Intermediate care in nursing home after hospital admission: a randomized controlled trial with one year follow-up

Effectiveness of community hospital post-acute care on mortality, re-admission, institutionalization, and activation of a home care programme in Emilia-Romagna region, Italy

BACKGROUND

In Italy, there is scant evidence on the impact of Community Hospitals (CHs) on clinical outcomes.

AIMS

To assess the effectiveness of CHs versus long-term care hospital or inpatient rehabilitation facilities on mortality, re-admission, institutionalization, and activation of a home care programme in the Emilia-Romagna Region (ERR-Italy) after acute hospitalisation.

METHODS

We implemented a cohort study drawing upon the ERR Administrative Healthcare Database System and including hospital episodes of ERR residents subject ≥ 65 years, discharged from a public or private hospital with a medical diagnosis to a CH or to usual care between 2017 and 2019. To control for confounding, we applied a propensity score matching.

RESULTS

Patients transferred to CHs had a significantly lower risk of dying but an increased risk of being readmitted to community or acute hospital within 30/90 days from discharge. The hazard of institutionalisation within 30/90 days was significantly lower in the whole population of the CH exposed group but not among patients with cardiac or respiratory chronic diseases or diabetes. The activation of a home care program within 90 days was slightly higher for those who were transferred to a CH.

DISCUSSION

The findings of our study show mixed effects on outcomes of patients transferred to CHs compared to those who followed the post-acute usual care and should be taken with cautious as could be affected by the so-called 'confounding by indication'.

CONCLUSIONS

The study contributes to the intermediate care available evidence from a region with a well-established care provision through CHs.

Effectiveness of integrating primary healthcare in aftercare for older patients after discharge from tertiary hospitals-a systematic review and meta-analysis

Background

Quality of aftercare can crucially impact health status of older patients and reduce the extra burden of unplanned healthcare resource utilisation. However, evidence of effectiveness of primary healthcare in supporting aftercare, especially for older patients after discharge are limited.

Methods

We searched for English articles of randomised controlled trials published between January 2000 and March 2022. All-cause hospital readmission rate and length of hospital stay were pooled using a random-effects model. Subgroup analyses were conducted to identify the relationship between intervention characteristics and the effectiveness on all-cause hospital readmission rate.

Results

A total of 30 studies with 11,693 older patients were included in the review. Compared with patients in the control group, patients in the intervention group had 32% less risk of hospital readmission within 30 days (RR = 0.68, P < 0.001, 95%CI: 0.56–0.84), and 17% within 6 months (RR = 0.83, P < 0.001, 95%CI: 0.75–0.92). According to the subgroup analysis, continuity of involvement of primary healthcare in aftercare had significant effect with hospital readmission rates (P < 0.001). Economic evaluations from included studies suggested that aftercare intervention was cost-effective due to the reduction in hospital readmission rate and risk of further complications.

Conclusion

Integrating primary healthcare into aftercare was designed not only to improve the immediate transition that older patients faced but also to provide them with knowledge and skills to manage future health problems. There is a pressing need to introduce interventions at the primary healthcare level to support long-term care.

Effectiveness of facility-based transition care on health-related outcomes for older adults: A systematic review and meta-analysis

BACKGROUND

Although Transition Care Programmes (TCP) are designed to assist older adults to regain functional ability after hospitalisation, it is unclear whether TCP improve older adults' health-related outcomes.

OBJECTIVES

The objective of the review was to synthesise the best available evidence for the effectiveness of TCP on health-related outcomes for older adults admitted to a transition care facility after hospitalisation.

METHODS

Searches were conducted using the databases PubMed, AMED (Ovid), Embase (Ovid), PscyINFO (Ovid) and CINAHL (Full text) and grey literature from January 2000 to May 2020 in English only. Studies that reported health-related outcomes of older adults (aged 65 and above) who received TCP in a facility setting were deemed eligible for inclusion following critical appraisal by two reviewers. Data were pooled in meta-analysis where possible, or reported narratively.

RESULTS

A total of 21 studies from seven countries [(n = 5 RCT, n = 16 observational cohort studies) participants' mean age 80.2 (±8.3)] were included. Pooled analysis (2069 participants, 7 studies) demonstrated that 80% of older adults undertaking TCP were discharged home [95% CI (0.78-0.82, p < 0.001), I² = 21.99%, very low GRADE evidence]. Proportions of older adults discharged home varied widely between countries (33.3%-86.4%). There was a significant improvement in ability to perform activities of daily living (2001 participants, 7 studies) as measured by the Modified Barthel Index [17.65 points (95% CI 5.68-29.62, p = 0.004), I²  = 0.00%, very low GRADE evidence].

