Nursing Home Care Services Research Articles

Current Medical and Social Conditions and Outcomes of Hospitalized Heart Failure Patients - Design and Baseline Information of the Cohort Study in Hiroshima.

Background: Information regarding current medical and social conditions and outcome of Japanese heart failure (HF) patients is needed. Methods and Results: The registry and follow-up study regarding the medical and social conditions and outcomes of hospitalized heart failure patients (REAL-HF) is maintained by 8 regional core hospitals, which provide an interprofessional team approach for HF patients, in Hiroshima Prefecture. We planned to enroll all adult patients hospitalized with symptomatic HF (congestive HF and/or low output syndrome) in 1 year from March 2017. We registered the clinical characteristics of each patient, including physical activity (able to walk independently), during the indexed hospitalization. Information regarding living circumstances, cognitive function test, questionnaire for quality of life (QOL), and interprofessional team approaches was also collected. For patients discharged home, we planned to follow all-cause death, all-cause unscheduled readmission, and the conditions of outpatient cardiac rehabilitation and home nursing-care services at 3 and 12 months after discharge. A total of 1,218 patients has been registered initially. Follow-up is ongoing, and data analysis is expected to be completed in 2019. Conclusions: The REAL-HF will provide a significant database on the current real conditions of hospitalized HF patients in a local district of Japan, elucidating medical and social risk factors of worsened QOL and prognosis.

The experiences of caregivers providing home care for terminally ill family members at the end of life: A phenomenological study in Bahrain

Objective: The aim of the study was to explore the lived experience of caregivers providing home care for terminally ill family members, with the objectives of describing their experiences of caring for relatives who are terminally ill with cancer and the needs of home caregiving in Bahrain.Methods: The study adopted a Heideggerian, hermeneutic phenomenological design, with a purposive sample of eight family caregivers. Data was generated through one to one, in-depth interviews and analyzed using Interpretative Phenomenological Analysis.Results: Three main themes emerged from the data: (1) the burden of care, (2) comforts, and (3) coping. The findings showed that the lived experience of home caregiving includes physical, emotional and financial burdens, combined with a lack of professional support. The collective experience was infused with intense emotions because of a lack of structured support, resulting in negative emotions that frequently affected the caregivers’ well-being and their ability to care for the ill person. Nevertheless, caregivers tried to maintain care and comforts for their terminally ill relative in the home. They adopted the home environment, arranged resources to ease caring and provided psychological care. Caregivers utilized three coping mechanisms, faith, personal strategies and distribution of the care responsibilities among family members.Conclusions: Caregivers were not prepared for the commitment and burdens of home care when a family member is terminally ill. A recommendation from the study findings is that training be offered on nursing care before patients discharge. In addition, a reactivation of the palliative care clinic hotline service would support family caregivers. A further recommendation is that home nursing care and hospice services be established to improve homecare services for family caregivers in Bahrain.

Care Arrangements in Dementia Care Networks: Findings From the DemNet-D Study Baseline and 1-Year Follow-Up.

This study was conducted to describe care arrangements for persons with dementia (PwDs) who are living at home with the support of a dementia care network (DCN). Data on the utilization of formal and informal support were collected in face-to-face interviews at baseline and 1-year follow-up with PwDs and caregivers receiving support from 1 of 13 DCNs. Men with dementia were supported by twice as many informal caregivers as women (2 vs. 1, respectively, p < .001). Regional differences were found in home-care nursing services, social care groups, companion home services, and day care. The care situations were considered stable by most caregivers. DCNs appear to contribute to a high degree of perceived stability in care situations. Future research should investigate possible gender differences in informal support networks. DCNs should continue their efforts in making low-threshold services in rural areas available and accessible.

New indices for home nursing care resource disparities in rural and urban areas, based on geocoding and geographic distance barriers: a cross-sectional study.

