Journal of the National Institute of Public Health2012 Vol.61 No.2 p.148−154

Topic：Issues and international trends towards the community-based integrated care system in Japan＜Review＞
Hospital care at home in France: an alternative to conventional
hospitalization with the same obligations towards quality and administration
Olivier TERRADE１），Takako TSUTSUI２），Alexis COTTENCIN３）
１）

Director of In-home Healthcare, Care and Home Hospitalization Structure.
Research Managing Director, National institute of Public Health.
３）
Guest Researcher, National institute of Public Health.
２）

Abstract
The system of Hospital Care at Home in France (hereafter HAD[1]) was recognized legally in France in 1970 and has beenreformed and adjusted many times since the first HAD facility was established.
These changes can be difficult to process, especially from the users’ point of view: earning the understanding of users withregard to new ways of working can be difficult when it concerns health, or more precisely, the treatment of a health condition.
Nevertheless, the FEDOSAD association ventured into home care with the support of local partners, health professionals,
and various public institutions at the national, regional, and departmental level. In this paper, we will present the stages of its
implementation, the difficulties encountered, the “providential events,” the professionals involved, the partnership established,
the text defining professional practices, and the limits of the system as experienced by an HAD FEDOSAD 21 facility
established in Dijon.
The role that HAD plays in geriatric care, the evolution of HAD, and the relationships with retirement homes will also be
discussed throughout the paper.
keywords: Hospital Care at Home (Hospitalisation à domicile), establishment, structure(accepted for publication, 11th April 2012)

Ⅰ．Integrated-care in France and HAD
As England has implemented HCH (Hospital Care atHome) and Australia HITH (Hospital In The Home),
France also has its own system of in-home healthcare
service delivery: l’Hospitalisation A Domicile (HAD). Even
though these systems show significant differences, they
have gathered interest and have been implemented or
further developed in recent years. In France, the patient’s
home is seen as an extension of the hospital, and HAD
facilities are considered as full healthcare facilities.
In 1973, a federation of HAD facilities (FNEHAD), wasestablished in France to ensure the delivery of high quality
care in the comfort of the user’s home. Since thenotification of 2000 from the Ministry of Health andSolidarity, HAD has been considered as a form of
hospitalization in the home of the patient and prescribed byhospitals or primary care physicians. HAD provides
seamless coordinated medical and paramedic care in thepatient’s home for a given period of time (subject tochanges depending on the evolution of the patient’s healthcondition).
The Director of the In-home Healthcare, Care and Home
Hospitalization Structure of the FEDOSAD [2] association,
M. Terrade Olivier, wrote the following paper. The
FEDOSAD association provides various in-home careservices in the French city of Dijon and includes a HAD
facility. This paper gives an insight into the HAD system,
the difficulties encountered by the FEDOSAD association,

Takako TSUTSUI
2-3-6 Minami, Wako, Saitama, 351-0197, Japan.
T e l: 048-458-6111
Fax: 048-458-6715
E-mail: tsutsui@niph.go.jp

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Hospital care at home in France

and the future of in-home care services in France.
Studying this system would certainly benefit Japan in its
attempt to implement a community-based care system that
integrates medical and long-term care.

Ⅱ．History of HAD
Dr. E.M. Bluestone, from Montefiore Hospital in New
York, started a home healthcare program that can beconsidered as the first American experience with HAD.
In 1950, the possibility of taking care of patients in theirhome started to be examined in France, especially forpatients with cancer.
In 1957, the Public Hospital System of Paris[3]established the first HAD facility.
In December 1970, HAD was legally recognized in
France through the Hospital Act (December 30, 1970).
The National Federation of Hospital Care at Home(FNEHAD [4]) was then created to fix the terms of HAD.
In 1974, the National Healthcare Fund defined thefunctioning rules of HAD.
In 1985, 28 facilities (36 in 1990) providing HAD services
had already been created.
The law of July 31, 1991, positioned HAD as a fullalternative to conventional hospitalization.
On October 2, 1992, decree 92-1101 related to alternative
structures of hospitalization as well as decree 92-1102
related to the functioning terms of HAD were adopted.
The notification and the complementary notification of
May 30, 2000, defined the types of care provided by HAD
facilities. Every HAD facility in France is following thesenotifications.
In 2000, the number of facilities providing HAD services
reached 78.
An order for the simplification of the organization andmanagement of the healthcare system went into effect on
September 30, 2003. This order terminated the pre-existingchange rate in which two hospital beds had to be cut before
one HAD bed was created.
The Ministry of Health defined conditions for accessing
HAD services through a February 4, 2004, notification.
A December 1, 2006, notification expressed once again
the general and comprehensive nature of HAD. This
notification also clarifies the conditions for accessing HAD
services as well as the obligations and roles of the various
persons involved in HAD. The need to further develop HAD
is also stressed throughout this notification.
In 2007, the number of facilities providing HAD reached207.
The HSPT [5] Law of July 21, 2009, also considers HAD
facilities as full healthcare facilities.

