Context Although home-based health care has grown over the past decade, its
effectiveness remains controversial. A prior trial of Veterans Affairs (VA)
Team-Managed Home-Based Primary Care (TM/HBPC) found favorable outcomes, but
the replicability of the model and generalizability of the findings are unknown.
Objectives To assess the impact of TM/HBPC on functional status, health-related
quality of life (HR-QoL), satisfaction with care, and cost of care.
Design and Setting Multisite randomized controlled trial conducted from October 1994 to
September 1998 in 16 VA medical centers with HBPC programs.
Participants A total of 1966 patients with a mean age of 70 years who had 2 or more
activities of daily living impairments or a terminal illness, congestive heart
failure (CHF), or chronic obstructive pulmonary disease (COPD).
Intervention Home-based primary care (n = 981), including a primary care manager,
24-hour contact for patients, prior approval of hospital readmissions, and
HBPC team participation in discharge planning, vs customary VA and private
sector care (n = 985).
Main Outcome Measures Patient functional status, patient and caregiver HR-QoL and satisfaction,
caregiver burden, hospital readmissions, and costs over 12 months.
Results Functional status as assessed by the Barthel Index did not differ for
terminal (P = .40) or nonterminal (those with severe
disability or who had CHF or COPD) (P = .17) patients
by treatment group. Significant improvements were seen in terminal TM/HBPC
patients in HR-QoL scales of emotional role function, social function, bodily
pain, mental health, vitality, and general health. Team-Managed HBPC nonterminal
patients had significant increases of 5 to 10 points in 5 of 6 satisfaction
with care scales. The caregivers of terminal patients in the TM/HBPC group
improved significantly in HR-QoL measures except for vitality and general
health. Caregivers of nonterminal patients improved significantly in QoL measures
and reported reduced caregiver burden (P = .008).
Team-Managed HBPC patients with severe disability experienced a 22% relative
decrease (0.7 readmissions/patient for TM/HBPC group vs 0.9 readmissions/patient
for control group) in hospital readmissions (P =
.03) at 6 months that was not sustained at 12 months. Total mean per person
costs were 6.8% higher in the TM/HBPC group at 6 months ($19,190 vs $17,971)
and 12.1% higher at 12 months ($31,401 vs $28,008).
Conclusions The TM/HBPC intervention improved most HR-QoL measures among terminally
ill patients and satisfaction among non–terminally ill patients. It
improved caregiver HR-QoL, satisfaction with care, and caregiver burden and
reduced hospital readmissions at 6 months, but it did not substitute for other
forms of care. The higher costs of TM/HBPC should be weighed against these