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A META-ANALYSIS OF HOSPITAL IN THE HOME

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Abstract

This meta-analysis of Hospital- in-the-Home (HITH) compared to in-hospital care identified 61 Randomised Controlled Trials from MEDLINE, Embase, Social Sciences Citation Index, CINAHL, EconLit, PsycINFO and the Cochrane Database of Systematic Reviews. HITH care led to reduced mortality (odds ratio [OR] 0.81;95% CI, 0.69 to 0.95;p = 0.008; 42 RCTs; 6992 patients), readmission rates (OR 0.75;95% CI,0.59 to 0.95;p = 0.02; 41 RCTs; 5372 patients) and cost (mean-difference 1567.11; 95% CI, 2069.53 to 1064.69; p < 0.001; 11 RCTs; 1215 patients). The number needed to treat at home to prevent one death was 50. Mortality data was homogenous, but heterogeneity was observed for readmission rates and cost. HITH had higher patient and carer satisfaction (21/ 22; 6/8 studies respectively); carer burden was nonsignificantly lower (8/11 studies). HITH is associated with reductions in mortality, readmission rates and cost, and increases in patient and carer satisfaction, but no change in carer burden.
IIAGG 2017 World Congress
Background: Nursing home (NH) residents with demen-
tia exhibit challenging behaviors or resistiveness to care
(RTC) that increase staff time, stress, and NH costs. RTC
is linked to elderspeak communication. Communication
training (CHAT) was provided to staff to reduce their use
of elderspeak.
Hypothesis: We hypothesized that CHAT would improve
staff communication and subsequently reduce RTC.
Methods: Thirteen NHs were randomized to intervention
and control groups. Dyads (n= 42) including 29 staff and
27 persons with dementia (PWD) were videorecorded dur-
ing care before and/or after the intervention, and at a three
month follow-up. Videos were behaviorally coded for 1)staff
communication (normal, elderspeak, or silence) and 2)resi-
dent behaviors (cooperative or RTC). Linear mixed modeling
was used to evaluate training effects.
Results: On average elderspeak declined from 34.6%
(SD=18.7) at baseline by 13.6 percentage points (SD=20.00)
post-intervention and 12.2 percentage points (SD=22.0) at
3-month follow-up. RTC declined from 35.7% (SD=23.2)
by 15.3 percentage points (SD = 32.4) post-intervention
and 13.4 percentage points (SD=33.7) at 3-months. Linear
mixed modeling determined that change in elderspeak was
predicted by the intervention (b=-12.20, p=.028) and base-
line elderspeak (b=-0.65, p < .001) while RTC change was
predicted by elderspeak change (b=0.43, p < .001); baseline
RTC (b=-0.58, p < .001); and covariates.
Conclusions: Abrief intervention can improve communi-
cation and reduce RTC, providing an effective nonpharma-
cological intervention to manage behavior and improve the
quality of dementia care. No adverse events occurred.
SESSION 4625 (SYMPOSIUM)
HOSPITAL AT HOME-A DELIVERY MODEL FOR 21ST
CENTURY GERIATRICS CARE
Chair: J.M.Jacobs, Hadassah-Hebrew University Hospital,
Jerusalem, Israel
Co-Chair: G.Caplan, Prince of Wales Hospital
The primary purpose of Hospital at Home (HaH) is to
enable the delivery of complex care at home as an alternative
to in-patient care. Traditional in-patient care for older people
frequently has numerous negative repercussions, and the ris-
ing number of HaH models from different Healthcare systems
bears witness to this developing niche in health care deliv-
ery. Compared to usual hospital care, HaH has proven high
patient satisfaction, quality of care outcomes, and evidence
favors reduced mortality and overall costs. Furthermore,
innovative and available technological advancements are
expanding the range of treatment options available at home,
and facilitating the delivery of care to a wide spectrum of
increasingly more complex patients.
Yet, HaH dissemination has been limited by numerous
barriers, including challenging logistics, bias towards facility-
based care, and lack of payment models. Recent advances in
HaH models seek to ameliorate such barriers, but they still
exist. Moreover, the implementation of HaH on a widespread
basis has not been well described in the research literature.
In addition to a critical review and meta-analysis of cur-
rent literature, this symposium will present innovative models
of HaH providing a wide platform of care for older adults,
and technologies facilitating care for specic patient groups
with acute heart failure, or requiring long term mechanical
ventilation. Challenges facing the implementation of wide-
spread HaH will be addressed.
Understanding the impact of new modes of Hospital at
Home care delivery, and ways at promoting implementation,
is of critical importance to geriatric health service delivery in
the 21st century.
