Patients' and caregivers' perceptions of the quality of hospital-at-home service: A scoping review

AIM

This scoping review aims to provide an overview of patients and caregivers perceptions of hospital-at-home (HaH) services.

BACKGROUND

HaH services provide patients with hospital-level care at home and are central to integrated healthcare systems. Despite favourable data from individual studies in the literature, in-depth analysis from patient and caregivers perspectives is lacking. This understanding is essential for the dissemination and scaling of HaH services.

DESIGN

The scoping review was performed using the PRISMA-ScR checklist and PAGER framework for the findings report and research recommendations.

METHOD

Literature from PubMed, Web of Science, Ovid, CINAHL, Cochrane and Mednar databases were searched. Relevant studies published between 1st January 2005 and 31st December 2022 were identified. The conceptual model of the development of patient perceptions of quality was used for data extraction and tabulation.

RESULTS

The review included 24 articles. Expectation attributions were identified as needs, types of service, hospitalisation experiences, family care preferences, social-demographics and coping skills. From patient's and caregiver's perspectives, HaH was safe, effective and viewed positively. Perceived concerns/barriers and enablers/facilitators were associated with individual, caregiver and system factors, but demonstrated an overall satisfaction in the HaH service.

CONCLUSION

HaH provides an excellent service according to patients' and caregivers' perceptions. However, gaps in care were identified such as prioritising patient-centred care, along with improved multidisciplinary continuity of care and future studies should incorporate these into their research of HaH.

RELEVANCE TO CLINICAL PRACTICE

Patients' and caregivers' HaH needs should be embedded in the design, development and implementation of HaH services.

PATIENT AND PUBLIC CONTRIBUTION

Not applicable for the study design of this scoping review.

Care Delivery Interventions for Individuals with Cancer: A Literature Review and Focus on Gastrointestinal Malignancies

BACKGROUND

Gastrointestinal malignancies represent a particularly challenging condition, often requiring a multidisciplinary approach to management in order to meet the unique needs of these individuals and their caregivers.

PURPOSE

In this literature review, we sought to describe care delivery interventions that strive to improve the quality of life and care for patients with a focus on gastrointestinal malignancies.

CONCLUSION

We highlight patient-centered care delivery interventions, including patient-reported outcomes, hospital-at-home interventions, and other models of care for individuals with cancer. By demonstrating the relevance and utility of these different care models for patients with gastrointestinal malignancies, we hope to highlight the importance of developing and testing new interventions to address the unique needs of this population.

Designing for flexibility in hybrid care services: lessons learned from a pilot in an internal medicine unit

Digital transformation in healthcare during the COVID-19 pandemic led to the development of new hybrid models integrating physical and virtual care. The ability to provide remote care by telemedicine technologies and the need to better manage and control hospitals' occupancy accelerated growth in hospital-at-home programs. The Sheba Medical Center restructured to create Sheba Beyond as the first virtual hospital in Israel. These transformations enabled them to deliver hybrid services in their internal medicine unit by managing inpatient hospital-care with remote home-care based on the patients' medical condition. The hybrid services evolved to integrate care pathways multiplied by the mode of delivery-physical (in person) or virtual (technology enabled)-and the location of care-at the hospital or the patient home. The study examines this home hospitalization program pilot for internal medicine at Sheba Medical Center (MC). The research is based on qualitative semi-structured interviews with Sheba Beyond management, medical staff from the hospital and the Health Maintenance Organization (HMO), Architects, Information Technology (IT), Telemedicine and Medtech organizations. We investigated the implications of the development of hybrid services for the future design of the physical built-environment and the virtual technological platform. Our findings highlight the importance of designing for flexibility in the development of hybrid care services, while leveraging synergies across the built environment and digital platforms to support future models of care. In addition to exploring the potential for scalability in accelerating the flexibility of the healthcare system, we also highlight current barriers in professional, management, logistic and economic healthcare models.

