substituting home care for hospitalization: the role of a quick response service for the elderly

q 1998 Human Sciences Press, Inc. 29

Journal of Community Health, Vol. 23, No. 1, February 1998

SUBSTITUTING HOME CARE FORHOSPITALIZATION: THE ROLE OF A QUICK

RESPONSE SERVICE FOR THE ELDERLY

Kevin Brazil, PhD; Cindy Bolton, MBA; Doreen Ulrichsen, BscN;and Christine Knott, BA

ABSTRACT: The purpose of the present study was to examine the role ofa rapid access home-based service as a means for the elderly to avoidadmission to an acute-care hospital. The setting for the study includedemergency departm ents in three acute care hospitals and a home careprogram in a mid-size Canadian city. Multiple sources of informationwere obtained to evaluate the service. Hospital emergency departmentrecords and home care records were reviewed. Patients who participatedin the service (n496) and physicians and nurses (n4119) who had in-volvement with the service were surveyed appraising the service in termsof relevance, access, quality and coordination. Study results revealed thatelderly women with multiple health problems who lived alone were themost frequent users of the service. The majority of the patients admittedto the service presented with problems of a functional nature that werethe result of a fall or mobility problems. The results indicated that theservice did avert hospital admissions and facilitated a process by whichpatients could avoid the intermediate step of hospitalization beforeplaced in a higher level of care or returning to previous levels of func-tioning. Economic analysis indicated that the value of the servicestemmed from the benefits to patients and caregivers rather than fromcost savings offered to acute care hospitals.

INTRODUCTION

The current course for Canada’s publicly funded health care sys-tem, known as Medicare, has been an unavoidable restructuring of themethod of delivering programs and services. This is due in part to escalat-ing health care costs, an aging population and increasing consumer parti-cipation. One of the most noticeable changes in the health care system hasbeen the attempt to avoid hospitalizations by arranging care in the home.

Kevin Brazil is Assistant Professor, Department of Clinical Epidemiology and Biostatistics,McMaster University, Research Coordinator, St. Joseph’s Health Care System, Hamilton; Cindy Bolton,Research Associate; Christine Knott, Research Assistant, Queen’s Health Policy Research Unit, Queen’sUniversity, Kingston; Doreen Ulrichson, Project Coordinator, Kingston, Frontenac and Lennox & Add-ington Health Unit Ð Home Care/Placement Division, Kingston, Canada.

Requests for reprints should be addressed to: Dr. Kevin Brazil, Research, Room 2205, St.Joseph’s Community Health Centre, 2757 King St. E., Hamilton, Ontario L8G 5E4, Canada.

30 JOURNAL OF COMMUNITY HEALTH

It is commonly accepted that the most frequent users of healthservices and hospitals are the elderly.

1 ± 3 Emergency Departments (EDs) in

acute care hospitals meet the needs of the elderly population by being aplace where they can receive urgent care and access a continuum of ser-vice needs.4 The demographic characteristics predictive of individuals whouse EDs and who are at risk of acute care hospitalization include: females60 years and older who live alone; limited mobility; reduced independencein activities relevant to daily living; multiple diagnoses; and a history ofprevious hospital admissions.5 ± 7 A multi-centre evaluation across the UnitedStates was conducted to document the pattern of ED use by the elderlypopulation.7 When compared with the non-elderly population, it was con-cluded that the older population is, 5.6 times more likely to be admitted tohospital and 6.1 times more likely to be classified as needing a comprehen-sive ED level of service. The data also indicates that elderly patients aremore likely to receive laboratory and radiographic tests, as well as spend-ing longer periods in EDs than non-elderly patients.

Fall related injuries are a common reason for ED use by the elderly.8

The risk of falls and fall-related injury increases with age due to a loss ofagility and visual acuity, predisposition to dizziness and syncope, and sideeffects from medications.

8,9 Approximately 30% of older adults will experi-

ence a fall annually, and 20% to 30% of these people will suffer moderateto severe injuries leading to loss of mobility, independence and an in-creased risk of death.9

Communities across Canada have identified the need for rapid ac-cess to intensive home-based services for appropriate Emergency Depart-ment (ED) patients so that admissions to acute care beds are avoided. Such aservice is often called a ªQuick Response Serviceº (QRS). A number of QRShave been initiated in Canada. These programs attempt to prevent unneces-sary hospital admissions by responding efficiently and coordinating deliveryof services in an individual’s home instead of in an acute care setting.10 Theseprograms tend to have the following characteristics:

x a strong link between hospital and local home care services;

x assessment and service coordination by a health care practitioner inthe hospital ED;

x more intensive in-home services than those normally offered byhome care programs;

x quick turnaround time from assessment to in-home service delivery;

x time-limited service (usually 5 days).

