Community-based Care Model Research Articles

Community paramedicine to support palliative care

Objective This commentary describes community paramedicine (CP) and the potentiality of an expanded scope of practice to provide home-based palliative care. Background The prevalence of individuals desiring palliative care within their home is growing, requiring the provision of high-quality care. CP is a novel approach to delivering care, allowing paramedics to provide community-based, non-urgent care as well as crisis and symptom management within the home. The need for home-based palliative care at earlier stages of the disease trajectory will be essential for the growing older adult population. Community-based models of care are essential in alleviating health systems burden by reducing emergency department visits and over-reliance on primary care. Methods A rapid review was conducted to determine current scope of practice and geographical coverage of CP programming, as well as a broader literature search describing current roles. Discussion An expanded scope of CP practice that provides palliative care has immense potential in alleviating health system burden while simultaneously improving patient health outcomes. Pilot CP palliative care programs in Alberta, Nova Scotia and Prince Edward Island have demonstrated the benefits of community paramedics providing palliative care through reduced emergency department visits and improved patient satisfaction. Community paramedics are well equipped to provide high-quality palliative care earlier within the patient’s disease trajectory and support the patient and caregiver through remote patient monitoring.

Economic evaluation of a novel community-based diabetes care model in rural Mexico: a cost and cost-effectiveness study

ObjectivesDiabetes is the leading cause of disability-adjusted life years in Mexico, and cost-effective care models are needed to address the epidemic. We sought to evaluate the cost and cost-effectiveness of...

A Community-Based Model to the COVID-19 Humanitarian Crisis.

A multidisciplinary group, mainly from Bergamo region - the epicenter of the COVID-19 pandemic crisis in Italy on march 2020– has developed concept of creating intermediate care facilities and proposes a three-tier model of community-based care, with the goal of reducing hospital admissions, contagion and mortality related to hospital overloading and optimizing human resources.

An interprofessional, community-based integrated care model for individuals with fibromyalgia: A pilot randomized controlled trial in a small urban centre

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

Economic Analysis of Mobile Integrated Health Care Delivered by Emergency Medical Services Paramedic Teams

Mobile integrated health care (MIH) is a new model of community-based health care to provide on-site urgent or nonurgent care. Niagara emergency medical services (NEMS) started MIH in 2018 to serve the Niagara region of Ontario, Canada. However, its economic impact is unknown. To compare time on task and cost between MIH and ambulance delivered by NEMS from a public payer's perspective. This economic evaluation was an analysis of the NEMS databases regarding responses to emergency calls by the NEMS from 2016 to 2019. Emergency calls serviced by MIH in 2018 to 2019 were used as an intervention cohort. Propensity score matching was used to identify a 1:1 matched cohort of calls serviced by regular ambulance response for the same period and 2 years prior. Statistical analyses were performed from January to April 2020. MIH compared with matched ambulance services. The main outcomes were the time on task (including time on scene and time at hospital) and costs. Costs were calculated in 2019 Canadian dollars using cost per minute and compared with the 3 ambulance cohorts. In 2018 to 2019, there were 1740 calls serviced by MIH for which a matched ambulance cohort was identified for the same period and 2 years prior. The mean (SD) time on task was 72.7 (51.0) minutes for MIH, compared with 84.1 (52.0) minutes, 84.3 (54.1) minutes, and 79.4 (42.0) minutes for matched ambulance in 2018 to 2019, 2017 to 2018, and 2016 to 2017, respectively. Of calls serviced by MIH, 498 (28.6%) required ED transport (ie, after MIH team assessment, transport to ED was deemed to be necessary or demanded by the patient), compared with 1300 (74.7%) calls serviced by ambulance in 2018 to 2019, 1294 (74.4%) in 2017 to 2018, and 1359 (78.1%) in 2016 to 2017. The mean (SD) total cost per 1000 calls was $122 760 ($78 635) for MIH compared with $294 336 ($97 245), $299 797 ($104 456), and $297 269 ($81 144) for regular ambulance responses in the 3 matched cohorts, respectively. Compared with regular ambulance response, MIH was associated with a substantial reduction in the proportion of patients transported to the ED, leading to a substantial saving in total costs. This finding suggests that the MIH model is a promising and viable solution to meeting urgent health care needs in the community, while substantially improving the use of scarce health care resources.

