The Gerontologist 43:807 (2003)
© 2003 The Gerontological Society of America
Authors’ Response
William G. Weissert, PhD,
Richard A. Hirth, MA, PhD,
Michael E. Chernew, PhD,
Sadhna Diwan, PhD and
Jinkyung Kim
John's thoughtful editorial—reflecting the insights of his many years as a major thinker on home care issues—offers much that we can agree with, including the focus on some of the limitations of our work. However, it is worth emphasizing that we never intended that the four outcomes we focus on would be the sole basis for allocating care and certainly would applaud any research measuring varying effectiveness (or value) by subgroups. The fundamental issue is that we do not believe that support for home- and community-based services can survive and thrive based solely on a desire to be "fair in response to disablement" (though we agree that is a valuable goal).
We believe instead that concrete outcomes must be defined and valued. This is certainly the trend in acute care medicine, and the first principle of any cost-effectiveness analysis would be to define outcomes. We are not so limited as to believe that all spending has to be justified by reduced spending elsewhere. In fact, the paradigm of cost effectiveness recognizes that better outcomes come at a cost. Broad measures of outcomes (such as caregiver as well as client well-being) are important, as is a detailed understanding of the effectiveness of home care services at improving outcomes.
Without demonstrating value in a concrete way, home care budgets will continue to come under pressure as fiscal pressures grow and demand increases. Moreover, it is likely that the outcomes from home care, no matter how defined, will not be optimal unless we can identify the set of individuals most likely to benefit. We are open to improved ways of defining outcomes and measuring population groups, but one way or another we believe that these steps intended to improve the performance of home care must be taken.
