Older People and Unpaid Carers’ Experiences of Hospital-at-Home

Introduction: Hospital at home (HAH) is an acute model of care that provides episodes of care to acutely unwell persons in their usual residence, i.e., their own home or in a care home. Providing intense and integrated care and treatment packages enables people to remain in their familiar environment and avoid the potential harm from in-patient stays. Background Research: Currently, hospital-at-home research in the United Kingdom and internationally is limited regarding the lived experiences of older people and their unpaid carers. When older people and carers are excluded from research or not considered, we cannot understand how their experiences of services impact their everyday lives. The research also provides insight into how professionals can support people outside of hospitals more effectively by integrating this care model with other statutory services, such as social care, occupational and physiotherapy. Hospital-at-home initiatives can potentially reduce the risks associated with hospitalisation, such as infection, mental health and physical decline. Older people, carers and health and social care professionals may find this exciting and helpful research. Involvement: The research is nested into a wider research programme which people with lived experience have framed. There is also a panel of people with lived experience of receiving adult social care and those who support them, all of which form the approach to public and patient involvement. Data Collection & Methodology: There will be approximately 65 participants in this qualitative study, including health and social care staff, older people, and unpaid carers. All participants will be offered a one-off 60-minute semi-structured interview allowing them to respond in their own words. This contrasts with previous HaH studies in the United Kingdom that rely on fixed yes or no responses in surveys or questionnaires. Inductive Thematic Analysis is being used to analyse the data. As the data collection and analysis is still in progress, results are not fully concluded; however, the aim is to have themes fully developed from the data before the conference in May 2023. Some initial themes have emerged from the interviews with professionals, including risk, person-centred care, communication, and service delivery. Findings: The findings will create learning opportunities for an international audience, for example, concerning effective interprofessional working and person-centred care in HAH. Indeed, there is evidence of international HAH models in the literature review so that any new learning can be cascaded internationally via this conference. For example, when referring to communication, there could be an effective communication system developed at the point of discharge from HAH back to the care of their general practitioner, as this is an area of concern emerging from the professional interviews. The next steps will be to complete the research and give feedback to the local site in England where the research is taking place and to the Applied Research Collaboration (ARC) that has funded the research. This will highlight ideas and improvements for the future of community-based health and social care for older people and their carers.

1548 Background: Hospital at Home (HaH) is part of a comprehensive patient-centered model that delivers multidisciplinary acute medical care in the home. While HaH has mainly been tested in general medical patients, uncertainties persist regarding the feasibility and acceptability of this model within oncology populations. This study assessed patient and caregiver characteristics associated with acceptability of a hypothetical HaH program in persons hospitalized with cancer and described patient medical needs. Methods: A cross-sectional survey assessing acceptability of a hypothetical HaH program, home characteristics, and demographics was completed by 250 patients and 33 caregivers. Eligible patients were English-speaking adults (18+ years) admitted to the medicine service at a cancer hospital. Acceptability was measured on a 5-point Likert scale and defined as responses of “strongly agree” or “agree” to the statement, “I would consent to the use of my home for my hospital care” if such a program were available. Surveys were conducted in person or via telephone during the index hospitalization. Unpaid adult caregivers were surveyed in person and acceptability of the hypothetical HaH program was similarly assessed. Characteristics of the hospitalization were assessed via the electronic health record. Continuous variables were compared between acceptability groups using Wilcoxon rank sum test; categorical variables were compared using Fisher’s exact test and Pearson’s chi-squared test. Results: Median patient age was 63, 134 (54%) were female, 38 (16%) identified as Black and 21 (8.8%) as Hispanic, and 171 (72%) completed some college education or more. 208 patients (83%) rated participation in HaH as acceptable, as did 28 (85%) caregivers. Patients living with metastatic disease were more likely to accept HaH (p<0.05). Acceptability differed by race (p<.05) and was lowest among Black patients (74%) and those who preferred not to provide their race (70%). Of those who rated HaH acceptable, 137 (66%) had advanced imaging or a surgical procedure after the first day of admission and 21 (10%) had an absolute contraindication to being hospitalized at home such as a home member using illicit drugs at home (15, 7%). Conclusions: Over 80% of persons hospitalized with cancer and their caregivers would agree to HaH. Those with advanced disease were more likely to agree to home hospitalization compared to curative-intent patients, but Black patients were less likely to agree to be hospitalized at home compared to white patients. Many patients had hospitalization characteristics (e.g., imaging) that may be challenging to coordinate from home, but few patients had safety-related contraindications to HaH. These findings will inform future efforts to evaluate and target HaH programs in oncology to patients most likely to agree to and benefit from them, and address barriers to uptake in certain racially minoritized populations.

