Implementation of Home Hospitalization and Early Discharge as an Integrated Care Service: A Ten Years Pragmatic Assessment

Home Hospitalization has proven efficacy, but its effectiveness and potential as an Integrated Care Service in a real world setting deserves to be explored. Objective: To evaluate implementation and 10 years follow-up of Home Hospitalization and Early Discharge as an Integrated Care Service in an urban healthcare district in Barcelona. Methods: Prospective study with pragmatic assessment. Patients: Surgical and medical acute and exacerbated chronic patients requiring admission into a highly specialized hospital, from 2006 to 2015. Intervention: Home-based individualized care plan, administered as a hospital-based outreach service, aiming at substituting hospitalization and implementing a transitional care strategy for optimal discharge. Main measurements: Emergency Department, readmissions and mortality. Patients’ and professionals’ perspectives, technologies and costs were evaluated. Results: 4,165 admissions (71 ± 15 yrs; Charlson Index 4 ± 3). In-hospital stay was 1 (0–3) days and the length of home-based stay was 6 (5–7) days. The 30-day readmission rate was 11% and mortality was 2%. Patients, careers and health professionals expressed high levels of satisfaction (98%). At the start, the service was reimbursed at a flat rate of 918€ per patient discharged, significantly lower than conventional hospitalization (2,879€) but still allowing the hospital to keep a balanced budget. At present, there is no difference in the payment schemes for both types of services. Conclusions: The service freed an average of 6 in-hospital days per patient. The program showed health value generation, as well as potential for synergies with community-based Integrated Care Services.


(1.3)Characteristics of the HH/ED program (1.3.1)Structure
It was based at the Integrated Care Unit, a transversal organization created in 2006 to foster coordinated care patients through the deployment of Integrated Care Services. It is a transversal department under the Medical and Nursing directions of the Hospital Clinic. Its mission was to provide support to the different medical specialties and to facilitate the bridging between the hospital-based specialized care and the community after hospital discharge. (1.3.2)Professional profile The central Home Hospitalization/Early Discharge program was carried out by specialized hospital teams. It was composed by one internal medicine physician, four full-time Registered Nurses with special training, plus one part-time Registered Nurse with special training, two part-time administrative officers with special training attending the call center as well as a PhD, RN coordinator. Seventy percent of Registered Nurses with special training are nurse plus Master and all of them have worked at least 15 years at the hospital (Intensive Care Unit or Emergency room) before moving to the Integrated Care Unit. The internal medicine physician has worked 10 years at the hospital (Internal Medicine ward, Emergency Room and Intensive Care Unit). All of professionals needed at least 3 months in our Unit, for additional training. (1.3.4)Organizational issues The Home Hospitalization/Early Discharge program was initiated early 2006, as a prolongation of previous pilot experiences with chronic respiratory patients [2][3][4][5]. The real deployment was initiated in patients with chronic respiratory disease and heart failure because of previous experience. Several hospital departments progressively joined the program diversifying patients' characteristics and worked with the Home Hospitalization/Early Discharge team in a joint protocol using the clinical guidelines of each specialty.
The program was open from Monday to Sunday, between 8.00 am and 09:00 pm. The period for patients' inclusion in the Home Hospitalization/Early Discharge program was from 09:00 am to 05:00 pm, from Monday to Friday, wherein the internal medicine physician was present at the Integrated Care Unit. Incidences occurring from 05:00 to 09:00 pm and during the weekend were attended by the Registered Nurses with special training that had access to doctors on duty. For incidences between 09:00 pm to 08:00 am, patients could either leave a voice message or contact directly one of the specialists on duty through the call center.

.2)Assessment
The essential information was grouped into five dimensions [6], namely: i) sociodemographics [7] ii) health team and system related factors [7]; iii) characteristics of patient's chronic conditions and Primary diagnosis [8][9][10][11] ; iv) risk factors and treatment [12] and, v) patient dependence factors (SF-36 [13], Barthel Index [14]) (Tables 1, 1S, 2, 2S, 4S). Additional information was obtained from the patient electronic health records following the current legislation on access and confidentiality of the clinical data. Assessment and follow-up were carried out using the Information and Communication Technology platform described in detail in [15].Thirty days after discharge, patients and caregivers were administered a questionnaire on satisfaction with the Home Hospitalization/Early Discharge program via telephone[7] . (1.4

.3)From hospital to home
Patients were transferred to home by ambulance on the same day of the evaluation after installing at home the equipment needed during Home Hospitalization/Early Discharge period. The program provides home equipment (oxygen, non invasive mechanical ventilation, nebulizer, pump, glucometer, etc) and offers the possibility to performing some tests at home (forced spirometry, etc), intravenous treatment (continue by pump or discontinue), measurements (blood or fluids testing), dressing and drains. Pharmacological treatment at home was prescribed by the Home Hospitalization/Early Discharge physician and prepared by the hospital pharmacy. The time elapsed between the end of the patient's evaluation and his/her arrival at home with all logistics ready for Home Hospitalization/Early Discharge did not exceed 4 hours. (1.