Ⅲ．Creation of HAD facility in Dijon
FEDOSAD is an association specializing in the care ofdependent or sick elderly persons. This association, which
had been delivering in-home social and nursing care,became interested in the HAD system and started toinvestigate the local needs of elderly persons in the city of
Dijon.
The FEDOSAD association had been providing in-homenursing care services since 1987 and thus had expertise inanswering the care needs of users in a home setting.
Furthermore, the association had already beenrecognized as an innovative structure as it had
implemented an Apartment with Coordinated Therapeutic
Care. This apartment was created as a part of the CityHospital Network that supports the care of patients with
HIV. This experimental project was made possible becauseof the recognition of HIV patients as a target for in-homenursing care services (SSIAD [6]) and thanks to thecollaboration of a teaching hospital in Dijon, which
allocated one physician of the infectious diseasedepartment and a social worker to the project.
These are the reasons FEDOSAD chose to experimentwith HAD in Dijon in partnership with the teaching hospitaland the Hospital Regional Agency (ARH [7]), which later
became the Healthcare Regional Agency (ARS [8]). This
experimentation was made possible by using staff from thein-home nursing care services (SSIAD) and from theteaching hospital (one care assistant and 0.25 coordinating
nurses for every three beds in HAD).
In September 2002, the ARH started a debate on “How to
improve care in the Dijon area,” which eventually led to thecreation of a HAD facility in that city.
During the next six months, many meetings, studies, anddiscussions with healthcare professionals and private
hospital personnel were conducted. This led to the creationof a HAD facility that could provide care for 35 patients (10of the 35 beds are for the exclusive use of the geriatricdepartment of Dijon’s hospital).
In August 2003, the documents required for the creationof the facility were sent to the relevant authorities. Finally,
the CROSMS [9] and the COMEX [10] authorized thecreation of this facility at the beginning of 2004.
The HAD venture in Dijon started at this moment,
involving recruitment of personnel, creation of job
descriptions, intern planning, and communication withother health professionals.
The facility finally opened in November 2004.

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certification from the French Authority for Health [13],measures against nosocomial infections, pain management,
drug use, and medical waste.

Ⅳ．Administration of HAD
Once the authorization was granted, it was necessary toorganize the internal structure of the facility and to recruit
staff members.
Meetings were held with independent physicians,
members of the Independent Nurses Association, andpharmacists and chemists, in collaboration with theteaching hospital, private hospitals, networks, the Local
Center of Information and Coordination (CLIC [11]), andother services (in-home nursing care services, home help
providers). After these meetings, agreement contracts weresigned, and the teaching hospital decided to allocate acoordinating physician [12] in charge of medical decisions.
As HAD facilities provide services 24 hours a day, 7 daysa week, it was necessary to bring the facilities up to code,
keep a stock of supplies, and build a place to handle
medical waste.
Vehicles were also purchased to enable staff members tomake home visits.

Ⅴ．Legal framework, concise procedures,and specific regulations
Until 2009, the French health care code had considered
HAD facilities as an alternative to hospitalization. However,in July 2009, they became recognized as full healthcare
facilities and as a full healthcare system.
HAD facilities are healthcare facilities that provide
coordinated medical and non-medical care in the patient’s
home for a given period of time (subject to changes
depending on the evolution of the patient s healthcondition). This care differs from that provided by other athome care services with regard to the complexity andfrequency of the care provided.
It is important to remember that HAD is a type of
hospitalization. This means that without HAD services, theuser would have been placed in a conventional hospital. The
user’s personal physician can directly prescribe HAD
services even if there was no previous stay at aconventional hospital. The primary care physician isfrequently consulted regarding the situation at home. He
has to agree with the use of HAD, and it is recommended
that he pay a weekly visit to the patient.
Thus, HAD facilities are considered as hospital facilities
where patients do not come or stay. As such, these facilities
have to follow the same rules and regulations as public or
private hospitals, including those pertaining to continuity
and constancy in care delivery, safety and quality,