BackgroundHospital at home (HaH) provides hospital‐level care at home as a substitute for traditional hospital care. Interest in HaH is increasing markedly. While multiple studies of HaH have demonstrated that HaH provides safe, high‐quality, cost‐effective care, there remain many unanswered research questions. The objective of this study is to develop a research agenda to guide future HaH‐related research.MethodsSurvey of attendees of first World HaH Congress 2019 for input on research for the future HaH development. Selection and ranking of important topic areas for future HaH‐related research. Development of research domains and research questions and issues using grounded theory approach, supplemented by focused literature reviews.Results240 conference attendees responded to the survey (response rate, 55.3%). The majority were from Europe (64%) and North America (11%) and were HaH program leaders (29%), HaH physicians (27%), and researchers (13%). Nine research domains for future HaH research were identified: 1) definition of the HaH model of care; 2) the HaH clinical model; 3) measurement and outcomes of HaH; 4) patient and caregiver experience with HaH; 5) education and training of HaH clinicians; 6) technology and telehealth for HaH; 7) regulatory and payment issues in HaH; 8) implementation and scaling of HaH; and 9) ethical issues in HaH. Key research issues and questions were identified for each domain.ConclusionsWhile highly evidence‐based, unanswered research questions regarding HaH remain, focusing research efforts on the domains identified in this study will serve to improve HaH for all key HaH stakeholders.

This paper examines utilization of paid and unpaid home health care using data from a nationally representative sample of HIV-positive persons receiving medical care in early 1996 (N = 2,864). Overall, 21.0% used any home care, 12.2% used paid care and 13.6% used unpaid care. Most (70.0%) users of home care received care from only one type of provider. Substantially more hours of unpaid than paid care were used. We also found evidence of a strong association between type of service used and type of care provider: 62.4% of persons who used nursing services only received paid care only; conversely, 55.5% of persons who used personal care services only received care only from unpaid caregivers. Use of home care overall was concentrated among persons with AIDS: 39.5% of persons with AIDS received any home health care, compared to 9.5% of those at earlier disease stages. In addition to having an AIDS diagnosis, logistic regression analyses indicated that other need variables significantly increased utilization; a higher number of HIV-related symptoms, lower physical functioning, less energy, a diagnosis of CMV and a recent hospitalization each independently increased the odds of overall home care utilization. Sociodemographic variables had generally weak relationships with overall home care utilization. Among users of home care, non-need variables had more influence on use of paid than unpaid care. Both paid and unpaid home health care is a key component of community-based systems of care for people with HIV infection. The results presented in this paper are the first nationally representative estimates of home care utilization by persons with HIV/AIDS and are discussed with reference to policy and future research.

Hospital at Home (HaH) provides intensive, hospital-level care in patients' homes for acute conditions that would normally require hospitalisation, using multidisciplinary teams. As a programme of complex medical-social interventions, a HaH programme theory has not been fully articulated although implicit in the structures, functions, and activities of the existing HaH services. We aimed to unearth the tacit theory from international evidence and test the soundness of it by studying UK HaH services. We conducted a literature review (29 articles) adopting a 'realist review' approach (theory articulation) and examined 11 UK-based services by interviewing up to 3 staff members from each service (theory testing). The review and interview data were analysed using Framework Analysis and Purposive Text Analysis. The programme theory has three components- the organisational, utilisation and impact theories. The impact theory consists of key assumptions about the change processes brought about by HaH's activities and functions, as detailed in the organisational and utilisation theories. HaH teams should encompass multiple disciplines to deliver comprehensive assessments and have skill sets for physically delivering hospital-level processes of care in the home. They should aim to treat a broad range of conditions in patients who are clinically complex and felt to be vulnerable to hospital acquired harms. Services should cover 7days a week, have plans for 24/7 response and deliver relational continuity of care through consistent staffing. As a result, patients' and carers' knowledge, skills, and confidence in disease management and self-care should be strengthened with a sense of safety during HaH treatment, and carers better supported to fulfil their role with minimal added care burden. There are organisational factors for HaH services and healthcare processes that contribute to better experience of care and outcomes for patients. HaH services should deliver care using hospital level processes through teams that have a focus on holistic and individually tailored care with continuity of therapeutic relationships between professionals and patients and carers resulting in less complexity and fragmentation of care. This analysis informs how HaH services can organise resources and design processes of care to optimise patient satisfaction and outcomes.

