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Hernandez C, Herranz C, Baltaxe E, Seijas N, González-Colom R, Asenjo M, Coloma E, Fernandez J, Vela E, Carot-Sans G, Cano I, Roca J, Nicolas D. The value of admission avoidance: cost-consequence analysis of one-year activity in a consolidated service. Cost Eff Resour Alloc 2024; 22:30. [PMID: 38622593 PMCID: PMC11017527 DOI: 10.1186/s12962-024-00536-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 03/21/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Many advantages of hospital at home (HaH), as a modality of acute care, have been highlighted, but controversies exist regarding the cost-benefit trade-offs. The objective is to assess health outcomes and analytical costs of hospital avoidance (HaH-HA) in a consolidated service with over ten years of delivery of HaH in Barcelona (Spain). METHODS A retrospective cost-consequence analysis of all first episodes of HaH-HA, directly admitted from the emergency room (ER) in 2017-2018, was carried out with a health system perspective. HaH-HA was compared with a propensity-score-matched group of contemporary patients admitted to conventional hospitalization (Controls). Mortality, re-admissions, ER visits, and direct healthcare costs were evaluated. RESULTS HaH-HA and Controls (n = 441 each) were comparable in terms of age (73 [SD16] vs. 74 [SD16]), gender (male, 57% vs. 59%), multimorbidity, healthcare expenditure during the previous year, case mix index of the acute episode, and main diagnosis at discharge. HaH-HA presented lower mortality during the episode (0 vs. 19 (4.3%); p < 0.001). At 30 days post-discharge, HaH-HA and Controls showed similar re-admission rates; however, ER visits were lower in HaH-HA than in Controls (28 (6.3%) vs. 34 (8.1%); p = 0.044). Average costs per patient during the episode were lower in the HaH-HA group (€ 1,078) than in Controls (€ 2,171). Likewise, healthcare costs within the 30 days post-discharge were also lower in HaH-Ha than in Controls (p < 0.001). CONCLUSIONS The study showed higher performance and cost reductions of HaH-HA in a real-world setting. The identification of sources of savings facilitates scaling of hospital avoidance. REGISTRATION ClinicalTrials.gov (26/04/2017; NCT03130283).
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Affiliation(s)
- Carme Hernandez
- Hospital at Home Unit, Hospital Clínic de Barcelona. Villarroel, 170, 08036, Barcelona, Spain.
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.
| | - Carme Herranz
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Consorci d'Atenció Primària de Salut de l'Eixample (CAPSBE), Barcelona, Spain
| | - Erik Baltaxe
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel
| | - Nuria Seijas
- Hospital at Home Unit, Hospital Clínic de Barcelona. Villarroel, 170, 08036, Barcelona, Spain
| | - Rubèn González-Colom
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Maria Asenjo
- Hospital at Home Unit, Hospital Clínic de Barcelona. Villarroel, 170, 08036, Barcelona, Spain
| | - Emmanuel Coloma
- Hospital at Home Unit, Hospital Clínic de Barcelona. Villarroel, 170, 08036, Barcelona, Spain
- Institut Clínic de Medicina i Dermatologia (ICMID), Hospital Clínic de Barcelona, Barcelona, Spain
| | - Joaquim Fernandez
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Institut Clínic de Medicina i Dermatologia (ICMID), Hospital Clínic de Barcelona, Barcelona, Spain
| | - Emili Vela
- Àrea de Sistemes d'Informació. Servei Català de la Salut, Barcelona, Spain
- Digitalization for the Sustainability of the Healthcare System (DS3), Catalan Health Service, Barcelona, Spain
| | - Gerard Carot-Sans
- Àrea de Sistemes d'Informació. Servei Català de la Salut, Barcelona, Spain
- Digitalization for the Sustainability of the Healthcare System (DS3), Catalan Health Service, Barcelona, Spain
| | - Isaac Cano
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Josep Roca
- Hospital at Home Unit, Hospital Clínic de Barcelona. Villarroel, 170, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Institut Clínic Respiratori (ICR), Hospital Clínic de Barcelona, Barcelona, Spain
| | - David Nicolas
- Hospital at Home Unit, Hospital Clínic de Barcelona. Villarroel, 170, 08036, Barcelona, Spain
- Institut Clínic de Medicina i Dermatologia (ICMID), Hospital Clínic de Barcelona, Barcelona, Spain
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Ribbink ME, MacNeil Vroomen JL, Franssen R, Kolk D, Ben ÂJ, Willems HC, Buurman BM. Investigating the Effectiveness of Care Delivery at an Acute Geriatric Community Hospital for Older Adults in the Netherlands: A Prospective Controlled Observational Study. J Am Med Dir Assoc 2024; 25:704-710. [PMID: 38159913 DOI: 10.1016/j.jamda.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES Hospital admission in older adults is associated with unwanted outcomes such as readmission, institutionalization, and functional decline. To reduce these outcomes, the Netherlands introduced an alternative to hospital-based care: the Acute Geriatric Community Hospital (AGCH). The AGCH is an acute care unit situated outside of a hospital focusing on early rehabilitation and comprehensive geriatric assessment. The objective of this study was to evaluate if AGCH care is associated with decreasing unplanned readmissions or death compared with hospital-based care. DESIGN Prospective cohort study controlled with a historic cohort. SETTING AND PARTICIPANTS A (sub)acute care unit (AGCH) and 6 hospitals in the Netherlands; participants were acutely ill older adults. METHODS We used inverse propensity score weighting to account for baseline differences. The primary outcome was 90-day readmission or death. Secondary outcomes included 30-day readmission or death, time to death, admission to long-term residential care, occurrence of falls and functioning over time. Generalized logistic regression models and multilevel regression analyses were used to estimate effects. RESULTS AGCH patients (n = 206) had lower 90-day readmission or death rates [odds ratio (OR) 0.39, 95% CI 0.23-0.67] compared to patients treated in hospital (n = 401). AGCH patients had a lower risk of 90-day readmission (OR 0.38, 95% CI 0.21-0.67) but did not differ on all-cause mortality (OR 0.89, 95% CI 0.44-1.79) compared with the hospital control group. AGCH patients had lower 30-day readmission or death rates. Secondary outcomes did not differ. CONCLUSIONS AND IMPLICATIONS AGCH patients had lower rates of readmission and/or death than patients treated in a hospital. Our results support further research on the implementation and cost-effectiveness of AGCH in the Netherlands and other countries seeking alternatives to hospital-based care.