Why U.S. Patients Declined Hospital-at-Home during the COVID-19 Public Health Emergency: An Exploratory Mixed Methods Study

To understand why US patients refused participation in hospital-at-home (H@H) during the coronavirus disease 2019 Public Health Emergency, eligible adult patients seen at 2 Mayo Clinic sites, Mayo Clinic Health System-Northwest Wisconsin region (NWWI) and Mayo Clinic Florida (MCF), from August 2021 through March 2022, were invited to participate in a convergent-parallel study. Quantitative associations between H@H participation status and patient baseline data at hospital admission were investigated. H@H patients were more likely to have a Mayo Clinic patient portal at baseline (P-value: .014), indicating a familiarity with telehealth. Patients who refused were more likely to be from NWWI (P-value < .001) and have a higher Epic Deterioration Index score (P-value: .004). The groups also had different quarters (in terms of fiscal calendar) of admission (P-value: .040). Analyzing qualitative interviews (n = 13) about refusal reasons, 2 themes portraying the quantitative associations emerged: lack of clarity about H@H and perceived domestic challenges. To improve access to H@H and increase patient recruitment, improved education about the dynamics of H@H, for both hospital staff and patients, and inclusive strategies for navigating domestic barriers and diagnostic challenges are needed.

Avoiding Escalation to the Emergency Department by Activating an In-Home Rapid Response Team in the 30 Days After Hospital-at-Home Discharge

BACKGROUND

Mayo Clinic's virtual hybrid hospital-at-home program, Advanced Care at Home (ACH) monitors acute and post-acute patients for signs of deterioration and institutes a rapid response (RR) system if detected.

OBJECTIVE

This study aimed to describe Mayo Clinic's ACH RR team and its effect on emergency department (ED) use and readmission rates.

METHODS

This was a retrospective review of all post-inpatient (restorative phase) ACH patients admitted from July 6, 2020 through June 30, 2021. If the restorative patient had a clinical decompensation, an RR was activated. All RR activations were analyzed for patient demographic characteristics, admitting and escalation diagnosis, time spent by virtual team on the RR, and whether the RR resulted in transport to the ED or hospital readmission.

RESULTS

Three hundred and twenty patients were admitted to ACH during the study interval; 230 received restorative care. Seventy-two patients (31.3%) had events that triggered an RR. Fifty (69.4%) of the RR events were related to the admission diagnosis (p < 0.001; 95% CI 0.59-0.80). Twelve patients (16.7%) required transport to an ED for further treatment and were readmitted and 60 patients (83.3%) were able to be treated successfully in the home by the RR team (p < 0.001; 95% CI 0.08-0.25).

CONCLUSIONS

The use of an ACH RR team was effective at limiting both escalations back to an ED and hospital readmissions, as 83% of deteriorating patients were successfully stabilized and managed in their homes. Implementing a hospital-at-home RR team can reduce the need for ED use by providing critical resources and carrying out required interventions to stabilize the patient's condition.

mHealth App to Facilitate Remote Care for Patients With COVID-19: Rapid Development of the DrCovid+ App

BACKGROUND

The 2019 novel COVID-19 has severely burdened the health care system through its rapid transmission. Mobile health (mHealth) is a viable solution to facilitate remote monitoring and continuity of care for patients with COVID-19 in a home environment. However, the conceptualization and development of mHealth apps are often time and labor-intensive and are laden with concerns relating to data security and privacy. Implementing mHealth apps is also a challenging feat as language-related barriers limit adoption, whereas its perceived lack of benefits affects sustained use. The rapid development of an mHealth app that is cost-effective, secure, and user-friendly will be a timely enabler.

OBJECTIVE

This project aimed to develop an mHealth app, DrCovid+, to facilitate remote monitoring and continuity of care for patients with COVID-19 by using the rapid development approach. It also aimed to address the challenges of mHealth app adoption and sustained use.

METHODS

The Rapid Application Development approach was adopted. Stakeholders including decision makers, physicians, nurses, health care administrators, and research engineers were engaged. The process began with requirements gathering to define and finalize the project scope, followed by an iterative process of developing a working prototype, conducting User Acceptance Tests, and improving the prototype before implementation. Co-designing principles were applied to ensure equal collaborative efforts and collective agreement among stakeholders.