BackgroundAging in place is the crucial object of long-term care policy worldwide. Approximately 15.6–19.4 % of people aged 15 or above live with a disability, and 15.3 % of them have moderate or severe disabilities. The allocation of home nursing care services is therefore an important issue. Service providers in Taiwan vary substantially across regions, and between rural and urban areas. There are no appropriate indices for describing the capacity of providers that it is due to the distances from care recipients. This study therefore aimed to describe and compare distance barriers for home nursing care providers using indices of the “profit willing distance” and the “tolerance limited distance”.MethodsThis cross-sectional study was conducted during 2012 and 2013 using geocoding and a geographic information system to identify the distance from the providers’ locations to participants’ homes in urban (Taipei City) and rural (Hualien County) areas in Taiwan. Data were collected in-person by professionals in Taiwanese hospitals using the World Health Organization Disability Assessment Schedule 2.0. The indices were calculated using regression curves, and the first inflection points were determined as the points on the curves where the first and second derivatives equaled 0.ResultsThere were 5627 participants from urban areas and 956 from rural areas. In urban areas, the profit willing distance was 550–600 m, and we were unable to identify them in rural areas. This demonstrates that providers may need to supply services even when there is little profit. The tolerance limited distance were 1600–1650 m in urban areas and 1950–2000 m in rural areas. In rural areas, 33.3 % of those living inside the tolerance limited distance and there was no provider within this distance, but this figure fell to just 13.9 % in urban areas. There were strong disparities between urban and rural areas in home nursing care resource allocation.ConclusionsOur new “profit willing distance” and the “tolerance limited distance” are considered to be clearer and more equitable than other evaluation indices. They have practical application in considering resource distribution issues around the world, and in particular the rural–urban disparities for public resource.

Facility-Related Factors Influencing the Place of Death and Home Care Rates for End-Stage Cancer Patients.

In Japan, palliative home care is subject to increasing demand from patients. However, the number of deaths at home is still not as high as that of palliative home care users. This study aimed to clarify factors influencing the place of death and home care rates, involving end-stage cancer patients targeted for palliative care by a general home-visit nursing agency. A total of 87 patients who had used palliative home nursing care services provided by the study facility within a 6-year period after its opening were studied. The numbers of deaths at home supported by family physicians and those in hospital after readmission were 70 and 17, respectively. The numbers of deaths at home using services provided by the study facility and nurses belonging to it time-dependently increased, revealing a strong correlation between them. Furthermore, the place of death and home care rates were closely associated with the mean duration of home nursing services and home visits in collaboration with family physicians in charge. These results suggest that it may be possible to increase the rate of home care for end-stage cancer patients and meet their desires regarding the place of death through approaches to establish trust-based relationships with them and their families, such as strengthening manpower in home-visit nursing agencies and promoting collaboration between visiting nurses and family physicians in charge during home visits.

Current Status of Home Visit Programs: Activities and Barriers of Home Care Nursing Services

The purpose of this study was to examine the current status of home care nursing services provided by community health nurses and to identify barriers to the services. A cross-sectional survey was conducted with three types of community health care nurses. Participants were 257 nurses, 46 of whom were hospital based home care nurses, 176 were community based visiting nurses, and 35 were long term care insurance based visiting nurses. A structured questionnaire on 7 domains of home care nursing services with a 4-point Likert scale was used to measure activities and barriers to care. Data were analyzed using SPSS WIN 21.0 program. Hospital based home care nurses showed a high level of service performance activity in the domain of clinical laboratory tests, medications and injections, therapeutic nursing, and education. Community based visiting nurses had a high level of service performance in the reference domain. Long term care insurance based visiting nurses showed a high level of performance in the service domains of fundamental nursing and counseling. The results show that although health care service provided by the three types of community health nurse overlapped, the focus of the service is differentiated. Therefore, these results suggest that existing home care services will need to be utilized efficiently in the development of a new nursing care service for patients living in the community after hospital discharge.

Development of Evaluation Indicators for Integrated Home Care

Purpose: The purpose of this study was to develop integrated evaluation indicators of home care services in the hope that the increasing group of long-term home care patients could receive quality care services. Methods: The development involves a methodological study on a development phase and a verification phase. The main survey at a verification stage was conducted by the staffs at 146 institutions who agreed to participate on this study. Results: The evaluation index for the integrated home visit care consisted of five categories and 57 indicators including Managing Institution (12), Environment and Safety (3), Right and Responsibility (7), Process of Care (31) and Results of Care (4). The criterion-related validity was verified in regard to the participation in the 2010 evaluation of long-term home-care institutions by the National Health Insurance Corporation. Conclusion: The evaluation index of the integrated home visiting care developed in this study is considered suitable to utilize as evaluating indicators in managing and evaluating the way of how institutions integrate and provide home visit care services as well as home nursing care services.

Does government oversight improve access to nursing home care? Longitudinal evidence from US counties.