CONCLUSIONS

The proportion of older adults discharged home from TCP compared to other discharge destinations differs between countries. This could be due to the intensity of the rehabilitation delivered and the maximum length of stay allowed prior to discharge.

IMPLICATIONS FOR PRACTICE

Future studies that comprehensively evaluate the efficacy of TCP on health-related outcomes including quality of life are required. Further investigation is required to identify which aspects of TCP affect successful discharge home.

Identifying the Association Between Older Adults' Characteristics and Their Health-Related Outcomes in a Transition Care Setting: A Retrospective Audit

Introduction: Continued evaluation of Transition Care Programs (TCP) is essential to improving older adults' outcomes and can guide which older adults may benefit from undertaking TCP. The aim of this study was to audit a transition care service to identify the association between the characteristics of older adults undertaking a facility-based TCP and (i) discharge destination and (ii) functional improvement.

Materials and methods: An audit (n = 169) of older adults aged 60 years and above who completed a facility-based TCP in Australia was conducted. Outcomes audited were performance of activities of daily living (ADL) measured using the Modified Barthel Index (MBI) and discharge destination. Data were analyzed using logistic regression and linear mixed modeling.

Results: Older adults [mean age 84.2 (±8.3) years] had a median TCP stay of 38 days. Fifty-four older adults (32.0%) were discharged home, 20 (11.8%) were readmitted to hospital and 93 (55%) were admitted to permanent residential aged care. Having no cognitive impairment [OR = 0.41 (95% CI 0.18-0.93)], being independent with ADL at admission [OR = 0.41 (95% CI 0.16-1.00)] and a pre-planned team goal of home discharge [OR = 24.98 (95% CI 5.47-114.15)] was significantly associated with discharge home. Cases discharged home showed greater improvement in functional ability [MBI 21.3 points (95% CI 17.0-25.6)] compared to cases discharged to other destinations [MBI 9.6 points (95% CI 6.5-12.7)].

Conclusion: Auditing a facility-based TCP identified that older adults who were independent in ADL and had good cognitive levels were more likely to be discharged home. Older adults with cognitive impairment also made clinically significant functional improvements.

Can facility-based transitional care improve patient flow? Lessons from four Canadian regions

Units providing transitional, subacute, or restorative care represent a common intervention to facilitate patient flow and improve outcomes for lower acuity (often older) inpatients; however, little is known about Canadian health systems' experiences with such "transition units." This comparative case study of diverse units in four health regions (48 interviews) identified important success factors and pitfalls. A fundamental requirement for success is to clearly define the unit's intended population and design the model around its needs. Planners must also ensure that the unit be resourced and staffed to deliver truly restorative care. Finally, streamlined processes must be developed to help patients access and move through the unit. Units that were perceived as more effective appeared to have satisfactorily addressed these population, capacity, and process issues, whereas those perceived as less effective continued to struggle with them. Findings suggest principles to support optimal design and implementation of transition units.

Understanding transitional care programs for older adults who experience delayed discharge: a scoping review

Background

Many hospitalized older adults cannot be discharged because they lack the health and social support to meet their post-acute care needs. Transitional care programs (TCPs) are designed to provide short-term and low-intensity restorative care to these older adults experiencing or at risk for delayed discharge. However, little is known about the contextual factors (i.e., patient, staff and environmental characteristics) that may influence the implementation and outcomes of TCPs. This scoping review aims to answer: 1) What are socio-demographic and/or clinical characteristics of older patients served by TCPs?; 2) What are the core components provided by TCPs?; and 3) What patient, caregiver, and health system outcomes have been investigated and what changes in these outcomes have been reported for TCPs?

Methods

The six-step scoping review framework and PRISMA-ScR checklist were followed. Studies were included if they presented models of TCPs and evaluated them in community-dwelling older adults (65+) experiencing or at-risk for delayed discharge. The data synthesis was informed by a framework, consistent with Donabedian’s structure-process-outcome model.