RESULTS

DrCovid+ was developed on Telegram Messenger and hosted on a cloud server. It features a secure patient enrollment and data interface, a multilingual communication channel, and both automatic and personalized push messaging. A back-end dashboard was also developed to collect patients' vital signs for remote monitoring and continuity of care. To date, 400 patients have been enrolled into the system, amounting to 2822 hospital bed-days saved.

CONCLUSIONS

The rapid development and implementation of DrCovid+ allowed for timely clinical care management for patients with COVID-19. It facilitated early patient hospital discharge and continuity of care while addressing issues relating to data security and labor-, time-, and cost-effectiveness. The use case for DrCovid+ may be extended to other medical conditions to advance patient care and empowerment within the community, thereby meeting existing and rising population health challenges.

Experiences of Patients and Their Caregivers Admitted to a Hospital-at-Home Program in Singapore: a Descriptive Qualitative Study

BACKGROUND

Hospital at Home (HaH) programs have been shown to improve clinical outcomes, quality of care, and patient satisfaction. However, how Asian patients experience HaH remained underexplored.

OBJECTIVE

To explore the perceptions and experiences of patients and caregivers admitted to a hospital-at-home program in Singapore.

DESIGN

Descriptive qualitative study design.

PARTICIPANTS

Purposive sampling was used to conduct 36 interviews with 13 patients, nine Legally Acceptable Representatives (LARs), and 14 caregivers until data saturation was achieved.

INTERVENTIONS

NUHS@Home is a HaH program providing care through a multi-disciplinary team, enabled by remote vital signs monitoring through a tablet and wireless blood pressure and oxygen meters.

APPROACH

This study used in-depth semi-structured individual interviews. Interviews were transcribed and thematically analyzed using Braun and Clark's six-step inductive approach.

KEY RESULTS

The overarching theme identified was "Enablers, difficulties, and improvements to the HaH experiences" which was supported by three key themes: (1) Perceived better care at home, (2) Importance of social support, and (3) Organizational structures required to support HaH. Participants described overall HaH experiences around factors contributing to their impeding engagement, overall satisfaction, and quality of care.

CONCLUSIONS

Although HaH is unfamiliar to the Singapore population, most of the participants in this study had an overall positive experience. The key challenges found in this paper were the stress and inconvenience caused to caregivers. The enablers for positive HaH experiences were (1) consideration of patient's family members as key participants in the patients' therapeutic alliance; (2) the HaH care team must be accessible, approachable, and reassuring, and communicate frequently and timely with patients and their families; and (3) financing strategies to ensure HaH out-of-pockets costs remain affordable which are critical to keeping HaH as an option for patients and families.

Smartphones and Threshold-Based Monitoring Methods Effectively Detect Falls Remotely: A Systematic Review

In the US, at least one fall occurs in at least 28.7% of community-dwelling seniors 65 and older each year. Falls had medical costs of USD 51 billion in 2015 and are projected to reach USD 100 billion by 2030. This review aims to discuss the extent of smartphone (SP) usage in fall detection and prevention across a range of care settings. A computerized search was conducted on six electronic databases to investigate the use of remote sensing technology, wireless technology, and other related MeSH terms for detecting and preventing falls. After applying inclusion and exclusion criteria, 44 studies were included. Most of the studies targeted detecting falls, two focused on detecting and preventing falls, and one only looked at preventing falls. Accelerometers were employed in all the experiments for the detection and/or prevention of falls. The most frequent course of action following a fall event was an alarm to the guardian. Numerous studies investigated in this research used accelerometer data analysis, machine learning, and data from previous falls to devise a boundary and increase detection accuracy. SP was found to have potential as a fall detection system but is not widely implemented. Technology-based applications are being developed to protect at-risk individuals from falls, with the objective of providing more effective and efficient interventions than traditional means. Successful healthcare technology implementation requires cooperation between engineers, clinicians, and administrators.

