As people age, they tend on average to have greater health care needs and therefore more health spending. At some point many people have difficulty taking care of themselves, both in regard to health care and to other activities of daily living. Traditionally, many of these people have ended up in nursing homes, where their quality of life is often not high, and which can be a very expensive setting for care. An alternative is delivering more care in the person’s home and providing other assistance that may allow them to live at least semi-independently for some period of time. A draft report from the Agency for Healthcare Research and Quality deals with the issues of whether one or the other alternative is cheaper or provides better or worse care. (AHRQ Report) As is usually the case, the report is largely a literature review, and is also usually the case, there isn’t a lot of conclusive or even relevant research. The researchers looked at three primary questions: the characteristics of the older adults served in each setting; the impact of care in each setting on outcomes and the trajectory of outcomes; and the relative costs of each setting.
The researchers identified 46 studies with relevant information, none of which were randomized clinical trials. The authors found that there tended to be very significant differences between the populations cared for in each setting, with nursing home residents being significantly more impaired. Interestingly, however, people who received home and community-based care tended to be more impaired than those in assisted living facilities. In the studies that compared outcomes, particularly rates of physical or cognitive decline, no significant difference was found among people in nursing homes and people who were being treated in their residences with home care and community-based services, although the evidence was judged to be of low quality for all of the key questions. In terms of costs, as might be expected, long-term care costs were lower for the home care cohort, but somewhat surprisingly, medical expenditures were also higher for this group, but total costs were higher for nursing home residents. The researchers outlined additional research that would be helpful to guide policymakers in determining what types of care and programs to support.