While QRSs are viewed by many as the most effective means toaddress the health care needs typical of the frail elderly, there is little in

K. Brazil, C. Bolton, D. Ulrichsen , and C. Knott 31

the published literature which describes either the character of these ser-vices or their contribution to the community. The purpose of this paper isto report an evaluation of a QRS which was implemented as a one yeardemonstration project in a mid-sized Canadian city.

THE SETTING

In 1992, the Ontario Government made available one-time fundingfor the establishment of QRSs in hospital EDs. The city of Kingston wasone of several communities which was selected for a twelve month demon-stration project to examine the viability of the QRS concept. The HomeCare Program which served the city and surrounding region was the desig-nated host agency for the initiative. All three acute care hospitals whichserved the region participated in the project. Two of the facilities wereteaching hospitals affiliated with the medical school in the city. The thirdfacility was a community hospital located in a small outlying rural commu-nity.

According to a 1991 Census, the catchment area had a populationof 166,330. Twelve percent or 19,615 people were 65 years of age andolder (65`). Females comprised 63.4% of this age cohort. Approximately30% of this population lived alone which was slightly higher than the pro-vincial average of 27.7%.11

THE CLINICAL SERVICE

The QRS for this health district was designed to address the needsof individuals who presented at one of the three participating hospital EDsor who were seen in the community by a family physician. The service wasdesigned to provide visits from registered nurses (maximum of 4 visits perday) and assistance from a homemaker (up to 24 hours per day) to amaximum of five days. A key feature of the QRS was that these serviceswere to be provided to clients within three hours of admission to the pro-gram. Patients accessed the service by a referral from a family physician orfrom an ED. Eligibility criteria for the service included; the patient was inneed of professional and/or home support services, patients medical con-dition was such that adequate treatment could be provided at home andclose medical supervision was available by a community family physician.Figure 1 illustrates the assessment and care process.

Emergency Department-Initiated Referrals. ED staff assessed patients onadmission and directed those considered appropriate for QRS to the ser-

32 JOURNAL OF COMMUNITY HEALTHF

IGU

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1


vice. The QRS case manager, who was responsible for patient assessmentand coordination of services would assess the patient and decide whetherhe or she should be admitted to QRS or alternate services. Once a patientwas deemed appropriate for QRS, arrangements were made to transportthe patient home and the necessary professional and support services wereinitiated. In some instances it was necessary that the home support workermeet the patient in the ED to accompany him or her home.

Community-Initiated Referrals. QRS also included community accessto an enhanced and rapid coordinated services as an essential componentto avoiding unnecessary ED visits. A single telephone number was estab-lished for the service in all areas of the health district. Family physicians,requesting QRS for their patients, called the number and were connectedto QRS case managers. The case manager would assess the patient in theirhome and would determine if the patient would be appropriate for theQRS services or alternate services.

Reassessment of QRS Patients. Within 72 hours of admission to theservice the QRS case manager visited the patient in his or her home. Thecase manager reassessed the patient and adjusted the services as the pa-tient’s condition dictated. Community nurses who served the patient,along with the QRS case manager contributed to the assessment as neces-sary. The case manager visited the patient in his or her home again on thefifth and final day of service to reassess the plan of care. The patient’s planof care was agreed upon by both the patient and/or caregiver and thecommunity case manager. Following this final assessment, the patient wastransferred from the QRS to the most appropriate level of care (i.e., regu-lar Home Care Program, a long term care facility, an acute care hospital,or to other community agencies).

METHODS

Measures and Procedures

Patient Characteristics. Information from multiple sources were ob-tained to describe the patients that received QRSs. ED Records were ab-stracted to describe patients’ means of arrival, triage status, proceduresperformed, length of stay, diagnosis and discharge destination. Home Carerecords were also abstracted to collect patient demographic and healthstatus variables. Patient utilization statistics for QRS and Home Care ser-vices prior and subsequent to QRS involvement were also abstracted.