Previous studies have demonstrated that hospital at home (HaH) care is associated with lower costs than traditional hospital care. Most prior studies were small, not U.S.-focused, or did not include post-acute costs in their analyses. Our objective was to determine if combined acute and 30-day post-acute costs of care were lower for HaH patients compared to inpatient comparisons in a Center for Medicare and Medicaid Innovation Center demonstration of HaH. A single-center New York City retrospective observational cohort study of patients admitted to either HaH or inpatient care from September 1, 2014 through August 31, 2017. Eligible patients were 18 years or older, required inpatient admission, lived in Manhattan, and met home safety requirements. Comparison individuals met the same criteria and were included if they refused HaH care or were admitted when HaH was not available. HaH care was substitutive hospital-level care and 30-days of post-acute transitional care. Main outcomes were costs of care of the acute and post-acute 30-day episodes. We matched subjects on age, sex, and insurance and conducted regression analyses using an unadjusted model and one adjusted for several patient characteristics. Of 523 Medicare admission episodes, data were available for 201 episodes in the HaH arm and 101 episodes of usual care. HaH patients were older (81.6 [SD=12.3] years vs. 74.6 [SD=14.0], p < 0.0001) and more likely to have activities of daily living (ADL) impairments (75.4% vs. 46.5%, p < 0.0001). Unadjusted mean costs were $5054 lower for HaH episodes compared to inpatient episodes. Regression analysis with matching showed HaH costs were $5116 (95% CI -$10,262 to $30, p=0.05) lower, and when adjusted for age, sex, insurance, diagnosis, and ADL impairments, $5977 (95% CI -$10,758 to -$1196, p=0.01) lower. HaH combined with 30-day post-acute transition care was less costly than inpatient care.

As Congress considers renewing the Acute Hospital Care At Home (AHCaH) waiver, which provides a full hospital payment for Hospital at Home (HaH) care, evaluating uncertainty around the future of HaH payment is critical. Our qualitative study explored HaH leaders’ experiences with implementing HaH (N=18, clinical/medical directors, operational and program managers) from 14 new and pre-existing programs across the U.S. We conducted semi-structured interviews with HaH programs diverse by size, urbanicity, and geography. We analyzed transcripts using a thematic approach. Participants across settings and regions wanted greater clarity about the waiver’s future. Lack of clarity affected staffing (nurses reluctant to take temporary jobs) and investment in establishing programs (building EMR components, changing workflows, creating inpatient processes in an outpatient setting). Programs adapted to uncertainty in multiple ways: 1) operating parallel waiver and non-waiver programs; 2) seeking to determine/ calculate the HaH value for their institution; 3) determining which patients would benefit most from HaH; and 4) seeking additional health system financing options beyond the CMS reimbursement (new programs) or relying on existing contracts with payers (existing programs). Implementing HaH is a complex and resource intensive process. Greater clarity from CMS regarding the waiver’s future state will encourage programs to invest the resources that they need to establish their programs long-term. Waiver extension/ permanence would also enable programs to develop and test measures of value, making rigorous evaluations possible to optimize different HaH components.

Hospital at home (HaH) provides hospital-level care at home as a substitute for brick-and-mortar hospital care. Multiple HaH studies demonstrate HaH provides safe, high-quality, cost-effective care. However, practices have varied approaches to delivering care and no HaH-specific national standards exist. We aimed to develop national practice standards for HaH and assess practice performance against the standards. The HaH Users Group (HaHUG), the national convener of HaH practices, assembled the Practice Standards Council in 2019 to develop evidence-based standards for HaH. We reviewed existing international standards and the requirements of the Centers for Medicare and Medicaid Services Acute Hospital Care at Home Waiver. We engaged in multiple iterative rounds to develop domains and standards within each domain and then held an open comment period. We distributed an online survey for all HaHUG practices to self-assess whether they did not meet (score, -1), met (score, 0), or exceeded (score, +1) each standard. The American Hospital Association's Annual Survey was used to describe practices that did and did not complete the practice standards survey. Final practice standards included 31 standards in 7 domains: leadership; education and training; human resources management; quality and quality improvement; safe practice and environment; and clinical standards and protocols. The majority of HaH practices self-rated that they met or exceeded standards: scores ranged from -5 to 31; mean score of 9.75 (SD, 12.60). Forty-nine of 213 eligible HaH practices completed the survey (response rate, 23.0%). Most hospitals were large (65% > 299 beds), nonprofit (85%), teaching (90%) centers that cared for a large proportion of patients with Medicaid. We present the first national practice standards for HaH. The vast majority of HaH practices met or exceeded these standards by their own assessment. There was a range of performance across standards, demonstrating strengths and opportunities for ongoing development and quality improvement.

