The Expanding Role of Healthcare Epidemiology—Home and Long-Term Care

During the last decade, there have been major shifts in the delivery of health care in the United States. Mergers of hospitals, movement to outpatient and ambulatory-care services, managed care, and reform of the US healthcare system have resulted in a dramatic relocation of patient care from hospitals to outpatient and out-of-hospital settings, including the home. This change, which has been motivated largely by the continuing increase in hospital healthcare costs and the search for cost-effective alternatives to hospital-based treatments, has led to a heightened interest in providing care in the home setting. Reflecting this interest, the Health Care Finance Administration has predicted that expenditures for the provision of home health care will increase from approximately $2 billion in 1988 to nearly $25 billion in 1999.1 Advantages of home health care include decreased duration of hospitalization, cost savings, decreased psychosocial impact through avoidance of hospitalization, and the provision of care in a familiar surrounding with supportive family members.2,3 For many patients, home health care meets their medical needs without compromising the efficacy and safety present in the hospital setting. The type of service delivered by different home healthcare agencies ranges from assigning nursing personnel to each patient to providing all the care received at home to agencies that merely deliver the needed supplies while the patient or family members provide the home care. Undoubtedly, market forces will continue to propel the healthcare industry to increase quality while decreasing costs. The 1995 Joint Commission on Accreditation of Healthcare Organization's Accreditation Manual for Home Care ta es that performance expectations for home health care will begin to rise progressively in 1996 and in the years to follow.4 In many areas of the home care industry, technology is being introduced in new settings without the benefit of either an infection control infrastructure or, in some instances, appropriate infection control recommendations. Therefore, hospital epidemiologists and others in infection control need to provide input into efforts to monitor the adequacy f such care, measure outcomes, and compare the quality of the care provided by different homehea thcare agencies. The question remains, what are the benefits and risks associated with our costcontainment efforts? Concomitant with the expansion in nonhospitalbased healthcare delivery systems has been concern over the occupational risk to healthcare workers of i fectious diseases. Healthcare-worker concerns about the risk of occupational acquisition of bloodborne pathogens has resulted in expanded infection control recommendations, the Occupational Safety and Health Administration's Bloodborne Pathogen Standard, and the emergence of many technological advances to reduce the risk of healthcare-worker