Averted Hospital Admissions. A key feature to the study was to identifypatients who, through admission to the QRS, had avoided a hospital ad-


mission. Averted admissions were identified through the following protocol:when an ED or community family physician referred a patient to the QRS, acase manager conducted an assessment to establish eligibility for the service.Once eligibility was established the case manager asked the referring physi-cian whether this patient would have been admitted to the hospital if QRSwas not available. If the physician indicated that the patient would have beenadmitted to the hospital, the patient was classified as an ªaverted admissionº.This protocol allowed investigators to identify the number of patients redi-rected from a possible hospital admission to the QRS.

Patient Survey. All patients received a telephone survey within aweek of being discharged from the service. Patients were interviewed re-garding their satisfaction with the quality of the services they received, andwhether it met their health needs.

Hospital and Community Provider Survey. All ED Nurses and ED Physi-cians received a survey in the mail three months after the service was initi-ated. This survey coincided with the completion of a ten week periodwhen QRS case managers were on site within the ED and were involved incase finding and providing staff education regarding the service.

Community nurses who treated QRS patients were identified and asample randomly selected from community nursing agencies’ records andwere mailed a questionnaire at the end of the 12 month demonstrationperiod. All family physicians who had referred a patient to the QRS alsoreceived a mail survey at the end of the 12 month period. These providerswere surveyed to assess their familiarity with the characteristics of the ser-vice, and the quality of the service which was provided. They were alsoasked to describe the characteristics of an appropriate referral to the QRS.

Economic Analysis. Analysis was conducted to estimate the potentialcost-savings QRS offered to participating hospitals through averting hospi-tal admissions. Primary diagnosis codes (ICD-9) of patients who had beenclassified as averted admissions were used to calculate potential hospitalcost-savings. Primary diagnoses were cross-referenced with Case Mix Group(CMGs) codes. Based on the CMG diagnosis codes, per patient, resourceintensity weights were obtained which provided an estimated averagelength of stay and associated costs.

RESULTS

Client Profile

During its 12 months of operation the QRS admitted a total of 123patients. Seventy-five percent of those patients were female. The average


age of patients was 78 years old and 38% of these were between 75 and 84years of age. Fifty-one percent of QRS patients lived in a house, 66% livedalone. Most patients resided within the city (70%). Admission assessmentsto the QRS revealed that the most frequent presenting problems werefunctional in nature and were the result of falls or mobility problems (Ta-ble 1).

Admission assessments also identified a significant number of pa-tients in need of assistance with personal care and household management(Table 2). The predominate primary medical diagnosis for those patientsadmitted to the QRS pertained to musculoskeletal injuries, particularlyfractures (38%).

TABLE 1

QRS Patients’ Presenting Problems

Category Presenting Problems by Category Frequency

Functional Falls 35Mobility 22Safety Concerns 3Total 60

Physical Pain (hip, leg, back) 18Urinary & Fecal Problems 11Nausea / Dizziness 8Respiratory Infection 4Weakness 4Total 45

Mental Confusion 17Dementia 4Total 21

Social Caregiver Relief 8Spouse/Caregiver Admitted to Hospital 5Communication Difficulties 2Total 15

Pharmacy-Related Non-compliance with Medications 2Narcotic Overdose 1Total 3

*Some patients had more than one presenting problem.


TABLE 2

Patient Functional Status on Admission to QRS

MENTAL ORIENTATION

Alert 83 (67.5%)Confused 26 (21.1%)Memory Deficit 11 (8.9%)Missing 3 (2.4%)

PERSONAL CARE Dependent Independent Data Missing

Physical Transfers 74 (60.2%) 24 (19.5%) 25 (20.3%)Dressing 93 (77.0%) 28 (23.0%) 2 (1.6%)Feeding 22 (17.9%) 100 (81.3%) 1 (0.8%)Bathing 90 (73.2%) 31 (25.2%) 2 (1.6%)Medication Management 89 (72.4%) 29 (23.6%) 5 (4.1%)

HOUSEHOLDMANAGEMENT Dependent Independent Data Missing

Meal Preparation 114 (92.7%) 5 (4.1%) 4 (3.2%)Vacuuming 117 (95.1%) 2 (1.6%) 4 (3.2%)Dishes 113 (91.9%) 5 (4.1%) 5 (4.0%)Shopping 111 (90.2%) 3 (2.4%) 9 (7.3%)

Table 3 indicates that most of the patients admitted to the servicereported having been admitted to a hospital or having had an EmergencyDepartment visit within the three months prior to receiving QRS. The ma-jority of QRS patients (66%) were receiving Home Care services at thetime they were admitted to the service.