Gains in life expectancy around the world have increasingly placed pressure on governments to ensure that the elderly receive assistance with activities of daily living. This research examines the impact of government oversight of Medicaid payment policies on access to nursing home care services in the United States. Variation in price levels induced by a federal policy shift in 1997 is used to identify the effect of Medicaid reimbursements on the number of nursing homes and beds available. Court rulings prior to the policy change are used to categorically define a range of oversight treatments at the state level. Difference-in-differences estimates indicate a significant decline in access to nursing home care services for individuals living in states in which courts consistently ruled that Medicaid reimbursements did not meet the minimum standard implied by federal law. The findings suggest that nursing home care services were made more accessible through a combination of legislative and judicial oversight of Medicaid payment policies.

A Study on the Realization of Mobile Homecare Nursing Service Based on Effective Security

Demands on homecare nursing are on the rise due to increase of medical demand for the aged; however, as the homecare nursing should provide service by visiting home, there are limits in the IT infra that manages and inquires the medical information of patients in current situations. This paper developed an application for inquiring about the information of patients and homecare nursing patient clients in the middle of medical services thanks to the recent development of mobile service, and improved the safety of service by applying an effective security method suitable for mobile platform. As homecare nurses can confirm the details of homecare nursing requests, inquiries by reserved patients, progress records, etc. at home in real time, it is likely possible that a good quality of homecare nursing service that provides tailored information according to the patients’ status is realized.

The role of a clinical nurse consultant dementia specialist: A qualitative evaluation

Delay in diagnosis and difficulties in accessing appropriate health care services plague dementia care delivery in the community setting, potentiating the risk for misdiagnosis, inappropriate management, poor psychological adjustment and reduced coping capacity and ability to forward plan. We evaluated a clinical nurse consultant role with a speciality in dementia to provide person-centred pre-diagnosis support in the community. Clients, with a six-month history of cognitive and functional decline in the absence of delirium but no formal diagnosis of dementia, were recruited from a Home Care Nursing Service and an Aged Care Assessment Service located in the Western Suburbs of Melbourne, Victoria, Australia. The role of a clinical nurse consultant was highly regarded by clients and other health professionals. This paper discussing the CNC role and the outcomes of the role suggests it was successful in providing timely assistance and support for consumers and support for other health professionals.

Planning of Nursing Home Care Services in Jordan: Its Reality and Challenges

United Nations Principles for Older Persons acknowledge five rights to elderly or older persons, these rights are the right of independence, care, self, fulfillment, dignity, participation. The demographic Indication witnessed increasing trends in population pyramid at developed countries on aging rates world wide, especially in most of developing countries. So in order to address this growing dilemma at our civilized world its proved at statistics surveys, on current research work as it will try to expose to efforts the plans made by many Jordanian Civil &Governmental initiatives for facing this category for the purpose of providing high standards services at both health and social care services for elderly people and to help them reaching a self-realization, and to encourage them in developing their potential through resources available in different aspects of the community educationally, culturally, spiritually and even through recreational activities. The present study aims to identify current capabilities that available in serving elderly people at two main Nursing Home Centers in Jordan located in Amman. Its limitation to only two most serving accommodated numbers of elder's Nursing Home centers the first is: White Beds Society and the second is: Centre for Princess Muna older women Nursing homes / Orthodox Charity as both are largest and oldest of Nursing homes centers serving elderly. The research concluded many numerous results most important are: There shall specialized cooperation bodies in charge of deals with other institutions working in the field of aging society, as of governmental organizations, hospitals, accredited qualified manpower to deal with this deer category of our society. secondly. Assist homes for elderly in budgetary provisions of adequate budget to them.

Dying at Home: A Literature Review (741)

1.Describe important empirically driven components of dying at home.2.Discuss complicated meanings for patients, caregivers and providers of dying at home. Background. Dying at home may have initially been introduced as a response to misguided and poor care of dying patients in hospitals. However, the significant increase in place of death for hospice patients in inpatient settings versus private residences suggests that dying at home is a concept needing reclarification and evaluation. Research objectives. The purpose of this review was to develop a literature-based definition of the concept “dying at home” that could be used as a conceptual framework to guide further research. Methods. Three electronic databases (ie, CINAHL, PubMed, and PsychINFO) were searched with restriction to English language, humans, and older adults (age greater than 65 years) for dying or death and home nursing or home care services or hospice care. Overall, 405 abstracts were collected; abstracts were reviewed for saliency and criteria for inclusion was a focus on location of care of the dying at home, explication of the meaning of dying at home, and a data based publication. A total of 35 articles met the criteria. Content was analyzed and integrated into the final framework. Results. Major themes identified in these articles included predictors of place of death, multiple meanings of being “at home,” expressed end-of-life preferences, transitions, and caregiver involvement. A preliminary framework focused on dying at home was elucidated and included adequate resources, a physical location of care, patient preference, caregiver preference, awareness of prognosis, caregiver support, a time-limited course, access to symptom management and feeling “at home.” Conclusion. Dying at home is a multi-layered, complex concept for patients, caregivers, and providers influenced by many factors. A more cautious view of dying at home as a gold standard should be considered for future hospice policy discussions. Implications for research, policy, or practice. Clinically relevant research in this area calls for a better understanding of needs, appropriateness, and evaluation of the role of dying at home in patient and caregiver outcomes.