Evaluating the Impact of a Pilates Intervention on Physical Function in Children with Hypermobility Spectrum Disorder: A Study Protocol Using Single-Case Experimental Design

Background: Pilates has been shown to be an effective intervention for adults with musculoskeletal conditions with only a few examples available in the literature for children. As musculoskeletal pain is a major symptom experienced by children with Hypermobility Spectrum Disorder (HSD), they may benefit from practicing Pilates to improve postural alignment, strength and motor control to effectively distribute movement load and decrease adverse load through involved joints. Method: This study aims to evaluate the impact of a Physiotherapy-led Pilates intervention on school aged children with HSD and the benefits of this approach on pain, physical function and quality of life when delivered in a community-based model of care. A single-case experimental design (SCED) that incorporates a multiple baseline design will be used. Children with HSD, aged from 8 to 12 years, will commence concurrently in this study. Participants will undergo multiple assessments through all phases of the study which incorporates an A-B-A withdrawal design. The initial baseline period will be randomised from 5 to 7 weeks duration, then participants will enter the intervention period for 8 weeks followed by a withdrawal period of 5 weeks. The Physiotherapy-led Pilates intervention will consist of individual, 45 minute bi-weekly sessions, performed on both mat and the Pilates Reformer with an additional home program of mat exercises performed weekly. The study hypotheses are that children will show: 1) a decrease in pain; 2) an increase in their physical function as measured by muscle strength, postural control, fatigue and physical activity levels; and 3) an improvement in their Health Related Quality of Life in the domains of physical, emotional, social and school functioning. Conclusion: The findings will add specific responsiveness information to the scientific evidence for Physiotherapy-led Pilates for children with HSD.

Efficacy of home treatment of patients with mental disorders - a research review.

The aim of this study is to review research on the efficacy of home treatment for mental disorders compared to other forms of community-based treatment. The first section describes studies comparing treatment as usual with CMHT (Community Mental Health Team), the second section compares CMHT with more intensive forms of community-based care, such as CM (Case Management) and ACT (Assertive Community Treatment, and the third section focuses on interventions that are alternatives to hospitalization, described as CRT or MCHT (Crisis Resolution Team or Mobile Crisis Home Treatment). The community-based model of psychiatric health care is nowadays recognized as the best systemic solution to improve its organization and functioning. In comprehensive care in the community, home treatment plays an important role. Treatment teams most often take the form of a general Community Mental Health Team - CMHT, which, like community mental health services in Poland, provides a wide range of interventions. There are several forms of treatment within CMHTs: ACT, CM, CRT and MHCT. Home treatment is more effective compared to standard inpatient and post-hospital care. Care under a Community Mental Health Team reduces the number and duration of hospitalizations and is characterized by higher treatment satisfaction. For patients with psychotic disorders, more intensive forms of community-based care - such as ACT, CM, and CRT - are particularly valuable and effective.

Exploring Models of Nursing and Midwifery in the Community: International and National Perspectives

Across the world, primary care is increasingly being embraced as central to healthcare services. Effective delivery requires an efficient and cost-effective community-based model of care. However, no single overarching model of nursing and midwifery practice in the community exists in the literature. A collaboration of experts, headed by Professor Patricia Leahy-Warren from the Catherine McAuley School of Nursing and Midwifery at University College Cork in Ireland, is addressing this complex but critical gap to guide the development of nursing and midwifery in the community in Ireland.

Improving Treatment of Substance Use Disorders through Community Drug Treatment Clinics: An Experiential Account.

India has a huge burden of substance use disorder (SUD). The national response to the problem of SUD has been to support addiction treatment centers either in government hospitals or in nongovernmental settings. The existing number of addiction treatment facilities is less compared to the burden of substance use in India. The existing models of treatment in India place undue emphasis on inpatient treatment of SUD. Community-based treatment aims to bring the treatment of SUD closer to the patients in their community. Community-based treatment of SUD utilizes existing services available in the community by establishing an integrated network of community-based services. There have been different models of community-based care for the management of SUD in India. Most of them, however, address short-term withdrawals and do not provide long-term treatment in community. National Drug Dependence Treatment Centre, AIIMS, New Delhi, has been providing community-based treatment for SUD since the 1990s. Two of the three community drug treatment clinics (CDTCs) are in operation for more than 5 years now and cater to the population residing within a defined catchment area. The CDTCs use infrastructure available in the community to operate the clinics. The clinics are run daily by a team of nursing staff, while the doctor is available only twice a week. A menu of options, ranging from short-term treatment to long-term agonist maintenance treatment is provided in the clinic. Both pharmacotherapy and psychosocial interventions are provided. Each clinic caters to hundreds of patients through these facilities. There is a need to expand CDTCs in India considering their cost-effectiveness, acceptability, and overall effectiveness, especially in urban colonies with higher substance-related problems.