Averted Hospital Admissions. A key objective to the QRS was to pro-vide an alternative to hospitalization and thus render cost saving to hospi-tals. Identifying how successful the service was in accomplishing this objec-tive was an important goal of this project. The project used the avertedadmission classification protocol for a nine month period during whichtime 71 patients were admitted to the service. Responding Physicians clas-sified 47 (66%) of these patients as ªaverted hospital admissionsº.


TABLE 3

Self-Reported Emergency and Hospital Admissions 3 Months Prior toQRS

Number of Emergency Depart-ment visits in the three monthsprior to admission to Quick Re-sponse Service (Patient re-ported)

Number of Visits

Number of

Patients

0 14 (11.4%)1 41 (33.3%)2 35 (28.5%)3 or more 30 (24.4%)Missing Data 3 (2.4%)

Number of Hospital Admissionsin the three months prior to ad-mission to Quick Response Ser-vice (Patient reported)

Number of AdmissionsNumber of

Patients

0 14 (11.4%)1 69 (56.1%)2 26 (21.1%)3 or more 11 (10.6%)Missing Data 3 (2.4%)

Service Utilization Features

The average monthly rate of admission to the QRS was 10 patientswith a range of 3 to 19. Most admissions to the service were first timeadmissions (92%). Community physicians were responsible for 45% of ad-missions to the service. This group (N430) represented a small propor-tion of community physicians practising in the community. The remainingadmissions came from ED physicians. While the majority of admissionsoriginated from the EDs, the pattern of referral during the demonstrationperiod shifted. During the initial project period the majority of referralscame from the ED physicians, by the end of the project most referralscame from family physicians in the community. This pattern of referralmay be attributed to the removal of the QRS Case Manager from the EDten weeks after the initiation of QRS identifying the importance of thecase finding and the educational role of the ED case manager. The busiestmonth for QRS was December and the busiest day of the week was Friday.The most frequent admission time was between 2:00 and 4:00 p.m., whichaccounted for 24% of all QRS encounters.

Sixty-five percent of patients admitted to the service through the EDs


typically arrived to the hospital by ambulance. Once admitted to the emer-gency department QRS patients typically spent an average of 4 hours and 47minutes in the ED from their time of admission to discharge. Fifty-twopercent of QRS patients were classified as ªUrgentº meaning that the ªlife,limb or functionº of patients were threatened if care had not been providedin four hours. While in the EDs, QRS patients received tests such as x-ray(26%), haematology (24%), and electrocardiograms (EKG/ECG) (17%).

While on the QRS the typical number of nursing visits for a patientwas four accompanied by an average of 68 hours of homemaking . Themajority of patients (73%) admitted to the service stayed on for the fullfive day period.

Table 4 illustrates that at the time of admission to QRS most pa-tients lived alone. Upon discharge, the living situations changed for manypatients. Many QRS patients moved from living alone to a higher level ofcare such as retirement homes, homes for the aged, nursing homes andhospitals. At discharge the majority of patients were transferred from QRSto regular home care services (71%). These patients were tracked for thethirty days they received these services. At the end of the thirty-day periodall patients continued to receive home care services.

TABLE 4

Comparison of Living Situation on QRS Admission and on Discharge

Living Situation On Admission On Discharge

Co-habitation

Lives Alone 81 (65.9%) 58 (47.2%)Lives with Spouse 26 (21.1%) 19 (15.4%)Lives with Friend 2 (1.6%) 1 (0.8%)Lives with Family 10 (8.1%) 11 (8.9%)Other* 4 (3.3%) 34 (27.6%)

Place of Residence

House 63 (51.6%) 49 (40.1%)Apartment 38 (31.1%) 26 (21.3%)Senior Citizen’s Apartment 18 (14.8%) 13 (10.6%)Retirement/Rest Home 3 (2.4%) 10 (8.2%)Nursing Home N/A 8 (6.5%)Hospital Acute N/A 15 (12.3%)Hospital Chronic N/A 1

*Other refers to rest home, retirement home or group home.


Hospital Cost Savings

Calculations of cost savings QRS produced were based on the nine-month period when the averted admission protocol was in effect. Patientsadmitted to QRS during this time frame were classified as averted or non-averted admissions using the protocol discussed in the methodology sec-tion. During this period 71 patients were admitted to QRS, 47 (66%) ofwhom were classified as averted admissions. Only forty-five of these pa-tients were included in the cost calculations in the economic analysis, sincetwo patients refused to consent for their charts to be reviewed. Table 5identifies potential cost-savings the QRS offered the hospitals.

