Journal Article

The return home model: design and implementation of a geriatric home-care model for long-term care eligible older adults

Fischer-Reif, Irit, Katz, Glynis, Rose, Adam J., Mayan, Inbal, Yaffe, Kristine, Allen, Isabel E., Yakov, Gila, Sabar, Ron

2025

Overview

Background Most older adults prefer to “age in place” within their communities. This preference cannot always be honored and dependent older adults may transfer to a long-term care facility. The Return Home is an Israel Ministry of Health initiated care model designed to prevent or delay a transfer of the dependent older adult to a long-term facility. The intervention team included a physician, nurse, social worker, occupational therapist, physical therapist, and a dietician, all participating in in-home visits. This study’s aim was to examine the Return Home model’s feasibility to prevent long-term care placement in a complex, dependent geriatric population. Methods We analyzed data from the electronic medical record (EMR) of the provider. Participants were recruited by the Israeli Ministry of Health from July 2021 to November 2022 at the time of hospital discharge. Caregiver input was obtained from interviews at the beginning and end of the one-year intervention. Results 138 patients were enrolled in the intervention. 86 (62%) completed the intervention in their homes, 39 (28%) died during the intervention, 5 (4%) were transferred to a long-term facility, 8 (6%) were dis-enrolled. Prescription medication usage declined by 0.79 medications per person on average. Forty patients had pressure ulcers at the time of admission; all of these ulcers healed during the program, after an average time of 1.5 months. Caregiver burden measured by the Zarit score, declined from 20.9 to 9.7, t (156) = 11.88, p  < 0.001. Conclusions The Return Home intervention demonstrated the feasibility of preventing or delaying long-term care placement for a complex, dependent geriatric population. Further evaluation is needed to determine effectiveness and inform broader implementation.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Activities of daily living / Adults / Aged / Aged, 80 and over / Aging / Aging in place / Analysis / Bedsores / Caregiver burden / Caregivers / Chronic illnesses / Consent / Delirium / Dependent older adults / Dietitians / Drugs / Electronic health records / Electronic medical records / Electronic records / Enrollments / Feasibility / Female / Geriatrics / Geriatrics - methods / Health Administration / health and health care / Health aspects / Health care policy / Health maintenance organizations / Health Policy / Health Promotion and Disease Prevention / Health services / Health Services Research / HMOs / Home care / Home care services / Home Care Services - organization & administration / Home Care Services - standards / Home Care Services - statistics & numerical data / Home Care Services - trends / Home care services industry / Home environment / Home-care geriatric model / Humans / Interdisciplinary aspects / Intervention / Israel / Long term / Long term care placement / Long term health care / Long-term care / Long-Term Care - methods / Long-Term Care - statistics & numerical data / Long-term care facilities / Long-term care of the sick / Male / Medical care / Medical records / Medicine / Medicine & Public Health / Methods / Needs assessment / Nurses / Occupational therapy / Older people / Patients / Pilot projects / Placement / Preferences / Prescribing / Pressure / Public Health / Social workers / Teams / Ulcers