Impact of an Acquisition Advanced Practice Provider on Home Hospital Patient Volumes and Length of Stay

In July 2020, Mayo Clinic introduced a hospital-at-home program, known as Advanced Care at Home (ACH) as an alternate option for clinically stable medical patients requiring hospital-level care. This retrospective cohort study evaluates the impact of the addition of a dedicated ACH patient acquisition Advanced Practice Provider (APP) on average length of stay (ALOS) and the number of patients admitted into the program between in Florida and Wisconsin between 6 July 2020 and 31 January 2022. Patient volumes and ALOS of 755 patients were analyzed between the two sites both before and after a dedicated acquisition APP was added to the Florida site on 1 June 2021. The addition of a dedicated acquisition APP did not affect the length of time a patient was in the emergency department or hospital ward prior to ACH transition (2.91 days [Florida] vs. 2.59 days [Wisconsin], p = 0.22), the transition time between initiation of the ACH consult to patient transfer home (0.85 days [Florida] vs. 1.16 days [Wisconsin], p = 0.28), or the total ALOS (6.63 days [Florida] vs. 6.34 days [Wisconsin], p = 0.47). The average number of patients acquired monthly was significantly increased in Florida (38.3 patients per month) compared with Wisconsin (21.6 patients per month) (p < 0.01). The addition of a dedicated patient acquisition APP resulted in significantly higher patient volumes but did not affect transition time or ALOS. Other hospital-at-home programs may consider the addition of an acquisition APP to maximize patient volumes.

Negotiating safety and responsibility in caregiving to children receiving hospital-at-home: A Norwegian study of parents and homecare nurses' experiences

Healthcare policies in Western countries increasingly emphasise the avoidance of hospitalisation to reduce hospital admissions. Hospital-at-home for children is a treatment offered to children at home that would otherwise require hospitalisation. Norway practices a model where homecare services play a significant role in assisting the hospital when children need home visits beyond the capacity of what the hospital can offer. Although homecare nurses' work has been affected by several changes in recent decades, few have reported on what these changes imply for homecare nurses' work and family caregivers. The aim of this study was to explore how parents and homecare nurses worked and collaborated in home visits to children receiving hospital-at-home, focusing on how they negotiated caregiving. We conducted 16 interviews: six interviews with parents and 10 interviews with homecare nurses. The interviews were analysed thematically. Both parents and homecare nurses described these home visits as challenging, indicating experiences of distrust. Parents had carefully observed homecare nurses, checking whether they knew how to treat the child and perform the clinical procedures. Homecare nurses had invested much energy into being perceived as calm and trustworthy by the parents. We applied the perspective of negotiation to understand the work and collaboration reported by parents and homecare nurses when unsafety or uncertainty was experienced during home visits, revealing the complexity of their roles in dealing with such events. The results showed the reciprocal dependency between the parents and the homecare nurses that enabled them to perform caregiving work in partnership, sharing responsibility. Our findings suggest that the collaboration with hospital-at-home has an impact on the feeling of safety and control for both parties. We question whether there is a danger of too much responsibility being left with the parents when homecare services are involved.

Influences of COVID-19 pandemic on hospital-at-home functions in Finland - a questionnaire survey

OBJECTIVE

To investigate functions of Finnish hospital-at-home (HAH) during the first year of COVID19-pandemic 2020 compared with the previous year 2019.

DESIGN

Retrospective questionnaire survey.

SETTING

Finnish HAHs from Northern, Eastern, Southern, Western and Central parts of Finland participated in a questionnaire web-based questionnaire survey. The numbers of patients, activities and staff in 2019 and 2020, participation in the care of COVID19 patients, availability of protective clothing, attitudes of patients towards home care and development of new practices in the corona era were asked using both predefined and free questions.

SUBJECTS

questionnaire was sent to the nurses and physicians in charge of the HAHs (N = 13), 77% responded. The HAHs provided services to a total of 1,196,783 inhabitants in their municipalities.

RESULTS

There were no significant changes in the numbers of patients, staff or activities between the years 2019 and 2020. Although nurses did viral tests, COVID19 patients were cared only in 40% of HAHs. Protective clothing was well available. New instructions for infection management were created.

CONCLUSIONS

The COVID-19 pandemic did not largely influence the functions of the examined Finnish HAHs in 2020. Most activities and patients' characteristics remained unchanged from 2019. The role of HAHs should be further developed in Scandinavian countries, particularly during pandemics.Key PointsHospital-at-home (HAH) is a cost-effective model to provide hospital-like services.Data about the role of HAHs during COVID19 pandemics is lacking in the Nordic countries.This study shows that, the large Finnish municipal HAHs have been not influenced by pandemics.