Patient Survey

All patients admitted to the QRS were contacted by telephonewithin one week of discharge to measure their satisfaction with the servicesprovided. Ninety-six surveys were completed (78%), with patient care-giver’s completing thirty-three of the questionnaires (34%).

Overall, the majority (95%) of respondents reported that the ser-vice met their health needs. Seventy-six respondents (80%) felt that thequality of care provided at home was the same as the care that they wouldhave received if patients had been admitted to the hospital. While 99% of

TABLE 5

Potential Hospital Cost Savings

Source ofReferral

Total aPatients

Total aAverted

Admissions1

*Total AverageLength of Stay

*Total Av.Cost Units ($)

Community 40 25 175.2 $127,073.06Acute CareHospital

31 22 166.6 $105,428.64

TOTALS 71 452 341.8 $232,501.70

* Based on Case Mix Group Directory and Canadian Institute for Health Information(CIHI) Cost Units.

* Total Average Length of Stay is based on a formula calculated from distributed caseswithin the case mix group (CMG)

1Averted admissions were determined during the nine-month time period ( January 1995 ±September 1995) the protocol was in effect.

2Two clients failed to provide consent, therefore, the total number of averted admissions was45 rather than 47.


the patients were satisfied with the nursing care received it was interestingto note that only 63% were satisfied with the level of home making supportthey received. Those respondents who felt that the quality of care receivedat home was not the same as the care received in the hospital providedreasons such as: ªthe home service seemed disjointedº, ªthe nurses in thehospital are better trained and keep more recordsº, and ªthe quality ofmedical care provided by physicians in the hospital is betterº.

Service Provider Surveys

To assess the reactions of service providers to the QRS demonstra-tion project four groups were surveyed: ED nurses, ED attending physi-cians, community nurses and community family physicians. Sixty-five EDnurses (86%) and 15 ED attending physicians across the three hospitalsresponded to the survey. Sixteen (53%) community nurses randomly se-lected from QRS patient charts and twenty-three (68%) community familyphysicians who referred patients to the service responded to the survey.

All of the ED physicians and 90% of the responding ED nurses feltthat the QRS was a necessary service to provide from the ED and that theQRS was a necessary service to the community (Physicians 100%, Nurses94%). A greater percentage of ED physicians (71%) than ED nurses(48%) expressed confusion between the role of the QRS and regularHome Care Services. However, both groups felt that the presence of theQRS Case Manager in the hospital during the first 10 weeks of the projectincreased their understanding of the roles of both the Home Care Pro-gram and the QRS.

All of the responding community nurses and most (91%) of thecommunity family physicians felt that the QRS was a necessary servicewithin the community. Most community nurses felt they received a suffi-cient orientation about the service (87%), understood their role and re-sponsibilities as a visiting nurse to the QRS clients (94%), accessed thecase manager easily (94%), and that both short and long-term goals ofservice established with the QRS clients were realistic (100%). Thirteen(81%) of the community nurse respondents indicated that the QRS re-cords were effective in maintaining communication amongst the visitingnurses and other health care services. However, 31% felt QRS patientswere exposed to unnecessary duplicate assessments.

The majority of responding community family physicians (83%)felt they understood how to reach QRS for their clients and 91% felt it wasa necessary service within the community. Most (87%) of the family physi-cians reported that they received sufficient orientation about QRS, under-


stood their role and responsibilities as a family physician to the QRS clients(83%), reached the case manager easily (96%), and were satisfied with thecommunication with the QRS case manager (96%). The majority of familyphysicians (96%) were satisfied with the continuum of care arranged fortheir patient at the conclusion of QRS and agreed that QRS supportedindependent or assisted living.

All service provider respondents characterized the appropriate pa-tient for a QRS referral as one who had experienced a sudden onset ofdependency (i.e., due to injury, illness, loss of caregiver, disability, reducedmental capabilities), who could be managed at home but who was unableto care completely for themselves.

DISCUSSION

The Ontario Ministry of Health funded the QRS initiative to studyit’s efficacy as a home-based service offering an alternative to hospital care.Ethical and logistical reasons prevented the evaluation of the service toinclude the use of a control or comparison group. Thus there was noopportunity to assess whether the QRS contributed to positive or adversehealth outcomes. The evaluation of QRS did provide information on thecharacteristics of the population who used the service and how they ac-cessed and subsequently used the service.

