by Katherine Dedyna
Victoria Times Colonist: Tuesday November 30, 1999
Itís cheaper to care for seniors in their own homes rather than in facilities, says a new study which adds weight to the home-care side of a debate about where elderly Canadians should live out their last days.
The preliminary study, done by Victoria-based Hollander Analytical Services Ltd. and released Monday, looked at the cost-effectiveness of keeping seniors in their own homes versus sending them to care facilities.
The study is part of the National Evaluation of the Cost-Effectiveness of Home Care - a $1.5 million series of studies on elderly care.
"The central finding of the study was that, on average, the overall health care costs to government for clients in home care are about one half to three-quarters of the costs for clients in facility care, by level of care," said analyst Marcus Hollander, who has been a health services researcher and administrator for more than 25 years.
An estimated 1,200 elderly people are waiting for long-term care beds in the Capital Health Region. And the need for 300 new beds is deemed the biggest problem facing the region according the CEO Tom Closson.
The CHR home-care budget of $31.7 million is 10 per cent in the red, prompting a cap on new clients and a plan to cut $2.2 million by March. In the face of the provinceís refusal to boost grants any higher where usage is already high Ė a new limit has been imposed of 120 hours of home-based assistance per person per month.
But just adding more money to home care is not the answer - what is needed is directing that in the best and most efficient way, says Hollander.
"The thing that is most exciting for me is that if we can get it right, we can both improve care and reduce costs. Typically, what people think is that if youíre reducing costs, care will suffer."
For much of the past year, Hollander used BC data to determine whether home care for the elderly is a cost-effective alternative to long-term care facilities.
For instance, the average annual cost for an extended care client in 1993-94 in community care cost the system $24,378 versus $39,060 for a person in a facility at the same level of care.
How much of the cost savings are attributable to the burden assumed by families providing their own care at some is the subject of another of the 15 studies that will make up the entire evaluation.
The entire project is co-directed by Neena Chappell, director of the UVIC Centre on Aging.
The issue of home versus facility care is ever more pressing. According to the 1996 census, there were 3.6 million seniors in Canada. By 2016, the number of citizens over 65 will rise to 5.9 million, highlighting the need for determining cost and care strategies as undertaken by the federal Health Transition Fund.
Hollander is not pushing easy answers, pointing out the cost of home care versus facility care differs dramatically depending on the condition of the patients. "For clients who died, the cost for home care were higher, compared to clients in long-term care facilities."
That's because a crisis for a very sick person receiving home care can set into motion the full arsenal of expensive acute-care measures to prolong life even for a very short time, whereas staff at residential facilities appear to be meeting client needs without admission to acute-care hospitals.
People who were in stable condition in their homes cost about half as much a those in facilities, but those whose status was in transition cost up to 90 per cent as much.
Hollander found that half of the overall health care costs for home care clients were incurred by acute-care hospital services - "a new and I think very important finding," says Hollander.
Other significant costs arose at transition points, when the health and care needs of the clients changed. He suggests everything from palliative care programs to allow people to die comfortably at home and measures to re-stabilize patients at so called transition points in their care and discourage hospital admissions.
Hollander does not suggest that such measures will apply to all health districts at all times, just that decision makers might want to check their data to see where costs have been maximized.
Although keeping seniors in their homes, where they have strongly indicated they want to remain as long as possible, has been the thrust of CHR policy, supporters fear long-term care in the community is in jeopardy. Hollanderís review of the literature supported the stance that home care provides as much if not greater satisfaction.
The high cost of dying for home care patients points to the opportunity for innovative palliative care programs that allow people to die at home rather than be rushed to hospital. Hollander also suggests more investigation of ways to prevent hospital use as well as targeted care for those in transition that will allow quick restabilization.
Itís already happening to some extent, but there is a need to move aggressively when a personís health status changes, he says.
"People deteriorate for a longer period of time before it becomes very clear and there is an intervention." In the CHR, clients already receive 80 per cent more home care than the provincial average. There is already a community transition program in place to move people quickly out of hospital and minimize returns as well as palliative care at home.
"What to me was really exciting about the findings was that they present potential opportunities for further efficiencies."
It is also a chance for Canadian decision makers to use Canadian data. American studies have shown that home care is not cost-effective when compared to facility care, but Hollander notes that these studies did not make a direct comparison of the cost of the two systems.
B.C. data were central to the study, because this the only jurisdiction that maintains standardized classification system for all elderly clients that access the system.
The preliminary study compared costs for five levels of care needed by those in home care or institutional care using new client admission dating back to 1987.
The final report will include data up to 1997 and all 15 substudies of the national evaluation will be completed and publicly released by November 2000.
Now is the time to assess continuing care service to maximize the benefits for elderly and disabled citizens.
"There is some urgency to this proposed review of continuing care as it has, as an entity and as a concept, been neglected for most of the 1990s," the study says.
Hollander also would like to see portability of continuing care across Canada and standardized classification systems across the country to allow research into the area.
"Currently most jurisdictions have some type of waiting period for bother residential and community based long term care services. Many families are currently burdened with the necessity of paying privately for the care of their aged parent if they wish to bring them to the jurisdiction in which the son or daughter is living."
And he suggests consideration of moving all continuing care services into a universal style form of coverage that could see wealthy people charged fees for household help but nursing and care aids funded by government.
The CHRís Closson said he was pleased with the report because it suggested a good reason to stream people into the most appropriate care.
For example, Closson said the study suggested clients whose health is relatively stable are good candidates for home care. Clients whose health is relatively stable are good candidates for home care. Clients whose condition is likely to end with an acute care episode that requires hospitalization are likely better off in an institution.
"This study provides more evidence to help us make decisions on which kind of people are better off in home care and which kind of people are better off in residential care,í said Closson.
Nevertheless, he said the findings are a surprise because they run country to just about every other study that has ever been done of this subject.
And Closson said one question remains unanswered: what type of home environment is appropriate for home care. Some peopleís own circumstances, for example, family or economic situations may make home care inappropriate.
For more information on the study, see the Web site www.homecarestudy.com or call (250) 389-0123.