Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data

I didn't know I had executive dysfunction, now I can do something about it: perspectives about CO-OP from people with Parkinson's disease

PURPOSES

People with Parkinson's disease (PD) experience increasing disability across their lifespan. Holistic rehabilitation approaches are needed to maximize their daily functioning and quality of life (QoL). The Cognitive Orientation to daily Occupational Performance (CO-OP) approach targets daily functioning, with established efficacy in other neurological populations. This study is part of a larger trial of CO-OP with people with PD, describing the perspectives of people with PD who received CO-OP about its effect on their lives.

METHODS

People with PD participating in a randomized controlled trial (RCT) were interviewed following the CO-OP programme. Views about the feasibility, acceptability, and experiences of CO-OP were explored. Inductive thematic analysis was used to interpret the findings.

RESULTS

Analysis of interviews (n = 20) identified that CO-OP drove positive change in participants' daily lives. Participants reported transfer and generalization of learned strategies, suggesting effective use of skills learned in CO-OP.

CONCLUSIONS

Addressing a critical gap in PD management, findings suggest that CO-OP was perceived as effective in addressing a broad scope of PD-related issues. Findings hold particular significance for individuals experiencing long-term PD consequences, potentially offering a viable option to enhance participation and QoL. Findings support CO-OP as an implementable, acceptable, and potentially beneficial intervention in PD. Further research is warranted to establish efficacy.

Cost drivers and feasibility of a hospital-at-home programme for geriatric care in northeastern Mexico: a retrospective observational study

OBJECTIVE

The primary objective was to evaluate factors influencing the cost of a 'hospital at home' (HAH) for geriatric patients in a Northeastern Mexican hospital. Secondarily to evaluate the per capita global cost-effectiveness compared with traditional hospital care.

DESIGN

This retrospective analysis examined the costs incurred by geriatric patients in an HAH programme from February to December 2022 SETTING: We collected data from clinical records and assessed medication and procedure costs through the hospital's financial department. Costs for traditionally hospitalised patients were reviewed for comparison.

PARTICIPANTS

Subjects of both genders aged 70 and older who were treated in HAH during 2022 and hospitalised subjects with the same age and gender treated in the same period.

INTERVENTION

NA PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome: factors that influence costs in HAH. Secondary, global per capita cost comparison between HAH and hospital care.

RESULTS

We examined the expenses associated with 416 home visits to 49 patients in the HAH programme. The main factors influencing the programme's overall cost were medical care and procedure-related disorders (β=0.333, p=0.002), sleep-regulators (β=0.561, p<0.001), laxatives (β=0.330, p=0.001) and anticoagulants (β=0.228, p=0.025). The HAH programme's per capita cost was three times lower compared with that of traditional hospital care and resulted in a 40% reduction in hospitalisation days.

CONCLUSIONS

This study highlights that the main factors influencing the HAH programme's costs include medical care and procedure-related disorders, as well as medication extensively used in the elderly population. Additionally, we demonstrated the cost-effectiveness of the HAH programme, which produces substantial savings and is a financially viable alternative to traditional hospital care.

Improving sustainability and mitigating the environmental impact of anaesthesia and surgery along the perioperative journey: a narrative review

Climate change, environmental degradation, and biodiversity loss are adversely affecting human health and exacerbating existing inequities, intensifying pressures on already strained health systems. Paradoxically, healthcare is a high-polluting industry, responsible for 4.6% of global greenhouse gas emissions and a similar proportion of air pollutants. Perioperative services are among the most resource-intensive healthcare services and are responsible for some unique pollutants. Opportunities exist to mitigate pollution throughout the entire continuum of perioperative care, including those that occur upstream of the operating room in the process of patient selection and optimisation, delivery of anaesthesia and surgery, and the postoperative recovery period. Within a patient-centred, holistic approach, clinicians can advocate for healthy public policies that modify the determinants of surgical illness, can engage in shared decision-making to ensure appropriate clinical decisions, and can be stewards of healthcare resources. Innovation and collaboration are required to redesign clinical care pathways and processes, optimise logistical systems, and address facility emissions. The results will extend beyond the reduction of public health damages from healthcare pollution to the provision of higher value, higher quality, patient-centred care.

Clinical Characteristics and Outcomes of Patients With COVID-19 Treated in Mayo Clinic's Advanced Care at Home Program

OBJECTIVES

Mayo Clinic's hospital-at-home program, Advanced Care at Home (ACH), launched in 2020. While hospital-at-home literature reported safe and effective care for the general patient population and those with COVID, comparative outcomes between these two groups were unknown. The aim of this retrospective analysis was to compare the outcomes of COVID and non-COVID patients enrolled in ACH and evaluate if COVID patients can be safely treated in this setting.

METHODS

Demographics, clinical characteristics, and safety outcomes were retrospectively analyzed to compare COVID and non-COVID patients discharged from ACH between November 2020 and May 2022. Patient characteristics analyzed included severity of illness (SOI) and risk of mortality (ROM), calculated using All Patient Refined Diagnosis Related Groups (APR-DRG). Hospitalization-specific variables included length of stay (LOS), escalation of care, and 30-day readmission rates.

RESULTS

Of 1051 patients, 173 (16%) had COVID, and 878 (84%) were non-COVID patients. The average age in the COVID cohort was 66.6 (15.3) years, compared with 72.2 (14.0) in the non-COVID cohort. Extreme SOI was higher in the COVID group (43.3% versus 17.4%), as was extreme ROM (46.2% versus 16.2%), but LOS was shorter (5.7 versus 7 days). Escalation of care (7.5% in COVID cohort versus 8.4%) and 30-day readmission outcomes (9.2% for COVID patients versus 12.9%) were not statistically different between the groups.

CONCLUSIONS

Despite higher SOI and ROM, COVID patients had shorter LOS with outcomes that were not statistically different from non-COVID patients. COVID patients can be safely and efficiently cared for in ACH.

The Professional Guest: conceptualizing home visits in palliative care settings

Background

Home-based palliative care is a growing trend, necessitating a deeper understanding of the unique challenges faced by professional staff members in this setting. The shift to home-based care has been driven by advances in technology, changing demographics, and a move toward more patient-centered approaches. As a care setting, the home environment offers distinct characteristics, presenting both advantages and drawbacks for patients and healthcare providers.

Objectives

This study aims to explore the experiences and perceptions of professional staff members providing palliative care in patients' homes.

Design

A qualitative descriptive study.

Methods

Qualitative study with 36 home-based hospice professionals using questionnaires and interviews. Thematic analysis identified key themes in staff experiences and challenges.

Results

The central theme of "The Professional Guest" highlights the hybrid identity and boundary role professional staff members must navigate, being both medical professionals and guests in the patient's domain. Four sub-themes emerged: (1) Observing and Applying, emphasizing the conscious scanning of the home environment to build trust and tailor care plans; (2) Asking for Permission, respecting the patient's territory and adapting to their norms; (3) Expecting the Unexpected, maintaining flexibility and improvising in unfamiliar situations; and (4) Preparing the Ground for Your Absence, equipping patients and families with comprehensive self-care guidance during professional staff members' absences.

Conclusion

The "Professional Guest" phenomenon captures the complexities of providing care in patient's homes, necessitating a delicate balance between professionalism and personal vulnerability. Specialized training programs and policies should be developed to support professional staff members in navigating this hybrid identity and effectively negotiating the boundaries between professional and personal spheres.

The mobile seniors' clinic - an innovative transition of care for frail older adults

BACKGROUND

This study aims to evaluate the impact of Quebec's first hospital-at-home-inspired mobile Seniors' Clinic, the "Clinique des Ainés (CDA)", on frail older adults' returns to the Emergency Department (ED), mortality, and hospital Length Of Stay (LOS) and rehospitalizations.

METHODS

Design: Quasi-experimental pre-post implementation cohort study.

POPULATION

Patients aged ≥ 75 years admitted to the short-term geriatric unit after an ED consultation (control) or included by the CDA (intervention).

OUTCOMES

return to ED (RtoED), mortality, ED & hospital LOS, and rehospitalizations.

STATISTICAL ANALYSES

Multivariable regression modelling.

RESULTS

Overall, 891 patients were included. At the intervention site (CDA) (n = 437), RtoED were similar at 30 (17.5% & 19.5%, p = 0.58), 90 (34.4% & 37.3%, p = 0.46) and 180 days (47.2% & 54.0%, p = 0.07) in the pre and post-implementation phases. No mortality differences were found. The hospitalization LOS was significantly shorter (28.26 and 14.22 days, p < 0.01). At 90 days, rehospitalization LOS was decreased by 8.51 days (p = 0.02) and by 6.48 days at 180 days (p = 0.03). Compared to the control site (n = 454) in the post-implementation phase, RtoED was 54% at the intervention site compared to 44.1% (p = 0.02) at 180 days. The CDA had a lower adjusted probability of mortality at 90 days compared to the control site (4.8% VS 11.7%, p = 0.03). No rehospitalization LOS differences were noted.