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Affiliation(s)
- Marthe E Ribbink
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Janet L MacNeil Vroomen
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Remco Franssen
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Daisy Kolk
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ângela Jornada Ben
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, the Netherlands
| | - Hanna C Willems
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bianca M Buurman
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; ACHIEVE - Center of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands
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Edgar K, Iliffe S, Doll HA, Clarke MJ, Gonçalves-Bradley DC, Wong E, Shepperd S. Admission avoidance hospital at home. Cochrane Database Syst Rev 2024; 3:CD007491. [PMID: 38438116 PMCID: PMC10911897 DOI: 10.1002/14651858.cd007491.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
BACKGROUND Admission avoidance hospital at home provides active treatment by healthcare professionals in the patient's home for a condition that would otherwise require acute hospital inpatient care, and always for a limited time period. This is the fourth update of this review. OBJECTIVES To determine the effectiveness and cost of managing patients with admission avoidance hospital at home compared with inpatient hospital care. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL on 24 February 2022, and checked the reference lists of eligible articles. We sought ongoing and unpublished studies by searching ClinicalTrials.gov and WHO ICTRP, and by contacting providers and researchers involved in the field. SELECTION CRITERIA Randomised controlled trials recruiting participants aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital inpatient care. DATA COLLECTION AND ANALYSIS We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. We performed meta-analysis for trials that compared similar interventions, reported comparable outcomes with sufficient data, and used individual patient data when available. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes. MAIN RESULTS We included 20 randomised controlled trials with a total of 3100 participants; four trials recruited participants with chronic obstructive pulmonary disease; two trials recruited participants recovering from a stroke; seven trials recruited participants with an acute medical condition who were mainly older; and the remaining trials recruited participants with a mix of conditions. We assessed the majority of the included studies as at low risk of selection, detection, and attrition bias, and unclear for selective reporting and performance bias. For an older population, admission avoidance hospital at home probably makes little or no difference on mortality at six months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.68 to 1.13; P = 0.30; I2 = 0%; 5 trials, 1502 participants; moderate-certainty evidence); little or no difference on the likelihood of being readmitted to hospital after discharge from hospital at home or inpatient care within 3 to 12 months' follow-up (RR 1.14, 95% CI 0.97 to 1.34; P = 0.11; I2 = 41%; 8 trials, 1757 participants; moderate-certainty evidence); and probably reduces the likelihood of living in residential care at six months' follow-up (RR 0.53, 95% CI 0.41 to 0.69; P < 0.001; I2 = 67%; 4 trials, 1271 participants; moderate-certainty evidence). Hospital at home probably results in little to no difference in patient's self-reported health status (2006 patients; moderate-certainty evidence). Satisfaction with health care received may be improved with admission avoidance hospital at home (1812 participants; low-certainty evidence); few studies reported the effect on caregivers. Hospital at home reduced the initial average hospital length of stay (2036 participants; low-certainty evidence), which ranged from 4.1 to 18.5 days in the hospital group and 1.2 to 5.1 days in the hospital at home group. Hospital at home length of stay ranged from an average of 3 to 20.7 days (hospital at home group only). Admission avoidance hospital at home probably reduces costs to the health service compared with hospital admission (2148 participants; moderate-certainty evidence), though by a range of different amounts and using different methods to cost resource use, and there is some evidence that it decreases overall societal costs to six months' follow-up. AUTHORS' CONCLUSIONS Admission avoidance hospital at home, with the option of transfer to hospital, may provide an effective alternative to inpatient care for a select group of older people who have been referred for hospital admission. The intervention probably makes little or no difference to patient health outcomes; may improve satisfaction; probably reduces the likelihood of relocating to residential care; and probably decreases costs.
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Affiliation(s)
- Kate Edgar
- Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Steve Iliffe
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Helen A Doll
- Clinical Outcomes Assessments, ICON Commercialisation and Outcomes, Dublin, Ireland
| | - Mike J Clarke
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | | | - Eric Wong
- St. Michael's Hospital and Unity Health Toronto, University of Toronto, Toronto, Canada
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Wallis JA, Shepperd S, Makela P, Han JX, Tripp EM, Gearon E, Disher G, Buchbinder R, O'Connor D. Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis. Cochrane Database Syst Rev 2024; 3:CD014765. [PMID: 38438114 PMCID: PMC10911892 DOI: 10.1002/14651858.cd014765.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
BACKGROUND Worldwide there is an increasing demand for Hospital at Home as an alternative to hospital admission. Although there is a growing evidence base on the effectiveness and cost-effectiveness of Hospital at Home, health service managers, health professionals and policy makers require evidence on how to implement and sustain these services on a wider scale. OBJECTIVES (1) To identify, appraise and synthesise qualitative research evidence on the factors that influence the implementation of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home, from the perspective of multiple stakeholders, including policy makers, health service managers, health professionals, patients and patients' caregivers. (2) To explore how our synthesis findings relate to, and help to explain, the findings of the Cochrane intervention reviews of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home services. SEARCH METHODS We searched MEDLINE, CINAHL, Global Index Medicus and Scopus until 17 November 2022. We also applied reference checking and citation searching to identify additional studies. We searched for studies in any language. SELECTION CRITERIA We included qualitative studies and mixed-methods studies with qualitative data collection and analysis methods examining the implementation of new or existing Hospital at Home services from the perspective of different stakeholders. DATA COLLECTION AND ANALYSIS Two authors independently selected the studies, extracted study characteristics and intervention components, assessed the methodological limitations using the Critical Appraisal Skills Checklist (CASP) and assessed the confidence in the findings using GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research). We applied thematic synthesis to synthesise the data across studies and identify factors that may influence the implementation of Hospital at Home. MAIN RESULTS From 7535 records identified from database searches and one identified from citation tracking, we included 52 qualitative studies exploring the implementation of Hospital at Home services (31 Early Discharge, 16 Admission Avoidance, 5 combined services), across 13 countries and from the perspectives of 662 service-level staff (clinicians, managers), eight systems-level staff (commissioners, insurers), 900 patients and 417 caregivers. Overall, we judged 40 studies as having minor methodological concerns and we judged 12 studies as having major concerns. Main concerns included data collection methods (e.g. not reporting a topic guide), data analysis methods (e.g. insufficient data to support findings) and not reporting ethical approval. Following synthesis, we identified 12 findings graded as high (n = 10) and moderate (n = 2) confidence and classified them into four themes: (1) development of stakeholder relationships and systems prior to implementation, (2) processes, resources and skills required for safe and effective implementation, (3) acceptability and caregiver impacts, and (4) sustainability of services. AUTHORS' CONCLUSIONS Implementing Admission Avoidance and Early Discharge Hospital at Home services requires early development of policies, stakeholder engagement, efficient admission processes, effective communication and a skilled workforce to safely and effectively implement person-centred Hospital at Home, achieve acceptance by staff who refer patients to these services and ensure sustainability. Future research should focus on lower-income country and rural settings, and the perspectives of systems-level stakeholders, and explore the potential negative impact on caregivers, especially for Admission Avoidance Hospital at Home, as this service may become increasingly utilised to manage rising visits to emergency departments.