A META-ANALYSIS OF HOSPITAL IN THE HOME
G.Caplan1, N.Sulaiman1, D.Mangin 4, N.Aimonino
Ricauda 2, A.Wilson 3, L.Barclay 1, 1. Department of
Geriatric Medicine, Prince of Wales Hospital, Sydney,
Sydney, New South Wales, Australia, 2. Unit of Geriatrics
and Metabolic Bone Diseases, Molinette Hospital, AOU
Città della Salute e della Scienza” of Torino;, Torino, Italy,
3. Universtiry of Leicester, Leicester, United Kingdom, 4.
University of Otago, Christchurch, New Zealand
This meta-analysis of Hospital- in-the-Home (HITH)
compared to in-hospital care identied 61 Randomised
Controlled Trials from MEDLINE, Embase, Social Sciences
Citation Index, CINAHL, EconLit, PsycINFO and the
Cochrane Database of Systematic Reviews. HITH care led
to reduced mortality (odds ratio [OR] 0.81;95% CI, 0.69
to 0.95;p = 0.008; 42 RCTs; 6992 patients), readmission
rates (OR 0.75;95% CI,0.59 to 0.95;p = 0.02; 41 RCTs;
5372 patients) and cost (mean-difference 1567.11; 95% CI,
2069.53 to 1064.69; p < 0.001; 11 RCTs; 1215 patients).
The number needed to treat at home to prevent one death
was 50. Mortality data was homogenous, but heterogene-
ity was observed for readmission rates and cost. HITH had
higher patient and carer satisfaction (21/ 22; 6/8 studies
respectively); carer burden was nonsignicantly lower (8/11
studies).
HITH is associated with reductions in mortality, readmis-
sion rates and cost, and increases in patient and carer satis-
faction, but no change in carer burden.
THE HOSPITAL AT HOME/MACT ‘PLATFORM’
MODEL—A SPECTRUM OF FACILITY-LEVEL CARE
PROVIDED AT HOME
B.A.Leff1, L.De Cherrie2, A.Wajnberg2, A.Federman2,
T. Soones2, A.Brody3, A.Siu2, 1. Johns Hopkins University
School of Medicine, Baltimore, Maryland, 2. Icahn School
of Medicine, Mount Sinai, New York, New York, 3. New
York University, New York, New York
To date, Hospital at Home (HaH) care has focused on
substitutive admission avoidance or early discharge models.
In the context of a U.S. Federal innovation award program
for the Center for Medicare and Medicaid Services, we have
evolved the HaH model into a care “platform” for older
adults. In addition to providing substitutive admission avoid-
ance care, the platform includes: 1) “observation” stay at
home; 2)acute palliative care at home; 3)acute care for hos-
pital adverse patients (people who refuse hospital admission
under all circumstances) at home; and 4)subacute rehabilita-
tion care at home as a substitute for admission to inpatient
subacute rehabilitation. This platform evolved in recognition
of the evolving health care delivery system, the need to create
greater demand for HaH resources, provide adequate patient
Innovation in Aging, 2 0 1 7, Vol. 1, No. S1
1246
Copyedited by: OUP
... This could indicate that although overall times waiting in the ED or BAM hospital prior to transition to ACH was increasing at both sites over time, the Florida site prevented a significant increase in this time by getting the option of ACH as an alternative to the physical hospital to these patients in a faster timeframe. Nevertheless, we believe that reducing the patients' physical time in the ED or BAM hospital ward is crucial to both provide the best patient experience as well as drive down the cost of care which has been reported in other HaH studies [19,20]. ...
... Fear of prolonged ALOS in HaH and the subsequent costs associated may push some patients or providers to not use this modality. However, previous HaH studies have shown a reduction in comparative costs [19,20]. Our study shows that ALOS does not increase as we added an APP resource. ...
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In July 2020, Mayo Clinic introduced a hospital-at-home program, known as Advanced Care at Home (ACH) as an alternate option for clinically stable medical patients requiring hospital-level care. This retrospective cohort study evaluates the impact of the addition of a dedicated ACH patient acquisition Advanced Practice Provider (APP) on average length of stay (ALOS) and the number of patients admitted into the program between in Florida and Wisconsin between 6 July 2020 and 31 January 2022. Patient volumes and ALOS of 755 patients were analyzed between the two sites both before and after a dedicated acquisition APP was added to the Florida site on 1 June 2021. The addition of a dedicated acquisition APP did not affect the length of time a patient was in the emergency department or hospital ward prior to ACH transition (2.91 days [Florida] vs. 2.59 days [Wisconsin], p = 0.22), the transition time between initiation of the ACH consult to patient transfer home (0.85 days [Florida] vs. 1.16 days [Wisconsin], p = 0.28), or the total ALOS (6.63 days [Florida] vs. 6.34 days [Wisconsin], p = 0.47). The average number of patients acquired monthly was significantly increased in Florida (38.3 patients per month) compared with Wisconsin (21.6 patients per month) (p < 0.01). The addition of a dedicated patient acquisition APP resulted in significantly higher patient volumes but did not affect transition time or ALOS. Other hospital-at-home programs may consider the addition of an acquisition APP to maximize patient volumes.
