Home care services should be driven by client characteristics to ensure that high quality care is provided to those elderly deserving the care in the population. Home care services should be allocated based on assessment of individual risks, needs and benefits of services.

Background: In the state of Michigan, the current method of allocating services, known as 'targeting', is problematic since home care services for elderly clients are selected on a zeroone basis: eligible for home care or not. This process is flawed since there is no standardization in patient assessment for services, nor is there a measure to determine when care is no longer needed. Those that are ineligible for services receive no assistance, whereas those that are eligible are often provided with more care than is generally needed. Conversely, another method of care distribution, known as 'titrating allocates home care services according to need. Titrating is focused on resource allocation of services based on risks, benefit potential, and value of the benefits to the consumer. This study described the benefits of titrating of home care to clients in comparison to the distribution of care by targeting home care services to the elderly population.

Methods: In order to compare the two methods of home care service allocation, this study incorporates a systematic review and synthesis of the published literature, regression analysis of risk predictors, and comparison of actual resource allocations with simulated budgets. Risk predictors for the regression analysis include hospitalization, nursing home admission, decline in physical functioning and death.

Findings: Titration of care produces better outcomes in comparison to the distribution of care by targeting, since care is allocated by need. Budgets can be custom-made and designed for each client to reflect: risk of adverse outcome, effectiveness of home care in mitigating these outcomes, and the value of the outcome to be avoided. Case managers could be responsible for assessing an individuals risk and benefit associated with their situation. Although this is not common practice, the use of risk estimates-with proper training--to allocate care services has been shown to be successful.

Directing care based on risk produces greater outcomes effectiveness, and focusing the care around risks produces better progress markers for individual clients. This method of rationing care services will also provide useful standards against which to judge and reward high-quality program performance.

Conclusions: More variation in care should be explained by client characteristics to ensure that high quality care is provided to those elderly deserving the care in the population. Home care services should be titrated, based on assessment of individual risks, needs and benefits of services.

Reference: Weissert W, Chernew M, Hirth R. Titrating Versus Targeting Home Care Services to Frail Elderly Clients: An application of Agency Theory and Cost-Benefit Analysis to Home Care Policy. Journal of Aging and Health 2003; 15(1): 99-123.

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