CONCLUSIONS

The Clinique des Ainés showed effectiveness in caring for frail older patients in their homes by decreasing their hospital LOS by half and 90 days mortality risk. It was a safe care trajectory without a clinically significant increase in ED returns or mortality.

Recovery environments in places of daily living: a scoping review and conceptual analysis

BACKGROUND

Owing to advances in medical technology and the promotion of at-home medical care, patients are more frequently being treated in their places of daily living after discharge from acute care hospitals. As medical care and lifestyle are closely linked, the quality of life of the patient and their families therefore depends on the adequate preparation of the recovery environment. Hence, modifying this environment to ensure that the patient's lifestyle and medical care are complementary is often vital. This study aimed to clarify the concept of recovery environments in places of daily living.

METHODS

The literature search and selection of articles were based on a scoping review conducted in Scopus and PubMed, while data extraction and analysis were based on conceptual analysis. Thirty-two articles met the inclusion criteria.

RESULTS

Our analysis of these articles allowed us to classify four types of recovery environments in places of daily living: physical environments appropriate to the health status of the recovering patient, collaborative environments in which intra-family roles are empowered, community environments in which recovering patients are accepted, and service environments in which the required services can be accessed. We also noted the main roles of medical professionals for building relationships with patients: providing decision-making support in places of daily living, creating an environment that empowers patients and their families, and modifying the service environment.

CONCLUSIONS

For patients, the main aims of recovery environments in places of daily living are to make them physically comfortable, maintain their identity, and improve their quality of life. Although this study is only a first step towards conceptualizing recovery environments in places of daily living and the final results are tentative, we are nonetheless confident that it will be important for advancing the field of home healthcare research.

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.

Barriers to hospital-at-home acceptance: a systematic review of reasons for patient refusal

Background

Hospital-at-home (H@H) models have gained recognition as a safe and potentially cost-effective solution for the current rising global healthcare needs. However, despite these models' potential, their adoption has been limited partly due to patients refusing care at home. This systematic review analyses the reasons behind their refusal.

Methods

We searched five databases: Embase, Google Scholar, PubMed, Scopus, and Web of Science, limiting our search to papers from 2005 to 2024. Our search focused on papers reporting patient-provided reasons for declining treatment in a H@H setting without language or country restrictions. In addition to reasons for refusal, we extracted patient demographics and predictors for refusal to ensure a broad understanding of the factors influencing patient decisions. The quality of the studies included was evaluated using the Mixed Methods Appraisal Tool (MMAT) version 2018.

Results

From the 1,067 articles identified, seven met our inclusion criteria. The papers reported reasons from 418 patients participating in diverse H@H models from the United States, United Kingdom, Spain, and Singapore, primarily focusing on acute home-based care. The most common reasons for declination included concerns about model effectiveness, safety at home, preference for in-hospital care, physician advice, family burden, and visitor concerns. Additionally, common significant demographic factors associated with decliners were the enrollment site, partnership or marital status, risk of adverse outcomes, and previous healthcare utilization.

Conclusions

Understanding patients' motivations for declining H@H is crucial for its successful implementation. Targeted communication strategies and collaboration between healthcare providers are paramount to ensure that patients understand the benefits and safety of H@H models. Future research should explore effective communication and engagement techniques to address patient apprehensions and broaden H@H adoption.

Continuous Temperature Telemonitoring of Patients with COVID-19 and Other Infectious Diseases Treated in Hospital-at-Home: Viture® System Validation

Body temperature must be monitored in patients receiving Hospital-at-Home (HaH) care for COVID-19 and other infectious diseases. Continuous temperature telemonitoring (CTT) detects fever and patient deterioration early, facilitating decision-making. We performed a validation clinical study assessing the safety, comfort, and impact on healthcare practice of Viture®, a CTT system, compared with a standard digital axillary thermometer in 208 patients with COVID-19 and other infectious diseases treated in HaH at the Navarra University Hospital (HUN). Overall, 3258 pairs of measurements showed a clinical bias of -0.02 °C with limits of agreement of -0.96/+0.92 °C, a 95% acceptance rate, and a mean absolute deviation of 0.36 (SD 0.30) °C. Viture® detected 3 times more febrile episodes and revealed fever in 50% more patients compared with spot measurements. Febrile episodes were detected 7.23 h (mean) earlier and modified the diagnostic and/or therapeutic approach in 43.2% of patients. Viture® was validated for use in a clinical setting and was more effective in detecting febrile episodes than conventional methods.

Ambulatory models for autologous stem-cell transplantation: a systematic review of the health impact

Autologous stem-cell transplantation (ASCT) is the standard of care for the management of multiple myeloma and has a well-established role in the treatment of some types of lymphoma. Over the last decades, the number of ASCT performed has increased significantly, leading to elevated pressure and cost for healthcare services. Conventional model of ASCT includes the admission of patients to a specialized Transplant Unit at any stage of the procedure. To optimize healthcare provision, ambulatory (outpatient/at-home) setting should be the focus moving forward. Thus, ambulatory ASCT model permits reducing average hospital stays and pressures on healthcare services, with significant cost-saving benefits and high degree of patient and caregiver satisfaction. In addition, it facilitates the bed resource for other complex procedures such as allografts or CAR-T cell therapy. The aim of this systematic review is to document the health impact, feasibility and safety of the outpatient/at-home ASCT models, which are increasingly being applied around the world.

Overcoming barriers to implementation: mapping implementation strategies in four hospital in home programs within the Veterans Health Administration

The Hospital at Home model, called Hospital-in-Home (HIH) in the Department of Veterans Affairs, delivers coordinated, high-value care aligned with older adult and caregiver preferences. Documenting implementation barriers and corresponding strategies to overcome them can address challenges to widespread adoption. To evaluate HIH implementation barriers and identify strategies to address them, we conducted interviews with 8 HIH staff at 4 hospitals between 2010 and 2013. We utilized qualitative directed content analysis guided by the Consolidated Framework for Implementation Research (CFIR) and mapped identified barriers to possible strategies using the CFIR-Expert Recommendations for Implementing Change (ERIC) Matching Tool. We identified 11 barriers spanning 5 CFIR domains. Three implementation strategies - identifying and preparing champions, conducting educational meetings, and capturing and sharing local knowledge - achieved high expert endorsement for each barrier. A mix of strategies targeting resources, organizational readiness and fit, and leadership engagement should be considered to support the sustainability and spread of HIH.

Working as a physiotherapist in a rapid response team: 'An emotional rollercoaster'

BACKGROUND AND INTRODUCTION

Rapid Response Teams (RRTs) are multidisciplinary, 'hospital at home' services which have developed over the last 10 years, aiming to improve recovery from illness more efficiently, prevent unnecessary hospital admission, and prevent early admission to residential care. However, little is known about the experience of professionals working in these roles.

PURPOSE

The aim of this study was to explore how working in an RRT is experienced and perceived by physiotherapists.

METHODS

This study used phenomenographically inspired methodology. Six participants who were working in RRTs were recruited to this study and all were working in the South of England. Data were collected via semi-structured interviews, and phenomenographic analysis was undertaken.

RESULTS

Participants working in RRTs described a range of varied, concrete lived-through experiences in addition to a more rhetorical discussion of how they conceptualized their work. Six main categories of description were generated from the analysis; each was assigned a metaphor. These included 'the detective,' 'the guru,' 'the lone ranger,' 'the team player,' 'the bricoleur,' and 'an emotional rollercoaster'; all categories were present with varied meanings. 'An emotional rollercoaster' was present within and throughout participants' descriptions of all other categories.

CONCLUSION

This study provides valuable insights into physiotherapists' experience and conceptualization of working within this discipline, which may have implications for physiotherapy practice, workforce development, new and current RR physiotherapy services, RRT health professionals, and physiotherapy education.

Assessment of the Impact of Home-Based Hospitalization on Health Outcomes: An Observational Study

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.

Effectiveness and Safety of Postoperative Hospital at Home for Surgical Patients: A Cohort Study

OBJECTIVE

To determine the feasibility and effectiveness of a Hospital at Home (HaH) enabled early transfer pathways for surgical patients.

BACKGROUND

HaH serves as a safe alternative to traditional hospitalization by providing acute care to patients in their homes through a comprehensive range of hospital-level interventions. To our knowledge, no studies have been published to date reporting a large cohort of early home-transferred patients after surgery through a HaH unit.

METHODS

Cohort study enrolling every patient admitted to the HaH unit of a tertiary hospital who underwent any of 6 surgeries with a predefined early transfer pathway and fitting both general and surgery inclusion criteria (clinical and hemodynamic stability, uncomplicated surgery, presence of a caregiver, among others) from November 2021 to May 2023. Protocols were developed for each pathway between surgical services and HaH to deliver the usual postoperative care in the home setting. Discharge was decided according to protocol. An urgent escalation pathway was also established.