150

Ⅵ．What type of care for what type of patient?
Care provided by HAD facilities is regularly adjusted andnormalized in a care protocol, which determines the goal,
the follow-up, and the fee for services. This protocol is thus
a clinical, psychosocial, and therapeutic care plan
contracted by a primary care physician and a coordinating
physician.
Three main types of care are provided: palliative andsupportive care provided continuously to patients who will
not recover (this care may be provided until the end of thepatient’s life), rehabilitative care for patients who may makea full recovery or whose condition may improve, and onetime care provided for a short period of time that requires
special skills to administer it.
The strength of the Dijon HAD facility (hereafter the
HAD FEDOSAD 21 facility) is the giving of care in acomprehensive manner, which includes psychosocial care.
The care services involve the family and others close to thepatient because they are often the key to providing
successful care. To ensure such care is provided, the facility
includes a psychologist and a social worker to makeallowances for the needs and expectations of not only thepatient but also of other caregivers.

Ⅶ．HAD facilities: providing users with HAD
while improving decision-making on
healthcare issues
The HAD FEDOSAD 21 facility does whatever it can torespect the choices of users. However, the limits of in-homecare sometimes go against what the user or themultidisciplinary team would want.
This is because HAD is just one step in a larger care
process and serves as a stepping-stone to otherindependent professionals or in-home nursing careproviders who will take care of the patient once his or her
condition is stabilized. On the other hand, if the patient’s
condition gets to the point where HAD is no longer asuitable option, then the patient will be transferred toa conventional hospital. Nevertheless, as the HAD
FEDOSAD 21 facility has various internal resources(skilled staff) and as the department of ambulatory
palliative care of the teaching hospital signed a contract
with the facility, it is possible to properly support patients intheir own home until the end.

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Every healthcare facility, private or public, has to becertified. This certification applies to healthcare facilities ina legal meaning and concerns the activities conducted by
the staff of the facility involved with providing care topatients.
The certification process has been established to ensurehigh quality care and safety for the patient and to promote
continuous assessments and improvements. Another goal is
to gain the public’s trust by making the results of audits
available to them.
In order to be certified by the French Authority for
Health, the HAD FEDOSAD 21 facility established six workgroups focusing on different issues (management, logistics,
quality management, risk management, information
technology, patient processing).
Three of the work groups, comprising mainly field staff(staff from the facility and independent healthcare
professionals), started working on how to assess
professional practice regarding items such as in-hometransfusion, drug channels, and end-of-life care at home.
The facility supported multiplicity in practices andviewpoints, internal or external, by including a plurality ofprofessionals in its steering committees. For example,
many professionals from outside the facility (teaching
hospital staff, pharmacists, primary care physicians, etc.)
participated actively in the steering committees andcontributed to follow-up on quality procedures. In June
2009, the HAD FEDOSAD 21 facility was certified by the
French Authority for Health (HAS). This accreditation isrenewed through various audits conducted every two years.

Ⅸ．Reinforced and specialized partnership
There is no standardized model of organization for HAD.
Commensurate with its status, a HAD facility may include
a variable number of independent staff members working in
partnership with it.
These partnerships are based on agreements between
the facility and the independent professionals to define thelegal framework. The professionals must follow thepractices established within the facility concerning items
such as continuity of care, information-sharing, and carefiles and must take part in care quality assessments.
In October 2007, a notification authorized HAD facilities
to take care of patients staying in retirement homes,
whether or not such homes provided care. The notification
followed the passing of a convention between the two types

Ⅹ．Partnership with general practitioners
At the beginning of HAD, the lack of knowledge among
general practitioners about the HAD system led to somedifficulties.
However, through media communication and information
sharing, FNEHAD improved this situation. In 2008, twothirds of general practitioners said they had used HAD
services at least once during the year.
This partnership still needs to be reinforced because
general practitioners are frequently consulted regarding
the patient’s situation at home and must consent to the useof HAD services before they can be delivered. Moreover,general practitioners work together with coordinating
physicians to consolidate the patient’s care plan because
they already have valuable information on the patient, thepatient’s family, and the patient’s home.

