Ability to generalize the study findings is limited because of the recruitment procedures that resulted in a convenience sample and the fact that the study design did not allow for blinded data collection. To counterbalance the lack of blinding, all possible measures were taken to separate data collection and intervention, but during telephone interviews, participants talked about the interventions and made blinded data collection impossible.
Self-reported measures were used in this study. Because of the large numbers of healthcare organizations involved, it was not feasible to obtain objective data from patient records. Self-reported measures had several disadvantages. First, the 3-month period of data collection increased the chance that events were not recalled and, thus, not reported. If data were incomplete or information was unclear, study nurses contacted participants by telephone and included next of kin to provide the information needed, but self-reported recalls over the telephone without a daily falls diary are a limitation. Over- or underestimation of events is possible. Second, the lack of objective measures precluded cost-effectiveness analyses. From an integrated economic perspective, it can be assumed that HCP has the potential to pay for itself. Over the 9-month period, the intervention for each participant, including preparation and baseline assessments, four home visits, and subsequent follow-up visits, cost approximately the equivalent of $1,250. Nevertheless, a reduction in healthcare expenditures can be assumed, because one hospital admission in every 10 participants was prevented, along with one acute event in every 4.3 participants and one fall in every 7.1 participants receiving the intervention. Although data on costs for acute hospitalization, acute events, and falls are not available, the expenditures for falls are likely to be high, seeing that, in addition to the 69% with moderate consequences (pain, hematomas, concussions), 8.5% of the participants in the sample who experienced falls suffered severe consequences (fractures, open wounds) and needed additional treatment. Further measures on cost effectiveness should be included in future studies. Given the greater priority of prevention and health promotion within the program, expenses due to nursing home admission could have been avoided. Greater effort through interprofessional collaboration served to pool resources and might have contributed to reduce expenditures. The implementation of HCP on a city-wide level is currently being discussed. Any implementation will include an assessment of the cost effectiveness.
One of the strengths of this study was the use of the principles of health promotion, empowerment, partnership, and family-centeredness to guide the intervention. Intervention nurses were asked to establish an ongoing caring relationship with the participants during the 9-month intervention. This approach explains why withdrawal from the study was low (n = 22, 4.7%), with two-thirds occurring within the first month of the intervention.
Although evidence-based protocols guided the health consultation sessions, they were also customized to the participants' individual situations. Participants' goals were taken into account, activities were negotiated, and their usefulness for and feasibility in everyday life were evaluated during the following sessions.