Community rehabilitation for older people: day hospital or home-based services?

The geriatric day hospital (GDH) has been a cornerstone of geriatric medicine internationally for over four decades. It remains a unique service. Only the GDH has been able to offer an outpatient service comprising multidisciplinary, comprehensive geriatric assessment and rehabilitation. It has therefore fulfiled an obvious need for frail older people living at home. Long before the modern concept of intermediate care became a health care policy, the GDH was discussed in terms of preventing admissions, aftercare and ‘saving hospital beds’ [1]. Early randomised controlled trials demonstrated that rehabilitation provided in GDHs was associated with improved outcomes compared with usual care (essentially observational control groups) [2]. However, concerns about the costs of GDH care, particularly the inherent non-pay costs of facility overheads and ambulance travel [3], have undermined confidence in the service. Recent national reports from Belgium and New Zealand have questioned the role of the GDH in the overall provision of health care for older people [4, 5]. Home-based rehabilitation (HR) has emerged as a viable and attractive alternative to the GDH. It is argued that HR has the potential to be more patient-centred. First, because there is no ambulance travel for the patient and therefore no anxiety associated with preparing the person to leave the home. Second, HR is more likely to address the liferestricting issues for the individual patient with a focus on the rehabilitation domain of participation rather than the less patient-centred domain of activity limitation. Lastly, there are greater opportunities to involve the family carer(s) and other community staff in the rehabilitation process. On the other hand HR may lack sufficient treatment intensity, may not be sufficiently multidisciplinary, may put too many demands on carers, or may be impractical due to a cramped environment.