RESULTS

During the study period, 325 patients were included: 141 were bariatric surgeries, 85 kidney transplants, 45 thoracic surgeries, 37 cystectomies, 10 appendicectomies, and 7 ventral hernia repairs. The overall escalation of care during HaH occurred in 7.3% of patients and 30-day readmissions in 7%. Most adverse events were managed at home and the overall mortality was zero. The total mean length of stay was 8 days (interquartile range 2-14), and patients with HaH were transferred home 3 days (interquartile range 1-6) earlier than the usual pathway; a total of 1551 bed-days were saved.

CONCLUSIONS

The implementation of early home transfer pathways for surgical patients through HaH is feasible and effective, with favorable safety outcomes.

Implementing Systemwide Physician Change Management in an Integrated Health Care Setting: Improving Physician Participation in an Advanced Care at Home Model

INTRODUCTION

Advanced Care at Home is a clinical model that delivers hospital-level care in a patient's home. This model of care has been studied for decades, but there have been difficulties scaling the model to a higher census because of poor physician participation. Kaiser Permanente at Home, an Advanced Care at Home model created by Kaiser Permanente Northwest, was able to quickly increase its patient census by using several different change management interventions. The aim of this study was to describe the specific physician change management interventions used and to determine their relative impacts on physician participation with Kaiser Permanente at Home.

METHODS

This study used a retrospective qualitative approach. Hospitalist and emergency department (ED) physicians completed an online survey in December 2021. This was followed by focused, one-on-one interviews that were held in February 2022. Content analysis was performed using a general inductive approach to identify core themes.

RESULTS

Of 78 ED and 79 hospitalist physicians recruited, 35% submitted responses. Of these respondents, 16 (29%) were ED physicians, and 39 (61%) were hospitalist physicians. Of these respondents, 90% rated Kaiser Permanente at Home favorably over the course of a year. More than 90% of respondents rated a combination of multiple approaches as impactful, but respondents overwhelmingly noted that physician-to-physician engagement was the most important (51%).

CONCLUSION

In the development of the Kaiser Permanente at Home, physicians highlighted that a multifactorial change management approach centered on peer-to-peer engagement had the most substantial effect on their participation, a process that could extend up to a year.

Distilling lessons from home hospital implementation: a narrative scoping review

INTRODUCTION

Multiple Cochrane Reviews have demonstrated 'hospital at home' (HaH) as a promising healthcare model to be explored, with benefits such as higher care quality, reduced readmissions, shorter lengths of stay, lower cost and greater patient satisfaction. While there have been many reviews focusing on the quantitative clinical outcomes of HaH, there is generally a lack of collation of qualitative insights from stakeholders and lessons learnt from past HaH implementation.

METHODS

We performed a systematic literature search on four databases and included 17 papers involving the provision of acute and/or subacute care by healthcare professionals in patients' homes. Review characteristics and relevant outcomes were extracted from the reported findings and tables in the reviews, and these included stakeholder attitudes and factors contributing to the success of HaH implementation.

RESULTS

Factors relating to patients and caregivers included home setup, preference for care and death settings, and support for caregiver. Factors involving the healthcare professionals and intervention included a multidisciplinary care team, accessibility to emergency care and support, training of providers and patients, adequate manpower allocation, robust eligibility and referral criteria, sufficient awareness of the HaH referral pathway, communication and medication management.

CONCLUSION

HaH presents a promising alternative care model, and many of the success factors identified, including the strong push for multidisciplinary single care teams, existing frameworks for data sharing and strong community network, are already present today. As such, Singapore appears to be well positioned to adopt a new care model like HaH.

The Hospitalist Movement 25 Years Later

Hospitalists are generalists who specialize in the care of hospitalized patients. In the 25 years since the term hospitalist was coined, the field of hospital medicine has grown exponentially and established a substantial footprint in the medical community. There are now more hospitalists than practicing physicians in any other internal medicine subspecialty. Several key forces catalyzed the growth in the field of hospital medicine, including the quality, safety, and value movements; residency duty hour restrictions; the emergence of electronic health records; and the COVID-19 pandemic. Looking ahead, we see new opportunities in the realms of technology and telemedicine, and challenges persist in regard to balancing financial considerations with increasing workload and burnout. Hospitalists must remain nimble and seize emerging opportunities to continue supporting the field's prominence and growth.

Identifying Optimal Acute Care Comparators to Inform the Evaluation of an Advanced Care at Home Pilot Program

BACKGROUND

Hospital at Home (H@H) programs-which seek to deliver acute care within a patient's home-have become more prevalent over time. However, existing literature exhibits heterogeneity in program structure, evaluation design, and target population size, making it difficult to draw generalizable conclusions to inform future H@H program design.

OBJECTIVE

The objective of this work was to develop a quality improvement evaluation strategy for a H@H program-the Kaiser Permanente Advanced Care at Home (KPACAH) program in Northern California-leveraging electronic health record data, chart review, and patient surveys to compare KPACAH patients with inpatients in traditional hospital settings.

METHODS

The authors developed a 3-step recruitment workflow that used electronic health record filtering tools to generate a daily list of potential comparators, a manual chart review of potentially eligible comparator patients to assess individual clinical and social criteria, and a phone interview with patients to affirm eligibility and interest from potential comparator patients.

RESULTS

This workflow successfully identified and enrolled a population of 446 comparator patients in a 5-month period who exhibited similar demographics, reasons for hospitalization, comorbidity burden, and utilization measures to patients enrolled in the KPACAH program.

CONCLUSION

These initial findings provide promise for a workflow that can facilitate the identification of similar inpatients hospitalized at traditional brick and mortar facilities to enhance outcomes evaluations for the H@H programs, as well as to identify the potential volume of enrollees as the program expands.

Heart failure management at home: a non-randomised prospective case-controlled trial (HeMan at Home)

BACKGROUND/OBJECTIVES

Heart failure (HF) is a growing clinical and economic burden for patients and health systems. The COVID-19 pandemic has led to avoidance and delay in care, resulting in increased morbidity and mortality among many patients with HF. The increasing burden of HF during the COVID-19 pandemic led us to evaluate the quality and safety of the Hospital at Home (HAH) for patients presenting to their community providers or emergency department (ED) with symptoms of acute on chronic HF (CHF) requiring admission.

DESIGN/OUTCOMES

A non-randomised prospective case-controlled of patients enrolled in the HAH versus admission to the hospital (usual care, UC). Primary outcomes included length of stay (LOS), adverse events, discharge disposition and patient satisfaction. Secondary outcomes included 30-day readmission rates, 30-day ED usage and ED dwell time.

RESULTS

Sixty patients met inclusion/exclusion criteria and were included in the study. Of the 60 patients, 40 were in the HAH and 20 were in the UC group. Primary outcomes demonstrated that HAH patients had slightly longer LOS (6.3 days vs 4.7 days); however, fewer adverse events (12.5% vs 35%) compared with the UC group. Those enrolled in the HAH programme were less likely to be discharged with postacute services (skilled nursing facility or home health). HAH was associated with increased patient satisfaction compared with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score in North Carolina. Secondary outcomes of 30-day readmission and ED usage were similar between HAH and UC.

CONCLUSIONS

The HAH pilot programme was shown to be a safe and effective alternative to hospitalisation for the appropriately selected patient presenting with acute on CHF.

Family caregiver involvement and role in hospital at home for adults: the patients' and family caregivers' perspective - a Norwegian qualitative study

BACKGROUND

Hospital at home (HaH) provides acute healthcare services in patients' homes instead of traditional in-patient care. Research has reported positive outcomes for patients and reduced costs. Although HaH has developed into a global concept, we have little knowledge about the involvement and role of family caregivers (FCs) of adults. The aim of this study was to explore FC involvement and role during HaH treatment as perceived by patients and FCs in a Norwegian healthcare context.

METHODS

A qualitative study was carried out among seven patients and nine FCs in Mid-Norway. The data was obtained through fifteen semi-structured interviews; fourteen were performed individually and one as duad interview. The age of the participants varied between 31 and 73 years, and mean age of 57 years. A hermeneutic phenomenological approach was used, and the analysis was performed according to Kvale and Brinkmann's description of interpretation.

RESULTS

We identified three main categories and seven subcategories regarding FC involvement and role in HaH: (1) Preparing for something new and unfamiliar, including the subcategories `Lack of involvement in the decision process` and `Information overload affecting caregiver readiness`, (2) Adjusting to a new everyday life at home, including the subcategories `The critical first days at home`, `Coherent care and support in a novel situation`, and `Prior established family roles influencing the new everyday life at home`, (3) FCs` role gradually diminishes and looking back, including the subcategories `A smooth transition to life beyond hospital at home` and `Finding meaning and motivation in providing care`.

