Long-Term Care for Older Adults: A Review of Home and Community-Based Services Versus Institutional Care [Internet]

Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Nov. Report No.: 12(13)-EHC134-EF.


Objectives: To compare long-term care (LTC) for older adults delivered through Home and Community-Based Services (HCBS) with care provided in nursing homes (NHs) by evaluating (1) the characteristics of older adults served through HCBS and in NHs; (2) the impact of HCBS and NH care on outcome trajectories of older adults; and (3) the per person costs of HCBS and NH care, costs for other services such as acute care, and family burden.

Data Sources: Bibliographic databases MEDLINE® and AGELINE®; grey literature in the form of program evaluation reports and reports and analyses from Web sites of relevant State and Federal agencies and research organizations; citation searches of articles; and hand searches.

Review Methods: We included randomized controlled trials (RCTs) and observational studies that directly compared LTC for older adults (age ≥60) served through HCBS and in NHs. Studies were limited by date (1995–March 2012), language (English), and geographical location (United States and other economically developed countries with well-established health and LTC systems). Because assisted living (AL) encompasses elements of institutions, we treated it as a separate category within HCBS. We compared the characteristics of LTC recipients and the impact of the setting on outcome trajectories for physical function, cognition, mental health, mortality, use of acute care services, harms, and costs. We qualitatively synthesized results. We assessed the risk of bias and applicability of individual studies and graded the overall strength of evidence for each examined outcome.

Results: We identified 42 relevant studies (37 peer reviewed, 5 grey literature). We identified no RCTs. Of the 37 peer-reviewed articles, 22 evaluated recipient characteristics at a specific time, and 15 analyzed outcome trajectories over time (of which 14 were used in the longitudinal analytic set). On average, NH residents had more limitations in physical and cognitive function than both HCBS recipients and AL residents, but mental health and clinical status were mixed. The 14 studies that compared the outcome trajectories of HCBS recipients or AL residents with NH residents over time had a high risk of bias, resulting in low or insufficient evidence for all outcomes examined. In comparing AL with NH, low-strength evidence suggested no differences in outcomes for physical function, cognition, mental health, and mortality. In comparing HCBS with NHs, low-strength evidence suggested that HCBS recipients experienced higher rates of some harms while NH residents experienced higher rates of other harms. Evidence was insufficient for other outcome domains and comparisons. Evidence was also insufficient for cost comparisons.

Conclusions: Determining whether and how the delivery of LTC through HCBS versus NHs affects outcome trajectories of older adults is difficult due to scant evidence and the methodological limitations of studies reviewed. More and better research is needed to draw robust conclusions about how the setting of care delivery influences the outcomes and costs of LTC for older adults.

Publication types

  • Review

Grants and funding

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Contract No.290-2007-10064-I. Prepared by: Minnesota Evidence-based Practice Center, Minneapolis, MN