An evaluation of home and health care services, cost-effectiveness, and health-related quality of life of older adult home care clients
Creators: Flemming, Julie A.
Publisher: name: University of Alberta Library
Year: 2023

<pre><code>   Home care services can provide both health interventions and support with daily tasks to assist individuals to remain in the community. Within Canada, home care services are not federally regulated, leading to each province and territory offering a different milieu of support. Alberta’s provincial health authority, Alberta Health Services (AHS), provides home care through specialized health care and non-regulated care services based on a client’s identified needs. Challenges exist in identifying the optimal types and amounts of services as demand for care grows and home care, like other health care programs, must work within a budget. Current information is inadequate regarding factors affecting the Health-Related Quality of Life (HRQoL) of older home care clients, and cost-effective health interventions for this group. Navigating care provision through the COVID-19 pandemic has made service provision in this area even more complex. The aim of this dissertation was to investigate cost-effective interventions provided within home care and factors that impacted the HRQoL of this population, to thereby support clinical intervention selection and health policy development. 

   This dissertation includes five studies, starting with two systematic reviews addressing economic reporting of rehabilitation interventions and implementation of alternative home care programs. Three further observational retrospective exploratory evaluations assessed factors related to changes in home care clients’ HRQoL, with one evaluation specifically addressing changes during COVID-19. These three studies used regular clinical practice data from AHS, and through a validated mapping process to estimate the Health Utility Index 3 scores, investigated longitudinal changes in client HRQoL outcomes. 

   This research provides evidence to support decision-making regarding the services of home care clients. Using the Consolidated Health Economic Evaluation Reporting Standards guidelines, inconsistent reporting was identified in economic evaluations of rehabilitation services. Several interventions comparing new or alternative home care to standard home care were identified, but only a few such as preventative nursing and restorative care or reablement were found to be cost-effective. This research reports on factors associated with decreases in HRQoL for home care clients including additional diagnosis during the study period, being in an older age group, and more care time provided by clinical specialties and non-regulated staff. Larger decreases in the average HRQoL were found during COVID-19, compared to before the pandemic, with greater decreases in ambulation and cognition. Within the Edmonton zone, the majority of older adult home care clients were found to have a decrease in HRQoL irrespective of type of care activity or profession providing care. 

   Demonstration of the cost-effectiveness of home care services, including rehabilitation, within a budget-constrained environment, is required for the development of these programs. However, as there are low numbers of home care studies within Canada and inconsistent reporting of economic evaluations, additional research is required for the implementation of value-based interventions to support the well-being of home care clients. As large decreases were found in the health attributes of cognition and ambulation clients with decreases in these areas can be an ideal group to target for intervention. Educating health care providers regarding factors associated to decreased HRQoL outcomes such as clients with recent diagnosis, being in an older age group and higher levels of clinical specialty and non-regulated care time may support enhanced client care. Better knowledge from changes in HRQoL can build provider awareness for appropriately tailored interventions based on client need. This research highlights COVID-19 related challenges for the home care population and discusses the importance of healthcare professionals maintaining effective communication. 

   Further research is suggested for home care populations that are traditionally underrepresented, barriers to full reporting of economic information, and interventions that may be cost-effective for this context. Additional evaluation is also warranted regarding the usefulness of implementing an embedded Outcome Scale for HRQoL within the RAI-HC, to allow for care providers and policymakers to easily monitor client outcomes, subgroups of the home care population, and possibly the impact of moving to a higher level of care.
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