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Affiliation(s)
- Jason A Wallis
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Cabrini Health, Malvern, Australia
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Petra Makela
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jia Xi Han
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Evie M Tripp
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Emma Gearon
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Gary Disher
- New South Wales Ministry of Health, St Leonards, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Denise O'Connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Wang X, Stewart C, Lee G. Patients' and caregivers' perceptions of the quality of hospital-at-home service: A scoping review. J Clin Nurs 2024; 33:817-838. [PMID: 37817557 DOI: 10.1111/jocn.16906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/22/2023] [Accepted: 10/02/2023] [Indexed: 10/12/2023]
Abstract
AIM This scoping review aims to provide an overview of patients and caregivers perceptions of hospital-at-home (HaH) services. BACKGROUND HaH services provide patients with hospital-level care at home and are central to integrated healthcare systems. Despite favourable data from individual studies in the literature, in-depth analysis from patient and caregivers perspectives is lacking. This understanding is essential for the dissemination and scaling of HaH services. DESIGN The scoping review was performed using the PRISMA-ScR checklist and PAGER framework for the findings report and research recommendations. METHOD Literature from PubMed, Web of Science, Ovid, CINAHL, Cochrane and Mednar databases were searched. Relevant studies published between 1st January 2005 and 31st December 2022 were identified. The conceptual model of the development of patient perceptions of quality was used for data extraction and tabulation. RESULTS The review included 24 articles. Expectation attributions were identified as needs, types of service, hospitalisation experiences, family care preferences, social-demographics and coping skills. From patient's and caregiver's perspectives, HaH was safe, effective and viewed positively. Perceived concerns/barriers and enablers/facilitators were associated with individual, caregiver and system factors, but demonstrated an overall satisfaction in the HaH service. CONCLUSION HaH provides an excellent service according to patients' and caregivers' perceptions. However, gaps in care were identified such as prioritising patient-centred care, along with improved multidisciplinary continuity of care and future studies should incorporate these into their research of HaH. RELEVANCE TO CLINICAL PRACTICE Patients' and caregivers' HaH needs should be embedded in the design, development and implementation of HaH services. PATIENT AND PUBLIC CONTRIBUTION Not applicable for the study design of this scoping review.
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Affiliation(s)
- Xiyi Wang
- School of Nursing, Shanghai Jiao Tong University, Shanghai, China
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Carolyne Stewart
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Geraldine Lee
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
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Levine AA, Shin MH, Adjognon OL, Engle RL, Sullivan JL. Overcoming barriers to implementation: mapping implementation strategies in four hospital in home programs within the Veterans Health Administration. Home Health Care Serv Q 2024:1-18. [PMID: 38174378 DOI: 10.1080/01621424.2023.2301413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
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.
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Affiliation(s)
- A Alex Levine
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Marlena H Shin
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
| | - Omonyele L Adjognon
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
| | - Ryann L Engle
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
| | - Jennifer L Sullivan
- COIN LTSS, Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, Providence, Rhode Island, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, West Roxbury, Massachusetts, USA
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Desai MP, Ross JB, Blitzer S, Como N, Horton DJ, Ostergar J, Hernández C, Levine DM. Hospital-Level Care at Home for Acutely Ill Adults in Rural Settings: Proof of Concept. Home Healthc Now 2024; 42:21-30. [PMID: 38190160 DOI: 10.1097/nhh.0000000000001227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Residents in rural areas face barriers to accessing acute care. Rural home hospital (RHH) or delivery of acute care at home could represent an important clinical care model. This study assessed the feasibility and acceptability of RHH as a substitute to traditional hospital care. Patients were cared for by a remote RHH attending physician and an RHH registered nurse deployed to the home. The study team conducted daily check-ins with RHH clinicians to assess workflows for completion. Surveys assessed patient experience and qualitative interviews assessed perceived acceptability, safety, and quality of care. We completed qualitative analysis of the interviews and coded qualitative data into domains and subdomains through an iterative process. RHH was successfully deployed to three acutely ill patients in rural Utah. RHH admission, daily care, and discharge processes were accomplished for each patient. From qualitative analysis, we identified four domains: (1) Perceived comfort level during RHH admission, (2) Perceived safety during RHH admission, (3) Perceived quality of care during RHH admission, and (4) Perception of RHH workflows. We found acute care was delivered to rural homes with satisfactory patient and clinician experience. Team dynamics, technology build, robust clinical and operational workflows, and care coordination were important to a successful admission. Learnings from this study can inform program design and training for RHH teams and startup for larger RHH evaluation. Home hospital care is expanding rapidly in the United States and RHH could represent an important clinical care model.