Perceptions of Hospital-at-Home Among Stakeholders: a Meta-synthesis

BACKGROUND

Hospital-at-home (HaH) provides acute healthcare in patients' homes as an alternative to traditional hospital inpatient care. HaH has been shown to improve clinical outcomes, increase patient satisfaction, and reduce hospitalization costs. Despite its effectiveness, the uptake of HaH remains slow and little is known about factors that impact the quality and transferability of HaH. This review aimed to qualitatively synthesize existing literature to examine the perspectives of stakeholders to identify areas of improvement in this model of care.

METHODOLOGY

Six electronic databases (Cumulative Index of Nursing and Allied Health Literature, PubMed, Embase, PsychINFO, Scopus, and Mednar) were searched from inception date until 3 February 2021. The included studies were assessed for quality using the Critical Appraisal Skills Program tool. This review was registered on the International Prospective Register of Systematic Reviews. The meta-synthesis was completed according to Sandelowski and Barroso's guidelines.

RESULTS

Sixteen articles met the inclusion criteria. The overarching synthesized theme was "the intricacies of developing HaH," and the four main themes were (1) factors influencing patient selection, (2) advantages of HaH, (3) challenges of HaH, and (4) enablers for HaH development.

CONCLUSION

Overall, high levels of satisfaction were expressed by various stakeholders. Continuity of care remains an important factor for patient-centeredness in HaH. Caregivers should be involved in the decision-making process and supported throughout the HaH duration to prevent caregiver burnout. Collaboration and coordination among healthcare professionals are vital and can be strengthened through training and technological advancements of remote patient monitoring. Institutional and organizational support for stakeholders may make HaH a viable solution to modern healthcare challenges.

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

During a pandemic when hospitals are stretched and patients need isolation, the role of hospital‐in‐the‐home (HITH) providing acute medical care at home has never been more relevant. We aimed to define and address the challenges to acute home care services posed by the COVID‐19 pandemic. Planning for service operation involves staffing, equipment availability and cleaning, upskilling in telehealth and communication. Planning for clinical care involves maximising cohorts of patients without COVID‐19 and new clinical pathways for patients with COVID‐19. The risk of SARS‐CoV‐2 transmission, specific COVID‐19 clinical pathways and the well‐being of patients and staff should be addressed in advance.

Should I stay or should I go? A retrospective propensity score-matched analysis using administrative data of hospital-at-home for older people in Scotland

OBJECTIVES

To compare the characteristics of populations admitted to hospital-at-home services with the population admitted to hospital and assess the association of these services with healthcare costs and mortality.

DESIGN

In a retrospective observational cohort study of linked patient level data, we used propensity score matching in combination with regression analysis.

PARTICIPANTS

Patients aged 65 years and older admitted to hospital-at-home or hospital.

INTERVENTIONS

Three geriatrician-led admission avoidance hospital-at-home services in Scotland.

OUTCOME MEASURES

Healthcare costs and mortality.

RESULTS

Patients in hospital-at-home were older and more socioeconomically disadvantaged, had higher rates of previous hospitalisation and there was a greater proportion of women and people with several chronic conditions compared with the population admitted to hospital. The cost of providing hospital-at-home varied between the three sites from £628 to £2928 per admission. Hospital-at-home was associated with 18% lower costs during the follow-up period in site 1 (ratio of means 0.82; 95% CI: 0.76 to 0.89). Limiting the analysis to costs during the 6 months following index discharge, patients in the hospital-at-home cohorts had 27% higher costs (ratio of means 1.27; 95% CI: 1.14 to 1.41) in site 1, 9% (ratio of means 1.09; 95% CI: 0.95 to 1.24) in site 2 and 70% in site 3 (ratio of means 1.70; 95% CI: 1.40 to 2.07) compared with patients in the control cohorts. Admission to hospital-at-home was associated with an increased risk of death during the follow-up period in all three sites (1.09, 95% CI: 1.00 to 1.19 site 1; 1.29, 95% CI: 1.15 to 1.44 site 2; 1.27, 95% CI: 1.06 to 1.54 site 3).