Results

TCP patients were typically older women with multiple chronic conditions and some cognitive impairment, functionally dependent and living alone. The review identified five core components of TCPs: assessment; care planning and monitoring; treatment; discharge planning; and patient, family and staff education. The main outcomes examined were functional status and discharge destination. The results were discussed with a view to inform policy makers, clinicians and administrators designing and evaluating TCPs as a strategy for addressing delayed hospital discharges.

Conclusion

TCPs can influence outcomes for older adults, including returning home. TCPs should be designed to incorporate interdisciplinary care teams, proactively admit those at risk of delayed discharge, accommodate persons with cognitive impairment and involve care partners. Additional studies are required to investigate the contributions of TCPs within integrated health care systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02099-9.

Factors associated with success in transition care services among older people in Australia

BACKGROUND

The Australian Transition Care Program (TCP) is a national intermediate care service aiming to optimise functional independence and delay entry to permanent care for older people leaving hospital. The aim of this study was to describe the outcomes of TCP and identify demographic and clinical factors associated with TCP 'success', to assist with clinical judgements about suitable candidates for the program.

METHOD

We conducted a descriptive cohort study of all older Australians accessing TCP for the first time between 2007 and 2015. Logistic regression models assessed demographic and clinical factors associated with change in performance on a modified Barthel Index from TCP entry to discharge and on discharge to community. Fine-Gray regression models estimated factors associated with transition to permanent care within 6 months of TCP discharge, with death as a competing event.

RESULTS

Functional independence improved from entry to discharge for 46,712 (38.4%) of 124,301 TCP users. Improvement was more common with younger age, less frailty, shorter hospital stay prior to TCP, and among women, those without a carer, living outside a major city, and without dementia. People who received TCP in a residential setting were far less likely to record improved functional impairment and more likely to be discharged to permanent care than those in a community setting. Discharge to community was more common with younger age and among women and those without dementia. Nearly 12% of community TCP and 63% of residential TCP users had transitioned to permanent care 6 months after discharge. Entry to permanent care was more common with older age, higher levels of frailty, and among those with dementia.

CONCLUSIONS

More than half of TCP users are discharged to home and remain at home after 6 months. However, residential-based TCP may have limited efficacy. Age, frailty, carer status, and dementia are key factors to consider when assessing program suitability. Future studies comparing users to a suitably matched control group will be very helpful for confirming whether the TCP program is meeting its aims.

Defining the characteristics of intermediate care models including transitional care: an international Delphi study

BACKGROUND

Although there is growing utilisation of intermediate care to improve the health and well-being of older adults with complex care needs, there is no international agreement on how it is defined, limiting comparability between studies and reducing the ability to scale effective interventions.

AIM

To identify and define the characteristics of intermediate care models.

METHODS

A scoping review, a modified two-round electronic Delphi study involving 27 multi-professional experts from 13 countries, and a virtual consensus meeting were conducted.

RESULTS

Sixty-six records were included in the scoping review, which identified four main themes: transitions, components, benefits and interchangeability. These formed the basis of the first round of the Delphi survey. After Round 2, 16 statements were agreed, refined and collapsed further. Consensus was established for 10 statements addressing the definitions, purpose, target populations, approach to care and organisation of intermediate care models.

DISCUSSION

There was agreement that intermediate care represents time-limited services which ensure continuity and quality of care, promote recovery, restore independence and confidence at the interface between home and acute services, with transitional care representing a subset of intermediate care. Models are best delivered by an interdisciplinary team within an integrated health and social care system where a single contact point optimises service access, communication and coordination.

CONCLUSIONS

This study identified key defining features of intermediate care to improve understanding and to support comparisons between models and studies evaluating them. More research is required to develop operational definitions for use in different healthcare systems.

The effectiveness of intermediate care including transitional care interventions on function, healthcare utilisation and costs: a scoping review

Aim

This scoping review examined the effectiveness of intermediate care including transitional care interventions for middle-aged and older adults on function, healthcare utilisation, and costs.

Findings

While some studies report positive outcomes on hospital utilisation, the evidence is limited for their effectiveness on emergency department attendances, institutionalisation, function, and cost-effectiveness.

Message

Intermediate care including transitional care interventions were associated with reduced hospital stay but this finding was not universal.

Electronic supplementary material

The online version of this article (10.1007/s41999-020-00365-4) contains supplementary material, which is available to authorized users.

Background and aim

Intermediate care describes services, including transitional care, that support the needs of middle-aged and older adults during care transitions and between different settings. This scoping review aimed to examine the effectiveness of intermediate care including transitional care interventions for middle-aged and older adults on function, healthcare utilisation, and costs.