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Sharabi A, Abutbul E, Grossbard E, Martsiano Y, Berman A, Kassif-Lerner R, Hakim H, Liber P, Zoubi A, Barkai G, Segal G. Six-Lead Electrocardiography Enables Identification of Rhythm and Conduction Anomalies of Patients in the Telemedicine-Based, Hospital-at-Home Setting: A Prospective Validation Study. Sensors (Basel) 2023; 23:8464. [PMID: 37896557 PMCID: PMC10611340 DOI: 10.3390/s23208464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/01/2023] [Accepted: 10/07/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND The hospital-at-home (HAH) model is a viable alternative for conventional in-hospital stays worldwide. Serum electrolyte abnormalities are common in acute patients, especially in those with many comorbidities. Pathologic changes in cardiac electrophysiology pose a potential risk during HAH stays. Periodical electrocardiogram (ECG) tracing is therefore advised, but few studies have evaluated the accuracy and efficiency of compact, self-activated ECG devices in HAH settings. This study aimed to evaluate the reliability of such a device in comparison with a standard 12-lead ECG. METHODS We prospectively recruited consecutive patients admitted to the Sheba Beyond Virtual Hospital, in the HAH department, during a 3-month duration. Each patient underwent a 12-lead ECG recording using the legacy device and a consecutive recording by a compact six-lead device. Baseline patient characteristics during hospitalization were collected. The level of agreement between devices was measured by Cohen's kappa coefficient for inter-rater reliability (Ϗ). RESULTS Fifty patients were included in the study (median age 80 years, IQR 14). In total, 26 (52%) had electrolyte disturbances. Abnormal D-dimer values were observed in 33 (66%) patients, and 12 (24%) patients had elevated troponin values. We found a level of 94.5% raw agreement between devices with regards to nine of the options included in the automatic read-out of the legacy device. The calculated Ϗ was 0.72, classified as a substantial consensus. The rate of raw consensus regarding the ECG intervals' measurement (PR, RR, and QT) was 78.5%, and the calculated Ϗ was 0.42, corresponding to a moderate level of agreement. CONCLUSION This is the first report to our knowledge regarding the feasibility of using a compact, six-lead ECG device in the setting of an HAH to be safe and bearing satisfying agreement level with a legacy, 12-lead ECG device, enabling quick, accessible arrythmia detection in this setting. Our findings bear a promise to the future development of telemedicine-based hospital-at-home methodology.
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Affiliation(s)
- Adam Sharabi
- Beyond Virtual Hospital, Sheba Medical Center, Faculty of Medicine, Tel-Aviv University, Tel Aviv 5265601, Israel
- Faculty of Medicine, University of Nicosia, 2408 Nicosia, Cyprus
| | - Eli Abutbul
- Beyond Virtual Hospital, Sheba Medical Center, Faculty of Medicine, Tel-Aviv University, Tel Aviv 5265601, Israel
- Faculty of Medicine, University of Nicosia, 2408 Nicosia, Cyprus
| | - Eitan Grossbard
- Beyond Virtual Hospital, Sheba Medical Center, Faculty of Medicine, Tel-Aviv University, Tel Aviv 5265601, Israel
- Faculty of Medicine, University of Nicosia, 2408 Nicosia, Cyprus
| | - Yonatan Martsiano
- Beyond Virtual Hospital, Sheba Medical Center, Faculty of Medicine, Tel-Aviv University, Tel Aviv 5265601, Israel
- Faculty of Medicine, University of Nicosia, 2408 Nicosia, Cyprus
| | - Aya Berman
- Dan Petah-Tikvah District at Clalit Health Services, Petah Tikva 4922297, Israel
| | - Reut Kassif-Lerner
- Department of Pediatric Intensive Care, The Edmond and Lily Safra Children’s Hospital Sheba Medical Center, Affiliated to the Faculty of Medicine, Tel-Aviv University, Tel Aviv 5265601, Israel
| | - Hila Hakim
- Beyond Virtual Hospital, Sheba Medical Center, Faculty of Medicine, Tel-Aviv University, Tel Aviv 5265601, Israel
| | - Pninit Liber
- Beyond Virtual Hospital, Sheba Medical Center, Faculty of Medicine, Tel-Aviv University, Tel Aviv 5265601, Israel
| | - Anram Zoubi
- Beyond Virtual Hospital, Sheba Medical Center, Faculty of Medicine, Tel-Aviv University, Tel Aviv 5265601, Israel
| | - Galia Barkai
- Beyond Virtual Hospital, Sheba Medical Center, Faculty of Medicine, Tel-Aviv University, Tel Aviv 5265601, Israel
| | - Gad Segal
- Beyond Virtual Hospital, Sheba Medical Center, Faculty of Medicine, Tel-Aviv University, Tel Aviv 5265601, Israel
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Haywood HB, Fonarow GC, Khan MS, Van Spall HGC, Morris AA, Nassif ME, Kittleson MM, Butler J, Greene SJ. Hospital at Home as a Treatment Strategy for Worsening Heart Failure. Circ Heart Fail 2023; 16:e010456. [PMID: 37646170 DOI: 10.1161/circheartfailure.122.010456] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 07/17/2023] [Indexed: 09/01/2023]
Abstract
Hospital at home (HaH) is an innovative care model that may be particularly suited for heart failure (HF). Outpatient visits and inpatient care have been the 2 traditional settings for HF care, yet may not match the social and medical needs of patients at all times. Alternative models such as HaH may represent an effective and patient-centered option for select patients with worsening HF. To date, limited research in HF and other disease states has supported HaH as being safe and lower cost than traditional inpatient admission. Supporting HaH are new payment structures, such as Medicare's Acute Hospital Care at Home waiver program. In combination with outpatient visits, outpatient intravenous diuretic clinics, inpatient care, and cardiac intensive care, HaH could be a core component of a comprehensive care model with the potential to match resource utilization with the needs of patients across the spectrum of HF severity, and improve patient outcomes.
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Affiliation(s)
- Hubert B Haywood
- Department of Medicine, Duke University Medical Center, Durham, NC (H.B.H.)
| | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center (G.C.F.)
| | | | - Harriette G C Van Spall
- Department of Medicine (H.G.C.V.S.), McMaster University, Hamilton, ON, Canada
- Population Health Research Institute (H.G.C.V.S.), McMaster University, Hamilton, ON, Canada
| | | | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (M.E.N.)