CONCLUSIONS

Our findings indicate that in these three cohorts, the populations admitted to hospital-at-home and hospital differ. We cannot rule out the risk of residual confounding, as our analysis relied on an administrative data set and we lacked data on disease severity and type of hospitalised care received in the control cohorts.

Effectiveness and safety of ertapenem used in hospital-at-home units: data from Spanish Outpatient Parenteral Antimicrobial Therapy Registry

AIM

To evaluate the effectiveness and safety of ertapenem in patients hospitalized at home.

PATIENTS & METHODS

Retrospective analysis of data from Spanish Outpatient Parenteral Antimicrobial Therapy (OPAT) registry.

RESULTS

Data from 1428 patients (median age 70 years; 5.4% institutionalized) and 1547 infectious processes (24% self-administration) were analyzed. Clinical cure or improvement was achieved in 93.8% of cases. Rate of related readmissions was 4.2%, of clinically important complications -3.9%, and of adverse drug reactions -3.2%. High comorbidity burden, contagion in nursing home and certain types of infection were associated with worse prognosis. Self-administration was effective and safe, except in case of nursing home-acquired infections.

CONCLUSION

Ertapenem OPAT was effective and safe. Caregivers in nursing homes should be better trained in OPAT-related procedures.

Being in control and striving for normalisation: A Norwegian pilot study on parents' perceptions of hospital-at-home

In recent decades, there has been a shift from hospitalisation to home care throughout the Western world, even for children. Hospital-at-home for children is in a developmental phase and represents a new service model in Norway. The aim of this pilot study conducted in a Norwegian healthcare setting was to explore how parents with a sick child experienced early hospital discharge and further care at home. The qualitative data are drawn from nine interviews with parents with a child admitted to hospital-at-home. Transcripts of interviews were analysed using a method of qualitative content analysis. In the analysis, Antonovsky's salutogenic perspective on how people cope in demanding life situations was applied. The results show that the parents experienced hospital-at-home as providing a calmer, more predictable family life compared to hospitalisation. They argued that good information and training in medical procedures prior to hospital discharge made hospital-at-home easier to master. The participants pointed out the importance of the professionals' competence and their ability to interact with the child and the parent. The certitude that they could return to the hospital at any time made them feel safe and in control. The parents associated hospital-at-home with a kind of normalisation of their family life. They had a prominent need for normalisation, and this was probably a motivation for agreeing to the hospital-at-home arrangement. The findings indicate that hospital-at-home for children is a good solution if the parents are well prepared and feel in control. In addition, certain structural conditions must be in place before this type of health care is established; there must be a certain volume of patients and the distance to the hospital must be clearly limited. Norwegian policymakers should initiate more pilot testing of hospital-at-home for children. Users and clinicians should be involved in establishing and evaluating these services.

Efficiency of a self-administered outpatient parenteral antimicrobial therapy (s-opat) for infective endocarditis within the context of a shortened hospital admission based on hospital at home program

OBJECTIVE

This study aimed to evaluate the efficiency of treatment of infectious endocarditis (IE) via Self-administered Outpatient Parenteral Antimicrobial Therapy (S-OPAT) supported by a shortening hospital admission program in a hospitalization-at-home unit (HAH), including a short review of the literature.

METHODS

Ambispective cohort study of 57 episodes of IE in 54 patients treated in an HAH unit between 1988 and 2014 who receive S-OPAT after prior intra-hospital clinical stabilization. Characteristics of each episode of IE, safety and efficiency of the care model, were analyzed.

RESULTS

Forty-three (76%) patients were males with a median age of 61 years (SD = 16.5). A total of 37 (65%) episodes affected the native valve (42% the aortic valve). In 75%, a micro-organism was isolated, of which 88% were Gram-positive bacteria. No deaths occurred during HAH program, clinical complications appeared in 30% of episodes, only 6 patients were re-admitted to hospital although no patient died. In the 12 months' follow-up 3 cases had a recurrence. The average cost of a day stay in HAH was €174 while in traditional cardiology hospitalization was €1100. The total average cost of treatment of each episode of IE managed entirely in hospital was calculated as €54,723. Application of the S-OPAT model based on HAH meant a cost reduction of 32.72%.

