PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of canfamphysLink to Publisher's site
 
Can Fam Physician. 2010 November; 56(11): 1166–1174.
PMCID: PMC2980438

Language: English | French

Integrating Physician Services in the Home

Evaluation of an innovative program

Intégrer les services médicaux à domicile

Moira Stewart, PhD
Director of the Centre for Studies in Family Medicine at The University of Western Ontario (UWO) in London
John F. Sangster, MD MClSc CCFP
Professor Emeritus in the Department of Family Medicine at UWO
Bridget L. Ryan, MSc PhD
Postdoctoral Fellow in the Centre for Studies in Family Medicine at UWO
Jeffrey S. Hoch, MA PhD
Research Scientist at the Centre for Research on Inner City Health of the Keenan Research Centre in the Li Ka Shing Knowledge Institute in Toronto, Ont
Irene Cohen, MD CCFP
Family physician and an Adjunct Professor at Whitehills Medical Centre in London, Ont
Carol L. McWilliam, MScN EdD
Professor in the School of Nursing at UWO
Joan Mitchell, RN(EC)
Nurse practitioner at the Byron Family Medical Centre in London, Ont.
Evelyn Vingilis, PhD CPsych
Director of the Population and Community Health Unit at UWO
Christine Tyrrell
Former Administrative Manager of the Department of Pediatrics at University of Alberta in Edmonton

Abstract

OBJECTIVE

To evaluate a new program, Integrating Physician Services in the Home (IPSITH), to integrate family practice and home care for acutely ill patients.

DESIGN

Causal model, mixed-method, multi-measures design including comparison of IPSITH and non-IPSITH patients. Data were collected through chart reviews and through surveys of IPSITH and non-IPSITH patients, caregivers, family physicians, and community nurses.

SETTING

London, Ont, and surrounding communities, where home care is coordinated through the Community Care Access Centre.

PARTICIPANTS

A total of 82 patients receiving the new IPSITH program of care (including 29 family physicians and 1 nurse practitioner), 82 non-randomized matched patients receiving usual care (and their physicians), community nurses, and caregivers.

MAIN OUTCOME MEASURES

Emergency department (ED) visits and satisfaction with care. Analysis included a process evaluation of the IPSITH program and an outcomes evaluation comparing IPSITH and non-IPSITH patients.

RESULTS

Patients and family physicians were very satisfied with the addition of a nurse practitioner to the IPSITH team. Controlling for symptom severity, a significantly smaller proportion of IPSITH patients had ED visits (3.7% versus 20.7%; P = .002), and IPSITH patients and their caregivers, family physicians, and community nurses had significantly higher levels of satisfaction (P < .05). There was no difference in caregiver burden between groups.

CONCLUSION

Family physicians can be integrated into acute home care when appropriately supported by a team including a nurse practitioner. This integrated team was associated with better patient and system outcomes. The gains for the health system are reduced strain on hospital EDs and more satisfied patients.

RÉSUMÉ

OBJECTIF

Évaluer un nouveau programme appelé Integrating Physicians Services in the Home (IPSITH) visant à intégrer médecine familiale et soins à domicile pour des patients gravement malades.

TYPE D’ÉTUDE

Modèle étiologique, méthodes mixtes, conception à paramètres multiples incluant la comparaison de patients IPSITH et non IPSITH. Les données ont été tirées d’une revue de dossiers et d’enquêtes auprès des patients IPSITH et non IPSITH, des soignants, des médecins de famille et des infirmières du milieu.

CONTEXTE

London, Ontario, et certaines localités voisines où la coordination des soins à domicile dépend d’un Community Care Access Centre.

PARTICIPANTS

Un total de 82 patients traités selon le nouveau programme de soins IPSITH (incluant 29 médecins de famille et une infirmière praticienne), 82 patients appariés non randomisés traités de la façon habituelle (et leurs médecins de famille), des infirmières du milieu et des soignants.

PRINCIPAUX PARAMÈTRES À L’ÉTUDE

Visites aux services d’urgence (SU) et degré de satisfaction concernant les soins. L’analyse comprenait une évaluation des processus du programme IPSITH et une évaluation des issues en comparant les patients IPSITH et non IPSITH.