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX (J.B.)
- Department of Medicine, University of Mississippi, Jackson (J.B.)
| | - Stephen J Greene
- Division of Cardiology, Duke University Medical Center, Durham, NC (M.S.K., S.J.G.)
- Duke Clinical Research Institute, Durham, NC (S.J.G.)
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10
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Zawada SK, Sweat J, Paulson MR, Maniaci MJ. Staff Successes and Challenges with Telecommunications-Facilitated Patient Care in Hybrid Hospital-at-Home during the COVID-19 Pandemic. Healthcare (Basel) 2023; 11:healthcare11091223. [PMID: 37174766 PMCID: PMC10178711 DOI: 10.3390/healthcare11091223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/15/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
Technology-enhanced hospital-at-home (H@H), commonly referred to as hybrid H@H, became more widely adopted during the COVID-19 pandemic. We conducted focus group interviews with Mayo Clinic staff members (n = 14) delivering hybrid H@H in three separate locations-a rural community health system (Northwest Wisconsin), the nation's largest city by area (Jacksonville, FL), and a desert metropolitan area (Scottsdale, AZ)-to understand staff experiences with implementing a new care delivery model and using new technology to monitor patients at home during the pandemic. Using a grounded theory lens, transcripts were analyzed to identify themes. Staff reported that hybrid H@H is a complex care coordination and communication initiative, that hybrid H@H faces site-specific challenges modulated by population density and state policies, and that many patients are receiving uniquely high-quality care through hybrid H@H, partly enabled by advances in technology. Participant responses amplify the need for additional qualitative research with hybrid H@H staff to identify areas for improvement in the deployment of new models of care enabled by modern technology.
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Affiliation(s)
- Stephanie K Zawada
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic College of Medicine and Science, 13400 E. Shea Blvd., Scottsdale, AZ 85259, USA
| | - Jeffrey Sweat
- Social Science Department, University of Wisconsin-Stout, 712 Broadway St. S, Menomonie, WI 54751, USA
| | | | - Michael J Maniaci
- Mayo Clinic Florida, 4500 San Pablo Rd., Jacksonville, FL 32224, USA
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Cerdan de las Heras J, Andersen SL, Matthies S, Sandreva TV, Johannesen CK, Nielsen TL, Fuglebjerg N, Catalan-Matamoros D, Hansen DG, Fischer TK. Hospitalisation at Home of Patients with COVID-19: A Qualitative Study of User Experiences. Int J Environ Res Public Health 2023; 20:1287. [PMID: 36674043 PMCID: PMC9858642 DOI: 10.3390/ijerph20021287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 06/17/2023]
Abstract
Hospitalisation at Home (HaH) is a new model providing hospital-level care at home as a substitute for traditional care. Biometric monitoring and digital communication are crucial, but little is known about user perspectives. We aim to explore how in-patients with severe COVID-19 infection and clinicians engage with and experience communication and self-monitoring activities following the HaH model. A qualitative study based on semi-structured interviews of patients and clinicians participating in the early development phase of HaH were conducted. We interviewed eight clinicians and six patients. Five themes emerged from clinicians: (1) staff fear and concerns, (2) workflow, (3) virtual closeness, (4) patient relatives, and (5) future HaH models; four themes emerged from patients: (1) transition to home, (2) joint responsibility, (3) acceptability of technologies, and (4) relatives. Despite technical problems, both patients and clinicians were enthusiastic about the conceptual HaH idea. If appropriately introduced, treatment based on self-monitoring and remote communication was perceived acceptable for the patients; however, obtaining vitals at night was an overwhelming challenge. HaH is generally acceptable, perceived patient-centred, influencing routine clinical workflow, role and job satisfaction. Therefore, it calls for educational programs including more perspective than issues related to technical devices.
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Affiliation(s)
- Jose Cerdan de las Heras
- Department of Clinical Research, Copenhagen University Hospital—North Zealand, 3400 Hillerød, Denmark
| | - Signe Lindgård Andersen
- Department of Clinical Research, Copenhagen University Hospital—North Zealand, 3400 Hillerød, Denmark
| | - Sophie Matthies
- Department of Clinical Research, Copenhagen University Hospital—North Zealand, 3400 Hillerød, Denmark
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Hospital—North Zealand, 3400 Hillerød, Denmark
| | | | - Caroline Klint Johannesen
- Department of Clinical Research, Copenhagen University Hospital—North Zealand, 3400 Hillerød, Denmark
- Department of Virology and Microbiological Special Diagnostics, Statens Serum Institut, 2300 Copenhagen, Denmark
| | - Thyge Lynghøj Nielsen
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Hospital—North Zealand, 3400 Hillerød, Denmark
| | - Natascha Fuglebjerg
- Department of Clinical Research, Copenhagen University Hospital—North Zealand, 3400 Hillerød, Denmark
| | | | - Dorte Gilså Hansen
- Institute of Public Health, Research Unit of General Practice, University of Southern Denmark, 5230 Odense, Denmark
| | - Thea K. Fischer
- Department of Clinical Research, Copenhagen University Hospital—North Zealand, 3400 Hillerød, Denmark
- Department of Public Health, University of Copenhagen, 1353 Copenhagen, Denmark
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12
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Denecke K, May R, Borycki EM, Kushniruk AW. Digital health as an enabler for hospital@home: A rising trend or just a vision? Front Public Health 2023; 11:1137798. [PMID: 36875371 PMCID: PMC9981936 DOI: 10.3389/fpubh.2023.1137798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/30/2023] [Indexed: 02/19/2023] Open
Abstract
Background Hospital@home is a model of healthcare, where healthcare professionals actively treat patients in their homes for conditions that may otherwise require hospitalization. Similar models of care have been implemented in jurisdictions around the world over the past few years. However, there are new developments in health informatics including digital health and participatory health informatics that may have an impact on hospital@home approaches. Objectives This study aims to identify the current state of implementation of emerging concepts into the hospital@home research and models of care; to identify strengths and weaknesses, opportunities, and threats associated with the models of care; and to suggest a research agenda. Methods We employed two research methodologies, namely, a literature review and a SWOT (strengths, weaknesses, opportunities, and threats) analysis. The literature from the last 10 years was collected from PubMed using the search string "hospital at home" OR "care at home" OR "patient at home." Relevant information was extracted from the included articles. Results Title and abstract review were conducted on 1,371 articles. The full-text review was conducted on 82 articles. Data were extracted from 42 articles that met our review criteria. Most of the studies originated from the United States and Spain. Several medical conditions were considered. The use of digital tools and technologies was rarely reported. In particular, innovative approaches such as wearables or sensor technologies were rarely used. The current landscape of hospital@home models of care simply delivers hospital care in the patient's home. Tools or approaches from taking a participatory health informatics design approach involving a range of stakeholders (such as patients and their caregivers) were not reported in the literature reviewed. In addition, emerging technologies supporting mobile health applications, wearable technologies, and remote monitoring were rarely discussed. Conclusion There are multiple benefits and opportunities associated with hospital@home implementations. There are also threats and weaknesses associated with the use of this model of care. Some weaknesses could be addressed by using digital health and wearable technologies to support patient monitoring and treatment at home. Employing a participatory health informatics approach to design and implementation could help to ensure the acceptance of such care models.