Hospital at Home (HaH) programs continue to proliferate in the United States. There are few evaluations of recently started HaH programs. We evaluated a recently started HaH program by conducting a retrospective cohort study comparing outcomes of those admitted to HaH versus those who stayed in the brick-and-mortar hospital. All participants were patients of a large southeastern health system who were invited to participate in HaH. We used electronic health record data for the evaluation, and propensity score matching to minimize effects from the non-random assignment to group. HaH is an attempt to replicate hospital care in the patient’s home. Patients are monitored remotely. They receive in-person visits by nurses, paramedics, and advanced practice providers under the supervision of a hospital medicine attending. Attending physicians conducted virtual visits daily. The primary outcome was hospital readmission at 30 days. We also evaluated mortality, length of stay, and falls. Six hundred and seventy-one patients were invited to HaH and had complete data. Median age was 76 years (IQR: 69-84 years). Fifty-two percent participated in HaH. Length of stay was similar for HaH versus non-HaH (median 5.0 vs 4.0 days, p = .067). Patients in HaH were readmitted within 30 days more frequently than non-HaH (11.9% vs 7.78%, propensity-score adjusted HR 1.78, 95% CI 1.09-2.91). Mortality at 90 days was similar for HaH versus non-HaH (10.6% vs 10.1%, propensity score adjusted HR 1.42 [95% CI, 0.68-2.97]). HaH has similar outcomes as brick-and-mortar, although this new HaH program had a higher risk of readmission.

Sartain SA, Maxwell MJ, Todd PJ, et al. Randomised controlled trial comparing an acute paediatric hospital at home scheme with conventional hospital care. Arch Dis Child2002 ; 87 : 371...

Hospital at Home (HaH) programs have been shown to improve quality of care and patient satisfaction, and reduce bed occupancy rate in hospitals. Despite the prevalence of HaH in Western countries, studies in Asia are limited and the perception of HaH remains underexplored in Asian context. Understanding the perceptions of stakeholders is vital before implementing HaH in any new settings. Thus, the aim of this study is to explore the perceptions of referring physicians, care providers, patients, and caregivers on HaH programs in a multiracial country such as in Singapore. This study used a descriptive qualitative design. Participants from 2 tertiary hospitals in Singapore, including 13 referring physicians, 10 care providers, 15 patients, and 3 caregivers, were interviewed between June 2020 and September 2020. Data were analyzed using inductive thematic analysis. The overarching theme titled "The stakeholders' perception on HaH" was pillared by 4 main themes: (1) patients suitable for HaH; (2) perceived advantages and benefits of HaH; (3) perceived risks, anxiety, and concerns about HaH; and (4) potential enablers of HaH. Overall, the findings reported that most of the stakeholders embraced HaH. Timely medical interventions and support from care providers were reportedly important factors to maintain patient safety and quality of care. The importance of having adequate resources and sound financing mechanisms to develop a successful HaH program was also highlighted. This study offered insights into HaH from the perspectives of stakeholders in Singapore and facilitate the planning of future HaH pilot programs in multiracial Singapore and other Asian countries.

Objectives With a lack of existing comprehensive reviews, the aim of this mixed-method systematic review was to synthesise the evidence on the early impacts of the pandemic on unpaid dementia carers across the globe. Methods This review was registered on PROSPERO [CDR42021248050]. PubMed, CINAHL, Embase, Scopus and Web of Science were searched from 2020 to July 2021. Studies were included if they reported on the different impacts of the pandemic on unpaid dementia carers aged 18+, with papers published in English, German, Polish, or Spanish. A number of research team members were involved in the selection of studies following PRISMA guidance. Results Thirty-six studies (43 papers) from 18 countries reported on the early impact of the pandemic on unpaid dementia carers. Impacts were noted on accessing care and support; carer burden; and well-being. Studies found that carers had limited access to care and support services, increased workload, enhanced feelings of social isolation, and reduced wellbeing. Specifically, reductions in access to care and support increased carer’s unpaid caring tasks, removing any opportunities for temporary respite, and thus further increasing carer burden and reducing mental well-being in many. Conclusions The needs of unpaid dementia carers appear to have increased during the pandemic, without adequate support provided. Policy initiatives need to enable better mental health support and formal care provision for unpaid carers and their relatives with dementia, whilst future research needs to explore the long-term implications of carer needs in light of care home restrictions and care delivery.