Elderly women with multiple health problems who lived alone werethe most frequent users of the QRS. The majority of patients admitted tothe service presented with problems of a functional nature that were theresult of a fall or mobility limitations. Many QRS patients were alreadyreceiving Home Care services when they were admitted to the service.Most had either been admitted to a hospital or an ED visit within threemonths of Quick Response involvement.

The QRS did facilitate a process by which patients who experi-enced an unexpected change in health status could avoid the intermediatestep of hospitalization before placement in a higher level of care or resum-ing prior routines. Analyses of home and community based care versusacute or long-term care is often reported in terms of cost-effectiveness orcost savings. The increasing emphasis on care provided in the home versusthe acute care setting has generated controversy regarding the cost-effec-tiveness of this substitution model. QRS which is associated with home careis often expected to demonstrate that they either replace or reduce thecost of existing acute, institutional or chronic care; and that Home Carecan be provided with no additional cost to the health care system.12


A review of numerous studies have demonstrated that care of indi-viduals in the home is desirable and readily sought after by patients, care-givers and service providers.12,13 These studies have also rejected the hy-pothesis that home care is a cost-effective substitute for acute care. It hasbeen argued that the dramatic reduction in institutional costs anticipatedby increased home care utilization has been outweighed by the additionalcosts of expanding Home Care programs in order to meet the demand.13

There are differences in the basic cost structures between hospitalsand home care. A relatively high proportion of hospital costs are fixedcosts. The fixed costs associated with physical plant and equipment areunaffected by changes in service levels in the short term. Conversely,Home Care has relatively low fixed costs. These differences in cost struc-tures imply that the nature and timing of QRS savings for hospitals will notmirror the nature and timing of increases in the costs of community basedagencies.14 Averted admissions in hospitals do not translate into immediatefinancial savings. At the same time, caseloads are increased for communityservice providers, with high variable resulting costs. In the present studythe volume of patients who participated in QRS was lower than antici-pated, resulting in a smaller impact on institutions than expected. Theeconomic analysis reinforced conclusions from the research literature thatthe value of QRS stems from perceived benefits by service providers, pa-tients and caregivers rather than actual cost savings offered to acute carehospitals.

Canada, like many other health care systems faces increased chal-lenges from changes in the social, political and economic environment.One response to these challenges is the shift to community based careoccurring not only in Canada but in the United States. As a demonstrationproject, the QRS identified a number of initiatives which could be madewithin communities to augment existing services to address the needs ofthe frail elderly. Services in communities could be arranged where theQRS concept of quick response time and front-end services is melded withregular home care services meeting the needs of the frail elderly who pre-sent in EDs. Further, the development of service arrangements whichwould allow emergency admissions to long term care services (e.g., respitebed) after regular business hours would help the elderly avoid unnecessaryhospital admissions.

Education of health care providers in the assessment and care ofthe frail elderly would enhance the competencies of those who service thispopulation. It would also facilitate the development of a more effectivemultidisciplinary approach towards the care of the elderly. Public educa-tion and awareness would further benefit the frail elderly. Specifically, the


public should be made aware of how to access service options in the com-munity. The low number of referrals made by community family physiciansin the study calls for the need to enhance awareness among communityphysicians regarding how to access service options in the community. Re-search conducted by Craven 15 revealed that a lack of knowledge aboutcommunity and social services was a significant factor contributing to lowreferral rates by Canadian family physicians. Interventions to increase phy-sician’s knowledge about community service would encourage the familyphysician to become more involved with community agencies and to ac-tively manage patients at home. In the current environment of fiscal re-straint these initiatives can assist local service planners to pursue the QRSobjective of preventing unnecessary services hospital admissions throughaugmenting existing services in the community.

REFERENCES

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department use and care. J Am Geriatr Soc 1987; 35: 398 ± 404.6. Beland F, Lemay A, Philbert L, Maheux B, Gravel, G. Elderly patients use of hospital-based emer-

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12. Cummings JE, Weaver FM. Cost-effectiveness of home care. Clin in Geriatr Med 1991; 7:865 ± 875.13. Weissert WG. One more battle lost to friendly fire Ð or if you spend too much it’s hard to save

money. Med Care Suppl 1993; 31:SS119± SS121.14. Cameron S, Rajacich D, Charette M. Quick response program evaluation in Windsor/Essex

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substituting home care for hospitalization: the role of a quick response service for the elderly

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