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Affiliation(s)
| | - Richard May
- Harz University of Applied Sciences, Wernigerode, Germany
| | - Elizabeth M Borycki
- School of Health Information Science, University of Victoria, Victoria, BC, Canada
| | - Andre W Kushniruk
- School of Health Information Science, University of Victoria, Victoria, BC, Canada
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13
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Inzitari M, Arnal C, Ribera A, Hendry A, Cesari M, Roca S, Pérez LM. Comprehensive Geriatric Hospital at Home: Adaptation to Referral and Case-Mix Changes During the COVID-19 Pandemic. J Am Med Dir Assoc 2023; 24:3-9.e1. [PMID: 36470320 PMCID: PMC9647017 DOI: 10.1016/j.jamda.2022.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To describe the evolution of a Hospital at Home (HAH) based on comprehensive geriatric assessment (CGA), including its adaptability to changing case-mixes and pathways during the COVID-19 pandemic. DESIGN Observational study of consecutive admissions to a combined step-up (admissions from home) and step-down (hospital discharge) HAH during 3 periods: prepandemic (2018‒February 2020) vs pandemic (March‒December 2020, and January‒December 2021). SETTING AND PARTICIPANTS Participants were all consecutive patients admitted to a CGA-based HAH, located in Barcelona, Spain. Referrals followed acute events or exacerbation of chronic conditions, by either primary care (step-up) or after post-acute discharge (step-down). METHODS HAH intervention based on CGA and incorporated geriatric rehabilitation. Patient case-mix, functional evolution (Barthel index), and mortality were compared across periods and between pathways. RESULTS HAH capacity expanded 3 fold from 15 to 45 virtual beds and altogether managed 688 consecutive patients [mean age (SD) = 82.5 (9.6) years; 59% women]. Pandemic case-mix was slightly older (mean age = 83.5 vs 82 years, P = .012) than prepandemic, with greater mobility impairment. Across periods, step-up increased (26.1%, 40.9%, 48.2%, P < .01) because of medical events, skin ulcers, and post-acute stroke, whereas step-down decreased; multivariable models showed no differences in functional improvement or mortality. When comparing pathways, step-up featured older patients with higher comorbidity, worse functional status, and lower absolute functional gain than step-down (5.6 vs 13 points of Barthel index, P < .01), remaining statistically significant after adjusting for covariates (P = .003); no differences in mortality were observed. CONCLUSIONS AND IMPLICATIONS A multipurpose, step-down and step-up CGA HAH expanded its activity and adapted to changing case-mixes and pathways throughout COVID-19 pandemic waves. Although further quantitative and qualitative studies are needed to assess the impact of this model, our results suggest that harnessing the adaptability of HAH may help advance a paradigm shift toward more person-centered, cost-effective models of clinical care aimed at older adults.
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Affiliation(s)
- Marco Inzitari
- Research on Aging, Frailty and Care Transitions in Barcelona (REFiT-BCN), Parc Sanitari Pere Virgili and Vall d'Hebron Institute (VHIR), Barcelona, Spain; Faculty of Health Sciences, Universitat Oberta de Catalunya (UOC), Barcelona, Spain.
| | - Cristina Arnal
- Research on Aging, Frailty and Care Transitions in Barcelona (REFiT-BCN), Parc Sanitari Pere Virgili and Vall d’Hebron Institute (VHIR), Barcelona, Spain,Department of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Aida Ribera
- Research on Aging, Frailty and Care Transitions in Barcelona (REFiT-BCN), Parc Sanitari Pere Virgili and Vall d’Hebron Institute (VHIR), Barcelona, Spain,CIBER of Epidemiology and Public Health (CIBERESP), Barcelona, Spain
| | - Anne Hendry
- School of Health and Life Sciences, University of the West of Scotland, Scotland, United Kingdom
| | - Matteo Cesari
- IRCCS Istituti Clinici Scientifici Maugeri, University of Milan, Milan, Italy
| | - Sílvia Roca
- Research on Aging, Frailty and Care Transitions in Barcelona (REFiT-BCN), Parc Sanitari Pere Virgili and Vall d’Hebron Institute (VHIR), Barcelona, Spain
| | - Laura Mónica Pérez
- Research on Aging, Frailty and Care Transitions in Barcelona (REFiT-BCN), Parc Sanitari Pere Virgili and Vall d’Hebron Institute (VHIR), Barcelona, Spain
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14
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Mas MA, Sabaté RA, Manjón H, Arnal C. Developing new hospital-at-home models based on Comprehensive Geriatric Assessment: Implementation recommendations by the Working Group on Hospital-at-Home and Community Geriatrics of the Catalan Society of Geriatrics and Gerontology. Rev Esp Geriatr Gerontol 2023; 58:35-42. [PMID: 36635118 DOI: 10.1016/j.regg.2022.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/11/2022] [Accepted: 12/13/2022] [Indexed: 01/12/2023]
Abstract
Last decade, the Government of Catalonia have urged an integrated care strategy for planning the care model to older populations living with frailty, multimorbidity and advanced illnesses. Based on international evidence that was reviewed by a group of experts from the Catalan Society of Gerontology and Geriatrics, we summarised some recommendation to adapt hospital-at-home care to older populations in our system. We defined Comprehensive Geriatric Assessment (CGA) hospital-at-home (HaH) as a specialised home hospitalisation service formed by interdisciplinary teams, characterised by using the clinical methodology of CGA, and by adapting geriatric units' protocols for the provision of person-centred care at home. Main benefits of CGA-HaH in these populations are: response to heath crises according to individualised care plans based on the situational diagnosis carried out by Primary Care teams; provision of a comprehensive health and social approach tailored to the complexity of cases and situations; and adaptation of multipurpose hospitalisation, by working on different person-centred care, aspects, such as caregivers support on care provision, focusing on function or home adaptation.
