Denying elderly home-care clients "frills" such as housecleaning actually ends up costing the health system a bundle over the long term, according to a groundbreaking new study. Those denied help with daily chores use $4,000 more a year on health services and are more than twice as likely to end up in costly nursing homes.

"While the original logic of cutting people who needed only housecleaning seemed reasonable at the time, our results show the logic is false," Marcus Hollander, health economist and the study's principal author, said. "We found that a significant proportion of people seemed to have a health-care crisis a year or two after their services were cut that ultimately cost the system more."

The study is being released today at a meeting of the Canadian Health Economics Research Association.

It is one of the first to demonstrate that investing early in home care can actually save money over the long term.

It comes at a time when most home-care programs in the country, to save money, are stripping the elderly of low-level care that allows them to live independently in the community. Dr. Hollander said the approach should be rethought immediately because it is a false economy.

"These simple, cheap services appear to help maintain the elderly person's functioning and prevent his or her deterioration," he said. Having a homemaker perform simple chores such as cleaning, as little as once a week, provides stimulus and stability and acts as an early warning system for serious health problems, the researchers found. They said those denied the services feel lonely and abandoned, which seems to precipitate health crises.

The study was conducted in British Columbia, where the government unwittingly created a large-scale natural experiment. In 1994, the province instituted a policy of cutting services to clients with minimal home-care needs. But the policy of eliminating housecleaning services was implemented in some jurisdictions and ignored in others.

That allowed researchers to examine the health outcomes of home-care clients with and without low-level services over many years.

The research found there was no difference between the groups in the first year, which seems to justify the cuts.

But in the second and third years, the cost of caring for those stripped of homemaking services soared, and their health outcomes plummeted.

In the third year, annual costs per person for all health services averaged $7,808 for those who still had housecleaning, compared with $11,903 for those whose services were cut.

More important, 17 per cent of those who lost their housecleaning ended up in long-term care institutions three years after the cuts, compared with only 7 per cent of those who still had the housecleaning.

This makes a tremendous financial difference. The homemaking services cost the government about $2,500 a year; the basic institutional care, more than $42,000 a year.

Earlier research by Dr. Hollander showed that most moves from community care to institutional care are precipitated by an event such as a fall. This is far more likely to happen if the home is untidy. (Falls are the leading cause of hospital and nursing-home admission and one of the leading causes of death among the elderly.)

Furthermore, the death rate was 50 per cent higher among those who lost their low-level help than among those who still had their homes cleaned. After three years, 22 per cent of the former group had died, compared with 15 per cent of the latter.

"Ignoring the preventive aspects of home care may not only lead to increased costs in the overall health system, but may also lead to increased suffering and distress for a significant proportion of people who are cut from care," Dr. Hollander said.

The research was commissioned by Health Canada, which has funded 15 major studies to determine the efficiency and cost-effectiveness of home care. The results have been more dramatic than anyone expected.

For example, an earlier study found that governments can cut treatment costs for elderly patients by as much as half by providing care in the community instead of in institutions. It revealed that each patient cared for in the community rather than a facility saves the health system an average of $8,000 a year, regardless of the severity of the patient's condition.

In fact, what the research has driven home forcefully is that stability is a key to caring for patients cost-effectively, a view that has been reinforced in the new study.

Nationally, governments spend about $2.1-billion a year on home care.

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