Design

A scoping review of the literature was conducted including studies published between 2002 and 2019 with a transitional care and/or intermediate care intervention for adults aged ≥ 50. Searches were performed in CINAHL, Cochrane Library, EMBASE, Open Grey and PubMed databases. Qualitative and quantitative approaches were employed for data synthesis.

Results

In all, 133 studies were included. Interventions were grouped under four models of care: (a) Hospital-based transitional care (n = 8), (b) Transitional care delivered at discharge and up to 30 days after discharge (n = 70), (c) Intermediate care at home (n = 41), and (d) Intermediate care delivered in a community hospital, care home or post-acute facility (n = 14). While these models were associated with a reduced hospital stay, this was not universal. Intermediate including transitional care services combined with telephone follow-up and coaching support were reported to reduce short and long-term hospital re-admissions. Evidence for improved ADL function was strongest for intermediate care delivered by an interdisciplinary team with rehabilitation at home. Study design and types of interventions were markedly heterogenous, limiting comparability.

Conclusions

Although many studies report that intermediate care including transitional care models reduce hospital utilisation, results were mixed. There is limited evidence for the effectiveness of these services on function, institutionalisation, emergency department attendances, or on cost-effectiveness.

Electronic supplementary material

The online version of this article (10.1007/s41999-020-00365-4) contains supplementary material, which is available to authorized users.

Key Service Improvements After the Introduction of an Integrated Orthogeriatric Service

Introduction:

Models of orthogeriatric care have been shown to improve functional outcomes for patients after hip fractures and can improve compliance with best practice guidelines for hip fracture care.

Methods:

We evaluated improvements to key performance indicators in hip fracture care after implementation of a formal orthogeriatric service. Compliance with Irish Hip Fracture standards of care was reviewed, and additional outcomes such as length of stay, access to rehabilitation, and discharge destination were evaluated.

Results:

Improvements were observed in all of the hip fracture standards of care. Mean length of stay decreased from 19 to 15.5 days (mean difference 3.5 days; P < .05). A higher proportion of patients were admitted to rehabilitation (16.7% vs 7.9%, P < .05), and this happened in a timelier fashion (17.8 vs 24.8 days, P < .05). We found that less patients required convalescence post-hip fracture.

Discussion:

A standardized approach to integrated post-hip fracture care with orthogeriatrics has improved standards of care for patients.

Conclusion:

Introduction of orthogeriatric services has resulted in meaningful improvements in clinical outcomes for older people with hip fractures.

Interventions to Promote Early Discharge and Avoid Inappropriate Hospital (Re)Admission: A Systematic Review

Increasing pressure on limited healthcare resources has necessitated the development of measures promoting early discharge and avoiding inappropriate hospital (re)admission. This systematic review examines the evidence for interventions in acute hospitals including (i) hospital-patient discharge to home, community services or other settings, (ii) hospital discharge to another care setting, and (iii) reduction or prevention of inappropriate hospital (re)admissions. Academic electronic databases were searched from 2005 to 2018. In total, ninety-four eligible papers were included. Interventions were categorized into: (1) pre-discharge exclusively delivered in the acute care hospital, (2) pre- and post-discharge delivered by acute care hospital, (3) post-discharge delivered at home and (4) delivered only in a post-acute facility. Mixed results were found regarding the effectiveness of many types of interventions. Interventions exclusively delivered in the acute hospital pre-discharge and those involving education were most common but their effectiveness was limited in avoiding (re)admission. Successful pre- and post-discharge interventions focused on multidisciplinary approaches. Post-discharge interventions exclusively delivered at home reduced hospital stay and contributed to patient satisfaction. Existing systematic reviews on tele-health and long-term care interventions suggest insufficient evidence for admission avoidance. The most effective interventions to avoid inappropriate re-admission to hospital and promote early discharge included integrated systems between hospital and the community care, multidisciplinary service provision, individualization of services, discharge planning initiated in hospital and specialist follow-up.

Admission rates in a general practitioner-based versus a hospital specialist based, hospital-at-home model: ACCESS, an open-labelled randomised clinical trial of effectiveness

BACKGROUND

Hospital at home (HaH) is an alternative to acute admission for elderly patients. It is unclear if should be cared for a primarily by a hospital intern specialist or by the patient's own general practitioner (GP). The study assessed whether a GP based model was more effective than a hospital specialist based model at reducing number of hospital admissions without affecting the patient's recovery or number of deaths.

