The end of hospitals

Can home care fix our crumbling health system?
Luca Rossato/Flickr

For the last several years, there’s been a lot of apocalyptic chatter about whether the aging population—or “gray tsunami”—will overwhelm the health system. That, coupled with the fact that there seems to be a shortage of hospital beds, has politicians offering up home-care services as an alternative to hospital and long-term care, and health-policy wonks pondering what a system without hospitals would look like.

This week, Ontario Health Minister Deb Matthews was the latest such politico to announce the Liberal plan to invest $60 million in home-care for seniors and the disabled. Though details about the program were not yet available, Matthews said it would offer services ranging from a health professional’s house visit, to phone and online consultations.

The supposed benefits? Improved access, more cost-effective care, reduced visits to hospital, and less pressure on long-term care facilities. As Matthews’ campaign office spokesperson put it, a hospital stay can cost $1,000 per patient per day while long-term care rings in at $150 per day.

But is the suggestion that home-care programs are an efficient alternative evidence-based?

Science-ish called a leading researcher on home-care efficacy, Dr. Sasha Shepperd (PhD), and she said, “The only way you can say home care has saved on hospital care is if you close down the hospital, which politically is not a very popular thing to do.”

Otherwise, costs are simply being added to the health-care system by creating parallel services. “If you’re not going to close down hospital wards because you’ve got this home-care program, those beds will get filled up by other people.”

Dr. Marcus J. Hollander (PhD), a health policy analyst and home care expert, reiterated Dr. Shepperd’s take on the supposed cost-substitution effect of expanding home-care services. “In order to actually save money, you need to hold back residential care and reduce hospital beds. Simply putting money into home care itself will typically be an add-on cost.”

But closing down hospital wards while expanding care in the home is an unlikely and possibly dangerous solution. In a Cochrane review (co-authored by Dr. Shepperd) about home care to avoid hospital admission, researchers found that although care at home “provides an alternative to inpatient admission for some patients, the volume of such patients recruited to the included trials is low and some of these patients will require access to hospital services, thus making the closure of a ward or hospital in favour of hospital at home an unrealistic option.” In other words, patients who receive most of their care at home may still need to go to a hospital once in a while, so home care isn’t an actual substitute.

As for the actual evidence about whether home-care is cheaper than other types of care, Dr. Shepperd said it’s currently scant. “Overall, the evidence shows either there is no difference in cost between acute home-care and acute care in hospital or in some cases, home care is more expensive.” (See the cost analysis in this review of the effects of services in the home for patients discharged early from hospital.)

There is one thing we do know for sure about home care: patients tend to prefer it, which is probably why politicians create platforms around it. In the UK, where the primary-care system is much more advanced than ours, many evidence reviews on shifting acute care from the hospital into the community have been undertaken, such as this June 2011 report Getting out of Hospital. It suggests there are potential gains to be made from expanding at least some acute inpatient and day care services from hospital to the community, including better health outcomes for patients and greater patient satisfaction with services.

But before the government throws money into growing home-care services, Dr. Shepperd suggested gathering more evidence about its efficacy through randomized-controlled trials so that we can really understand the health and cost benefits associated with each type of health-care delivery.

Science-ish is a joint project of Maclean’s, The Medical Post, and the McMaster Health Forum. Julia Belluz is the associate editor at The Medical Post. Got a tip? Seen something that’s Science-ish? Message her at [email protected] or on Twitter @juliaoftoronto