1
|
Siu AL, Leff B. Importance of early consideration of scaling and sustainability for aging-related care models: Case study of Hospital at Home. J Am Geriatr Soc 2024. [PMID: 38943488 DOI: 10.1111/jgs.19042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/20/2024] [Accepted: 05/26/2024] [Indexed: 07/01/2024]
Abstract
For aging-related research, there is a pressing need to attend to the dissemination and implementation of evidence-based interventions. Some aging-related interventions with established effectiveness may be poorly disseminated and implemented due to behavioral, organizational, payment, or other constraints. To provide insight into the beginning to end process of translation and implementation, we present a case history of the three-decade progression of Hospital at Home (HaH) now nearing national dissemination. We summarize research at various phases with particular attention to implementation considerations. Reviewing over three decades of HaH-related research dating from initial discovery to translation and implementation, we found that the content and importance of different constructs (e.g., inner practice vs. outer environmental setting) and the choice of implementation strategies differed depending on implementation context (testing of effectiveness, scaling, or sustainability). Early effectiveness studies mostly examined implementation issues related to the intervention, the practice setting, and the individuals involved. However, explicit and early consideration of scale and sustainment was not the primary focus. For example, HaH program intake is primarily through hospital emergency departments (ED). Initial efforts would have benefited from incorporating strategies (e.g., incorporating ED leadership into program leadership) to address night and weekend admissions. Many regulatory barriers did not surface during initial considerations. Considering implementation issues late may contribute to delay in bringing discoveries to population impact. The experience with HaH suggests that scale and sustainability bear earlier consideration because barriers and facilitators to implementation are likely to be different in content and importance at different phases of implementation.
Collapse
Affiliation(s)
- Albert L Siu
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatrics Research, Education, and Clinical Center (GRECC) at the James J. Peters VA Medical Center, Bronx, New York, USA
| | - Bruce Leff
- Division of Geriatric Medicine, Department of Medicine, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
2
|
Correia Azevedo P, Rei C, Grande R, Saraiva M, Guede-Fernández F, Oliosi E, Londral A. Assessment of the Impact of Home-Based Hospitalization on Health Outcomes: An Observational Study. ACTA MEDICA PORT 2024; 37:445-454. [PMID: 38848706 DOI: 10.20344/amp.20474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/18/2024] [Indexed: 06/09/2024]
Abstract
INTRODUCTION In Portugal, evidence of clinical outcomes within home-based hospitalization programs remains limited. Despite the adoption of homebased hospitalization services, it is still unclear whether these services represent an effective way to manage patients compared with inpatient hospital care. Therefore, the aim of this study was to evaluate the outcomes of home-based hospitalization compared with conventional hospitalization in a group of patients with a primary diagnosis of infectious, cardiovascular, oncological, or 'other' diseases. METHODS An observational retrospective study using anonymized administrative data to investigate the outcomes of home-based hospitalization (n = 209) and conventional hospitalization (n = 192) for 401 Portuguese patients admitted to CUF hospitals (Tejo, Cascais, Sintra, Descobertas, and the Unidade de Hospitalização Domiciliária CUF Lisboa). Data on demographics and clinical outcomes, including Barthel index, Braden scale, Morse scale, mortality, and length of hospital stay, were collected. The statistical analysis included comparison tests and logistic regression. RESULTS The study found no statistically significant differences between patients' admission and discharge for the Barthel index, Braden scale, and Morse scale scores, for both conventional and home-based hospitalizations. In addition, no statistically significant differences were found in the length of stay between conventional and home-based hospitalization, although patients diagnosed with infectious diseases had a longer stay than patients with other conditions. Although the mortality rate was higher in home-based hospitalization compared to conventional hospitalization, the mortality risk index (higher in home-based hospitalization) assessed at admission was a more important predictor of death than the type of hospitalization. CONCLUSION The study found that there were no significant differences in outcomes between conventional and home-based hospitalization. Home-based hospitalization was found to be a valuable aspect of patient- and family-centered care. However, it is noteworthy that patients with infectious diseases experienced longer hospital stays.