CONCLUSIONS

FCs played an important role in HaH, although their tasks, involvement and effort varied across different phases during HaH treatment. The study findings contribute to a greater understanding of the dynamic nature of the caregiver experiences during HaH treatment, which can guide healthcare professionals on how they can provide timely and appropriate support to FCs in HaH over time. Such knowledge is important to decrease the risk of caregiver distress during HaH treatment. Further work, such as longitudinal studies, should be done to examine the course of caregiving in HaH over time to correct or support the phases described in this study.

Assessing the impact of digital patient monitoring on health outcomes and healthcare resource usage in addition to the feasibility of its combination with at-home treatment, in participants receiving systemic anticancer treatment in clinical practice: protocol for an interventional, open-label, multicountry platform study (ORIGAMA)

INTRODUCTION

Digital patient monitoring (DPM) tools can enable more effective clinical care and improved patient outcomes in cancer. However, their broad adoption requires ease of use and demonstration of real-world clinical utility/impact. ORIGAMA (MO42720) is an interventional, open-label, multicountry platform study investigating the clinical utility of DPM tools and specific treatments. ORIGAMA will begin with two cohorts that aim to assess the impact of the atezolizumab-specific Roche DPM Module (hosted on the Kaiku Health DPM platform (Helsinki, Finland)) on health outcomes and healthcare resource usage, and its feasibility to support at-home treatment administration, in participants receiving systemic anticancer treatment. Other digital health solutions may be added to future cohorts.

METHODS AND ANALYSIS

In Cohort A, participants with metastatic non-small cell lung cancer (NSCLC), extensive-stage SCLC or Child Pugh A unresectable hepatocellular carcinoma will be randomised to a locally approved anticancer regimen containing intravenous atezolizumab (TECENTRIQ, F. Hoffmann-La Roche Ltd/Genentech) and local standard-of-care support, with/without the Roche DPM Module. Cohort B will assess the feasibility of the Roche DPM Module in supporting administration of three cycles of subcutaneous atezolizumab (1875 mg; Day 1 of each 21-day cycle) in the hospital, followed by 13 cycles at home by a healthcare professional (ie, flexible care), in participants with programmed cell-death ligand 1-positive, early-stage NSCLC. The primary endpoints are the mean difference in change of the participant-reported Total Symptom Interference Score at Week 12 from baseline (Cohort A) and flexible care adoption rate at Cycle 6 (Cohort B).

ETHICS AND DISSEMINATION

This study will be conducted according to the Declaration of Helsinki, and/or the applicable laws and regulations of the country in which the research is conducted, whichever affords the greater protection to the individual. The study received its first Ethics Committee approval in Spain in October 2022. Participants will provide written informed consent in a face-to-face setting. The results of this study will be presented at national and/or international congresses and disseminated via publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05694013.

Implementation of a virtual and in-person hybrid hospital-at-home model in two geographically separate regions utilizing a single command center: a descriptive cohort study

BACKGROUND

As providers look to scale high-acuity care in the patient home setting, hospital-at-home is becoming more prevalent. The traditional model of hospital-at-home usually relies on care delivery by in-home providers, caring for patients in urban communities through academic medical centers. Our objective is to describe the process and outcomes of Mayo Clinic's Advanced Care at Home (ACH) program, a hybrid virtual and in-person hospital-at-home model combining a single, virtual provider-staffed command center with a vendor-mediated in-person medical supply chain to simultaneously deliver care to patients living near an urban hospital-at-home command center and patients living in a rural region in a different US state and time zone.

METHODS

A descriptive, retrospective medical records review of all patients admitted to ACH between July 6, 2020, and December 31, 2021. Patients were admitted to ACH from an urban academic medical center in Florida and a rural community hospital in Wisconsin. We collected patient volumes, age, sex, race, ethnicity, insurance type, primary hospital diagnosis, 30-day mortality rate, in-program mortality, 30-day readmission rate, rate of return to hospital during acute phase, All Patient Refined-Diagnosis Related Groups (APR-DRG) Severity of Illness (SOI), and length of stay (LOS) in both the inpatient-equivalent acute phase and post-acute equivalent restorative phase.

RESULTS

Six hundred and eighty-six patients were admitted to the ACH program, 408 in Florida and 278 in Wisconsin. The most common diagnosis seen were infectious pneumonia (27.0%), septicemia / bacteremia (11.5%), congestive heart failure exacerbation (11.5%), and skin and soft tissue infections (6.3%). Median LOS in the acute phase was 3 days (IQR 2-5) and median stay in the restorative phase was 22 days (IQR 11-26). In-program mortality rate was 0% and 30-day mortality was 0.6%. The mean APR-DRG SOI was 2.9 (SD 0.79) and the 30-day readmission rate was 9.7%.

CONCLUSIONS

The ACH hospital-at-home model was able to provide both high-acuity inpatient-level care and post-acute care to patients in their homes through a single command center to patients in urban and rural settings in two different geographical locations with favorable outcomes of low mortality and hospital readmissions.

Perspectives of people with Parkinson's disease and family carers about disease management in community settings: A cross-country qualitative study

AIM

To explore perceptions of people with Parkinson's disease and family carers about the use and impact of health and social care services, community and voluntary sector resources for the management of Parkinson's disease.

BACKGROUND

Resources from outside the formal health care system and collaborations between different levels and sectors could address the unmet needs of people with Parkinson's disease and their family carers and improve the management of Parkinson's disease in the community setting.

DESIGN

A qualitative exploratory study was carried out in Denmark, Norway, Spain and the United Kingdom and was reported using the COREQ.

METHODS

Individual semi-structured interviews were conducted with people with Parkinson's disease and family carers between May and August 2020. Interviews were digitally recorded, transcribed verbatim and analysed using thematic analysis. A meta-ethnographic approach was used to analyse and synthesise cross-national findings.

RESULTS

Forty-seven people with Parkinson's disease and 39 family carers participated in the four countries. Four themes and eight sub-themes emerged: (1) Personalised care for needs throughout the Parkinson's disease journey; (2) Accessibility of different types of support systems (including initiatives to support emotional well-being, physical rehabilitation, information on the healthcare services, voluntary associations and community groups); (3) Multiagency collaborations, a more comprehensive approach; (4) Acknowledgment of people with Parkinson's and family carers own role in Parkinson's disease management.

CONCLUSIONS

An integrated and person-and-community-centred approach, which includes the participation of the health, social, voluntary and community sectors, is desired by people with Parkinson's disease and their family carers to improve the management of Parkinson's in the community setting. These findings could contribute to the creation of more sustainable care systems at the European level that would better respond to individual and changing needs in people with Parkinson's disease and their family carers, and in other long-term conditions.

PATIENT OR PUBLIC CONTRIBUTION

The Patient and Public Involvement groups contributed to the design of the study, the interview guides and validation of findings.

RELEVANCE TO CLINICAL PRACTICE

This study will inform the management of Parkinson's disease at the community level and the use of resources not only directly linked to the health system. Taking into account all the actors that provide care and support to people with Parkinson' disease and family carers facilitates the creation of strategies that better respond to individual needs. Nurses and other health and social care professionals in the community and specialist levels of care should collaborate to develop multisectoral strategies that promote personalised and integrated care throughout the Parkinson's journey.

Outcomes of a “hospital at home” programme for the supervised home recovery of COVID-19 patients in Singapore

Background

The Singapore General Hospital COVID-19 Virtual Ward is a “hospital at home” (HaH) programme for the supervised home recovery of higher-acuity COVID-19 patients from the hospital and the community.

Objective

To describe how an existing HaH programme was redesigned so that COVID-19 patients could be remotely monitored at home and report the outcomes of the first 100 patients in this Virtual Ward.

Methods

Patients received an admission package comprising instructions and equipment for home monitoring, and uploaded their parameters into a clinical dashboard via a secure messaging app. Medical staff conducted video or telephone consultations daily. Patients were discharged according to time-based criteria, although some required SARS-CoV-2 PCR testing, which were conducted at home by a third-party medical provider. De-identified data of the first 100 patients were analysed by demographic details, indication for enrolment into the Virtual Ward, and the need for subsequent inpatient readmission.

Results

Of the first 100 patients admitted into the Virtual Ward, 58 were female, mean age was 63.1 years old (23–95 years), and 76 were fully vaccinated. There were 77 hospital referrals and 23 community referrals. The number of days of inpatient hospitalisation avoided was 717 days (average of 7.9 days per patient). Three hospital referrals (3.9%) were readmitted, while seven community referrals (30.4%) required subsequent hospitalisation.

Conclusion

The Virtual Ward programme demonstrates that selected COVID-19 patient can safely recover at home with remote medical support and monitoring, thereby expanding hospital capacity.