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Affiliation(s)
- Miquel Angel Mas
- Direcció Clínica Territorial de Cronicitat Metropolitana Nord, Institut Català de la Salut, Catalonia, Spain; Department of Geriatrics Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Rosa Ana Sabaté
- Department of Geriatrics Parc de Salut Mar, Barcelona, Spain.
| | - Helena Manjón
- Department of Geriatrics Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Cristina Arnal
- Departament of Geriatrics Hospital Vall d'Hebron, Barcelona, Spain
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15
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Gorbenko K, Baim-Lance A, Franzosa E, Wurtz H, Schiller G, Masse S, Ornstein KA, Federman A, Levine DM, DeCherrie LV, Leff B, Siu A. A national qualitative study of Hospital-at-Home implementation under the CMS Acute Hospital Care at Home waiver. J Am Geriatr Soc 2023; 71:245-258. [PMID: 36197021 DOI: 10.1111/jgs.18071] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/16/2022] [Accepted: 08/21/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services (CMS) announced the Acute Hospital Care at Home (AHCaH) waiver program in November 2020 to help expand hospital capacity to cope with the COVID-19 pandemic. The AHCaH waived the 24/7 on-site nursing requirement and enabled hospitals to obtain full hospital-level diagnosis-related group (DRG) reimbursement for providing Hospital-at-Home (HaH) care. This study sought to describe AHCaH implementation processes and strategies at the national level and identify challenges and facilitators to launching or adapting a HaH to meet waiver requirements. METHODS We conducted semi-structured interviews to explore barriers and facilitators of HaH implementation. The analysis was informed by the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework. Interviews were audio recorded for transcription and thematic coding. PRINCIPAL FINDINGS We interviewed a sample of clinical leaders (N = 18; clinical/medical directors, operational and program managers) from 14 new and pre-existing U.S. HaH programs diverse by size, urbanicity, and geography. Participants were enthusiastic about the AHCaH waiver. Participants described barriers and facilitators at planning and implementation stages within three overarching themes influencing waiver program implementation: 1) institutional value and assets; 2) program components, such as electronic health records, vendors, pharmacy, and patient monitoring; and 3) patient enrollment, including eligibility and geographic limits. CONCLUSIONS Implementation of AHCaH waiver is a complex process that requires building components in compliance with the requirements to extend the hospital into the home, in coordination with internal and external partners. The study identified barriers that potential adopters and proponents should consider alongside the strategies that some organizations have found useful. Clarity regarding the waiver's future may expedite HaH model dissemination and ensure longevity of this valuable model of care delivery.
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Affiliation(s)
- Ksenia Gorbenko
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Institute for Health Care Delivery Science, Mount Sinai Health System, New York, New York, USA
| | - Abigail Baim-Lance
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Veteran Affairs, James J. Peters VA Medical Center and Geriatric Research Education and Clinical Center, Bronx, New York, USA
| | - Emily Franzosa
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Veteran Affairs, James J. Peters VA Medical Center and Geriatric Research Education and Clinical Center, Bronx, New York, USA
| | - Heather Wurtz
- Human Rights Institute, University of Connecticut, Storrs, Connecticut, USA
| | - Gabrielle Schiller
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sybil Masse
- Department of Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex Federman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David M Levine
- Department of Medicine, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Ariadne Labs, Boston, Massachusetts, USA
| | - Linda V DeCherrie
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bruce Leff
- Division of Geriatric Medicine and Gerontology, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Albert Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Veteran Affairs, James J. Peters VA Medical Center and Geriatric Research Education and Clinical Center, Bronx, New York, USA
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16
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Hernandez C, Tukpah AMC, Mitchell HM, Rosario NA, Boxer RB, Morris CA, Schnipper JL, Levine DM. Hospital-Level Care at Home for Patients With Acute Respiratory Disease: A Descriptive Analysis. Chest 2022; 163:891-901. [PMID: 36372302 DOI: 10.1016/j.chest.2022.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Home hospital (HH) care is hospital-level substitutive care delivered at home for acutely ill patients who traditionally would be cared for in the hospital. Despite HH care programs operating successfully for years and scientific evidence of similar or better outcomes compared with bricks-and-mortar care, HH care outcomes in the United States for respiratory disease have not been evaluated. RESEARCH QUESTION Do outcomes differ between patients admitted to HH care with acute respiratory illness vs those with other acute general medical conditions? STUDY DESIGN AND METHODS This was a retrospective evaluation of prospectively collected data of patients admitted to HH care (2017-2021). We compared patients requiring admission with respiratory disease (asthma exacerbation [26%], acute exacerbation of COPD [33%], and non-COVID-19 pneumonia [41%]) to all other patients admitted to HH care. During HH care, patients received two nurse and one physician visit daily, IV medications, advanced respiratory therapies, and continuous heart and respiratory rate monitoring. Main outcomes were acute and postacute health care use and safety. RESULTS We analyzed 1,031 patients; 24% were admitted for respiratory disease. Patients with and without respiratory disease were similar: mean age, 68 ± 17 years, 62% women, and 48% White. Patients with respiratory disease more often were active smokers (21% vs 9%; P < .001). Eighty percent of patients showed an FEV1 to FVC ratio of ≤ 70; 28% showed a severe or very severe obstructive pattern (n = 118). During HH care, patients with respiratory disease showed less health care use: length of stay (mean, 3.4 vs 4.6 days), laboratory orders (median, 0 vs 2), IV medication (43% vs 73%), and specialist consultation (2% vs 7%; P < .001 for all). Ninety-six percent of patients completed the full admission at home with no mortality in the respiratory group. Within 30 days of discharge, both groups showed similar readmission, ED presentation, and mortality rates. INTERPRETATION HH care is as safe and effective for patients with acute respiratory disease as for those with other acute general medical conditions. If scaled, it can generate significant high-value capacity for health systems and communities, with opportunities to advance the complexity of care delivered.