Collapse
Affiliation(s)
| | - Cátia Rei
- Unidade de Hospitalização Domiciliária. CUF. Lisbon. Portugal
| | - Rui Grande
- Unidade de Hospitalização Domiciliária. CUF. Lisbon. Portugal
| | - Mariana Saraiva
- Unidade de Hospitalização Domiciliária. CUF. Lisbon. Portugal
| | - Federico Guede-Fernández
- Value for Health CoLAB. Lisbon; Laboratory for Instrumentation, Biomedical Engineering and Radiation Physics (LIBPhys). NOVA School of Science and Technology. Universidade NOVA de Lisboa. Lisbon. Portugal
| | - Eduarda Oliosi
- Value for Health CoLAB. Lisbon; Laboratory for Instrumentation, Biomedical Engineering and Radiation Physics (LIBPhys). NOVA School of Science and Technology. Universidade NOVA de Lisboa. Lisbon. Portugal
| | - Ana Londral
- Value for Health CoLAB. Lisbon; Comprehensive Health Research Center (CHRC). NOVA Medical School. Universidade NOVA de Lisboa. Lisbon. Portugal
| |
Collapse
|
3
|
Shi C, Dumville J, Rubinstein F, Norman G, Ullah A, Bashir S, Bower P, Vardy ERLC. Inpatient-level care at home delivered by virtual wards and hospital at home: a systematic review and meta-analysis of complex interventions and their components. BMC Med 2024; 22:145. [PMID: 38561754 PMCID: PMC10986022 DOI: 10.1186/s12916-024-03312-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/22/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Technology-enabled inpatient-level care at home services, such as virtual wards and hospital at home, are being rapidly implemented. This is the first systematic review to link the components of these service delivery innovations to evidence of effectiveness to explore implications for practice and research. METHODS For this review (registered here https://osf.io/je39y ), we searched Cochrane-recommended multiple databases up to 30 November 2022 and additional resources for randomised and non-randomised studies that compared technology-enabled inpatient-level care at home with hospital-based inpatient care. We classified interventions into care model groups using three key components: clinical activities, workforce, and technology. We synthesised evidence by these groups quantitatively or narratively for mortality, hospital readmissions, cost-effectiveness and length of stay. RESULTS We include 69 studies: 38 randomised studies (6413 participants; largely judged as low or unclear risk of bias) and 31 non-randomised studies (31,950 participants; largely judged at serious or critical risk of bias). The 69 studies described 63 interventions which formed eight model groups. Most models, regardless of using low- or high-intensity technology, may have similar or reduced hospital readmission risk compared with hospital-based inpatient care (low-certainty evidence from randomised trials). For mortality, most models had uncertain or unavailable evidence. Two exceptions were low technology-enabled models that involve hospital- and community-based professionals, they may have similar mortality risk compared with hospital-based inpatient care (low- or moderate-certainty evidence from randomised trials). Cost-effectiveness evidence is unavailable for high technology-enabled models, but sparse evidence suggests the low technology-enabled multidisciplinary care delivered by hospital-based teams appears more cost-effective than hospital-based care for those with chronic obstructive pulmonary disease (COPD) exacerbations. CONCLUSIONS Low-certainty evidence suggests that none of technology-enabled care at home models we explored put people at higher risk of readmission compared with hospital-based care. Where limited evidence on mortality is available, there appears to be no additional risk of mortality due to use of technology-enabled at home models. It is unclear whether inpatient-level care at home using higher levels of technology confers additional benefits. Further research should focus on clearly defined interventions in high-priority populations and include comparative cost-effectiveness evaluation. TRIAL REGISTRATION https://osf.io/je39y .