... For this question, we drew primarily on two Cochrane reviews of step-up and step-down hospital at home care [11,16]. Supporting evidence was drawn from 14 additional Cochrane and non-Cochrane reviews, of which six were in general populations [19][20][21][22][23][24], and eight were conditionspecific populations [17,[25][26][27][29][30][31][32]. One of the reviews identified is a review of reviews [21] and there is additional overlap in the included studies of some of these reviews. ...
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... Back in 2011, the report by the National Research Council (NRC) declared, "Health care is coming home" [4]. However, the literature is confusing because there are different terms of healthcare at home (Hospital in the home, HITH; Home Healthcare; Home Hospitalization; Early Supported Discharge) [5] and different types of services, some of which focus on specialities (surgical and medical specialities, rehabilitation medicine, geriatrics, psychiatry, infectious diseases, respiratory diseases), others on diagnostic groups (e.g. hip fracture or stroke), or a mixture of them [6] [7]. ...
... 4,6,[8][9][10][11][12][13][14][15][16][17] There have been numerous efforts to mitigate ED crowding such as leveraging alternative pathways to avoid hospital admissions, creation of full-capacity protocols to increase inpatient availability of beds, opening of nearby urgent care centers to offload low-acuity volume, and protocols triggering reductions in outside hospital transfers, direct admissions, and elective procedures. [18][19][20][21][22][23][24][25][26][27][28] While ED crowding has multiple negative operational impacts, the impact on patient experience for ED patients who are ultimately discharged has not been well studied. While long waits and throughput times have been shown to negatively impact experience, the aspects of crowding that most directly impact the experience of discharged ED patients are poorly understood. ...
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Introduction: While emergency department (ED) crowding has deleterious effects on patient care outcomes and operational efficiency, impacts on the experience for patients discharged from the ED are unknown. We aimed to study how patient-reported experience is affected by ED crowding to characterize which factors most impact discharged patient experience. Methods: This institutional review board-exempt, retrospective, cohort study included all discharged adult ED patients July 1, 2020-June 30, 2021 with at least some response data to the the National Research Corporation Health survey, sent to most patients discharged from our large, academic medical center ED. Our query yielded 9,401 unique encounters for 9,221 patients. Based on responses to the summary question of whether the patient was likely to recommend our ED, patients were categorized as "detractors" (scores 0-6) or "non-detractors" (scores 7-10). We assessed the relationship between census and patient experience by 1) computing percentage of detractors within each care area and assessing for differences in census and boarder burden between detractors and non-detractors, and 2) multivariable logistic regression assessing the relationship between likelihood of being a detractor in terms of the ED census and the patient's last ED care area. A second logistic regression controlled for additional patient- and encounter-specific covariates. Results: Survey response rate was 24.8%. Overall, 13.9% of responders were detractors. There was a significant difference in the average overall ED census for detractors (average 3.70 more patients physically present at the time of arrival, 95% CI 2.33-5.07). In unadjusted multivariable analyses, three lower acuity ED care areas showed statistically significant differences of detractor likelihood with changes in patient census. The overall area under the curve (AUC) for the unadjusted model was 0.594 (CI 0.577-0.610). The adjusted model had higher AUC (0.673, CI 0.657-0.690]; P<0.001), with the same three care areas having significant differences in detractor likelihood based on patient census changes. Length of stay (OR 1.71, CI 1.50-1.95), leaving against medical advice/without being seen (OR 5.15, CI 3.84-6.89), and the number of ED care areas a patient visited (OR 1.16, CI 1.01-1.33) was associated with an increase in detractor likelihood. Conclusion: Patients arriving to a crowded ED and ultimately discharged are more likely to have negative patient experience. Future studies should characterize which variables most impact patient experience of discharged ED patients.
... This is particularly relevant for patients with multiple comorbidities already at risk for increased healthcare utilization and readmission. Implementing this innovative model mitigates the increasing demand for traditional hospital beds and the negative aspects associated with lengthy and recurrent hospitalizations [9][10][11][12]. Here, we report the acute and postacute care of a severely ill patient suffering from short gut syndrome with a high ileostomy output and severe protein-calorie malnutrition successfully managed at home through the Mayo Clinic's ACH program. ...
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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.
