Assuring continuity of care through a hospital-based home health agency

Hospital at home versus in-patient hospital care

BACKGROUND

Hospital at home is defined as a service that provides active treatment by health care professionals, in the patient's home, of a condition that otherwise would require acute hospital in-patient care, always for a limited period.

OBJECTIVES

To assess the effects of hospital at home compared with in-patient hospital care.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register (November 2004), MEDLINE (1966 to 1996), EMBASE (1980 to 1995), Social Science Citation Index (1992 to 1995), Cinahl (1982 to 1996), EconLit (1969 to 1996), PsycLit (1987 to 1996), Sigle (1980 to 1995) and the Medical Care supplement on economic literature (1970 to 1990).

SELECTION CRITERIA

Randomised trials of hospital at home care compared with acute hospital in-patient care. The participants were patients aged 18 years and over.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Twenty two trials are included in this update of the review. Among trials evaluating early discharge hospital at home schemes we found an odds ratio (OR) for mortality of 1.79 95% CI 0.85 to 3.76 for elderly medical patients (age 65 years and over) (n = 3 trials); OR 0.58; 95% CI 0.29 to 1.17 for patients with chronic obstructive pulmonary disease (COPD) (n = 5 trials); and OR 0.78; 95%CI 0.52 to 1.19 for patients recovering from a stroke (n = 4 trials). Two trials evaluating the early discharge of patients recovering from surgery reported an OR 0.43 (95% CI 0.02 to 10.89) for patients recovering from a hip replacement and an OR 1.01 (95% CI 0.37 to 2.81) for patients with a mix of conditions at three months follow-up. For readmission to hospital we found an OR 1.76; 95% CI 0.78 to 3.99 at 3 months follow-up for elderly medical patients (n = 2 trials); OR 0.81; 95% CI 0.55 to 1.19 for patients with COPD (n = 5 trials); and OR 0.96; 95% CI 0.63 to 1.45 for patients recovering from a stroke (n = 3 trials). No significant heterogeneity was observed. One trial recruiting patients following surgery for hernia or varicose veins reported 0/117 versus 2/121 patients were re admitted (Ruckley 1978); another that 2/37 (5%) versus 1/49 (2%) (difference 3%, 95% CI -5% to 12%) of patients recovering from a hip replacement, 4/47 (9%) versus 1/39 (3%) (difference 6%, 95% CI -3% to 15%) of patients recovering from a knee replacement, and 7/114 (6%) versus 13/124 (10%) (difference -4% 95% CI -11% to 3%) of patients recovering from a hysterectomy were readmitted. A third trial analysing surgical and medical patients together reported that 42/159 versus 17/81 patients were readmitted at 3 months (OR 1.34 95% CI 0.66 to 2.20). Allocation to hospital at home resulted in a small reduction in hospital length of stay, but hospital at home increased overall length of care. Patients allocated to hospital at home expressed greater satisfaction with care than those in hospital, while the view of carers was mixed.

AUTHORS' CONCLUSIONS

Despite increasing interest in the potential of hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit. Early discharge schemes for patients recovering from elective surgery and elderly patients with a medical condition may have a place in reducing the pressure on acute hospital beds, providing the views of the carers are taken into account. For these clinical groups hospital length of stay is reduced, although this is offset by the provision of hospital at home. Future primary research should focus on rigorous evaluations of admission avoidance schemes and standards for original research should aim at assisting future meta-analyses of individual patient data from these and future trials.

Continuing care in the community

Early discharge from the hospital or home health agency necessitates effective continuity of care planning in order to assure that patients and families will have their health care needs met after discontinuance of formal health care services. In this article, we have defined continuity of care from several perspectives, presented two theoretical viewpoints on this concept, and, with four models of care that have actually been implemented, analyzed the commonalities and differences among models. In addition, recommendations for future research and care delivery for the purpose of enhancement of continuity of care have been made.

Home health care--providing a missing link

1. If nurses are to provide the continuity of care that helps patients at home achieve expected patient outcomes, nurses must diagnose actual and potential health problems and design a plan of care. 2. Before patient outcomes can be identified, nurses must first recognize, assess, and describe the patient's defining characteristics. 3. The study found that nurses use a limited range of nursing diagnoses and incompletely document the care they give. 4. Results of the study indicated that nurses provide continuity of care between the hospital and home; there is also a need for home-based health care to provide support for elderly caregivers whose health is less than good.