Colectomy Complicated by High-Output Ileostomy Managed in a Virtual Hybrid Hospital-at-Home Program

Chronically ill patients with superimposed acute illness requiring hospitalization are more likely to develop an extended length of stay, hospital-acquired infections, and adverse events throughout their hospitalization. An excellent alternative to managing this population of patients in the traditional bricks-and-mortal (BAM) hospital is the hospital-at-home (HaH) model. The Advanced Care at Home (ACH) program is Mayo Clinic's HaH model that provides acute and postacute care to high-acuity patients in their homes rather than in the traditional hospital and skilled nursing facility. We report a case of postoperative care through the ACH program of a patient suffering from short gut syndrome, high-output ileostomy, and severe protein-calorie malnutrition in the setting of previously diagnosed triple-negative invasive ductal carcinoma (IDC) of the right breast complicated by lung and brain metastasis. The patient had multiple complications that required repeated scare escalations directed by a multidisciplinary virtual care. Despite these complications, the ACH model of care was able to keep the patient in the home setting the majority of the time, limiting BAM hospital days, and eliminating the need to use the emergency department for acute escalation for 3 months. The patient was able to recover during this time period and proceed to successful take-down of the ileostomy. This case highlights the benefits of the ACH program by offering high-acuity hospital-level care to severely ill patients in the comfort of their homes. Highly qualified providers paired with curated technology in the home allowed for prompt identification of patient decompensation and timely initiation of treatment while avoiding institutionalization.

Actions taken to safeguard the intended health care chain of older people with multiple diagnoses - a critical incident study

Background

Older people with multiple diagnoses often have problems coping with their daily lives at home because of lack of coordination between various parts of the healthcare chain during the transit from hospital care to the home. To provide good care to those persons who have the most complex needs, regions and municipalities must work together. It is of importance to develop further empirical knowledge in relation to older persons with multiple diagnoses to illuminate possible obstacles to person-centred care during the transition between healthcare institutions and the persons livelihood. The aim of the present study was to describe nurses’ experienced critical incidents in different parts of the intended healthcare chain of older people with multiple diagnoses.

Methods

The sample consisted of 18 RNs in different parts of the healthcare system involved in the care of older people with multiple diagnoses. Data were collected by semi structured interviews and analysed according to Critical Incident Technique (CIT). A total of 169 critical incidents were identified describing experiences in recently experienced situations.

Results

The result showed that organizational restrictions in providing care and limitations in collaboration were the main areas of experienced critical incidents. Actions took place due to the lack of preventive actions for care, difficulties in upholding patients’ legal rights to participation in care, deficiencies in cooperation between organizations as well as ambiguous responsibilities and roles. The RNs experienced critical incidents that required moral actions to ensure continued person-centred nursing and provide evidence-based care. Both types of critical incidents required sole responsibility from the nurse. The RNs acted due to ethics, ‘walking the extra mile’, searching for person-centred information, and finding out own knowledge barriers.

Conclusions

In conclusion and based on this critical incident study, home-based healthcare of older people with multiple diagnoses requires a nurse that is prepared to take personal and moral responsibility to ensure person-centred home-based healthcare. Furthermore, the development of in-between adjustments of organizations to secure cooperation, and transference of person-centred knowledge is needed.

Remote vs In-home Physician Visits for Hospital-Level Care at Home: A Randomized Clinical Trial

IMPORTANCE

Home hospital care is the substitutive provision of home-based acute care services usually associated with a traditional inpatient hospital. Many home hospital models require a physician to see patients at home daily, which may hinder scalability. Whether remote physician visits can safely substitute for most in-home visits is unknown.

OBJECTIVE

To compare remote and in-home physician care.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial assessed 172 adult patients at an academic medical center and community hospital who required hospital-level care for select acute conditions, including infection, heart failure, chronic obstructive pulmonary disease, and asthma, between August 3, 2019, and March 26, 2020; follow-up ended April 26, 2020.

INTERVENTIONS

All patients received acute care at home, including in-home nurse or paramedic visits, intravenous medications, remote monitoring, and point-of-care testing. Patients were randomized to receive physician care remotely (initial in-home visit followed by daily video visit facilitated by the home hospital nurse) vs in-home care (daily in-home physician visit). In the remote care group, the physician could choose to see the patient at home beyond the first visit if it was felt to be medically necessary.

MAIN OUTCOMES AND MEASURES

The primary outcome was the number of adverse events, compared using multivariable Poisson regression at a noninferiority threshold of 10 events per 100 patients. Adverse events included a fall, pressure injury, and delirium. Secondary outcomes included the Picker Patient Experience Questionnaire 15 score (scale of 0-15, with 0 indicating worst patient experience and 15 indicating best patient experience) and 30-day readmission rates.

RESULTS

A total of 172 patients (84 receiving remote care and 88 receiving in-home physician care [control group]) were randomized; enrollment was terminated early because of COVID-19. The mean (SD) age was 69.3 (18.0) years, 97 patients (56.4%) were female, 77 (45.0%) were White, and 42 (24.4%) lived alone. Mean adjusted adverse event count was 6.8 per 100 patients for remote care patients vs 3.9 per 100 patients for control patients, for a difference of 2.8 (95% CI, -3.3 to 8.9), supporting noninferiority. For remote care vs control patients, the mean adjusted Picker Patient Experience Questionnaire 15 score difference was -0.22 (95% CI, -1.00 to 0.56), supporting noninferiority. The mean adjusted 30-day readmission absolute rate difference was 2.28% (95% CI, -3.23% to 7.79%), which was inconclusive. Of patients in the remote group, 16 (19.0%) required in-home visits beyond the first visit.

CONCLUSIONS AND RELEVANCE

In this study, remote physician visits were noninferior to in-home physician visits during home hospital care for adverse events and patient experience, although in-home physician care was necessary to support many patients receiving remote care. Our findings may allow for a more efficient, scalable home hospital approach but require further research.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04080570.

Effect of hospital-at-home vs. traditional brick-and-mortar hospital care in acutely ill adults: study protocol for a pragmatic randomized controlled trial

BACKGROUND

Delivering acute hospital care to patients at home might reduce costs and improve patient experience. Mayo Clinic's Advanced Care at Home (ACH) program is a novel virtual hybrid model of "Hospital at Home." This pragmatic randomized controlled non-inferiority trial aims to compare two acute care delivery models: ACH vs. traditional brick-and-mortar hospital care in acutely ill patients.

METHODS

We aim to enroll 360 acutely ill adult patients (≥18 years) who are admitted to three hospitals in Arizona, Florida, and Wisconsin, two of which are academic medical centers and one is a community-based practice. The eligibility criteria will follow what is used in routine practice determined by local clinical teams, including clinical stability, social stability, health insurance plans, and zip codes. Patients will be randomized 1:1 to ACH or traditional inpatient care, stratified by site. The primary outcome is a composite outcome of all-cause mortality and 30-day readmission. Secondary outcomes include individual outcomes in the composite endpoint, fall with injury, medication errors, emergency room visit, transfer to intensive care unit (ICU), cost, the number of days alive out of hospital, and patient-reported quality of life. A mixed-methods study will be conducted with patients, clinicians, and other staff to investigate their experience.

DISCUSSION

The pragmatic trial will examine a novel virtual hybrid model for delivering high-acuity medical care at home. The findings will inform patient selection and future large-scale implementation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05212077. Registered on 27 January 2022.

Home Hospital for Orthopaedic Surgery: Opportunities and Challenges of a New Delivery Model

ABSTRACT

Home Hospital (HH) is a clinical service involving the delivery of acute inpatient care in the home setting. Acute care services provided via HH include continuous telemonitoring, intravenous fluids and medications, nursing care, point-of-care imaging and laboratory tests, and in-person and virtual clinician visits. Despite offering an inpatient level of care, HH has lower fixed costs and less overhead than conventional hospital settings and offers rapid scalability. Originally implemented for acute medical conditions, HH has proven to be a safe and value-based care-delivery model for a variety of medical conditions, ranging from heart failure to chronic obstructive pulmonary disease exacerbations. For surgical conditions, HH represents an opportunity to reduce adverse hospital-acquired conditions, improve patient and caregiver satisfaction, and decrease cost. The patient profile of orthopaedic surgery inpatients matches that of patients who are most likely to benefit from HH-namely, those who are prone to functional decline, delirium, and nosocomial infections. A focus on surgeon leadership, quality and safety, and digital health with collection of patient-reported outcome measures (PROMs) will ensure that the potential of HH is realized as implementation and widespread rollout proceed.

Cost of home hospitalization versus inpatient hospitalization inclusive of a 30-day post-acute period

BACKGROUND

Previous studies have demonstrated that hospital at home (HaH) care is associated with lower costs than traditional hospital care. Most prior studies were small, not U.S.-focused, or did not include post-acute costs in their analyses. Our objective was to determine if combined acute and 30-day post-acute costs of care were lower for HaH patients compared to inpatient comparisons in a Center for Medicare and Medicaid Innovation Center demonstration of HaH.