RÉSULTATS

Patients et médecins de famille étaient très satisfaits de l’ajout d’une infirmière praticienne à l’équipe IPSITH. En tenant compte de la gravité des symptômes, une proportion significativement plus faible de patients IPSITH ont visité les SU (3,7 % contre 20,7 %, P = .002), et les patients IPSITH, leurs soignants, les médecins de famille et les infirmières du milieu avaient un niveau significativement plus élevé de satisfaction (P < ,05). La tâche de travail des soignants était la même dans les deux groupes.

When patients are acutely ill, there are 6 main care alternatives available to them: 1) hospitalization; 2) emergency department (ED) use; 3) formal hospital-in-the-home programs; 4) office or home visits with family physicians; 5) community home care agencies; and 6) telehealth. Hospitalizations are infrequent and of short duration for acute illnesses for a variety of reasons. Hospital-in-the-home programs are not widely available and do not normally include family physicians, yet patients prefer them to hospitalization.13 The usual alternatives to hospitalization in Canada are office care by family physicians, ED use, telehealth, and community home care. Despite the fact that patients might be cared for by both family physicians and community care providers, these providers usually operate with no formal links between them.4,5

Formal hospital-in-the-home programs have been widely studied.1,615 These studies demonstrate equivalent outcomes to hospitalization, that hospital-in-the-home models are acceptable to patients, and mixed results in terms of cost-effectiveness and the acceptability of hospital-in-the-home programs to family caregivers. There is also work concerning case management in the community for long-term conditions.1619 However, community-based care for acute illness that incorporates the patient’s family physician as part of a multi-disciplinary team is virtually unstudied. We do not know which community-based models of care for seriously ill adult patients work best for all participants: the patient, the family caregiver, the family physician, the nurses, and the system.

The evaluation reported here addressed this gap by quantitatively describing the implementation and process goals (such as participation, workload, and satisfaction) of a novel care program and by evaluating patient outcomes in a comparison study. Patients with acute or complex illness received enhanced home-based care from a multidisciplinary team including their own family physicians in a novel care program called Integrating Physician Services in the Home (IPSITH). The evaluation of this new IPSITH program using a causal model, mixed-method, multi-measures design2026 was undertaken with an assessment of the perspective of all players. The qualitative component is reported elsewhere.27,28

METHODS

Setting

The setting was London, Ont, and its surrounding communities, where home care was coordinated through a regional provincially funded agency called Community Care Access Centres of London and Middlesex (CCAC). The program was conducted from 2000 until 2002.

Program and intervention

The IPSITH program was developed and implemented by a team of stakeholders including health care providers, researchers, and policy makers. A medical coordinator (family physician, 1 day per week) and a full-time nurse practitioner were hired. Family physicians were invited to participate in recruitment meetings, where the IPSITH program was described and patient eligibility was explained. A medical infrastructure was put in place within the existing local CCAC that sought to enhance the usual care provided.

Usual care included a case manager, who ordered nursing and allied health professional services as required. Patients receiving usual care could be admitted to home care by family physicians or home care professionals, or as early discharges from hospital.

The IPSITH program included the usual care providers with the addition of the patients’ family physicians, the IPSITH nurse practitioner, and in most cases, a family member or friend who acted as a caregiver in the home. There were 44 family physicians who attended the recruitment meetings and enrolled in the program, indicating a willingness to admit patients to IPSITH. Of these, 29 physicians enrolled patients into the program. Additionally, relationships and processes were established. A pharmacy, oxygen suppliers, and diagnostic services agreed to provide their services in patients’ homes, and 39 specialists agreed to provide urgent consultation for IPSITH patients upon request, with 18 agreeing to see patients in their homes if requested. Processes were established for the initial assessment, out-of-hours coverage, a record system, rapid response to crises, and fast-track admissions to hospital when needed. Most medical care services were coordinated through the nurse practitioner, who maintained close communication with patients’ family physicians. Family physicians made home visits as deemed necessary.