Evaluation Findings of a Community-Based Intervention for Older Adults With a History of Trauma

Between 70% and 90% of Americans aged 65 and older have experienced at least one traumatic event such as a sexual or physical assault, disaster, illness, or terrorism. Trauma exposure in older adult populations is linked to physical, mental, and cognitive decline. A new approach to improve outcomes of trauma-affected older adults is Person-Centered, Trauma-Informed (PCTI) Care, which promotes the dignity, strength, and empowerment of trauma-affected individuals by incorporating knowledge about trauma into agency programs, policies, and procedures. The Administration for Community Living/Administration on Aging has awarded The Jewish Federations of North America (JFNA) a grant to develop innovative PCTI interventions for Holocaust survivors. This includes a community-based intervention whereby local leadership councils are developed to identify Holocaust survivor needs, distribute grant funding, train caregivers in PCTI care, and forge partnerships to advance community-led Holocaust survivor care. This program has been implemented in eight major US cities where 168 community leaders dispersed 25 grants serving approximately 500 Holocaust survivors. JFNA conducted an evaluation of the first six of the eight cities to determine the impact of this community-based model on participants and Holocaust survivors and investigate the process by which a community-based model can be replicated. This evaluation used surveys and semi-structured interviews to collect data on variables including understanding of PCTI care, awareness of Holocaust survivor needs, strength of community partnerships, and leadership council sustainability. This session will review evaluation findings including best practices for community-based models of PCTI care, and applicability of findings to other older populations.

Community-based integrated care versus hospital outpatient care for managing patients with complex type 2 diabetes: costing analysis.

Objective This study compared the cost of an integrated primary-secondary care general practitioner (GP)-based Beacon model with usual care at hospital outpatient departments (OPDs) for patients with complex type 2 diabetes. Methods A costing analysis was completed alongside a non-inferiority randomised control trial. Costs were calculated using information from accounting data and interviews with clinic managers. Two OPDs and three GP-based Beacon practices participated. In the Beacon practices, GPs with a special interest in advanced diabetes care worked with an endocrinologist and diabetes nurse educator to care for referred patients. The main outcome was incremental cost saving per patient course of treatment from a health system perspective. Uncertainty was characterised with probabilistic sensitivity analysis using Monte Carlo simulation. Results The Beacon model is cost saving: the incremental cost saving per patient was A$365 (95% confidence interval -A$901, A$55) and was cost saving in 93.7% of simulations. The key contributors to the variance in the cost saving per patient course of treatment were the mean number of patients seen per site and the number of additional presentations per course of treatment associated with the Beacon model. Conclusions Beacon clinics were less costly per patient course of treatment than usual care in hospital OPDs for equivalent clinical outcomes. Local contractual arrangements and potential variation in the operational cost structure are of significant consideration in determining the cost-efficiency of Beacon models. What is known about this topic? Despite the growing importance of achieving care quality within constrained budgets, there are few costing studies comparing clinically-equivalent hospital and community-based care models. What does this paper add? Costing analyses comparing hospital-based to GP-based health services require considerable effort and are complex. We show that GP-based Beacon clinics for patients with complex chronic disease can be less costly per patient course of treatment than usual care offered in hospital OPDs. What are the implications for practitioners? In addition to improving access and convenience for patients, transferring care from hospital to the community can reduce health system costs.