CONCLUSIONS

In suitably selected patients, treatment of IE based on S-OPAT supported by a shortening hospital admission care program by means of referral to a HAH unit is a safe and efficient care model which entails a significant cost saving for the public healthcare system.

Hospital-at-home Integrated Care Programme for the management of disabling health crises in older patients: comparison with bed-based Intermediate Care

Objective

to analyse the clinical impact of a home-based Intermediate Care model in the Catalan health system, comparing it with usual bed-based care.

Design

quasi-experimental longitudinal study.

Setting

hospital Municipal de Badalona and El Carme Intermediate Care Hospital, Badalona, Catalonia, Spain.

Participants

we included older patients with medical and orthopaedic disabling health crises in need of Comprehensive Geriatric Assessment (CGA) and rehabilitation.

Methods

a CGA-based hospital-at-home Integrated Care Programme (acute care and rehabilitation) was compared with a propensity score matched cohort of contemporary patients attended by usual inpatient hospital care (acute care plus intermediate care hospitalisation), for the management of medical and orthopaedics processes. Main outcomes measures were: (a) Health crisis resolution (referral to primary care at the end of the intervention); (b) functional resolution: relative functional gain (functional gain/functional loss) ≥ 0.35; and (c) favourable crisis resolution (health + functional) = a + b. We compared between-groups outcomes using uni/multivariable logistic regression models.

Results

clinical characteristics were similar between home-based and bed-based groups. Acute stay was shorter in home group: 6.1 (5.3-6.9) versus 11.2 (10.5-11.9) days, P < 0.001. The home-based scheme showed better results on functional resolution 79.1% (versus 75.2%), OR 1.62 (1.09-2.41) and on favourable crisis resolution 73.8% (versus 69.6%), OR 1.54 (1.06-2.22), with shorter length of intervention, with a reduction of -5.72 (-9.75 and -1.69) days.

Conclusions

in our study, the extended CGA-based hospital-at-home programme was associated with shorter stay and favourable clinical outcomes. Future studies might test this intervention to the whole Catalan integrated care system.

[Hospital-at-home at the end of life, challenges and limits]

The requests for hospital-at-home palliative care are made by health professionals as well as by patients and their families. Nurse coordinators assess them in order to identify the limits and assure high-quality care. Team meetings enable professionals to decide on a joint approach and provide support to the caregivers where necessary.

Should I stay or should I go home? A latent class analysis of a discrete choice experiment on hospital-at-home

OBJECTIVES

This study aimed 1) to quantify the strength of patient preferences for different aspects of early assisted discharge in The Netherlands for patients who were admitted with a chronic obstructive pulmonary disease exacerbation and 2) to illustrate the benefits of latent class modeling of discrete choice data. This technique is rarely used in health economics.

METHODS

Respondents made multiple choices between hospital treatment as usual (7 days) and two combinations of hospital admission (3 days) followed by treatment at home. The latter was described by a set of attributes. Hospital treatment was constant across choice sets. Respondents were patients with chronic obstructive pulmonary disease in a randomized controlled trial investigating the cost-effectiveness of early assisted discharge and their informal caregivers. The data were analyzed using mixed logit, generalized multinomial logit, and latent-class conditional logit regression. These methods allow for heterogeneous preferences across groups, but in different ways.

RESULTS

Twenty-five percent of the respondents opted for hospital treatment regardless of the description of the early assisted discharge program, and 46% never opted for the hospital. The best model contained four latent classes of respondents, defined by different preferences for the hospital and caregiver burden. Preferences for other attributes were constant across classes. Attributes with the strongest effect on choices were the burden on informal caregivers and co-payments. Except for the number of visits, all attributes had a significant effect on choices in the expected direction.

CONCLUSIONS

Considerable segments of respondents had fixed preferences for either treatment option. Applying latent class analysis was essential in quantifying preferences for attributes of early assisted discharge.