Ⅸ

Ⅷ．Ensuring high quality care to gain
recognition from everyoneof facilities. This eventually led to a new type of cooperation
between healthcare facilities and medical-social facilities.
For an HAD facility to intervene when the retirement
home is one that already provides care (i.e., is a care centerfor dependent elderly persons [14]), the patient’s condition
must require highly qualified care that the care centercannot provide. This qualified care does not replace thenursing and social care that the care center staff members
may already provide.
The remuneration provided for HAD services delivered
in a care center is lower than that provided when theservices are delivered in the patient’s home. In this casealso, the HAD facility intervenes in order to prevent a
conventional hospitalization.
Both the HAD facility and the care center must agree on
the decision to intervene. The request for the intervention
is made by the primary care physician of the patient or by acare center physician. However, both physicians must give
their opinions on the matter since it is a form of medicalprescription. The care center physician must also explain
why the care center cannot by itself fully cover the needs ofthe patient.
The HAD FEDOSAD 21 facility has at times intervenedin this manner, and the interventions have reinforced interfacility cooperation and led to better standardization andbetter sharing of practices between the facilities.

．The role of HAD in geriatric care

HAD is a strong link in the geriatric care system, but it
still needs to be developed and reinforced, especially in the
countryside. The delivery of HAD services may prevent
disorientation and adaptability issues from arising by

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avoiding sudden changes of environment. However, HAD
services would not be possible without a reliable andefficient family or social environment. Most of the time, theuse of home help services is also necessary. The HAD
FEDOSAD 21 facility used to directly employ home-helpers
for the delivery of HAD services. However, due to the lackof funding from the national health insurance towards these
services, this method of employment is no longer
sustainable given the current financial situation.
HAD has now found its place in the healthcare system.
The system’s economic qualities and the clear improvementin the quality of life it provides to users are now wellestablished. However, HAD facilities require personnel witha high level of medical skills, considering the frequency ofpalliative care provided and the complexity of the users’
health conditions. Thus, HAD facilities can only work if
good collaboration is established between the coordinating
team, the primary care physician, and the other persons
involved.
If this collaboration is achieved, HAD facilities can play amajor role in establishing an efficient gerontology network.

Ⅹ
Ⅱ．Specific payment model
Since 2005, HAD has been entirely funded by the Frenchnational health insurance system through a fee-for-services
model called T2A. The model is similar to the one used in
private and public hospitals. All care delivered through the
HAD system is thus covered by the insurance.
The payment for services delivered by HAD facilities isbased on a special payment system: fee categories (called
GHT [15]) were established for the types of care delivered,and each day HAD facilities receive fees commensuratewith the type of care they provide. Each day of careprovided to a patient is classified into one fee category
through a computer program called “fonction groupage,”with the categories based on four RPSS [16] variables.
These variables are the main care type, the associated caretype (if there is one), the Karnofsky index (which measures
the functional impairment of the user), and the length ofcare delivered overall. These daily fee categories include allcosts that the HAD facility may have to cover, such as
payment for physicians and non-medical professionals,
drugs, use of medical equipment, and transportation for
medical reasons [17].
Every HAD facility also uses a computer program fortransferring medical information (PMSI) to the Technical
Information Agency on Hospitalization (ATIH [18]). Every
year, HAD facilities must submit their own statistics(SAE [19]) to the Directorate of Hospitalization and CareManagement (DHOS [20]) in order to determine the152

ICALIN [21] score of the facility.

ⅩⅢ．Organization of HAD FEDOSAD 21 Facility
The organization of the HAD FEDOSAD 21 facility has
closely followed the terms stipulated for the originallyauthorized project. It involved taking various steps suchas recruiting staff members, establishing procedures,finalizing an admission system, and setting up ateleprocessing system for employees to record their entry
and exit times from the patient’s home.
The coordinating physician quickly became accustomed
to this new way of providing care and, from the outset, an
important and necessary spirit of cooperation wasestablished between the physician and the coordinating
nurses. To ensure medical care could be provided 24 hours
a day, 7 days a week, a shift system was designed. Time wasalso secured for exchanging necessary information
regarding the evolution of the patient’s situation at home
and the patient’s needs, as well as for continuously
readjusting the care provided.
From the start, the HAD FEDOSAD 21 facility included
both facility members and independent professionals on its
steering committee to ensure it could immediately meet the
medical requirements of its patients. These professionals
shared their experiences and worked together to pursue,
develop, implement, and improve medical strategies. The
FEDOSAD association also created various entities within
the HAD FEDOSAD 21 facility such as a Nosocomial
Infections Control Department, a Medical Facility
Committee, a Committee for Pain Management, aCommittee on Hygiene and Work Safety, and a committee
in charge of facility-user relationships and care quality.
The FEDOSAD association already included many homecare services, which eventually led to better responsivenessand mutual cooperation. For example, a client using
FEDOSAD home-help services may have access to various
other services such as transportation to medical
appointments and, if his or her condition becomes worse,
have direct access to in-home nursing care services or even
to HAD services. Moreover, as the FEDOSAD associationis also managing care centers for dependent elderly
persons (EHPAD) and day care centers, it can easily offer
respite care services, which are beneficial for both thepatients and the various caregivers.

