No abstract

No abstract

We describe an approach to health care in the inner city: a multidisciplinary system of physicians and mid-level practitioners that provides individualized care to chronically ill, elderly, homebound, and nursing-home residents of urban Boston who would otherwise be forced into an inappropriate reliance on teaching hospitals. Linked to four neighborhood health centers, three home-care programs, and a teaching hospital, and financially self-supporting except for the home-care component, the system cared for 3000 ambulatory, 280 homebound, and 358 nursing-home patients in the representative year described. In-hospital use, particularly hospital days, was reduced when judged by existing data for comparable (though not identical) populations. Based on stable physician practices, the system offers a workable approach to the related problems of care, manpower, and cost in the urban core.

Fifty-seven elderly homebound patients with arthritis and orthopedic disabilities were randomized to a goal-oriented outreach rehabilitation program or to usual treatment. Although 64% of patient goals were met, there were no overall significant differences in functional scores, institutionalization, or contentment between treatment and control periods. Twenty-three patients had maintained clinical improvement at the end of the study and some patients were dramatically improved with simple measures. The program's marginal costs were modest and consisted primarily of expenses associated with therapist's visits. The total costs of assistive devices and home modifications amounted to $1,902. Twenty-five percent of the homebound population could benefit from such services but the actual number who would partake is small.A million people in the United States are homebound and studies of these individuals indicate that musculoskeletal disorders and arthritis are the most common causes of being homebound (1,2). A previous study from our center suggested that many individuals with musculoskeletal disorders affecting function could have benefited from simple rehabilitation measures to improve or maintain function (3). Among the homebound, 80% receive help from their immediate families and friends and 15% receive care from a nurse, home health aide, or paid homemaker (4). Physical and occupational therapy services in our community are limited by rules of third-party reimbursement. Rehabilitation services focus on acute conditions whereas chronic or slowly deteriorating disorders receive less attention.In 1980 we organized a study with two objectives:1. To evaluate, in a randomized controlled trial, the effects of stepped-up rehabilitation versus usual rehabilitation for improving and maintaining function of homebound patients with arthritis and musculoskeletal disorders; 2. To document the rehabilitation needs of homebound arthritis patients as they might be met by the current state of the art. DESCRIPTION OF SAMPLERecruitment. Patients receiving home care from four licensed home care programs serving Dorchester, Roxburyl Brookline, Jamaica Plain, and East Boston were screened for eligibility with the assistance of their nurses. Eligibility criteria included the presence of arthritis and musculoskeletal dysfunction: a potential for improvement by rehabilitation techniques as judged by a physician and a physical therapist; enrollment in the home care program for at least 3 months; and a lack of physical therapy. Distribution of patients is shown in mental illness, or the nurse's judgment of family situation that precluded participation in a study. Of the 337 subjects screened for entry, 244 did not meet the entry criteria (Table 2). Ninety-three subjects (27.6%) met the entry criteria and were invited to participate in the study; 57 (61.3%) agreed to do so. Acceptance rates were higher among females and differed across health centers but not by age group.Characteristics of the participants. Forty-six (81%) of the 57 subjec...