Patient participants

Eighty-two patients were enrolled consecutively in the IPSITH project. The IPSITH family physicians determined their patients’ eligibility for the program and admitted all patients deemed eligible with acute or complex conditions requiring care for an anticipated 5 to 10 days. Patients were asked to consent to the research component of the IPSITH project. For each IPSITH patient, a comparison (non-IPSITH) patient receiving usual acute care through CCAC was identified (matched on diagnosis and age within 10 years) by his or her CCAC case manager and asked to participate in the study. Both IPSITH and non-IPSITH physicians were asked to complete a Duke Severity of Illness Checklist29 for each patient to determine whether the IPSITH and non-IPSITH patients were adequately matched on disease symptom severity.

Data sources

The main sources of data were chart reviews, patient and caregiver interviews, and family physician and community nurse surveys. Survey response rates for the various participant groups were very high (75% to 100%), with the exception of non-IPSITH physicians (62.2%).

Chart reviews

Charts were reviewed to identify whether process goals were met, the number of physician home visits, and the number of telephone calls.

Patient and caregiver interviews

Interviews were conducted in the home within 2 weeks of discharge, including questions about patient and caregiver satisfaction (adapted from Richards et al30), patient and caregiver future preferences (one adapted from Richards et al30), patient ED use (adapted from Browne et al31,32), and caregiver burden.33

Family physician surveys

Surveys were mailed to participating physicians to collect information about patients’ disease symptom severity on a 5-point scale on the 4 dimensions of symptoms, complications, prognosis, and treatability (Duke Severity of Illness Checklist29), family physician satisfaction (1 item), barriers to providing home care (1 item), and attitudes about the relative quality of home and hospital care (1 item).

Community nurse surveys

Surveys were mailed to community nurses to collect information about nurse satisfaction (1 item) and attitudes about the relative quality of home and hospital care (1 item).

Analysis

The process evaluation describes the implementation of the IPSITH program through means and frequencies.

The non-randomized comparison of the IPSITH and non-IPSITH patient groups was conducted on the following outcomes: ED visits during the treatment period; ED visits during the 6 weeks following the treatment period; satisfaction (patient, caregiver, family physician, and nurse); caregiver burden; and patient and caregiver preferences for future care. Possible covariates (patient age, sex, diagnostic category, symptom severity, education, and income) were assessed for inclusion in the statistical models. Only symptom severity was found to vary between the IPSITH group and the non-IPSITH group, and thus was controlled for in all analyses. Analysis of variance was employed for continuous outcomes and logistic regression for dichotomous outcomes, controlling for the differences in symptom severity. Only 51 of 82 non-IPSITH family physicians returned their surveys including the Duke Severity of Illness Checklist. Of these, a further 15 indicated that they were unable to complete the Duke Severity of Illness Checklist because they did not have contact or involvement with their patients during the treatment episodes. This meant that for the non-IPSITH group, severity data were only available for 36 patients. The difference in severity between IPSITH and non-IPSITH patients for the remaining cases was imputed. The first step in imputation involved the observation that the difference in severity was related to diagnostic category. The second step involved assigning the median difference-in-severity scores from the actual data for each diagnostic category. In the third step, results were calculated with both the imputed symptom severity data (82 IPSITH and 82 non-IPSITH patients) and the actual severity data (36 IPSITH and 36 non-IPSITH patients).

Ethics approval, confidentiality, and security

The study received ethics approval from The University of Western Ontario Health Sciences Research Ethics Board. All data were kept strictly confidential.

RESULTS

Patient characteristics

Table 1 shows that there were no important demographic differences between the IPSITH patients and the non-IPSITH patients. Box 1 describes an example IPSITH case.

Box 1.

Example IPSITH case

  • Patient: 74-year-old married man with congestive heart failure, newly diagnosed type 2 diabetes, and atrial fibrillation, admitted for 13 days, then discharged to regular non-IPSITH home care
  • Received at home: oxygen within 2 hours of admission to the IPSITH program, furosemide twice daily for 7 days, oral medications, close monitoring, and health education
  • Diagnostics at home: bloodwork 3 times; measurement of oxygen saturation and blood gases; and a chest x-ray scan in garage (house not accessible to machine)
  • Number of visits: 5 family physician visits, 10 nurse practitioner visits, 16 home care nurse visits, and 1 physiotherapist visit
  • Outcome: Home for 55th wedding anniversary and finally able to breathe lying flat so he could sleep with his wife again

IPSITH—Integrating Physician Services in the Home.