Using Linked Health Service Data in The Evaluation of Innovative Models of Healthcare

IntroductionAgeing populations place considerable burden on healthcare systems. Innovative methods to implement and evaluate new care models to reduce unwarranted hospital presentations, are needed.
 Objectives and ApproachTo use linked Electronic Medical Record (EMR) data to evaluate a pilot community-based model of care to reduce hospital presentations in a cohort of patients at-risk of hospital representations following an acute admission. Patients admitted to a metropolitan hospital with a non-surgical condition andidentified as being at-risk of readmission using a state-wide risk algorithm, were eligible to receive a 30-day care navigation model of care. The intervention group were matched to similar eligible patients, who received usual care using propensity score matching. Linked data were obtained from the EMR based Data Warehouse to provide information on subsequent readmissions and community-based health service contacts. Readmission rates were compared at 30, 60, and 90-days post-discharge using Cox Proportional Hazards Regression, adjusted for confounders and weighted by the propensity score. Descriptive analyses were used to compare demographics and healthcare utilisations.
 ResultsData from 412,971 potentially eligible patients were extracted. Sixty-five received the intervention of which 63 were matched to 280 controls (aged 51-91 years, 54% female, 63% lived alone). At 30-days post-discharge (during intervention delivery) an 80% reduction in readmission rate in the intervention group was observed (Hazard Ratio [HR] 0.20; 95%Confidence Interval (CI) [0.01, 4.20]). At 60-days (HR 0.48; 95%CI [0.03, 8.05]) and 90-days (HR 0.83; 95%CI [0.06, 11.36]), readmission rate reductions decreased to 52% and 17% respectively. In the intervention group, 68.9% received an out-patient appointment compared to 40% of controls (P<0.001) and 7.7% received allied health compared to none of the controls (p=0.003) within 90-days post-discharge.
 Conclusion/ImplicationsResults have informed hospital-wide service implementation thereby demonstrating the value of linked EMR data and advanced statistical methods in the evaluation of real-world healthcare.

Exploring the dimensions of patient experience for community-based care programmes in a multi-ethnic Asian context.

IntroductionThe aim of this study is to explore patients’ experiences with community-based care programmes (CCPs) and develop dimensions of patient experience salient to community-based care in Singapore. Most countries like Singapore are transforming its healthcare system from a hospital-centric model to a person-centered community-based care model to better manage the increasing chronic disease burden resulting from an ageing population. It is thus critical to understand the impact of hospital to community transitions from the patients’ perspective. The exploration of patient experience will guide the development of an instrument for the evaluation of CCPs for quality improvement purposes.MethodsA qualitative exploratory study was conducted where face-to-face in-depth interviews were conducted using a purposive sampling method with patients enrolled in CCPs. In total, 64 participants aged between 41 to 94 years were recruited. A deductive framework was developed using the Picker Patient Experience instrument to guide our analysis. Inductive coding was also conducted which resulted in emergence of new themes.ResultsOur findings highlighted eight key themes of patient experience: i) ensuring care continuity, ii) involvement of family, iii) access to emotional support, vi) ensuring physical comfort, v) coordination of services between providers, vi) providing patient education, vii) importance of respect for patients, and viii) healthcare financing.ConclusionOur results demonstrated that patient experience is multi-faceted, and dimensions of patient experience vary according to healthcare settings. As most patient experience frameworks were developed based on a single care setting in western populations, our findings can inform the development of a culturally relevant instrument to measure patient experience of community-based care for a multi-ethnic Asian context.

Alcohol consumption increases non-adherence to ART among people living with HIV enrolled to the community-based care model in rural northern Uganda.

Non-adherence to anti-retroviral therapy (ART) is associated with considerable morbidity and mortality among people living with Human Immunodeficiency Virus (PLHIV). Community-based ART delivery model offers a decentralized and patient-centered approach to care for PLHIV, with the advantage of improved adherence to ART hence good treatment outcomes. However, data are limited on the magnitude of non-adherence to ART among PLHIV enrolled to the community-based ART model of care. In this study, we determined the frequency of non-adherence to ART and the associated factors among PLHIV enrolled to the community-based ART delivery model in a large health facility in rural northern Uganda. This analytic cross-sectional study randomly sampled participants from 21 community drug distribution points at the AIDS Support Organization (TASO) in Gulu district, northern Uganda. Data were collected using a standardized and pre-tested questionnaire, entered in Epi-Data and analyzed in Stata at univariate, bivariate, and multivariate analyses levels. Binary logistic regression analysis was used to determine factors independently associated with non-adherence to ART, reported using odds ratio (OR) and 95% confidence level (CI). The level of statistical significance was 5%. Of 381 participants, 25 (6.6%) were non-adherent to ART and this was significantly associated with alcohol consumption (Adjusted (aOR), 3.24; 95% CI, 1.24-8.34). Other factors namely being single/or never married (aOR, 1.97; 95% CI, 0.62-6.25), monthly income exceeding 27 dollars (aOR, 1.36; 95% CI, 0.52-3.55), being on ART for more than 5 years (aOR, 0.60; 95% CI, 0.23-1.59), receipt of health education on ART side effects (aOR, 0.36; 95% CI, 0.12-1.05), and disclosure of HIV status (aOR, 0.37; 95% CI, 0.04-3.20) were not associated with non-adherence in this setting. Non-adherence to ART was low among PLHIV enrolled to community-based ART delivery model but increases with alcohol consumption. Accordingly, psychosocial support programs should focus on alcohol consumption.

