Maximizing Dementia Patient Outcomes With Home-Based Primary Care
Creators: name: Noah, Hannah
Publisher: name: The University of North Carolina at Chapel Hill University Libraries
Year: 2017

description: Background: As the United States population ages, dementia will become more prevalent. Patients with dementia typically a significant investment of caregiver time, which can be very expensive, so any interventions for the dementia population that reduce resource use while enhancing patient outcomes would be hugely beneficial. Home-based primary care (HBPC), a system where healthcare providers travel to patient homes to deliver medical care, is one potential solution. Evidence thus far indicates that HBPC successfully reduces costs and enhances outcomes for the general homebound population. REACH (Reaching out to Enhance the Health of Adults in their Communities and Homes) is an example of a HBPC program based in central North Carolina. Objectives: This paper includes a systematic review of literature to evaluate evidence of how HBPC affects patient outcomes for the dementia population followed by an original investigation examining whether characteristics of dementia patients influence how REACH affects emergency department (ED) admission, hospitalization rates, and mortality. Methods: Data were extracted from chart reviews of 159 patients in University of North Carolina at Chapel Hill’s HBPC program, REACH. Patients with and without dementia were compared on the following characteristics: age; sex; race; number of chronic health conditions; number of independent activities of daily living (ADLs); marital status; presence of home health aide, physical therapist, occupational therapist, nurse, or social worker prior to REACH enrollment; and mortality within study period. I then calculated an incidence rate ratio (IRR) to determine whether the aforementioned characteristics significantly augmented the reduction in ED visits or hospitalizations following REACH enrollment. Finally, I calculated whether these characteristics significantly affected the odds of mortality during the study period. Results: The systematic review yielded three studies of low to fair quality that provided mixed results as to whether HBPC improves outcomes for dementia patients. In the REACH sample, presence of a home health aide (IRR = 0.59, 95% CI: 0.40-0.86), being married (IRR = 0.69, 95% CI: 0.50-0.97), older age (IRR = 0.94, 95% CI: 0.90-0.98), male sex (IRR=1.97, 95% CI: 1.47-2.64), being African-American (IRR=0.73, 95% CI: 0.54-0.98), and having fewer independent ADLs (IRR=1.14, 95% CI: 1.07-1.23) augmented REACH’s reduction in ED visits. Men (IRR=1.72, 95% CI: 1.02-2.91) and people with fewer independent ADLs (IRR=1.72, 95% CI: 1.05-1.23) had a greater reduction in hospitalizations. Patients with a HHA had 1.63 times the odds of mortality (95% CI = 1.02 – 2.60), female patients had 0.48 times the odds (95% CI = 0.24-0.99), African-American patients had 0.25 times the odds (95% CI = 0.10-0.65), and each independent ADL reduced odds by a factor of 0.83 (95% CI = 0.71-0.97). Conclusions: REACH does not have a differential impact on ED admissions and hospitalizations based on whether a patient has dementia. However, several patient characteristics that were more prevalent in dementia patients augmented REACH’s reduction in ED admissions and hospitalizations in this sample. Knowing these characteristics can help us target dementia patients who can most benefit from HBPC. Future research should focus on how we can design home health programs that optimize outcomes for dementia patients.