Table 1
Patient characteristics: A) Age and length of treatment; B) Diagnostic category, symptom severity, education, and income.

Physician characteristics

The IPSITH physicians (n = 29) and non-IPSITH physicians (n = 69) did not vary by sex, year of graduation, hospital privileges, solo or group practice, or urban or rural practice. They did vary by membership in the College of Family Physicians of Canada, with more IPSITH physicians being members (85.7% vs 55.0%; P = .008). They also varied by teaching status, with more IPSITH physicians teaching (55.1% vs 5.9%; P < .001).

Process evaluation: IPSITH program

Key process goals for the development of the IPSITH program were met. One hundred percent of IPSITH patients’ charts indicated that there had been prompt initial medical assessment and treatment, a written discharge plan, and physician communication with community providers. Table 2 shows the number of family physicians by the number of cases admitted. Table 3 describes the workload for IPSITH family physicians.

Table 2
Number of IPSITH family physicians by number of IPSITH cases admitted: The median (IQR) number of cases per family physician was 2 (1–3).
Table 3
Workload for the 29 IPSITH family physicians: A) Mean (range) measures of workload elements per patient (n = 82); B) Time of day of housecalls.

Most patients and family physicians were satisfied with the addition of the nurse practitioner to the home care team (Table 4). The nurse practitioner made an average of 4.96 visits and a median of 4 visits per patient.

Table 4
Patient and family physician satisfaction with the NP*

Figure 1 shows patients’ and caregivers’ preferences for location of care (home vs hospital); Figure 2 illustrates family physicians’ and community nurses’ assessment of quality of care (home vs hospital). Most patients, caregivers, and nurses reported that home care was strongly preferred to or much better than hospital care, compared with a minority of family physicians.

Figure 1
Patient and caregiver preferences for location of care (home vs hospital): Patients and caregivers were asked: “For the same condition in the future, where would you prefer treatment?”
Figure 2
Family physician and community nurse preference for location of care (home vs hospital): Family physicians and community nurses were asked: “Do you think care in the home, with necessary sevices provided, is as good as care in-hospital for acutely ...

Family physicians agreed that unscheduled telephone consultations (51.9%), distance to patients’ homes (67.1%), and home visits outside of office hours (53.2%) were barriers to providing acute care in the home. Additionally, 20.7% wrote in the “Other, please specify” section that poor remuneration was also a barrier.

Outcomes evaluation: comparing IPSITH and non-IPSITH groups

Controlling for the difference in symptom severity, there were statistically significant differences between the full set of IPSITH cases and non-IPSITH cases for ED visits both during (P = .002) and after (P = .034) the treatment period, as shown in Table 5, analysis 1. There were statistically significant differences between the subset of IPSITH cases and non-IPSITH cases for ED visits during the treatment period (P = .017) but not during the 6 weeks following (P = .092), as shown in Table 5, analysis 2.

Table 5
Comparison of ED use between groups

After controlling for symptom severity, satisfaction with in-home services was significantly higher (P < .05) among the IPSITH group than the non-IPSITH group patients (91.0% vs 72.8%), caregivers (98.6% vs 87.5%), family physicians (98.7% vs 96.8%), and nurses (96.6 vs 83.6%), and there was no difference in the total caregiver burden score between the IPSITH group and non-IPSITH group (mean score out of 4 was 2.09 vs 2.12, P = .817).

Patients in both groups strongly preferred home care (80.2%) to hospital care (5.6%), but for family caregivers the preference was not as strong (73.1% vs 9.7%).

DISCUSSION

Inconvenient and expensive ED visits occurred less frequently for patients in the IPSITH program. On the one hand, IPSITH was associated with at least 14 fewer patient visits to the ED during the treatment period and 12 fewer ED patient visits during the 6 weeks following the treatment period. On the other hand, IPSITH used alternative resources, such as the 150 housecalls by the family physicians and the salary of the nurse practitioner. Broadly speaking this is the resource utilization trade-off.