Comparative Study of Home Nursing Care Services under the Long-term Care Insurance System in Four Nations

Purpose: This comparative study analyzed information systems including manpower, contents of service, clients, and costs among four nations. Methods: A literature review of relevant publications from Korea, United States, Japan, and Germany supported the use of several plans to activate home nursing care services under the long-term care insurance system in Korea. Results: Korean home nursing care services require quality improvements. The results indicated that a rule is necessary that rations simple visiting service and home nursing care services under the long-term care insurance system, that an integrated management system for elderly care is required, and that the revised delivery of services needs to establish and reflect on various factors to estimate the value in a home visiting nursing care cost system. Conclusion: The data should be valuable in establishment of home nursing care services under the long-term insurance system in Korea.

An Economic Evaluation of the Home Nursing Care Services: Public Health Center Versus Private Hospital

AbstractPurpose: The purpose of this study was to compare the costs and benefits of home nursing care services between public health centers (PHC) and private hospitals. Method: Participants were 105 patients who had received home nursing care services from a private hospital or public health center. From a societal perspective, the researcher identified the costs and benefits of the services using performance data and calculated the net benefit and benefit/cost ratio. Result: The net benefit of the home nursing care service based in the PHC was 165.9 million won and benefit/cost ratio was 2.0, while the net benefit of the home nursing care services by the private hospital was 141.1 million won and benefit/cost ratio was 1.7. Both types of programs were economically validated. Conclusion: Home nursing care services were basically efficient as the results showed a positive net benefit. A cost-benefit analysis indicated that the PHC-based home nursing care services were more efficient than that of the private hospital. With limited human resources and management standards in public health centers, results suggest the need for a more systematic management of the home nursing care service to improve the health of this vulnerable community population.

Change Management in a Home Care Nursing Service

This article describes the approach taken in implementing a major organization change in a large home nursing service. Rather than prescribing a model for change, five key issues are outlined: establishing a mandate for change, project management methodology, staff engagement, using data and evaluation, and ensuring sustainability. Professional development was provided to middle managers across the organization to ensure that the capacity for managing change was available. A project identity was established and a detailed project plan identified roles, initiatives, deliverables, timelines, and accountabilities. Staff support for changes was improved through their involvement in creating solutions and developing new processes. Project indicators and reports were produced to monitor the impact of initiatives. The project evaluation showed that there had been considerable improvements in organization performance. Staff were positive about their involvement in the project and the opportunities that were created for them to address the identified issues.

Willingness to Use Formal Long-Term Care Services by Korean Elders and Their Primary Caregivers

ABSTRACT This study examined predictors of older adults' and primary caregivers' willingness to use formal long-term care (LTC) services to understand possible use patterns of mandatory public LTC insurance programs in Korea. It focused on views regarding who (adult children or the government) should bear the responsibility for older adults' care. Logistic regression models were estimated using data from 1,168 older Korean adults aged 65 or older and their primary caregivers from a national survey. The results showed that older adults' and their caregivers' views on care responsibility were a dominant predictor of their willingness to use both formal home care services and nursing home care services. Both older adults and their family caregivers' willingness to use LTC services should be considered when predicting demand for LTC services. Efforts should promote the perspective that formal LTC services are an acceptable social norm.

