Weissert W G
Health Serv Res. 1985 Oct;20(4):423-33.
A decade of research on home- and community-based long-term care shows that few of the assumptions behind expectations of tis potential cost-effectiveness were warranted. Few who use home- and community-based long-term care would otherwise have been long-stayers in nursing homes. Long-stayers tend to be older, sicker, more dependent, and poorer in social resources than those who use community care. Fewer still who use community care actually have their institutional stay averted or shortened by its use, even if they are at risk. But more effective targeting on those most likely to be institutionalized may lead to high screening costs and small, inefficient programs, because few patients in the community fit the profile for high risk of institutionalization. Conversely, the very sickest and most dependent patients may be cheaper to serve in a nursing home than in the community. Patient outcome benefits have also been limited: except for the higher contentment levels found in some studies, community care appears to produce no special outcome benefits in longevity, physical or mental functioning, or social activity levels. Nonetheless, community care serves a sick, dependent, and--most people would agree--deserving population of patients and their caretakers. A refocusing of public policy to target specifically on the functionally dependent rather than the aged per se may be the best hope for public support for community care.
十年以来，对居家和社区长期护理的研究表明，对其潜在成本效益预期背后的假设几乎没有一个是合理的。很少有使用居家和社区长期护理的人原本会长期住在养老院。长期住在养老院的人往往比使用社区护理的人年龄更大、病情更重、依赖性更强且社会资源更少。即使使用社区护理的人处于风险之中，实际上也很少有人能因此避免或缩短在机构中的停留时间。但是，更有效地针对那些最有可能被送进机构的人可能会导致高昂的筛查成本和规模小且效率低下的项目，因为社区中很少有患者符合高机构化风险的特征。相反，对于病情最重、依赖性最强的患者，在养老院提供服务可能比在社区更便宜。患者的结果效益也很有限：除了一些研究中发现的较高满意度外，社区护理在寿命、身体或心理功能或社会活动水平方面似乎没有产生特殊的结果效益。尽管如此，社区护理服务的是一群患病、依赖他人且——大多数人会认同——值得帮助的患者及其护理人员。重新调整公共政策，使其专门针对功能上有依赖的人群而非老年人本身，可能是社区护理获得公众支持的最大希望。
