Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

A preventive assessment program improved health for independent veterans

ACP J Club. 1994 Nov-Dec;121:72. doi:10.7326/ACPJC-1994-121-3-072


Source Citation

Fabacher D, Josephson K, Pietruszka F, et al. An in-home preventive assessment program for independent older adults: a randomized controlled trial. J Am Geriatr Soc. 1994 Jun;42:630-8.


Abstract

Objective

To evaluate the effectiveness of in-home geriatric assessments in providing preventive health care and improving the health and functional status of community-living older veterans.

Design

Randomized controlled trial with 1-year follow-up.

Setting

Suburb of Los Angeles.

Patients

254 community-living veterans aged ≥ 70 years (mean age 73 y) not currently enrolled in a Veterans Affairs outpatient clinic and not having a terminal illness or dementia. 51 patients (20%) were lost to follow-up.

Intervention

131 patients were randomly assigned to an initial in-home assessment within 2 weeks of enrollment. The home visit was done by a physician's assistant or nurse to screen for medical, functional, and psychosocial problems and environmental hazards. A letter describing findings and recommendations was sent to the patient, and follow-up visits were done at 4-month intervals. 123 patients were randomly assigned to the control group and received follow-up telephone interviews every 4 months to collect outcome data.

Main outcome measures

Compliance with recommendations, mortality, medication use, functional status, immunization rates, and nursing home and hospital use.

Main results

A mean of 4 new problems per patient were identified in the intervention group. Patients in the intervention group complied with 76% of the recommendations to see a health professional or to initiate a specific health practice. At 12 months, 4 patients in each group had died. Over-the-counter medication use increased in the control group (P < 0.05) and decreased in the intervention group. The 1-year score on the instrumental activities-of-daily-living (IADL) scale was higher in the intervention group than in the control group (P < 0.05); patients in the intervention group maintained their functional status, whereas patients in the control group experienced a decline. Immunization rates improved from 13% to 94% in the intervention group and from 21% to 34% in the control group (P < 0.001). 22% of patients in the intervention group were hospitalized compared with 24% in the control group. No patients were admitted to a nursing home.

Conclusion

An in-home geriatric assessment program was effective in improving health and functional status of community-living older veterans.

Sources of funding: Disabled American Veterans Charities of Greater Los Angeles and the Disabled American Veterans California Rehabilitation Foundation, Inc.

For article reprint: Dr. L. Z. Rubenstein, GRECC (11 E), Veterans Affairs Medical Center, Sepulveda, CA 91343, USA. FAX 818-895-9519.


Commentary

A major goal of geriatric medicine is maintaining the older person's ability to reside in the community. Home assessment often uncovers medical, psychosocial, and environmental hazards that threaten independence (1), but little is known about the effects of this intervention on patient outcomes.

Fabacher and colleagues report that a home assessment by a nurse or physician's assistant with geriatric training can improve immunization rates and has a modest effect on some outcome measures (use of over-the-counter medications and independence in IADL). It is important to distinguish their approach from home care—no direct services were provided, only recommendations and referrals. Participants receiving the intervention were eligible for veterans' services; were predominantly male; and had relatively high educational, cognitive, and functional levels. These factors limit the generalizability of the study findings. It is unlikely, for instance, that a 94% immunization rate would be achievable in a frailer population that has more economic and institutional barriers to receiving care.

Previous studies from Canada and Europe have shown that home assessments can increase the number of identified problems, decrease emergency room and hospital use, and have a modest effect on institutionalization and mortality. Interventions targeted to persons with poor health appear to be more cost effective than those given to healthy persons (2). In the United States, home assessments for community-dwelling elderly persons have shown a modest effect on use of certain long-term care services, without affecting hospital or short-term nursing home use (3). Targeting home assessments to high-risk hospital patients at the time of discharge may reduce subsequent hospital expenditures with little change in functional status (4). The popularity of home care continues to exceed what can be explained by measures of outcome. This may be the result of patient demand, reimbursement structures, community perceptions, or clinician expectations. How these perceptions will change as Medicare shifts to prospective reimbursement for home-based services remains to be determined.

Joseph Francis, MD, MPH
Department of Veterans Affairs and the Mid South Heathcare Network (VISN 9)Memphis, Tennessee, USA


References

1. Ramsdell JW. Geriatric assessment in the home. Clin Geriatr Med. 1991;7:677-93.

2. van Rossum E, Frederiks CM, Philipsen H, et al. Effects of preventive home visits to elderly people. BMJ. 1993;307:27-32.

3. Stuck AE, Aronow HU, Steiner A, et al. A trial of annual in-home comprehensive geriatric assessments for elderly people living in the community. N Engl J Med. 1995;333:1184-9.

4. Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-20.