The Relationship between Characteristics of Home Care Nursing Service Contracts under Managed Competition and Continuity of Care and Client Outcomes: Evidence from Ontario

The purpose of this study was to investigate the impact of the Request for Proposal (RFP) process - specifically, the profit status of provider agencies awarded contracts, the service volume awarded and contract duration - on the quality of home care services and outcomes. A cross-sectional (contract characteristics) and repeated measures (clients) design was used to collect data on the study variables. Primary data were collected in 2002-2003 from 11 Community Care Access Centres (CCACs) and 11 nursing provider agencies in Ontario. The sample included 750 home care clients recruited consecutively from home care referrals. Follow-up assessments were completed on 498 clients. CCACs and provider agencies completed written questionnaires about profit status, contract volume, duration of contract, potential for renewal, number of visits made by a principal nurse and number of visits made by a registered nurse. Data were collected on client health outcomes either at admission to home care service for new clients or at entry to the study for long-term clients, and then at discharge from service or at the end of six weeks, whichever came first, using the eight subscales of the Medical Outcome Study SF-36. Analysis was conducted using hierarchical linear modelling.For the most part, contract characteristics were not related to the consistency of principal nurse visits or client outcomes. Where differences existed, they were small. Clients of agencies awarded longer contracts received greater consistency in principal nurse visits than clients of agencies awarded shorter contracts. Clients cared for by for-profit agencies reported slightly higher satisfaction with care and better mental health outcomes than clients cared for by not-for-profit agencies. The percentage of visits made by a registered nurse was positively associated with social function outcome for clients at follow-up. In conclusion, the study findings suggest that contract characteristic variables had a small effect on home care client outcomes.

Paying for cancer care—a new dilemma

NHS spending is now at unprecedented levels. Over £90 billion is being spent this year alone and by 2008 this will reach £105 billion. Yet the quality of service provision and access to technology still does not match that of our European neighbours. Increasing the total budget spent on health is one solution. This can either come from increased taxation or by direct payment at the point of care: a co-payment. Another is a radical reform of the entire system from its insurance function through to its delivery system. Stripping away bureaucracy to reduce costs is an essential component of the reform process. A recent report1 suggests that we are heading for a £7 billion deficit in the NHS by 2011—and that's not allowing for step changes in technology. That represents an income tax increase of two pence in the pound for all those at work unless we use some other payment mechanism. Cancer care costs are spiralling out of control in every healthcare environment. Aging populations with a wide range of medical problems are consuming vastly increasing amounts of care. New technology—drugs, devices and procedures—are powerful inflationary drivers in an information rich, consumer-oriented world.2 Different healthcare systems are using a variety of approaches to dampen demand. Rationing, both overt and covert, inevitably leads to inequity. Britain's NHS is undergoing a slow reform process, but huge variations exist in the way patients access its services, depending on their location, education and socio-economic background. There are also major differences in prioritizing services by those responsible for their payment (the Primary Care Trusts, often advised by the local Cancer Networks). A study in 2006 showed clearly that new cancer drug use in Britain was consistently and significantly well below that of our EU neighbours.3 Similarly, another comparative EU study on the availability of radiotherapy last year ranked the UK near the bottom, on the level with the accession countries of Central Europe, even after the recent purchase of over 100 machines using lottery money.4 An alliance of British cancer charities have successfully lobbied for a second cancer plan to improve services. Whilst this would be beneficial, there is no evidence that any additional tax-based NHS funding will be available for this laudable concept. Cancer is seen as a ticked box in Britain. There is now evidence of a growing use of co-payments to break through the access barriers in the NHS. This applies to areas as diverse as implanted hearing aid devices, access to diagnostics such as MRI scans and home nursing care services. Politicians of all persuasions seem to be in denial about their existence and are reluctant to get involved in debate. Meanwhile cancer patients are beginning to develop sophisticated approaches to buying extra clinical services either from the NHS directly or through the selective use of the private sector to purchase upgrades to their basic NHS care. With drugs the economics are relatively straightforward, but with precision radiotherapy the issues are more complex and so far hidden from the political media limelight. There are 61 radiotherapy centres in the UK. Of these, 28 now have equipment to provide intensity modulated radiotherapy, which is now standard in the US and most of Western Europe. Only three British centres, however, provide intensity modulated radiotherapy routinely to significant numbers of patients: Clatterbridge (Liverpool), Ipswich and the Royal Marsden (London). Staff and funding shortages are blamed. Savvy patients are beginning to travel long distances for more precise radical radiotherapy in order to suffer fewer long-term side effects. The imminent publication of the National Radiotherapy Advisory Group report, which shows wide variation in radiotherapy utilization across the country, is clearly going stimulate new models for radiotherapy provision. Furthermore, delays abound, with a three-month waiting time for radiotherapy being common in the UK. In contrast, a centre in Zurich, Switzerland, currently has a working group engaged in re-engineering the time from first contact to radiotherapy delivery from five to three working days.

