The interplay between costs, quality, and organisation of home care in Europe

Health and long-term care systems in Europe are under pressure, as a shrinking labour force may no longer be able to provide for the needs of the growing number of older people living at home. The research described in this thesis was part of the ‘Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of Community Care’ (IBenC) project which was funded within the 7th Framework Program of the European Commission. The aim of the IBenC project was to develop a new benchmark methodology based on quality of care and cost of care utilisation to identify best practices in home care. Best practices that are able to produce good outcomes with limited resource use may make long-term care systems more sustainable. In this thesis, we developed consensus-based recommendations for the identification, measurement and valuation of healthcare utilisation and lost productivity that are applicable for cross-European economic evaluations. In addition, we showed that the interRAI-HC, a comprehensive geriatric assessment instrument that is widely used in routine care for care planning, can be validly used to estimate societal costs next to quality of care outcomes. This substantially improves the feasibility of performing economic evaluations among older home care clients, since there is no need to burden them with additional assessments. Next, we identified potentially modifiable (ADL and iADL impairment, limitations of going out because of fear of falling, oral problems, caregiver distress, presence of pain, urinary incontinence) and non-modifiable predictors (country of residence, living status, cognitive impairment, arthritis, history of a Cerebrovascular Accident, health instability, behavioural problems, multimorbidity, and number of prescribed medications) of societal costs generated by older home care clients across European countries. We showed that specific characteristics of home care models (patient-centred care; availability of specialised care professionals, level of monitoring of care performance) are related to societal costs. Further, we developed a novel method to benchmark home care organisations on two case-mix adjusted quality of care summary scales and healthcare costs. Last, internationally applicable benchmarks like the one we present in this thesis can provide information on the performance of home care within and across countries and regions with regard to both quality of care and costs.