Management of health crisis in nursing homes by adapting hospital-at-home integrated care programs: a local experience from Catalonia

Abstract

Introduction: It is essential to find new models of care adapted to older residents in social institutions, due to the increasing health complexity of users of these long term care settings. If hospital staff could be effective in managing health crisis in nursing homes, in a more integrated approach, it is unclear. Description of practice: New integrated care units were created in Catalonia, using Intermediate Care resources, in order to manage health crisis of older patients without using conventional hospitalization. A key supportive point of this project for the future is developing hospital-at-home interventions in older patients in the community, including nursing home. Interventions could be run after: a. direct assessment at nursing home or an Emergency Department visit (Admission Avoidance strategy); b. a short hospital stay (Early Discharge strategy). At nursing home, an individualized care plan was defined for each suitable case (medical stability with no severity criteria), sharing objectives with the staff of the setting, in order to stabilize health status and improve conditions associated with acute illness (as functional decline, delirium or nutritional risk). Targeted population and stakeholders: It was developed to attend nursing home residents of the urban area of Badalona, North of Barcelona. A previous analysis found that they have high risk baseline characteristics as old age and multiple chronic conditions related with morbidity and disability. More than a half of the users have low to severe grade of dementia. 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117026 – http://www.ijic.org/ A team of specialized hospital health staff and staff from rehabilitation community services developed an innovative program based on Comprehensive Geriatric Assessment for the management of health crisis leading to acute disability in this population, as a local experience. It is being evaluated for future implementation to other areas in Catalonia. Highlights (innovation, impact and outcomes) Innovations:The model of care from acute and postacute geriatric units was adapted to users in the community with a pragmatic approach. Impact: It is an opportunity to maintain highly vulnerable complex older patients in the community, by avoiding hospital admissions o shortening hospital stay in low severity health crisis. Outcomes: N 89 cases attended through 2 years. Main characteristics of patients were (median and IQR or %): age 86 (81-89.5), 77.5% female, number of geriatric conditions 4 (2-6), 57% of patients had dementia. Delirium was detected in 25% of acute health crisis. Main diagnostic groups were: 43% medical, 49% orthopaedic and 8% stroke (Admission Avoidance/Early Discharge strategy: 59/41%). Resolution of health crisis (medical and functional stabilization without hospital readmission) was possible in 80% of cases. Length of hospital-at-home intervention was 46 days. Conclusion: This alternative to conventional hospitalization program in nursing home seems possible and adapted to older patients at risk. Both strategies, admission avoidance and early discharge, could be included, for several medical and surgical conditions. The majority of cases could be managed without new hospitalizations. Discussion: Several organization changes are needed in order to develop this innovative approach. In our experience, hospital staff collaborated with community services, as a functional team. A good targeting process is necessary to avoid risks for patients and nursing homes. Health care technology need to be available to provide intense care outside the hospital. To implement this experience in our social and health system, changes in payment of services need to be considered. Lessons learnt: Integrating hospital care and community services in an individualized intervention in nursing homes for health crisis is an opportunity for the health and social systems. Several changes are needed in order to support implementation of this local experience to the whole system in Catalonia.