To compare differences in the functional outcomes experienced by patients cared for in Hospital at Home (HaH) and traditional acute hospital care. Survey questionnaire of participants in a prospective nonrandomized clinical trial. Three Medicare managed care health systems and a Veterans Affairs Medical Center. Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbations of chronic heart failure or chronic obstructive pulmonary disease, or cellulitis, 84 of whom were treated in HaH and 130 in an acute care hospital. Treatment in a HaH care model that substitutes for care provided in the traditional acute care hospital. Change in activity of daily living (ADL) and instrumental activity of daily living (IADL) scores from 1 month before admission to 2 weeks post admission to HaH or acute hospital and the proportion of groups that experienced improvement, no change, or decline in ADL and IADL scores. Patients treated in HaH experienced modest improvements in performance scores, whereas those treated in the acute care hospital declined (ADL, 0.39 vs -0.60, P=.10, range -12.0 to 7.0; IADL 0.74 vs -0.70, P=.007, range -5.0 to 10.0); a greater proportion of HaH patients improved in function and smaller proportions declined or had no change in ADLs (44% vs 25%, P=.10) or IADLs (46% vs 17%, P=.04). HaH care is associated with modestly better improvements in IADL status and trends toward more improvement in ADL status than traditional acute hospital care.

Background There is limited understanding of the contribution made by older people and their caregivers to acute healthcare in the home and how this compares to hospital inpatient healthcare.Objectives To explore the work of older people and caregivers at the time of an acute health event, the interface with professionals in a hospital and hospital at home (HAH) and how their experiences relate to the principles underpinning comprehensive geriatric assessment (CGA).Design A qualitative interview study within a UK multi-site participant randomised trial of geriatrician-led admission avoidance HAH, compared with hospital inpatient care.Methods We conducted semi-structured interviews with 34 older people (15 had received HAH and 19 hospital care) alone or alongside caregivers (29 caregivers; 12 HAH, 17 hospital care), in three sites that recruited participants to a randomised trial, during 2017–2018. We used normalisation process theory to guide our analysis and interpretation of the data.Results Patients and caregivers described efforts to understand changes in health, interpret assessments and mitigate a lack of involvement in decisions. Practical work included managing risks, mobilising resources to meet health-related needs, and integrating the acute episode into longer-term strategies. Personal, relational and environmental factors facilitated or challenged adaptive capacity and ability to manage.Conclusions Patients and caregivers contributed to acute healthcare in both locations, often in parallel to healthcare providers. Our findings highlight an opportunity for CGA-guided services at the interface of acute and chronic condition management to facilitate personal, social and service strategies extending beyond an acute episode of healthcare.

The quality of health care in hospital at home (HaH) has been measured in different countries using simple indicators and clinical results that only contribute to some dimensions of the quality of health care. We sought to generate indicators to comprehensively evaluate the quality of health care provided to HaH users through the e-Delphi technique. The e-Delphi technique was performed with the participation of 17 HaH experts. The methodological strategy applied in this study was divided into the following 3 phases: a preparatory phase; consultation phase; and consensus phase. Three rounds of consultations were conducted with experts. In round 1, they were asked to identify which aspects of HaH they believed should be evaluated using an indicator for each of the following 6 dimensions of health care quality: effectiveness; efficiency; timeliness; patient-centered care; equity; and safety. In round 2, they were asked to rate each indicator using a 5-point Likert-type scale with the following values: (1) Totally disagree; (2) Disagree; (3) Moderately agree; (4) Agree; and (5) Totally agree. The criteria for evaluating each indicator were as follows: (1) The indicator is a useful measure for assessing the quality of health care provided to HaH users. (2) The indicator is clearly and specifically written and does not require modification. (3) The indicator is essential and incorporates information that can be extracted from HaH program records. An indicator was considered approved if it received at least 65% approval from the expert panel for each evaluation criterion. In round 3, experts were asked to reassess their ratings, taking into account the opinions of the other experts. The reliability of this technique was ensured through credibility, reliability, and confirmability. We obtained ethical approval of the corresponding institutions and informed consent from the participating experts. Nine unpublished and reliable indicators were generated. In addition, 13 indicators were incorporated that evaluate aspects previously analyzed by other authors and/or national and international institutions, which were adapted to be used in HaH. The total indicators generated (n = 22) represented all dimensions of the quality of health care: safety; opportunity; effectiveness; efficiency; equity; and patient-centered care. The 22 indicators generated through the e-Delphi technique permit a comprehensive evaluation of the quality of health care provided to HaH users.