Planning and clinical role of acute medical home care services for COVID-19: consensus position statement by the Hospital-in-the-Home Society Australasia

Home-First or Hospital-First? A Propensity Score-Weighted Retrospective Cohort Study

OBJECTIVES

This study aimed to compare clinical and utilization outcomes between home-first and hospital-first models of care in the operation of a hospital-at-home (HaH) program.

DESIGN

This is a retrospective cohort study in which the primary outcome was a composite of oxygenation, intensive care unit admission, and all-cause mortality and the primary utilization outcome was length of stay (hospital and home bed days).

SETTINGS AND PARTICIPANTS

The study sample included 1025 patients with COVID-19 admitted to an HaH program in Singapore from September 23, 2021, to February 29, 2022.

METHODS

Propensity score weighting and regression analysis were used to adjust for confounding between both groups.

RESULTS

There was no significant difference in the odds of occurrence of the primary outcome between the home-first and hospital-first groups (OR, 1.17; 95% CI, 0.44-3.10). Home-first patients had a shorter length of stay by an average of 2.02 (95% CI, 1.10-2.93) days with no statistically significant difference in clinical outcomes compared with hospital-first patients.

CONCLUSIONS AND IMPLICATIONS

Patients with COVID-19 suitable for HaH should be considered for direct admission to HaH without need for an initial hospital stay.

An integrated understanding of the impact of hospital at home: a mixed-methods study to articulate and test a programme theory

BACKGROUND

Hospital at Home (HaH) provides intensive, hospital-level care in patients' homes for acute conditions that would normally require hospitalisation, using multidisciplinary teams. As a programme of complex medical-social interventions, a HaH programme theory has not been fully articulated although implicit in the structures, functions, and activities of the existing HaH services. We aimed to unearth the tacit theory from international evidence and test the soundness of it by studying UK HaH services.

METHODS

We conducted a literature review (29 articles) adopting a 'realist review' approach (theory articulation) and examined 11 UK-based services by interviewing up to 3 staff members from each service (theory testing). The review and interview data were analysed using Framework Analysis and Purposive Text Analysis.

RESULTS

The programme theory has three components- the organisational, utilisation and impact theories. The impact theory consists of key assumptions about the change processes brought about by HaH's activities and functions, as detailed in the organisational and utilisation theories. HaH teams should encompass multiple disciplines to deliver comprehensive assessments and have skill sets for physically delivering hospital-level processes of care in the home. They should aim to treat a broad range of conditions in patients who are clinically complex and felt to be vulnerable to hospital acquired harms. Services should cover 7 days a week, have plans for 24/7 response and deliver relational continuity of care through consistent staffing. As a result, patients' and carers' knowledge, skills, and confidence in disease management and self-care should be strengthened with a sense of safety during HaH treatment, and carers better supported to fulfil their role with minimal added care burden.

CONCLUSIONS

There are organisational factors for HaH services and healthcare processes that contribute to better experience of care and outcomes for patients. HaH services should deliver care using hospital level processes through teams that have a focus on holistic and individually tailored care with continuity of therapeutic relationships between professionals and patients and carers resulting in less complexity and fragmentation of care. This analysis informs how HaH services can organise resources and design processes of care to optimise patient satisfaction and outcomes.

A study of factors affecting the length of hospital stay (LOS) of COVID-19 patients: A qualitative evidence in Iranian hospital

BACKGROUND

The present study aimed to identify the administrators' and physicians' experiences and viewpoints about the factors affecting the length of stay (LOS) of COVID-19 patients and provide valid operational evidence.

MATERIALS AND METHODS

The current study was carried out qualitatively and phenomenologically on experts, officials, and administrators of hospitals in 2021. Purposeful sampling was performed with the maximum diversity. To achieve a comprehensive view, snowball sampling was conducted. Twenty-one experts in the field of healthcare and emerging diseases participated in this study. Semi-structured interviews were used to collect the data. The study sites were universities of medical sciences and hospitals of the Ministry of Health of Iran. The interview questions included questions about the factors affecting the LOS and strategies for controlling the LOS of COVID-19 patients in infectious units. Text analysis was performed through the content analysis method in MAXQDA-10 software.

RESULTS

Based on the experts' viewpoints, several factors affected the LOS in COVID-19 patients. These factors were divided into five clinical, preclinical, economic, social, and management subcategories. The proposed solutions included policy solutions (supportive policies, development of home care services, training and culture building, and establishment of clinical guidelines) and operational solutions (drug management, promotion of equipment and facilities, telehealth or telemedicine services, and promotion of clinical and support processes).