Patients, caregivers, family physicians, and nurses were all more satisfied in the IPSITH group than in the non-IPSITH group. The IPSITH patients and family physicians expressed strong satisfaction with the nurse practitioner, whose role in IPSITH was pivotal.28 Despite the high satisfaction, IPSITH did not appear to reduce the burden felt by family caregivers.

Limitations

First, there was a need to impute severity for many non-IPSITH patients because of missing data; nonetheless another analysis was conducted on all non-missing data with similar results. Second, the generalizability of the findings might be limited in that the IPSITH physicians were not randomly allocated and were likely early adopters. In addition, the 29 early adopters subdivide into a group of 5 committed family physicians who admitted half of the 82 patients. We speculate physician characteristics such as older age (related to an elderly patient population), positive attitudes to home care, and lack of time and distance barriers contributed to this commitment.

Conclusion

This evaluation suggests that the new program of enhanced community-based home care that integrates family physicians and a multidisciplinary team is feasible, acceptable to all participants, and associated with positive outcomes. Future work needs to confirm this suggestion in larger samples and with criterion-standard quasi-experimental design or randomized control trials. As well, studies could further elucidate the burden for family caregivers and identify the barriers that prevented widespread involvement from family physicians in community-based health care programs. Initiatives aimed at overcoming barriers, particularly incentives for family physicians and confidence-building experiences for family physicians relative to their own clinical care and in-home services could be piloted and evaluated. Further research, then, should be aimed at evaluating the process of taking community-based health care programs to a wider group of family physicians and patients.

Based on the success of the IPSITH project, a similar program of acute care at home has been adopted by the Southwestern Ontario CCAC as the Advanced Home Care Team. In this model, nurse practitioners coordinate and deliver care in consultation with family physicians and other health care professionals.

Acknowledgments

Funding was provided by the Canadian Health Services Research Foundation, the Ontario Ministry of Health and Long-Term Care, the Community Care Access Centre of London and Middlesex, the Middlesex-London Health Unit, and the Thames Valley District Health Council. Dr Stewart is funded by the Dr Brian W. Gilbert Canada Research Chair in Primary Health Care.

Notes

EDITOR’S KEY POINTS

  • This study sought to examine a community-based model of care for seriously ill adult patients that incorporated patients’ family physicians. Patients with acute or complex illness received enhanced home-based care from a multidisciplinary team including their own family physicians in a novel care program called Integrating Physician Services in the Home (IPSITH).
  • Patient, caregiver, physician, and nurse participants were very satisfied with the program, but there was no difference in caregiver burden between the IPSITH and non-IPSITH groups, and family physicians cited unscheduled telephone consultations, travel, home visits outside of office hours, and poor remuneration as barriers.
  • Although IPSITH was associated with at least 14 fewer patient visits to the emergency department during the treatment period and 12 fewer emergency department visits during the 6 weeks following the treatment period, IPSITH required alternative resources, such as 150 housecalls made by the family physicians and the salary of a nurse practitioner.

POINTS DE REPÈRE DU RÉDACTEUR

  • Cette étude voulait examiner un modèle de soins intra-communautaires pour des patients adultes gravement malades avec la participation du médecin de famille du patient. Le patient souffrant de maladie aiguë ou complexe recevait de meilleurs soins à domicile d’une équipe multidisciplinaire comprenant son propre médecin de famille dans le cadre d’un nouveau programme appelé Integrating Physicians Services in the Home (IPSITH).
  • Les patients, médecins, soignants et infirmières participants étaient très satisfaits du programme, mais il n’y avait pas de différence dans la tâche de travail des soignants entre les groupes IPSITH et non IPSITH, et les médecins de famille ont indiqué que les consultations téléphoniques non prévues, les déplacements, les visites à domicile en dehors des heures de bureau et la rémunération insuffisante faisaient problème.
  • Même si le programme IPSITH permettait une réduction d’au moins 14 visites de patients à l’urgence durant la période de traitement et de 12 visites à l’urgence au cours des 6 semaines suivantes, il exigeait des ressources additionnelles telles que 150 visites de médecin à domicile et le salaire d’une infirmière praticienne.

Footnotes

This article is eligible for Mainpro-M1 credits. To earn credits, go to www.cfp.ca and click on the Mainpro link.