METHODS

Pragmatic, randomised, open-labelled multicentre parallel group trial with two arms in four municipalities, four emergency departments and 150 GPs in Southern Denmark, including + 65 years old patients with an acute medical condition that required acute hospital in-patient care. The patients were randomly assigned to hospital specialist based model or GP model of HaH care. Five physical and cognitive performance tests were performed at inclusion and after 7 days. Primary outcome was number of hospital admissions within 7 days. Secondary outcomes were number of admissions within 14, 21 and 30 days, deaths within 30 and 90 days and changes in performance tests.

RESULTS

Sixty seven patients were enrolled in the GP model and 64 in the hospital specialist model. 45% in the hospital specialist arm versus 24% in the GP arm were admitted within 7 days (effect size 2.7, 95% CI 1.3-5.8; p = 0.01) and this remained significant within 30 days. No differences were found in death or changes in performance tests from day 0-7 days between the two groups.

CONCLUSIONS

The GP based HaH model was more effective than the hospital specialist model in avoiding hospital admissions within 7 days among elderly patients with an acute medical condition with no differences in mental or physical recovery rates or deaths between the two models.

REGISTRATION

No. NCT02422849 Registered 27 March 2015. Retrospectively registered.

Interorganizational Collaboration in Transitional Care - A Study of a Post-Discharge Programme for Elderly Patients

Introduction and aim:

This article reports a study of a post-discharge programme for elderly patients in Norway. It took place in an intermediate ward for transitional care and was based on collaboration between a municipality and a hospital, which was part of a health enterprise. The aim of the study was to analyse the collaboration and its possible effects on the quality of patient care, and the economic efficiency of the project for the organizations involved.

Methodology:

A mixed-methods approach, consisting of interviews, questionnaires and analyses of official documents and statistics.

Results:

The collaboration was working well on the top level of the organizations, but was more problematic on the operative level. However, there were clear signs of improvement. The patients who received transitional care were more satisfied with their stay at the ward than their previous stay at the hospital. They were discharged to their homes more often and perceived to have a higher level of functioning than the hospital patients. Average costs per patient were also lower in the ward than in the hospital departments.

Conclusion:

The collaboration had mainly positive impacts on the quality of patient care and the economic efficiency of elderly care in the municipality. However, the board of the health enterprise decided to close down the intermediate ward.

Three Different Outcomes in Older Community-dwelling Patients Receiving Intermediate Care in Nursing Home after Acute Hospitalization

OBJECTIVES

To evaluate the recovery and outcome of older communitydwelling patients admitted to intermediate care (IC) in nursing homes after acute hospitalization, and to compare patients who were able and unable to return directly to their own homes.

DESIGN

Prospective, observational, cohort study conducted between June 2011 and 2014.

SETTING

A 19- bed IC unit in a nursing home with increased multidisciplinary staffing.

PARTICIPANTS

A total of 961 community-dwelling patients, ≥70 years of age, considered to have a rehabilitation potential and no major cognitive impairment or delirium, transferred from internal medicine, cardiac, pulmonary and orthopaedic hospital departments.

MEASUREMENTS

Demographic data, clinical information, comprehensive geriatric assessment (CGA), discharge destination and length of stay. Residence status and mortality 1 month, 2 months, 3 months, and 6 months after discharge from the hospital.

RESULTS

The trajectory of recovery was divided into 3 groups: 1) Rapid recovery, able to return home after median 14 days in IC (n=785, 82%); 2) Slow recovery, requiring additional transfer to other nursing home after IC, but still able to return home within 2 months (n=106, 11%). 3) Poor recovery, requiring transfer to other nursing home after IC and still in a nursing home or dead at 2 months (n=66, 7%). Significant different clinical characteristics were demonstrated between the patients in the 3 groups. After 6 months, the recovery of patients with rapid or slow recovery was similar, 87% were living at home, compared to only 20% of the patients with poor recovery. In multiple logistic regression analysis, slow or poor recovery was significantly associated with low scores on the Barthel index and orthopaedic admission diagnosis.

CONCLUSIONS

Although the majority of patients selected for treatment in the IC unit were able to recover and return home, a group of patients needed extra time, up to 2 months, to recover and another group had a poor chance of recovering and returning home. Different caring pathways for different patient groups may be considered in the PAC setting.