunity to give back) Satisfaction from Providing Care (e.g., caregiving is rewarding) Caregiver Has Learned from Experience (e.g., increased patience) Client is W ell Looked A fter (e.g., client s needs are appropriately met) Caregiver Has Peace of M ind (e.g., because client is in a facility) Community (% ) Facility (% ) Supportive Housing (% ) 70 72 88 14 9 18 5 16 8 11 14 5 6 18 15 Caregiver Doing Duty 15 3 18 No Benefits 12 22 3 42
Benefits and Disadvantages (Study 2) (cont d) Disadvantages of Caregiving Community (% ) Facility (% ) Supportive Housing (% ) No Disadvantages 41 11 50 Coping with Client s Condition (e.g., deterioration) 5 10 13 Emotional Aspects (e.g., caregiving is em otionally 29 61 30 draining) Com m itm ent and Responsibility (e.g., tim e 16 40 33 constraints) Caregiver Feels Tied Down (e.g., decreased social life) 30 18 10 Employment Issues (e.g., disruption to work schedule) 5 6 5 Distance Caregiver Lives from Client 1 10 3 Caregiver s Own Health 7 9 0 43
Integrated Models of Care Delivery 44
Even If Home Care Is Cost-Effective, Is There Any Evidence That Savings Can Be Obtained In The Real World Yes. This was demonstrated by the BC Planning and Resource Allocation Model developed in 1989, within an integrated care system. There was a significant shift of clientele from long term facility care to home care, while the overall utilization rate remained relatively constant. However, to maximize efficiencies services need to be delivered in an integrated model of care where proactive trade-offs can be made between home care and long term care services. 45
Major Phases In The Utilization of Home Care & Facility Care Growth Phase, to March 1984 Restraint and Consolidation April 1984 - March 1989 Planning Model April 1989 March 1994 120 Regionalization April 1994 Onward 100 80 60 40 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 Home Care Utilization* 87.2 89.5 92 96.5 98.7 100.7 102.4 105.8 110.8 113.8 114.8 116.2 113 Facility Care Utilization+ 71.5 71.6 71.7 69.7 67.2 65.1 63 60.4 58.2 56.5 55.2 53.5 50.7 * Includes home and community based services + Includes long term care and chronic/extended care facilities Source: Adapted from: Hollander, M.J. (2001). Substudy 1: Final Report of the Study on the Comparative Cost Analysis of Home Care and Residential Care Services. Victoria, British Columbia: National Evaluation of the Cost-Effectiveness of Home Care. 46
The Benefits of Integration Coordinated/integrated care delivery systems for persons with ongoing care needs have the following benefits: - They are good clinically because they allow for well coordinated seamless care for clients across a wide range of services from Meals on Wheels to specialized geriatric assessment and treatment centres in hospitals. - They are good from a policy perspective because policies can be made at the broader systems level, across all care services in the system, to the benefit of the client. 47
The Benefits of Integration (cont d) - They are good economically because such systems allow for trade offs between, for example, less costly home care and more expensive long term facility care or acute care. Such efficiencies can increase value-for-money within the continuing care system, and within the broader health care system. - They are good because, if done well, it is possible simultaneously to both reduce costs (or increase efficiencies) and provide better care to clients. 48
Conclusions 49
Conclusions Long term home care can be a cost-effective alternative to long term facility care. Home support services are an integral part of long term home care, and an important care response to persons with legitimate health care needs. However, in order to maintain independence, the appropriate response to these needs is often, in large part, the provision of home support services. There is a growing body of evidence about the substantial economic contribution made by informal caregivers. 50
Conclusions (cont d) There is also an emerging literature on the costeffectiveness of supportive housing. Finally, there is now a substantial weight of research evidence to indicate the potential costeffectiveness of home care services within an integrated system of care delivery. It is therefore time to re-visit current national policy directions on continuing care services. 51
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