MyCare study: protocol for a controlled trial evaluating the effect of a community-based intervention on psychosocial, clinical outcomes and hospital admission rates for adults with severe mental illness

IntroductionPeople with serious mental illness (SMI) often fail to receive adequate treatment. To provide a higher level of support, mental health systems have been reformed substantially to integrate mental healthcare...

Infection prevention and control for labor and delivery, well baby nurseries, and neonatal intensive care units

During the early months of the COVID-19 pandemic, infection prevention and control (IP&C) for women in labor and mothers and newborns during delivery and receiving post-partum care was quite challenging for staff, patients, and support persons due to a relative lack of evidence-based practices, high rates of community transmission, and shortages of personal protective equipment (PPE). We present our IP&C policies and procedures for the obstetrical population developed from mid-March to mid-May 2020 when New York City served as the epicenter of the pandemic in the U.S. For patients, we describe screening for COVID-19, testing for SARS-CoV-2, and clearing patients from COVID-19 precautions. For staff, we address self-monitoring for symptoms, PPE in different clinical scenarios, and reducing staff exposures to SARS-CoV-2. For visitors/support persons, we address limiting them in labor and delivery, the postpartum units, and the NICU to promote staff and patient safety. We describe management of SARS-CoV-2-positive mothers and their newborns in both the well-baby nursery and in the neonatal ICU. Notably, in the well-baby nursery we do not separate SARS-CoV-2-positive mothers from their newborns, but emphasize maternal mask use and social distancing by placing newborns in isolates and asking mothers to remain 6 feet away unless feeding or changing their newborn. We also encourage direct breastfeeding and do not advocate early bathing. Newborns of SARS-CoV-2-positive mothers are considered persons under investigation (PUIs) until 14 days of life, the duration of the incubation period for SARS-CoV-2. We share two models of community-based care for PUI neonates. Finally, we provide our strategies for enhancing communication and education during the early months of the pandemic.

A community-based asthma program: Study design and methods of RVA Breathes

Disparities in pediatric asthma morbidity and healthcare utilization exist on the basis of race, ethnicity, environment, and income; interventions are needed to address these inequities. The following protocol describes an evidence-based intervention, RVA Breathes, designed to coordinate pediatric asthma care across family, home, community, and medical sectors. Community stakeholder feedback was utilized to refine the intervention specifically for the Richmond, Virginia community. The aims of this study are to assess the effect of RVA Breathes on asthma-related healthcare utilization, as well as secondary outcomes of asthma control, asthma symptoms, and quality of life. We will enroll 300 elementary school children from the Richmond City Public School system. Participants will be between the ages of 5–11, have a diagnosis of asthma, and have had an asthma exacerbation (as indicated by an asthma-related ED visit, hospitalization, unscheduled PCP visit, or use of systemic steroids) in the last two years. Participants will be randomized to one of three groups: asthma education + home environment remediation + school intervention, asthma education + home environment remediation, or a comparator condition. Data will be collected across one baseline research visit, four intervention sessions, and four follow-up research visits over the course of 18 months. A General Linear Mixed Model (GLMM) will be used to test primary aims. We expect the findings will provide support for coordination of asthma care across sectors. Further, we hope RVA Breathes will serve as a model of community-based pediatric asthma care.

RightPath: a model of community-based musculoskeletal care for children.