This article has been peer reviewed.

Cet article a fait l’objet d’une révision par des pairs.

Contributors

All authors were members of the research (evaluation) committee and were involved in the planning, execution, and evaluation of the project. All authors contributed to and approved the final manuscript. Dr Stewart was the principal investigator, responsible for all aspects of the research portion of the project. Dr Sangster was the Medical Director of the Community Care Access Centre and wrote the original proposal. Dr Ryan was the Research Project Coordinator for the project and conducted the analysis and participated in drafting the manuscript. Dr Hoch contributed to the analysis, in particular to the imputation of severity, and helped with the initial draft of the manuscript. Dr Cohen was the Medical Director for Integrating Physician Services in the Home (IPSITH), advised on the relevance of analyses, and created user-friendly presentations of results. Dr McWilliam was the lead researcher for the qualitative evaluation and advised on all aspects of the evaluation. Ms Mitchell was the nurse practitioner for the IPSITH project, advised on the relevance of analyses, and created user-friendly presentations of results. Dr Vingilis was responsible for the program evaluation framework and contributed to the analysis plan. Ms Tyrrell was the initial Program Coordinator for the project and was responsible for establishing the procedures for data collection. Dr McWhinney was responsible for the initial concept of the IPSITH program.

Competing interests

None declared

References

1. Leff B, Burton JR. The future history of home care and physician house calls in the United States. J Gerontol A Biol Sci Med Sci. 2001;56(10):M603–8. [PubMed]
2. SUPPORT Principal Investigators A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT) JAMA. 1995;274(20):1591–8. Erratum in: JAMA 1996;275(16):1232. [PubMed]
3. Coley CM, Li YH, Medsger AR, Marrie TJ, Fine MJ, Kapoor WN, et al. Preferences for home vs hospital care among low-risk patients with community-acquired pneumonia. Arch Intern Med. 1996;156(14):1565–71. [PubMed]
4. Oandasan I, Malik R, Waters I, Lambert-Lanning A. Being community-responsive physicians. Doing the right thing. Can Fam Physician. 2004;50:1004–10. [PMC free article] [PubMed]
5. Oandasan IF, Luong L, Wojtak A. Family physicians and home care agencies—valuing each other’s roles in primary care. Healthc Q. 2004;7(4):49–52. [PubMed]
6. Coast J, Richards SH, Peters TJ, Gunnell DJ, Darlow MA, Pounsford J. Hospital at home or acute hospital care? A cost minimisation analysis. BMJ. 1998;316(7147):1802–6. [PMC free article] [PubMed]
7. Leff B, Burton JR. Future directions: alternative approaches to traditional hospital care—home hospital. Clin Geriatr Med. 1998;14(4):851–61. [PubMed]
8. Hensher M, Fulop N, Coast J, Jefferys E. The hospital of the future. Better out than in? Alternatives to acute hospital care. BMJ. 1999;319(7217):1127–30. [PMC free article] [PubMed]
9. Soderstrom L, Tousignant P, Kaufman T. The health and cost effects of substituting home care for inpatient acute care: a review of the evidence. CMAJ. 1999;160(8):1151–5. [PMC free article] [PubMed]
10. Board N, Brennan N, Caplan GA. A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients. Aust N Z J Public Health. 2000;24(3):305–11. [PubMed]
11. Viney R, Haas M, Shanahan M, Cameron I. Assessing the value of hospital-in-the-home: lessons from Australia. J Health Serv Res Policy. 2001;6(3):133–8. [PubMed]
12. Berendsen AJ, Schuling J, Meyboom–de Jong B. Hospital care at home; a review of the literature on the effects of a form of transmural care [article in Dutch] Ned Tijdschr Geneeskd. 2002;146(48):2302–8. [PubMed]
13. Ram FS, Wedzicha JA, Wright J, Greenstone M. Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: systematic review of evidence. BMJ. 2004;329(7461):315. Epub 2004 Jul 8. Erratum in: BMJ 2004;329(7469):773. [PMC free article] [PubMed]