Paying for cancer care--a new dilemma

NHS spending is now at unprecedented levels. Over £90 billion is being spent this year alone and by 2008 this will reach £105 billion. Yet the quality of service provision and access to technology still does not match that of our European neighbours. Increasing the total budget spent on health is one solution. This can either come from increased taxation or by direct payment at the point of care: a co-payment. Another is a radical reform of the entire system from its insurance function through to its delivery system. Stripping away bureaucracy to reduce costs is an essential component of the reform process. A recent report1 suggests that we are heading for a £7 billion deficit in the NHS by 2011—and that's not allowing for step changes in technology. That represents an income tax increase of two pence in the pound for all those at work unless we use some other payment mechanism. Cancer care costs are spiralling out of control in every healthcare environment. Aging populations with a wide range of medical problems are consuming vastly increasing amounts of care. New technology—drugs, devices and procedures—are powerful inflationary drivers in an information rich, consumer-oriented world.2 Different healthcare systems are using a variety of approaches to dampen demand. Rationing, both overt and covert, inevitably leads to inequity. Britain's NHS is undergoing a slow reform process, but huge variations exist in the way patients access its services, depending on their location, education and socio-economic background. There are also major differences in prioritizing services by those responsible for their payment (the Primary Care Trusts, often advised by the local Cancer Networks). A study in 2006 showed clearly that new cancer drug use in Britain was consistently and significantly well below that of our EU neighbours.3 Similarly, another comparative EU study on the availability of radiotherapy last year ranked the UK near the bottom, on the level with the accession countries of Central Europe, even after the recent purchase of over 100 machines using lottery money.4 An alliance of British cancer charities have successfully lobbied for a second cancer plan to improve services. Whilst this would be beneficial, there is no evidence that any additional tax-based NHS funding will be available for this laudable concept. Cancer is seen as a ticked box in Britain. There is now evidence of a growing use of co-payments to break through the access barriers in the NHS. This applies to areas as diverse as implanted hearing aid devices, access to diagnostics such as MRI scans and home nursing care services. Politicians of all persuasions seem to be in denial about their existence and are reluctant to get involved in debate. Meanwhile cancer patients are beginning to develop sophisticated approaches to buying extra clinical services either from the NHS directly or through the selective use of the private sector to purchase upgrades to their basic NHS care. With drugs the economics are relatively straightforward, but with precision radiotherapy the issues are more complex and so far hidden from the political media limelight. There are 61 radiotherapy centres in the UK. Of these, 28 now have equipment to provide intensity modulated radiotherapy, which is now standard in the US and most of Western Europe. Only three British centres, however, provide intensity modulated radiotherapy routinely to significant numbers of patients: Clatterbridge (Liverpool), Ipswich and the Royal Marsden (London). Staff and funding shortages are blamed. Savvy patients are beginning to travel long distances for more precise radical radiotherapy in order to suffer fewer long-term side effects. The imminent publication of the National Radiotherapy Advisory Group report, which shows wide variation in radiotherapy utilization across the country, is clearly going stimulate new models for radiotherapy provision. Furthermore, delays abound, with a three-month waiting time for radiotherapy being common in the UK. In contrast, a centre in Zurich, Switzerland, currently has a working group engaged in re-engineering the time from first contact to radiotherapy delivery from five to three working days.

Analysis of a territorial approach to the delivery of nursing home care services based on historical data

We analyze a territorial approach to deliver nursing homecare services to a territory public health. We present the case of the CSSS assigned to Côte-des-Neiges, Métro center and Parc Extension, specifically the case of the Côte-des-Neiges site (CLSC CDN), where a territorial approach is used since 1980. We first give an historical comparison of patient visits delivered in 1998-1999 and in 2002-2003. We follow with an in-depth analysis of the home services delivered in 2002-2003 to determine whether or not the territorial approach can well support the changing needs of the population. We conclude that the territorial approach to deliver homecare nursing services does not sufficiently support fluctuations in population needs for services. Not only is it difficult to predict these fluctuations, but it is difficult to accurately quantify the true needs for services since the availability of nursing services tends to determine the services actually delivered. In sectors of the territory where resources are more scarce (based on previous population needs analyses) or demand for services is greater, the result is work overload for the nursing staff. In addition, this results in service delivery inequities across the entire territory. Therefore, a more dynamic assignment of clients to the nurses based on each nurse's work load and case load rather than based on the geographic location of clients is worth the extra administrative time in case assignment to ensure a more equitable case load attribution between nurses as well as less inequities between clients in terms of service delivery considering their needs.