ObjectivesMusculoskeletal (MSK) presentations are common (reported prevalence of one in eight children) and a frequent cause of consultations (6% of 7-year-olds in a cohort study from the UK). Many causes are self-limiting or raised as concerns about normal development (so-called normal variants). We aimed to describe a new model of care to identify children who might be managed in the community by paediatric physiotherapists and/or podiatrists rather than referral to hospital specialist services.MethodsUsing mixed methods, we tested the feasibility, acceptability and transferability of the model in two UK sites. Evaluation included patient flow, referral times, diagnosis and feedback (using questionnaires, focus groups and interviews).ResultsAll general practitioner referrals for MSK presentations (in individuals <16 years of age) were triaged by nurses or allied health professionals using a triage guide; ∼25% of all MSK referrals were triaged to be managed by community-based paediatric physiotherapists/podiatrists, and most (67%) had a diagnosis of normal variants. Families reported high satisfaction, with no complaints or requests for onward specialist referral. No children re-presented to the triage service or with serious MSK pathology to hospital specialist services in the subsequent 6 months after triage. Triagers reported paediatric experience to be important in triage decision-making and case-based learning to be the preferred training format.ConclusionThe triage model is acceptable, feasible and transferable to enable appropriate care in the community for a proportion of children with MSK complaints. This is a multi-professional model of better working together between primary community and specialist providers.

The Reliability and Validity of Short Form-12 Health Survey Version 2 for Chinese Older Adults

We assessed the information regarding the psychometric properties of the Short Form-12 Health Survey Version 2 (SF-12v2) among older adults in China. A cross-sectional study was conducted on a stratified representative sample of older adults (≥60 years) residing in community and nursing home settings in 2017-18. Reliability was estimated using the internal consistency method. Validity was assessed using convergent and discriminant validity checks, factor analyses (including both exploratory and confirmatory factor analyses [EFA and CFA]), and "known groups" construct validity. The final sample comprised 1000 older adults (451 community-dwelling and 549 institutional). Cronbach's α was 0.81 for the Physical Component Summary (PCS) and 0.83 for the Mental Component Summary (MCS), showing satisfactory internal consistency for both. Most items were strongly correlated with their represented component (Spearman's correlation coefficient: 0.62-0.87), although the correlation of SF items with PCS was a bit stronger than that with MCS. A two-factor structure (physical and mental health) indicated by EFA jointly accounted for 68.50% of the variance and presented adequate goodness-of-fit indices (GFI=0.98, AGFI=0.92, RMSEA=0.08, 90% Cl RMSEA=0.06 to 0.11, NFI=0.98, and CFI=0.98) in CFA. Known-groups comparison showed that SF-12v2 summary scores did well in differentiating subgroups of older adults by age, marital status, and self-reported health problems (P≤0.05). SF-12v2 is a reliable and valid health-related quality of life instrument for Chinese older adults that works equally well with older adults under institutional care and community-based home care models.

Costs and uptake of a community model of paediatric food allergy care versus specialist hospital care: A before-and-after controlled trial.

To compare the costs of community-based food allergy model of care (intervention cohort, IC) with a tertiary-hospital, specialist allergy clinic model of care (control cohort, CC). In this pragmatic controlled trial, children (aged 0-12 years) newly referred to the allergy clinic at Melbourne's Royal Children's Hospital with suspected/known food allergy to three or fewer foods were allocated to see either a community-based paediatrician, trained via online webinars and web-based clinical decision support tools for food allergy diagnosis and management, or a hospital allergist. Per-patient costs to the health-care system and out-of-pocket costs to families seen within 12 months (clinician time, allergy tests and medicare billing) were compared between the two models of care. At 12 months, 54/181 (30%) CC families had been seen in the allergy clinic and 93/115 (81%) of the IC families who chose to see a community paediatrician had been seen. In an intention-to-treat analysis (ITT), health-care system costs per IC patient were higher than the costs per CC patient (mean cost $333 versus $319, respectively; mean difference $14, 95% Confidence Interval (CI) -97 to 118, P = 0.81). Total out-of-pocket costs to family were $129 in the IC compared with $89 in the CC (mean difference $40, 95% CI $4-$77, P = 0.03). A community-based model of care for simple food allergy showed that costs to the health-care system were similar between the community model and hospital care but did not show reduced out-of-pocket costs to the families 12-months post-enrolment.