14. Armstrong CD, Hogg WE, Lemelin J, Dahrouge S, Martin C, Viner GS, et al. Home-based intermediate care program vs hospitalization. Cost comparison study. Can Fam Physician. 2008;54:66–73. [PMC free article] [PubMed]
15. Shepperd S, Doll H, Angus RM, Clarke MJ, Illife S, Kalra L, et al. Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data. CMAJ. 2009;180(2):175–82. [PMC free article] [PubMed]
16. Shapiro E. Case management in long term care: exploring its status, trends, and issues. J Case Manag. 1995;4(2):43–7. [PubMed]
17. Bergman H, Béland F. Evaluating innovation in the care of Canada’s frail elderly population. CMAJ. 2000;162(4):511–2. [PMC free article] [PubMed]
18. Dalby DM, Sellors JW, Fraser FD, Fraser C, van Ineveld C, Howard M. Effect of preventive home visits by a nurse on the outcomes of frail elderly people in the community: a randomized controlled trial. CMAJ. 2000;162(4):497–500. [PMC free article] [PubMed]
19. Aiken LS, Butner J, Lockhart CA, Volk-Craft BE, Hamilton G, Williams FG. Outcome evaluation of a randomized trial of the PhoenixCare intervention: program of case management and coordinated care for the seriously chronically ill. J Palliat Med. 2006;9(1):111–26. [PubMed]
20. Bernstein IN, Sheldon EB. Evaluative research. In: Smith RB, editor. Handbook of social science methods. Cambridge, MA: Ballinger Publications; 1983. pp. 93–132.
21. Greene JC, Caracelli VJ, Graham WF. Toward a conceptual framework for mixed-method evaluation designs. Educ Eval Policy Anal. 1989;11(3):255–74.
22. Petrosino A. Answering the why question in evaluation: the causal-model approach. Can J Program Eval. 2000;15(1):1–24.
23. Posovac EJ, Carey RG. Program evaluation: methods and case studies. 5th ed. Upper Saddle, NJ: Prentice-Hall; 1997.
24. Rossi PH, Freeman HE, Lipsey MW. Evaluation: a systematic approach. 6th ed. Newbury Park, CA: Sage; 1999.
25. Sidani S, Braden CJ. Evaluating nursing interventions: a theory-driven approach. Thousand Oaks, CA: Sage Publications; 1998.
26. Vingilis E, Pederson L. Using the right tools to answer the right questions: the importance of evaluative research techniques for health services evaluation in the 21st century. Can J Program Eval. 2001;16(2):1–26.
27. McWilliam CL, Stewart M, Sangster J, Cohen I, Mitchell J, Sutherland C, et al. Work in progress. Integrating physicians’ services in the home. Can Fam Physician. 2001;47:2502–9. [PMC free article] [PubMed]
28. McWilliam CL, Godfrey B, Stewart M, Sangster J, Mitchell J, Cohen I. Evolving the delivery of acute care services in the home. Home Health Care Serv Q. 2003;22(1):55–74. [PubMed]
29. Parkerson GR, Jr, Bridges-Webb C, Gervas J, Hofmans-Okkes I, Lamberts H, Froom J, et al. Classification of severity of health problems in family/general practice: an international field trial. Fam Pract. 1996;13(3):303–9. [PubMed]
30. Richards SH, Coast J, Gunnell DJ, Peters TJ, Pounsford J, Darlow MA. Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care. BMJ. 1998;316(7147):1796–801. Erratum in: BMJ 1998;317(7161):786. [PMC free article] [PubMed]
31. Browne GB, Arpin K, Corey P, Fitch M, Gafni A. Individual correlates of health service utilization and the cost of poor adjustment to chronic illness. Med Care. 1990;28(1):43–58. [PubMed]
32. Browne G, Gafni A, Roberts J, Goldsmith A, Jamieson E. Approach to the measurement of costs (expenditures) when evaluating health and social programmes. Hamilton, ON: McMaster University, Ontario Ministry of Health System-Linked Research Unit on Health and Social Service Utilization; 1995. Working Paper Series #95–11.
33. Zarit S, Zarit J. The Memory and Behavior Problems Checklist and the Burden Interview. University Park, PA: The Pennsylvania State University Gerontology Reprints/Preprints; 1990.

Articles from Canadian Family Physician are provided here courtesy of College of Family Physicians of Canada