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Több mint negyedszázada már, hogy a Magyar Máltai Szeretetszolgálat Egyesülettel, illetve a fenntartásában működő siófoki Gondviselés Háza intézményével kapcsolatba kerültem. Kezdetben gondozóként, majd szakmai vezetőként (támogató szolgáltatás és fogyatékos személyek nappali ellátása), 2008. augusztus 1-jétől pedig a Gondviselés Háza integrált intézmény vezetőjeként tevékenykedem. Segítői hivatásom több évtizedes gyakorlása során szembesültem a folyamatosan változó körülményekkel, melyek a társadalom, a szociális ellátórendszer, az intézményünk, a családok és egyének számára egyaránt nehézségeket, megoldásra váró élethelyzeteket generálnak. Írásom a demenciára fókuszál, a Gondviselés Házában tapasztaltakat alapul véve. A rövid bemutatkozás után a probléma komplex bemutatására, elemzésére törekszem. Bemutatom az intézményünk által alkalmazott terápiákat, beavatkozási módokat, értékelésüket, valamint a megoldási alternatívákat.
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Length of inpatient stay is decreasing generally. This decreases pressure on acute hospital beds and is believed to reduce the risk of hospital-acquired complications. To bridge the gap between hospital and home, specialist outreach teams are gaining in popularity. However, research evidence supporting outreach schemes, is scant and inconclusive; in particular doubt exists over the safety issues surrounding early discharge. This study compares the rehabilitation of two patient groups (n = 60) following knee replacement. The trial patients were discharged early, supported by an orthopaedic outreach team. The control group remained inpatients for their rehabilitation. Outcomes evaluated were clinical performance of the knee, patient satisfaction and complication rates. The trial group had a significantly better mean function score at 5 days (p = 0.04), but at 6 weeks, 12 weeks and 1 year, movement and function scores between groups showed no significant difference. Both groups continued to improve over the 1-year period. Patients in the trial group expressed greater satisfaction in their care and felt less of a burden to their families than the control group. There was no significant difference in the reported frequency of contact with GPs or in the number of serious complications between the groups.
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Delirium is a common problem, mostly affecting older patients in hospital, which results in greater mortality, nursing-home placement and cognitive and functional impairment. Delirium can be triggered by a wide range of conditions, treatments and procedures, as well as by certain environments. Some hospital environments have been causally implicated, but until it was possible to compare treatment in hospital with treatment in other places, the observation remained at the level of an association. However, the development of 'Hospital in the Home' services has allowed clinicians to explore this question scientifically. Recently, a number of studies comparing treatment of acute conditions, both medical and surgical, anq rehabilitation in hospital with treatment at home, have found a lower incidence of delirium with home treatment, as well as lower rates of the sequelae of delirium. Since delirium is an indicator of a wide range of subsequent poor outcomes, this information has broad implications for the delivery of hospital-level services to older patients, and means that health services should seek to provide Hospital in the Home services wherever older patients are treated.
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The policy in a number of countries is to provide people with a terminal illness the choice of dying at home. This policy is supported by surveys indicating that the general public and patients with a terminal illness would prefer to receive end of life care at home. To determine if providing home-based end of life care reduces the likelihood of dying in hospital and what effect this has on patients' symptoms, quality of life, health service costs and care givers compared with inpatient hospital or hospice care. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library) to October 2009, Ovid MEDLINE(R) 1950 to March 2011, EMBASE 1980 to October 2009, CINAHL 1982 to October 2009 and EconLit to October 2009. We checked the reference lists of articles identified for potentially relevant articles. Randomised controlled trials, interrupted time series or controlled before and after studies evaluating the effectiveness of home-based end of life care with inpatient hospital or hospice care for people aged 18 years and older. Two authors independently extracted data and assessed study quality. We combined the published data for dichotomous outcomes using fixed-effect Mantel-Haenszel meta-analysis. When combining outcome data was not possible we presented the data in narrative summary tables. We included four trials in this review. Those receiving home-based end of life care were statistically significantly more likely to die at home compared with those receiving usual care (RR 1.33, 95% CI 1.14 to 1.55, P = 0.0002; Chi (2) = 1.72, df = 2, P = 0.42, I(2) = 0% (three trials; N=652)). We detected no statistically significant differences for functional status (measured by the Barthel Index), psychological well-being or cognitive status, between patients receiving home-based end of life care compared with those receiving standard care (which included inpatient care). Admission to hospital while receiving home-based end of life care varied between trials and this was reflected by high levels of statistically significant heterogeneity in this analysis. There was some evidence of increased patient satisfaction with home-based end of life care, and little evidence of the impact this form of care has on care givers. The evidence included in this review supports the use of end of life home-care programmes for increasing the number of patients who will die at home, although the numbers of patients being admitted to hospital while receiving end of life care should be monitored. Future research should also systematically assess the impact of end of life home care on care givers.