Impact of home care versus alternative locations of care on elder health outcomes: an overview of systematic reviews

We synthesized systematic reviews evaluating the impact of home care versus alternative LOCs on elder health outcomes. Overall, we found 19 eligible systematic reviews covering 340 studies and 271,660 participants. Reviews originated from seven industrialised countries that are known to be experiencing rapid growth among their elder population. Categories of comparisons included: home with supports versus independent living at home, home care versus institutional care, and home rehabilitation versus conventional rehabilitation. Most reviews favoured home with support to independent living at home. Results for home care versus institutional care were mixed. Most reviews found no differences in health outcomes between rehabilitation at home versus conventional rehabilitation services. The quality of included systematic reviews was moderate. Our results lead us to make the following observations.

First, as aging in a desirable LOC may contribute to overall health and wellbeing in the late-life period [36, 37], we were not surprised to find several reviews that examined LOC as a function of elder health and wellbeing. Many elderly people prefer and choose to age at home [38–42]. Healthcare organizations and policy makers are increasingly challenged to better support a shift from institutionalized long-term care to support elders to remain in their community [43]. The included reviews indicate a growing literature of interventions designed to promote health, function and independent living among community dwelling elders. Yet, many older adults anticipate moving, often to a more institutionalized location. Even those who do not anticipate moving might be compelled to move due to unforeseen life changes (e.g. loss of a spouse, illness) [40, 44]. As life expectancy increases and more people in late life suffer from multimorbidity, their relocation will represent a significant market for new residential options beyond the limited choices of private nursing homes or public long-term care facilities [45]. Therefore, an improved understanding of the role of long-term LOCs on elders’ health and wellbeing is central to any strategy aimed at fostering elders’ quality of life [46].

Second, the impact of home care compared to institutional care on elder health outcomes was less clear. The Mottram et al. [7] and Wysocki et al. [29] reviews had similar PICOS questions, and despite the 13-year publication gap and new research, both concluded that there was insufficient evidence to draw firm conclusions. Similarly, most systematic reviews that examined location of rehabilitation services and elder health outcomes found no differences or insufficient evidence. Inconclusive findings suggest that informed patient preferences and individual needs should guide elders’ decision to move from home to an alternative LOC. Examination of LOC options and preferences should also incorporate contextual factors, such as the quality of available services or other interventions. Consistent the ecological model of aging and person-environment fit, elders’ specific needs (e.g., mobility, cognitive, social) must be evaluated and matched to available LOC options with appropriate interventions or services to address those needs.

Third, our results highlight that most home care research focuses on few LOC comparisons. Further, most systematic reviews did not compare across multiple potential LOCs. When examined individually, each comparison provided insight regarding potential outcomes of one LOC option compared to the other. However, it was not possible to integrate the findings to determine the best LOC based on elder health outcomes. Although we did not examine the primary studies, our overview identifies a need for better research targeting long-term LOC options for the late-life years. Improved research and additional investment will translate into more rigorous methods and generate a more complete understanding of the impact of LOCs on elders’ health.

Our findings should be interpreted within the context of its limitations. First, our search strategy focused on home care, thus terms such as ‘day hospital’ and ‘assisted living’ were not included. Also, we did not search the grey literature. Therefore, we might have missed eligible systematic reviews. Second, several factors made this literature challenging to synthesize. We found considerable heterogeneity within and across included systematic reviews regarding population characteristics, locations considered, measures used, and outcomes reported, precluding firm conclusions. LOCs were also poorly and inconsistently described in the literature. Development of an accepted taxonomy for LOCs would help advancement in this field. Third, the study designs of the included reviews made direct comparisons for LOCs difficult and we noted a risk of indication bias (elders’ health status correlates with the intervention and is a risk indicator for the outcome) within several of the primary studies. Causal relationships between LOCs and elder health outcomes could not be measured. Instead, this overview provides a broad summary of the state of knowledge regarding elder home care compared to alternative LOCs and elder health outcomes. Fourth, there was some primary study overlap across the systematic reviews, potentially over-representing certain findings. However, the purpose of an overview of systematic reviews is to provide a high level description of the state of the evidence [16]. To offset this limitation, we excluded studies with 100% of primary study overlap. Finally, new and relevant studies might have been excluded if they were not yet included in a systematic review.