Collapse
Affiliation(s)
- Chunhu Shi
- School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK.
| | - Jo Dumville
- School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
| | - Fernando Rubinstein
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Gill Norman
- School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Evidence Synthesis Group, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
- NIHR Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Akbar Ullah
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Manchester Centre for Health Economics, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | - Saima Bashir
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Manchester Centre for Health Economics, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | - Peter Bower
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Emma R L C Vardy
- School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Manchester, UK
- Oldham Care Organisation, Northern Care Alliance NHS Foundation Trust, Oldham, UK
| |
Collapse
|
4
|
Knight T, Kamwa V, Atkin C, Green C, Ragunathan J, Lasserson D, Sapey E. Acute care models for older people living with frailty: a systematic review and taxonomy. BMC Geriatr 2023; 23:809. [PMID: 38053044 PMCID: PMC10699071 DOI: 10.1186/s12877-023-04373-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 10/03/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND The need to improve the acute care pathway to meet the care needs of older people living with frailty is a strategic priority for many healthcare systems. The optimal care model for this patient group is unclear. METHODS A systematic review was conducted to derive a taxonomy of acute care models for older people with acute medical illness and describe the outcomes used to assess their effectiveness. Care models providing time-limited episodes of care (up to 14 days) within 48 h of presentation to patients over the age of 65 with acute medical illness were included. Care models based in hospital and community settings were eligible. Searches were undertaken in Medline, Embase, CINAHL and Cochrane databases. Interventions were described and classified in detail using a modified version of the TIDIeR checklist for complex interventions. Outcomes were described and classified using the Core Outcome Measures in Effectiveness Trials (COMET) taxonomy. Risk of bias was assessed using RoB2 and ROBINS-I. RESULTS The inclusion criteria were met by 103 articles. Four classes of acute care model were identified, acute-bed based care, hospital at home, emergency department in-reach and care home models. The field is dominated by small single centre randomised and non-randomised studies. Most studies were judged to be at risk of bias. A range of outcome measures were reported with little consistency between studies. Evidence of effectiveness was limited. CONCLUSION Acute care models for older people living with frailty are heterogenous. The clinical effectiveness of these models cannot be conclusively established from the available evidence. TRIAL REGISTRATION PROSPERO registration (CRD42021279131).
Collapse
Affiliation(s)
- Thomas Knight
- Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Vicky Kamwa
- Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Catherine Atkin
- Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Catherine Green
- Department of Geriatric Medicine, Whiston Hospital, Mersey and West Lancashire Teaching Hospital NHS Trust, Prescot, L35 5DR, UK
| | - Janahan Ragunathan
- Department of Geriatric Medicine, Royal Bolton NHS Foundation Trust, Bolton, BL4 0JR, UK
| | - Daniel Lasserson
- Warwick Medical School, Professor of Acute and Ambulatory Care, University of Warwick, Coventry, CV4 7AL, UK
| | - Elizabeth Sapey
- Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| |
Collapse
|
5
|
Gorbenko K, Baim-Lance A, Franzosa E, Wurtz H, Schiller G, Masse S, Ornstein KA, Federman A, Levine DM, DeCherrie LV, Leff B, Siu A. A national qualitative study of Hospital-at-Home implementation under the CMS Acute Hospital Care at Home waiver. J Am Geriatr Soc 2023; 71:245-258. [PMID: 36197021 DOI: 10.1111/jgs.18071] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/16/2022] [Accepted: 08/21/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services (CMS) announced the Acute Hospital Care at Home (AHCaH) waiver program in November 2020 to help expand hospital capacity to cope with the COVID-19 pandemic. The AHCaH waived the 24/7 on-site nursing requirement and enabled hospitals to obtain full hospital-level diagnosis-related group (DRG) reimbursement for providing Hospital-at-Home (HaH) care. This study sought to describe AHCaH implementation processes and strategies at the national level and identify challenges and facilitators to launching or adapting a HaH to meet waiver requirements. METHODS We conducted semi-structured interviews to explore barriers and facilitators of HaH implementation. The analysis was informed by the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework. Interviews were audio recorded for transcription and thematic coding. PRINCIPAL FINDINGS We interviewed a sample of clinical leaders (N = 18; clinical/medical directors, operational and program managers) from 14 new and pre-existing U.S. HaH programs diverse by size, urbanicity, and geography. Participants were enthusiastic about the AHCaH waiver. Participants described barriers and facilitators at planning and implementation stages within three overarching themes influencing waiver program implementation: 1) institutional value and assets; 2) program components, such as electronic health records, vendors, pharmacy, and patient monitoring; and 3) patient enrollment, including eligibility and geographic limits. CONCLUSIONS Implementation of AHCaH waiver is a complex process that requires building components in compliance with the requirements to extend the hospital into the home, in coordination with internal and external partners. The study identified barriers that potential adopters and proponents should consider alongside the strategies that some organizations have found useful. Clarity regarding the waiver's future may expedite HaH model dissemination and ensure longevity of this valuable model of care delivery.