METHODS

A single-center New York City retrospective observational cohort study of patients admitted to either HaH or inpatient care from September 1, 2014 through August 31, 2017. Eligible patients were 18 years or older, required inpatient admission, lived in Manhattan, and met home safety requirements. Comparison individuals met the same criteria and were included if they refused HaH care or were admitted when HaH was not available. HaH care was substitutive hospital-level care and 30-days of post-acute transitional care. Main outcomes were costs of care of the acute and post-acute 30-day episodes. We matched subjects on age, sex, and insurance and conducted regression analyses using an unadjusted model and one adjusted for several patient characteristics.

RESULTS

Of 523 Medicare admission episodes, data were available for 201 episodes in the HaH arm and 101 episodes of usual care. HaH patients were older (81.6 [SD = 12.3] years vs. 74.6 [SD = 14.0], p < 0.0001) and more likely to have activities of daily living (ADL) impairments (75.4% vs. 46.5%, p < 0.0001). Unadjusted mean costs were $5054 lower for HaH episodes compared to inpatient episodes. Regression analysis with matching showed HaH costs were $5116 (95% CI -$10,262 to $30, p = 0.05) lower, and when adjusted for age, sex, insurance, diagnosis, and ADL impairments, $5977 (95% CI -$10,758 to -$1196, p = 0.01) lower.

CONCLUSIONS

HaH combined with 30-day post-acute transition care was less costly than inpatient care.

Patient-reported outcomes of a short hospital stay after total knee replacement in a regional public hospital: a prospective cohort treated 2018-2019

BACKGROUND

Patient-reported outcomes and satisfaction following short length of stay (LoS) after total knee arthroplasty (TKA) in the Australian regional context remain unexplored. This study reports complications, outcomes and satisfaction of patients discharged from an enhanced recovery protocol (ERP), 6 weeks after TKA in a regional hospital.

METHODS

Prospective recruitment occurred between 2018 and 2019. Demographics, intraoperative data, complications and emergency department (ED) presentations were retrieved from hospital records. Complications were graded for severity using a published scale. Knee range of motion (ROM), timed up-and-go (TUG), 6-min walk test (6MWT) and Oxford Knee Scores (OKS) were assessed preoperatively and 6 weeks postoperatively. Patient satisfaction was assessed via questionnaire at the postoperative follow-up.

RESULTS

One hundred patients/117 primary TKAs were prospectively included. Median LoS was 2 days (interquartile range 1-3 days) with 74.4% and 88.4% of patients satisfied with their knee and LoS, at 6 weeks respectively. Twenty-seven patients presented to the ED a total of 37 times with complication severity of Grade III or less, and 10 patients were readmitted. Significant improvements in objective and subjective outcomes were observed, however only change in median OKS exceeded the minimal clinically important difference (MCID) threshold.

CONCLUSION

An enhanced recovery protocol after TKA in a regional hospital can achieve a median LoS of 2 days without compromising patient-reported outcomes and objective functional measures, whilst maintaining a high level of patient satisfaction with both the surgery and LoS. Further work is required to better optimize management of largely low-grade complications in this patient population.

The development of a home-based therapeutic platform for multiple myeloma

BACKGROUND

Multiple Myeloma (MM) accounts for 1-2% of all malignancies but is the second commonest haematological malignancy. It is characterized by a proliferation of malignant plasma cells. The treatment paradigm of MM in Australia is traditionally hospital-based, complex and costly. While MM comprises 1-2% of cancer diagnoses, it appears in the top ten cancer diagnoses requiring hospital admission. The cumulative time spent receiving treatment is a significant burden for patients. The ability to receive treatment at home and maximize time away from hospital-based settings is a key preference for patients receiving anticancer therapies over a prolonged period of time.

METHODS

The Peter MacCallum Cancer Centre and Royal Melbourne Hospital's combined Clinical Hematology Unit has collaborated with their Hospital in the Home departments to develop several innovative programs to address this.

RESULTS

We describe our current active programs and potential developments in home-based MM therapy.

CONCLUSION

We have enabled large numbers of patients to receive complex therapies in their own home and the COVID-19 pandemic has increased the pace of the roll out without any compromise in safety. We anticipate that the next raft of immunotherapies will be able to transition into the @Home treatment setting in the coming years.

Hospital-in-the-Home as a Model for Mental Health Care Delivery: A Narrative Review

Objective: Hospital-in-the-home (HITH) is a service model widely adopted in medical specialties to help alleviate pressure on the availability of inpatient beds and allow patients to receive acute care in familiar surroundings. To date, such models are not widely utilized in mental health care. The authors review existing HITH-type mental health services, focusing on the domains of design, implementation, and outcomes.Methods: An electronic database search was conducted of MEDLINE, PsycINFO, CINAHL, Embase, Scopus, Web of Science, and Google Scholar. Fifty-six studies were eligible for inclusion in this review. Because of heterogeneous methods and outcome reporting in the available research, a narrative approach was used to highlight key themes in the literature.Results: Mental health HITH services exist under a wide range of names with differing theoretical origins and governance structures. Common characteristics and functions are summarized. The authors found moderate evidence for a reduced number and length of hospital admissions as a result of mental health HITH programs. HITH is likely to be cost-effective because of these effects. Limited evidence exists for clinical measures, consumer satisfaction, and effects on caregivers and staff.Conclusions: Mental health HITH services are an effective alternative to inpatient admission for certain consumers. The authors propose a definition of HITH as any service intended to provide inpatient-comparable mental health care in the home instead of the hospital. Standardized studies are needed for systematic analysis of key HITH outcomes.

Demographic & clinical correlates of admission into a specialized psychiatric inpatient service for children and adolescents in Egypt: An observational retrospective study

WHAT IS KNOWN ON THE SUBJECT

Admitting children and adolescents in psychiatric inpatient units is a relatively new and still debatable practice in Egyptian society and in the entire Arab world.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

Egyptian young people diagnosed with complex behavioural problems, such as in other parts of the world, desperately need and do get benefit from inpatient psychiatric service. The demographic and clinical characteristics of children in need for such service are not clearly different from those reported in other parts of the world.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

More should be done to spread awareness, remove obstacles, and develop more specialized inpatient units, with trained child psychiatrists and psychiatric nurses to provide best care for children and adolescents diagnosed with severe emotional and behavioural problems in Egypt, the Arab world and other developing countries in the world.

ABSTRACT

Background To our knowledge, this is the first study that aims to investigate the demographic and clinical correlates of admission into a specialized inpatient psychiatric unit for children and adolescents in Egypt and the Arab world. Methods The files of all service users who presented for care in the outpatient service for children and adolescents in Tanta University between July 2017 and December 2019 were reviewed. Of the 1,195 files reviewed, 100 patients were admitted to the inpatient unit for 133 admission episodes with an average duration of 18.5 days per episode. Results The most common diagnosis among admitted children and adolescents was disruptive behaviour disorder. Having a diagnosis of bipolar disorder, eating disorder, or trauma-related disorders powerfully predicted admission. Both physical and sexual abuse also predicted admission, readmission and longer duration of admission. Conclusions The need for admission into specialized psychiatric inpatient units for children and adolescents is comparable to that in other parts of the world. There is an urgent necessity to develop such therapeutic units across the entire Arab world with subsequent need to establish suitable training programs for mental health workers to deal with children and adolescents diagnosed with severe psychiatric disorders in inpatient setting.

Characteristics, safety and cost-effectiveness analysis of self-administered outpatient parenteral antibiotic therapy via a disposable elastomeric continuous infusion pump at two county hospitals in Houston, Texas, United States

WHAT IS KNOWN AND OBJECTIVE

Outpatient parenteral antibiotic therapy (OPAT) is an attractive option for patients who require parenteral antimicrobials as outpatients. Few OPAT studies have assessed the impact of IV antibiotic therapy via elastomeric continuous pumps, with most having been conducted outside the United States and few in county hospitals. The OPAT program in Harris Health system, the county hospital system of Houston, Texas, United States, has implemented a disposable elastomeric continuous infusion pump (eCIP) for self-administered intravenous antibiotics (s-OPAT) since December 2018. Our goal was to describe the clinical characteristics of patients discharged with an eCIP, as well as the safety and cost-effectiveness of this pump.

METHODS

We retrospectively analysed patients discharged from Harris Health hospitals between 12/2018 and 02/2021 with s-OPAT via eCIP at home. We extracted various patient characteristics and outcomes related to OPAT.