CONCLUSION

One of the main tasks of hospital administrators is identifying the factors affecting the reduction of LOS. Among these factors, clinical and management factors in the hospital are more important and need more planning and attention by hospital officials.

Exploring the advancements of Australian OPAT

Outpatient parenteral antimicrobial therapy (OPAT) in Australia has evolved from modest beginnings to a well-established health service with proven benefits in patient outcomes. This is a comprehensive review of the current state of art Australian OPAT with vignettes of the types of OPAT models of care, antimicrobial prescribing and antimicrobial use. In addition, we highlight the similarities and differences between OPAT to other countries and describe Australian OPAT experiences with COVID-19 and paediatrics. Australian OPAT continues to advance with OPAT antifungals, novel treatment options and upcoming high-impact research.

COVID-19 challenges and changes for home care agencies and providers: a scoping review protocol

OBJECTIVE

This scoping review will explore the challenges experienced by home care agencies and home care providers during the COVID-19 pandemic and the changes made to overcome these challenges.

INTRODUCTION

The COVID-19 pandemic has presented many challenges to home care agencies and providers worldwide. In response, home care agencies and providers were forced to make changes to the way they operate in order to continue providing quality care to homebound patients.

INCLUSION CRITERIA

This scoping review will consider studies that explore the challenges experienced by home care agencies and providers during the COVID-19 pandemic and the changes implemented, or strategies, used to overcome the identified challenges. All geographic locations will be considered for inclusion.

METHODS

This review will be conducted in accordance with the JBI methodology for scoping reviews. Key information sources will include MEDLINE, CINAHL, Embase, Scopus, and Web of Science. Sources of unpublished studies and gray literature will include ProQuest Dissertations and Theses, OpenGrey, medRxiv, and bioRxiv. The review will be limited to articles published in English, from 2020 until present day. Two independent reviewers will use a data extraction tool to collect data. Along with a narrative summary, the results will be presented in diagrammatic or tabular format in a manner that aligns with the review objective and questions.

Telemedicine-assisted care of an older patient with COVID-19 and dementia: bridging the gap between hospital and home

Hospital at Home (HaH) has been proposed as a solution to relieve pressure on hospital beds during the COVID-19 pandemic; however, caregivers' feelings of inadequacy and concerns on the need for tighter clinical monitoring might lead to unnecessary and potentially harmful hospital admissions in frail older patients with mild or atypical COVID-19. Here we report the case of a 91-year old woman with severe dementia and atypical COVID-19 that could be successfully managed by our HaH thanks to her highly motivated caregivers and the support of a telemedicine solution (TMS) to provide caregiver training and support as well as supplementary telemonitoring. Despite some well-known issues on TMS use, the hybrid in-person and tele-visit approach of TMS-assisted HaH could help to create a "secure" environment, empowering caregivers to manage frail older adults with COVID-19 at home, avoiding unnecessary admissions to closed wards and their negative physical, functional and psychological outcomes.

Addressing consistency and demand uncertainty in the Home Care planning problem

Optimizing Home Care Services is receiving a great attention in Operations Research. We address arrival time consistency, person-oriented consistency and demand uncertainty in Home Care, while jointly optimizing assignment, scheduling and routing decisions over a multiple-day time horizon. Consistent time schedules are very much appreciated by patients who, in this setting, are very sensitive to changes in their daily routines. Also person-oriented consistency positively impacts on service quality, guaranteeing that almost the same set of caregivers take care of a patient in the planning horizon. Demand uncertainty plays a pivotal role, too, since both the set of patients under treatment and their care plan can change over time. To the best of our knowledge, this is the first paper dealing with all these aspects in Home Care via a robust approach. We present a mathematical model to the problem, and a pattern-based algorithmic framework to solve it. The framework is derived from the model via decomposition, i.e. suitably fixing the scheduling decisions through the concept of pattern. We propose alternative policies to generate patterns, taking into account consistency and demand uncertainty; when embedding them in the general framework, alternative pattern based algorithms originate. The results of a rich computational experience show that introducing consistency and demand uncertainty in pattern generation policies is crucial to efficiently compute very good quality solutions, in terms of robustness and balancing of the caregiver workload. In addition, a comparison with a simpler model, where no kind of consistency is imposed, shows the importance of considering consistency in pursuing a valuable patient-centered perspective, with a positive effect also on the efficiency of the solution approach.

Unexpected high frequency of early mortality in COVID-19: a single-centre experience during the first wave of the pandemic

We report the high frequency of early mortality in COVID‐19 patients (48.6% of 72 deaths). Early deaths were not explained by differences in age, sex and comorbidities, but they had a more severe disease at hospital admission compared with late deaths. These data highlight the importance of outpatient monitoring for the early identification of COVID‐19 patients who require hospital admission.