ⅩⅣ．Experiences with and feedback on HAD
FEDOSAD 21 Facility
It did not take long for someone like Jean to decide to use

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HAD services. He certainly has a long medical history: ten
years ago, he was diagnosed with an extremely rare orphan
disease with symptoms similar to those of multiple
sclerosis. He was told the only way to stabilize the disease
would be for him to receive an intravenous injection of avery expensive drug over a four-day period every two or
three months.
In the quietness of his hospital room, he thought about
the burden the treatment would impose on him and how
expensive would be the hospital and drugs without which
his condition could not be stabilized. “I thought about how
the money could be better spent on kids. I refused care but
the doctors got angry!” In the end, he accepted thetreatment, and from this point his tour of hospitals started.
At first, he went to a hospital close to his home but then had
to change to another one because the treatment was too
expensive. He then switched hospitals once more, this time
for one in Dijon city. In each case, he was forced to endure
a long waiting time because his treatment was of a lower
priority than other emergency cases. Even though theinjections caused him headaches, most of the time he had
to share a room with other patients. Thus, he was often
forced to hear the sounds of other patients’ TV sets orfamily visits. He sometimes had to stay in the hallway
because of the lack of available rooms and also experienced
the lack of sufficient staff members. “At first, I could deal
with the situation, but after a year or two, I started getting
progressively weaker and getting tired more and more
quickly. Finally I decided, ‘I’m not coming anymore…’”
But the day he made this decision, he met the
department chief in the hallway. The chief, who was at firstreluctant to the idea of using HAD services, finally asked
him if he would prefer to be treated at home.
When we spoke to Jean about this, he told us, “When I
have cards in my hand, I play them.” He then added, as if
wishing to apologize for the money that his treatment cost,“My treatment still costs less to society. It does not cut jobs,
it creates new ones!” Jean also frequently expresses his
satisfaction with the time he has spent with the in-homecare providers, their warmth, and their availability.

(creating a chart for the beneficial use of drugs, checking
the content of prescriptions). A psychologist and a social
worker were employed to support patients and to meetpossible needs of other employees. A pediatric nurse wasrecruited for the future development of pediatric care incollaboration with the teaching hospital.
Since its inception, the facility has had a high occupancy
rate. In 2011, it received 228 admission requests. Duringthat year, the facility was taking care of 50 persons a monthon average, for a total of 12,585 days of services provided.
Of the 59 patients who died in 2011, the end-of-life occurredat home for 47 of them. In 2011, the use of HAD services
lasted on average 17.25 days per patient.

ⅩⅥ．Difficulties
encountered
FEDOSAD 21 Facility

by

HAD

Many issues still remain to be addressed before a longlasting expansion of HAD can be secured. One of these isthat the payment model (T2A) has not been adjusted during
the last few years. Another is that funding for palliative care
has apparently been insufficient.
Moreover, HAD is still not well known by many
healthcare professionals regardless of whether they are
working in the community, in private or public hospitals, orproviding ambulatory care. Many physicians that may
prescribe HAD services, especially those working in
hospitals, still have some difficulties in understanding how
HAD works. Another issue concerns the lack of availabilityof in-home nursing care services (SSIAD) to take care ofpatients after their use of HAD services.
The lack of care providers is also a major issue, as many
professionals would rather work in an inpatient facility to
avoid the discomfort of going from one patient’s home toanother. This is an issue that in-home care providers will
surely have to face. Since going from home to home isenergy-sapping and time-consuming, in-home care providers
are more likely to get tired than those who work in
hospitals. This may eventually lead to a lack of humanresources.