RESULTS AND DISCUSSION

Among 481 OPAT patients during the study period, 91 patients received s-OPAT via eCIP. A total of 1925 days of s-OPAT were administered at home, with a median duration of 12 days. Eighty-three patients (93.4%) achieved a cure from infection, six patients (6.6%) had side effects, and nine patients (9.9%) experienced 30-day hospital readmission. Twenty-two patients (24.2%) presented to the ED during s-OPAT, with 13 patients (14.3%) presenting with PICC line concerns. We estimated that s-OPAT via eCIP saved $2,360,500 to $3,503,900 compared to inpatient-only therapy.

WHAT IS NEW AND CONCLUSION

Our study showed that patients with s-OPAT via eCIP had a high cure rate with a relatively low incidence of side effects and 30-day hospital readmission. ED visits during therapy were relatively high, which indicates the necessity of close patient monitoring via the OPAT program. eCIP appears to be a good option to facilitate an early disposition of patients in county hospitals.

Pediatric palliative care at home by Home Care Unit: how home nurses feel?

PURPOSE

Our Home Care Unit (HCU) undertakes close to twenty pediatric palliative care engagements per year. We investigated the factors underlying such care by independent home health nurses.

METHODS

This was a retrospective, observational, single-center study. Home nurses who had provided palliative pediatric care in the past 16 months were included.

RESULTS

Fifty-six questionnaires were sent out (response rate of 44.6%). Eight home nurses had never provided pediatric palliative care. Three-quarters of the home nurses (76%) acknowledged having misgivings accepting these duties. The factors that facilitated providing this care were the availability of the HCU doctor and nurses, the proactiveness of the HCU team, and house calls. In 76% of cases, the involvement of the home nurses exceeded the strictly professional setting. Forty-six percent of the home nurses were amenable to undertaking another pediatric palliative care engagement, although 48% deemed the remuneration to be somewhat lacking.

CONCLUSION

The analysis allowed us to identify several prerequisites for these care engagements: the availability and the proactiveness of the HCU team, communication, and planning. This study showed the pronounced personal involvement of home nurses in complex situations, with both the child and their entire family. Home nurses appear to be skilled at using the resources available to manage the exhaustion that can arise with such an engagement. Facilitating and respecting the choice to stay home of the child and their family was meaningful to them. The personal and professional enrichment were a source of motivation despite certain limitations (availability, remuneration).

Is Pathfinder a safe alternative to the emergency department for older patients? An observational analysis

BACKGROUND

many patients brought to emergency departments (EDs) following an emergency medical services (EMS) call have non-urgent needs that could be treated elsewhere. Older people are particularly vulnerable to adverse events while attending the ED. Alternative care pathway models can reduce ED crowding and improve outcomes. Internationally, there is no consensus on which model is recommended.

AIM

the aim of this study is to investigate the impact of the Pathfinder model on ED conveyance rates and patient safety.

METHODS

the Pathfinder service is a collaboration between the National Ambulance Service and Beaumont Hospital Occupational Therapy and Physiotherapy Departments. It is supported by the Government of Ireland's Sláintecare Integration fund. This is a retrospective cohort study of the Pathfinder service over a 5-month period.

RESULTS

one-hundred and seventy-eight patients were responded to by the Pathfinder 'Rapid Response Team'. Average age was 79.6 years (standard deviation 7.6), median clinical frailty score was 6 (interquartile range: 5-6). Sixty-four percent remained at home following initial review. None re-presented to the ED within 24 hours, and 10% re-presented within 7 days. The majority (67%) of patients required follow-up by the Pathfinder 'Follow-Up Team' and/or another community-based service. Feedback demonstrates 99% patient satisfaction with the service.

CONCLUSION

the Pathfinder service is a safe alternative to ED conveyance for older people following an EMS call. It is the first model of this kind to be evaluated in Ireland. The overwhelmingly positive feedback confirms that older people want this service. This model could expand, with local adaptation, nationally and internationally.

Home hospital as a disposition for older adults from the emergency department: Benefits and opportunities

The $1 trillion industry of acute hospital care in the United States is shifting from inside the walls of the hospital to patient homes. To tackle the limitations of current hospital care in the United States, on November 25, 2020, the Center for Medicare & Medicaid Services announced that the acute hospital care at home waiver would reimburse for "home hospital" services. A "home hospital" is the home-based provision of acute services usually associated with the traditional inpatient hospital setting. Prior work suggests that home hospital care can reduce costs, maintain quality and safety, and improve patient experiences for select acutely ill adults who require hospital-level care. However, most emergency physicians are unfamiliar with the evidence of benefits demonstrated by home hospital services, especially for older adults. Therefore, the lead author solicited narrative inputs on this topic from selected experts in emergency medicine and home hospital services with clinical experience, publications, and funding on home hospital care. Then we sought to identify information most relevant to the practice of emergency medicine. We outline the proven and potential benefits of home hospital services specific to older adults compared to traditional acute care hospitalization with a focus on the emergency department.

Service evaluation comparing Acute Care at Home for older people service and conventional service within an acute hospital care of elderly ward

AIMS AND OBJECTIVES

This study evaluated the impact of a consultant-led Acute Care at Home service in comparison with conventional hospital admission to a care of elderly ward.

BACKGROUND

Globally, there has been an increased demand for healthcare services caused by population growth and a rise in chronic conditions and an ageing population. Acute Care at Home services offer acute, hospital-level care in a person's own home. Five services have been commissioned across Northern Ireland since 2014 with limited research investigating their feasibility and effectiveness.

DESIGN

Quantitative design, using service evaluation methodology.

METHODS

A 1-year retrospective chart review was undertaken exploring admission demographics and post-discharge clinical outcomes of patients admitted to a Northern Ireland, Care of the Elderly ward (n = 191) and a consultant-led Acute Care at Home Service (n = 314) between April 2018-March 2019. Data were analysed using descriptive and inferential data analysis methods including frequencies, independent t tests and chi-square analysis. Outcome measurements included length of stay, 30-day, 3- and 6-month readmission and mortality rates, functional ability and residence on discharge. STROBE checklist was used in reporting this study.

RESULTS

Acute Care at Home services are associated with higher readmission and mortality rates at 30 days, 3 and 6 months. Fewer patients die while under Acute Care at Home care. Patients admitted to the Acute Care at Home services experience a reduced length of stay and decreased escalation in domiciliary care packages and are less likely to require subacute rehabilitation on discharge. There is no difference in gender, age and early warnings score between the two cohorts.

CONCLUSION

The Acute Care at Home service is a viable alternative to hospital for older patients. It prevents functional decline and the need for domiciliary care or nursing home placement. It is likely that the Acute Care at Home service has higher mortality and readmissions rates due to treating a higher proportion of dependent, frail older adults.

RELEVANCE TO CLINICAL PRACTICE

Acute Care at Home services continue to evolve worldwide. This service evaluation has confirmed that Acute Care at Home services are safe and cost-effective alternatives to traditional older people hospital services. Such services offer patient choice, reduce length of stay and costs and prevent functional decline of older adults. This study accentuates the need to expand Acute Care at Home provision and capacity throughout Northern Ireland.

Hospital-Level Care at Home for Acutely Ill Adults: a Qualitative Evaluation of a Randomized Controlled Trial

BACKGROUND

Substitutive hospital-level care in a patient's home ("home hospital") has been shown to lower cost, utilization, and readmission compared to traditional hospital care. However, patients' perspectives to help explain how and why interventions like home hospital accomplish many of these results are lacking.

OBJECTIVE

Elucidate and explain patient perceptions of home hospital versus traditional hospital care to better describe the different perceptions of care in both settings.

DESIGN

Qualitative evaluation of a randomized controlled trial.

PARTICIPANTS

36 hospitalized patients (19 home; 17 control).

INTERVENTION

Traditional hospital ("control") versus home hospital ("home"), including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing.

APPROACH

We conducted a thematic content analysis of semi-structured interviews. Team members developed a coding structure through a multiphase approach, utilizing a constant comparative method.

KEY RESULTS

Themes clustered around 3 domains: clinician factors, factors promoting healing, and systems factors. Clinician factors were similar in both groups; both described beneficial interactions with clinical staff; however, home patients identified greater continuity of care. For factors promoting healing, home patients described a locus of control surrounding their sleep, activity, and environmental comfort that control patients lacked. For systems factors, home patients experienced more efficient processes and logistics, particularly around admission and technology use, while both noted difficulty with discharge planning.

CONCLUSIONS

Compared to control patients, home patients had better experiences with their care team, had more experiences promoting healing such as better sleep and physical activity, and had better experiences with systems factors such as the admission processes. Potential explanations include continuity of care, the power and familiarity of the home, and streamlined logistics. Future improvements include enhanced care transitions and ensuring digital interfaces are usable.

TRIAL REGISTRATION

NCT03203759.