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Affiliation(s)
- Carme Hernandez
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA; Home Hospitalization, Medical and Nursing Direction, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERES, Barcelona, Spain
| | - Ann-Marcia C Tukpah
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Henry M Mitchell
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA
| | - Nicole A Rosario
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA
| | - Robert B Boxer
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Charles A Morris
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Jeffrey L Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - David M Levine
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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17
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KADAKIA KUSHALT, BALATBAT CELYNNEA, SIU ALBERTL, COHEN IGLENN, WILKINS CONSUELOH, DZAU VICTORJ, OFFODILE 2nd ANAEZEC. Hospital-at-Home: Multistakeholder Considerations for Program Dissemination and Scale. Milbank Q 2022; 100:673-701. [PMID: 36148893 PMCID: PMC9576240 DOI: 10.1111/1468-0009.12586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Policy Points Hospital-at-Home (HaH) is a home-based alternative for acute care that has expanded significantly under COVID-19 regulatory flexibilities. The post-pandemic policy agenda for HaH will require consideration of multistakeholder perspectives, including patient, caregiver, provider, clinical operations, technology, equity, legal, quality, and payer. Key policy challenges include reaching a consensus on program standards, clarifying caregivers' issues, creating sustainable reimbursement mechanisms, and mitigating potential equity concerns. Key policy prescriptions include creating a national surveillance system for quality and safety, clarifying legal standards for care in the home, and deploying payment reforms through value-based models.
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18
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Bove DG, Christensen PE, Gjersøe P, Lavesen M. Patients' experiences of being treated for acute illness at home as an alternative to hospital admission: a qualitative study in Denmark. BMJ Open 2022; 12:e060490. [PMID: 35613764 PMCID: PMC9174770 DOI: 10.1136/bmjopen-2021-060490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We aimed to investigate the experiences of Danish patients treated at home for an acute illness instead of being hospitalised. DESIGN This study had a qualitative design inspired by the methodology of interpretive description. Data were collected through semistructured interviews. SETTING Home treatment was conducted by a team of nurses (n=10-15) supported by physiotherapists and physicians, all affiliated with an emergency department, located in the capital region of Denmark. Interviews were conducted between August 2020 and April 2021. PARTICIPANTS Twenty-one patients, aged 34-94 years, narrated their experiences of being treated at home for an acute illness. RESULTS The overarching theme in our analyses was that 'being the centre of the nurses' attention provided safety, patient involvement and quality of life during home treatment'. The following six themes emerged from analyses: (1) exclusive attention facilitates involvement and activity; (2) hospitals are for the sick; (3) maintaining a meaningful everyday life; (4) the hospital exudes productivity and busyness; (5) family relations and roles are maintained; (6) and concerns of deterioration. CONCLUSIONS From a patient's perspective, home treatment made sense and was perceived as a quality improvement. Being the centre of nurses' attention induced a sense of safety, involvement and enhanced quality of life among patients during the treatment course for an acute illness.
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Affiliation(s)
- Dorthe Gaby Bove
- Department of Clinical Research, Nordsjællands Hospital, Hillerod, Denmark
- Centre for Nursing, University College Absalon, Campus Roskilde, Roskilde, Denmark
| | | | - Peter Gjersøe
- Department of Emergency Medicine, Nordsjællands Hospital, Hillerod, Denmark
| | - Marie Lavesen
- Department of Emergency Medicine, Nordsjællands Hospital, Hillerod, Denmark
- Helsingør Rehabilitation and Training Center, Helsingør Municipality, Helsingør, Denmark
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19
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Siu AL, Zhao D, Bollens-Lund E, Lubetsky S, Schiller G, Saenger P, Ornstein KA, Federman AD, DeCherrie LV, Leff B. Health equity in Hospital at Home: Outcomes for economically disadvantaged and non-disadvantaged patients. J Am Geriatr Soc 2022; 70:2153-2156. [PMID: 35363372 DOI: 10.1111/jgs.17759] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/02/2022] [Accepted: 03/09/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Albert L Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education, and Clinical Center, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Duzhi Zhao
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Evan Bollens-Lund
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sara Lubetsky
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gabrielle Schiller
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Pamela Saenger
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex D Federman
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Linda V DeCherrie
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Medically Home, Boston, Massachusetts, USA
| | - Bruce Leff
- Division of Geriatric Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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20
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Boone EJ, Shammash JB. Virtual Hospitalization at Home After the Covid-19 Pandemic: Time to Consider Our Future Community Healthcare Options. J Prim Care Community Health 2022; 13:21501319221112586. [PMID: 35838336 PMCID: PMC9289900 DOI: 10.1177/21501319221112586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The concept of acute hospitalization at home has been described for over
3 decades. Its scope, however, was largely limited to small
experimental trials and pilot studies. The Covid-19 pandemic changed
these circumstances. The convergence of the critical need for acute
hospital beds along with the growing sophistication and comfort in
virtual monitoring facilitated the rapid deployment of hospitalization
at home throughout many communities in the United States. Now in the
waning times of the pandemic, community health leaders and health
systems are questioning what the future role of home virtual
hospitalization might be. Might this concept be relegated to only
future times of critical bed shortage, or might it be part of a true
change in community healthcare delivery.
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Affiliation(s)
- Emily J Boone
- Hackensack Meridian School of Medicine, Hackensack, NJ, USA
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