ⅩⅤ．Strengths of HAD FEDOSAD 21 Facility
ⅩⅦ．For the future
One goal of the HAD FEDOSAD 21 facility has always
been to constantly improve the satisfaction of both patientsand employees. This is why the facility chose a mixed
organization involving independent nurses and a coordinatingkinesitherapist to promote collaboration among employees
and more flexible adjustment of professional practices. To
ensure safety and optimization of the drug channel, acoordinating pharmacist was recruited to check procedures

It is necessary to give physicians a better understandingof the HAD system and the utility of HAD services byimproving their knowledge about the admission criteria
and about the types of care that can be delivered.
Furthermore, HAD should increase their opportunities towork in care centers for dependent elderly persons(EHPAD) and should establish more partnerships with new

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services to enable them to specialize in new types of inhome care (pediatrics, chemotherapy). It is vital for a HAD
facility to be specialized in certain types of healthcare to
avoid being overwhelmed by having to provide too broad a
range of care services.
The goal of HAD is to become a sort of in-home hospital
facility. This goal can be reached, but it is our responsibility
to expand the system and general knowledge of it so thatpatients will have more choices about the way they receive
care. Nevertheless, the HAD system is already providing
relief for overcrowded hospitals and clinics, and thus
should be supported to help persons secure access to careand to establish a fair care system for everyone.

Reference[1] “HAD, Hospitalisation A Domicile” (In French)[2] “FEDOSAD, Fédération Dijonnaise des Oeuvres deSoutien A Domicile” (In French)[3] “AP-HP, Assistance Publique Hopitaux de Paris” (In
French)[4] “FNEHAD, Fédération Nationale des Etablissements
d’Hospitalisation A Domicile” (In French)[5] “HSPT, Hôpital Santé Patient Territoire” (In French)[6] “SSIAD, Services de Soins Infirmiers A Domicile” (In
French)[7] “ARH, Agence Régionale d’hospitalisation” (In French)[8] “ARH, Agence Régionale de Santé” (In French)[9] “CROSS, Comité Régional d’Organisation Sanitaire etSociale” (In French)[10] “COMEX, Commission Executive de l’ARH” (In
French)[11] “CLIC, Centre Local d Information et de Coordination”(In French)[12] One characteristic of the French HAD system is toinclude the position of a coordinating physician. In
theory, this physician is in charge of coordinating
services and does not provide care directly (except inemergency cases), despite being responsible for
medical care provided to the patient and forauthorizing the use of HAD services.
[13] “HAS, Haute Autorité de Santé” (In French)[14] “EHPAD, Etablissements Hospitaliers pour Personnes
Agées Dépendantes” (In French)[15] “GHT, Groupe Homogène de Tarif” (In French)[16] “RPSS, Résumé Par Sous-Séquences” (In French)[17] More precisely, remuneration for a HAD facility
includes the costs of primary care physicians, HAD
staff members, inspection fees, medical imaging,
independent professionals (nurses, kinesitherapists,
speech therapists), ambulance transportation (onlywhen the ambulance is called by HAD members),
medical equipment (transfusion equipment, syringe
pumps, ventilators), special medical equipment (carebeds, lifting aids, chairs), medical supplies, anddisposable equipment (used by HAD only). From thepatient’s point of view, all HAD services are completely
covered by insurance. However, this concerns HAD
services only and not other services that may be usedat the same time.
[18] “ATIH, Agence Technique de l’Information surl’Hospitalisation” (In French)[19] “SAE, Statistiques Annuelles des Etablissements” (In
French)[20] “DHOS, Direction de l’Hospitalisation et del’Organisation des Soins” (In French)[21] “ICALIN, Indicateur Composite des Activités de Lutte
contre les Infections Nosocomiales” (In French)

抄録
本稿は，これまで，日本で紹介されることがなかった，実際にこのHADを運営してきたディジョンのFEDOSADという組織における地域での取り組みを紹介したものである．
フランスのHAD（l’Hospitalisation A Domicile）と呼ばれる在宅における入院制度は，1970年に法律が制定されてから，これまで何度もの改革を経てきた．
とりわけ患者の視点から見れば，その変化を受けいれることは容易ではない．利用者の健康，或は利用者の健康状態への治療に関わるサービスに対しては，新しい提供体制を導入する度に利用者の理解を得ることが複雑な問題となる．
ここで紹介するDijon市で創設されたFEDOSADは，地域の専門家と国，地方，県レベルの機関からの支援を受け，在宅ケアという，いわばベンチャー産業に挑んだ組織体である．
本稿では，このHAD FEDOSAD 21事業体の創設当時から，これまで直面してきた問題点，幸運な出来事，関係のある
様々な専門家，プラクティスを定義する文書や，フランスにおけるこれらの制度の限界を紹介する．
さらに，日本への示唆として，フランスの高齢者医療制度におけるHADの位置づけとHADの開発および老人ホームとの関係について言及した．

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