Hospital-at-Home Interventions vs In-Hospital Stay for Patients With Chronic Disease Who Present to the Emergency Department: A Systematic Review and Meta-analysis

Importance

Hospitalizations are costly and may lead to adverse events; hospital-at-home interventions could be a substitute for in-hospital stays, particularly for patients with chronic diseases who use health services more than other patients. Despite showing promising results, heterogeneity in past systematic reviews remains high.

Objective

To systematically review and assess the association between patient outcomes and hospital-at-home interventions as a substitute for in-hospital stay for community-dwelling patients with a chronic disease who present to the emergency department and are offered at least 1 home visit from a nurse and/or physician.

Data Sources

Databases were searched from date of inception to March 4, 2019. The databases were Ovid MEDLINE, Ovid Embase, Ovid PsycINFO, CINAHL, Health Technology Assessment, the Cochrane Library, OVID Allied and Complementary Medicine Database, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov.

Study Selection

Randomized clinical trials in which the experimental group received hospital-at-home interventions and the control group received the usual in-hospital care. Patients were 18 years or older with a chronic disease who presented to the emergency department and received home visits from a nurse or physician.

Data Extraction and Synthesis

Risk of bias was assessed, and a meta-analysis was conducted for outcomes that were reported by at least 2 studies using comparable measures. Risk ratios (RRs) were reported for binary outcomes and mean differences for continuous outcomes. Narrative synthesis was performed for other outcomes.

Main Outcomes and Measures

Outcomes of interest were patient outcomes, which included mortality, long-term care admission, readmission, length of treatment, out-of-pocket costs, depression and anxiety, quality of life, patient satisfaction, caregiver stress, cognitive status, nutrition, morbidity due to hospitalization, functional status, and neurological deficits.

Results

Nine studies were included, providing data on 959 participants (median age, 71.0 years [interquartile range, 70.0-79.9 years]; 613 men [63.9%]; 346 women [36.1%]). Mortality did not differ between the hospital-at-home and the in-hospital care groups (RR, 0.84; 95% CI, 0.61-1.15; I2 = 0%). Risk of readmission was lower (RR, 0.74; 95% CI, 0.57-0.95; I2 = 31%) and length of treatment was longer in the hospital-at-home group than in the in-hospital group (mean difference, 5.45 days; 95% CI, 1.91-8.97 days; I2 = 87%). In addition, the hospital-at-home group had a lower risk of long-term care admission than the in-hospital care group (RR, 0.16; 95% CI, 0.03-0.74; I2 = 0%). Patients who received hospital-at-home interventions had lower depression and anxiety than those who remained in-hospital, but there was no difference in functional status. Other patient outcomes showed mixed results.

Conclusions and Relevance

The results of this systematic review and meta-analysis suggest that hospital-at-home interventions represent a viable substitute to an in-hospital stay for patients with chronic diseases who present to the emergency department and who have at least 1 visit from a nurse or physician. Although the heterogeneity of the findings remained high for some outcomes, particularly for length of treatment, the heterogeneity of this study was comparable to that of past reviews and further explored.

Geriatric Rehabilitation Inpatients Roam at Home! A Matched Cohort Study of Objectively Measured Physical Activity and Sedentary Behavior in Home-Based and Hospital-Based Settings

OBJECTIVES

This study aimed to describe objectively measured physical activity and sedentary behavior in geriatric rehabilitation patients receiving care in the home-based compared to the hospital-based setting.

DESIGN

Observational matched cohort study.

SETTING AND PARTICIPANTS

Home-based (patient's home) or hospital-based (ward) geriatric rehabilitation was delivered to inpatients within the REStORing health of acutely unwell adulTs (RESORT) observational, longitudinal cohort of the Royal Melbourne Hospital (Melbourne, Victoria, Australia).

METHODS

Patients were asked to wear ActivPAL4 accelerometers for 1 week and were assessed by a comprehensive geriatric assessment at admission, discharge, and followed up after 3 months. Hospital-based patients were matched to home-based patients for sex and baseline physical function [Short Physical Performance Battery (SPPB), activities (instrumental) of daily living, and Clinical Frailty Scale]. Differences in patient characteristics and physical activity (total, standing and walking durations, number of steps and sit-to stand transitions) and sedentary behavior (total, sitting and lying durations) were assessed.

RESULTS

A total of 159 patients were included: 18 home-based [mean age: 81.9 ± 8.6 years, 38.9% female, median (interquartile range [IQR]) SPPB: 7.0 (5.0-9.0)] and 141 hospital-based [mean age: 82.9 ± 7.8 years, 57.4% female, median (IQR) SPPB: 1.0 (0.0-4.0)] patients, of whom 18 were matched [mean age: 80.1 ± 7.4 years, 38.9% female, median (IQR) SPPB: 6.5 (4.8-10.0)]. Median physical activity measures were consistently higher in home-based patients compared to the total group of hospital-based patients. After matching, physical activity measures remained >2.4 times higher and were significantly different for all measures (total physical activity, standing and walking durations, and steps) except for sit-to-stand transitions. Sedentary behaviors were similar with home-based patients spending non-significantly more time sitting but significantly less time lying than hospital-based patients (matched and total).

CONCLUSIONS AND IMPLICATIONS

Home-based inpatients are more physically active than hospital-based inpatients independent of matching for sex and baseline physical function, which supports home-based geriatric rehabilitation.

Hospital-at-Home Expands Hospital Capacity During COVID-19 Pandemic

A Coronavirus Disease 2019 (COVID-19)-specific Hospital-at-Home was implemented in a 400-bed tertiary hospital in Barcelona, Spain. Senior or immune-compromised physicians oversaw patient care. The alternative to inpatient care more than doubled beds available for hospitalization and decreased the risk of transmission among patients and health care professionals. Mild cases from either the emergency department or after hospital discharge were deemed suitable for admission to the Hospital-at-Home. More than half of all patients had pneumonia. Standardized protocols and management criteria were provided. Only 6% of cases required referral for inpatient hospitalization. These results are promising and may provide valuable insight for centers undertaking Hospital-at-Home initiatives or in the case of new COVID-19 outbreaks.

An Integrated Mobile Acute Care Service Enhances Value

Reducing the cost of care while enhancing its quality and experience are essential components to success in value-based care. Because emergency department (ED) and hospital settings represent high-cost environments, the authors sought to reduce their unnecessary use by deploying a novel care delivery service that offers mobile, on-demand care for high-acuity conditions in patient homes. This study is a retrospective quality improvement evaluation of the initial year of the mobile acute care model in a health system with a substantial penetration of value-based care. Although all patients were eligible for mobile services as clinically indicated, those in accountable care organizations were prioritized by the care management teams. A variety of operational, clinical, and financial metrics were assessed to determine the program's performance and value. There were 3436 patient encounters during the study period, a utilization rate of 71% that trended upward throughout the year. Of these visits, 44% involved patients in value-based payment models; 80% of these represented patients in Medicare risk agreements. Throughout the year, progressively improving operational and clinical performance were observed, as were consistently high patient satisfaction scores. An estimated 63.8% of total mobile visits resulted in ED avoidance; 21.6% were emergency medical transport avoidant; 14.1% led to avoided hospital observation or inpatient stays. Patients were highly satisfied with the service. In-home mobile care for high-acuity illness can prevent unnecessary ED and hospital use for some patients and is associated with high patient satisfaction. Acute mobile care is a useful component of a value-based care strategy.

Impacts on health outcomes and on resources utilization for anticancer drugs injection at home, a complex intervention: a systematic review

BACKGROUND

As hospital-based home care is a complex intervention, we critically appraised the key elements that could ensure the completeness of assessment and explain the heterogeneity of the literature results about the comparison between home and hospital setting for the anticancer drugs injection within the same standards of clinical care.

METHODS

Systematic review was conducted. Medline, Embase, Cochrane Library, Web of Sciences, and Cumulative Index of Nursing and Allied Health (Cinahl) searched to February 1, 2019, and combined with grey literature. Methodological quality has been rated using the "Quality Assessment Tool for Quantitative Studies" developed by the Effective Public Health Practice Project (EPHHP) in addition to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement for economic studies and the consolidated criteria for reporting qualitative research (COREQ) checklist for qualitative studies.

RESULTS

Of 400 records identified, we identified 13 relevant studies (nine quantitative and four mixed-method studies). The quality of studies was hardly strong. The home-based anticancer injection involved highly heterogeneous home care interventions that generally kept a strong link with the hospital setting. The study schemes limited the comparison of clinical outcomes (OS, PFS, toxicity). Unlike the quality of life remaining similar, patients preferred to be treated at home. Cost savings were in favor of Hospital at Home, but the charge categories used to compare or the home intervention were heterogeneous and rarely integrating relatives' duties and hospital staff's time. Qualitative studies highlighted about benefits and barriers of home.

CONCLUSION

The current state of evidence shows as it still remains difficult to appraise the anticancer injection at home when considering the details of this complex intervention, the role of each stakeholder, and the missing data.