Mortality risk of patients in home care is modifiable.

We commend the authors of a recent CMAJ research article for their work developing the Risk Evaluation for Support: Predictions for Elder-Life in the Community Tool (RESPECT) using home care assessments in Ontario.1 We are concerned that their focus on using the algorithm to trigger palliative care and end-of-life conversations is too narrow and could mislead both patients and providers.

The interRAI Home Care tool is widely mandated across Canada to assess the strengths and needs of patients in long-stay home care and to support care planning. It was designed to be administered by trained assessors.2 Thus, the statement by the authors that information from the interRAI Home Care “can be easily self-reported by patients or their caregivers” is incorrect; such usage is likely to add further imprecision to the algorithm.

Second, the World Health Organization defines palliative care as the early identification and treatment of symptoms among people with life-threatening chronic illness (www.who.int/news-room/fact-sheets/detail/palliative-care). Most patients in long-stay home care have at least 1 life-threatening chronic condition: frailty.3 Admission to home care should be a trigger for advance care conversations and interventions. Existing outputs from the interRAI Home Care tool also identify patient needs and support care planning to address these, including interventions for symptom control.

Most importantly, the RESPECT algorithm quantifies mortality risk of frail patients within a fragmented, suboptimally resourced health care system that is not friendly to older adults. The mortality data used to derive this algorithm not only reflect frailty, they also reflect the impact of suboptimal care on the frail home care patient. Rather than being set in stone, this mortality risk is potentially modifiable through chronic disease interventions and involvement of specialized geriatric services.4 Thus, a narrow focus on just palliative and end-of-life care is insufficient.

The importance of empowering patients so that they may more effectively advocate for their care needs cannot be denied. The ensuing conversations are equally important. Patients and clinicians must understand the limitations of risk algorithms such as RESPECT. They must be aware of, and have access to, all relevant care options that could modify patient risk. Finally, they must also have access to the full information from the interRAI Home Care assessment to better understand and manage patient needs.2,5