Collapse
Affiliation(s)
- Ksenia Gorbenko
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Institute for Health Care Delivery Science, Mount Sinai Health System, New York, New York, USA
| | - Abigail Baim-Lance
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Veteran Affairs, James J. Peters VA Medical Center and Geriatric Research Education and Clinical Center, Bronx, New York, USA
| | - Emily Franzosa
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Veteran Affairs, James J. Peters VA Medical Center and Geriatric Research Education and Clinical Center, Bronx, New York, USA
| | - Heather Wurtz
- Human Rights Institute, University of Connecticut, Storrs, Connecticut, USA
| | - Gabrielle Schiller
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sybil Masse
- Department of Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex Federman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David M Levine
- Department of Medicine, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Ariadne Labs, Boston, Massachusetts, USA
| | - Linda V DeCherrie
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bruce Leff
- Division of Geriatric Medicine and Gerontology, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Albert Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Veteran Affairs, James J. Peters VA Medical Center and Geriatric Research Education and Clinical Center, Bronx, New York, USA
| |
Collapse
|
6
|
Hawkins B. Executive summary of the meeting of the 2022 ASHP Commission on Goals: Optimizing Hospital at Home and Healthcare Transformation. Am J Health Syst Pharm 2022. [PMID: 36048926 DOI: 10.1093/ajhp/zxac216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Bruce Hawkins
- American Society of Health-System Pharmacists, Bethesda, MD, USA
| |
Collapse
|
7
|
Siu AL, Zhao D, Bollens-Lund E, Lubetsky S, Schiller G, Saenger P, Ornstein KA, Federman AD, DeCherrie LV, Leff B. Health equity in Hospital at Home: Outcomes for economically disadvantaged and non-disadvantaged patients. J Am Geriatr Soc 2022; 70:2153-2156. [PMID: 35363372 DOI: 10.1111/jgs.17759] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/02/2022] [Accepted: 03/09/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Albert L Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education, and Clinical Center, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Duzhi Zhao
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Evan Bollens-Lund
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sara Lubetsky
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gabrielle Schiller
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Pamela Saenger
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex D Federman
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Linda V DeCherrie
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Medically Home, Boston, Massachusetts, USA
| | - Bruce Leff
- Division of Geriatric Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
8
|
Boone EJ, Shammash JB. Virtual Hospitalization at Home After the Covid-19 Pandemic: Time to Consider Our Future Community Healthcare Options. J Prim Care Community Health 2022; 13:21501319221112586. [PMID: 35838336 PMCID: PMC9289900 DOI: 10.1177/21501319221112586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The concept of acute hospitalization at home has been described for over
3 decades. Its scope, however, was largely limited to small
experimental trials and pilot studies. The Covid-19 pandemic changed
these circumstances. The convergence of the critical need for acute
hospital beds along with the growing sophistication and comfort in
virtual monitoring facilitated the rapid deployment of hospitalization
at home throughout many communities in the United States. Now in the
waning times of the pandemic, community health leaders and health
systems are questioning what the future role of home virtual
hospitalization might be. Might this concept be relegated to only
future times of critical bed shortage, or might it be part of a true
change in community healthcare delivery.
Collapse
Affiliation(s)
- Emily J Boone
- Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | | |
Collapse
|