4.4)Home intervention
At the time of arrival at home, a telephone call to the patient was made by the Registered Nurse with special training. All patients received basic therapeutic educational material. The interventions were planned following the international guidelines for each diagnostic group. The program was conducted with a patientoriented approach wherein management of co-morbid conditions and adherence to therapy had central roles. The home visits included: i) assessment of patient clinical status; ii) control of co-morbid conditions; iii) revision of the treatment plan including dressings and administration of intravenous treatment if prescribed; iv) reinforcement of therapeutic education and adherence; v) checking of the equipment installed at the patient's home; and, vi) assessment of environmental conditions. Remote patient selfmonitoring (pulse oximeter, spirometer, scale and glucometer) were available to incorporate in the individualized plan. The specific home-based interventions during the Home Hospitalization/Early Discharge period were: (i) intravenous therapies in 54%; ii) peripheral blood sampling for biological analysis in 53%, iii) transient oxygen therapy, 39% of the cases and nebulizer therapy in 24%; (iv) complex dressings and care in 21%; (v) arterial respiratory blood gas measurements in 13%; (vi); and; (vii) forced spirometry in 10% of the cases. Discharge from Home Hospitalization/Early Discharge could be related to improvement, cure, hospital admission or death. (1.4.5)Enhanced coordination of professionals across healthcare tiers Hospital infrastructure: department ward, emergency room area and laboratories. One physician of each specialized department provided support to the Home Hospitalization/Early Discharge team, if needed Services providers: a) During Home Hospitalization/Early Discharge: Companies providing respiratory equipment therapies, if needed. b) After Home Hospitalization/Early discharge. Primary care and palliative care team, the complex frail patient program and the outpatient clinic from the hospital to ensure transitional care. All services were coordinated by the Integrated Care Unit.

(2)RESULTS (2.1)Classification of diagnoses and clustering by diagnostic groups
As part of the disease classification process, up to 850 different ICD-9-CM coding [9] were included in the Home Hospitalization/Early Discharge, as main or secondary diagnoses. It is of note that 455 of them (54%) were chronic conditions. All 850 ICD-9 entities were grouped by biological systems [11]. The allocation of each admission into a specific subgroup was performed considering the principal diagnosis at admission.

(2.2)HH/ED readmissions
Comparisons between patients re-admitted within 30 days after Home Hospitalization/Early Discharge and those who did not, allowed identification of several variables showing a significant associations with early re-admissions, namely: men (p=0.001); older age (p<0.001), ex-smoker (p<0.001); number of co-morbidities (p=0.006), Charlson Index We observed that patients re-admitted within 30 days after Home Hospitalization/Early Discharge required more intravenous treatment (p<0.001), blood test (p=0.007) and more nebulizer therapy (p=0.030) at home (Table 2S). The analysis was evaluated for the entire study group, as well as for Home Hospitalization and Early Discharge separately.

(2.3)Analysis of other MAST dimensions[16] (Table 4S)
Patients' perspectives -The patient's rejection rate for inclusion to the program was kept at a level of 18% throughout the study period. It is of note, however, that both patients and caregivers accepting to participate showed a high rate of satisfaction: 99 % of the subjects reported that the treatment received was very good. Moreover, 90% of the patients and 94% of the caregivers stated that they would repeat the experience if needed.
Professionals' perspectives -Initial common resistances to implementation from both Hospital and Primary Care staff markedly decreased over time. Hospital-based specialists fear to lose beds; whereas primary care professionals look at the Home Hospitalization/Early Discharge program as intrusive. In contrast, professionals of the Home Hospitalization/Early Discharge team showed high degree of satisfaction throughout the deployment period.
Organizational and regulatory aspects -The re-engineering process initiated in 2006 through an innovative program fostering collaboration between specialized and primary care and the creation of the Integrated Care Unit facilitated the deployment of Home Hospitalization/Early Discharge, as explained in detail in [15]. The entire integrated care program deployed in NEXES enforced the bridging between hospital and community care throughout the study period.
Technologies -From the Information and Communication Technology standpoint, the four major lessons learnt during the study period were: i) interoperability at a health system level, across levels of care and among providers, is a must to optimize the program; ii) remote monitoring used by professionals visiting patient-home showed high efficacy and it was a source of cost-containment; iii) patient self-monitoring showed limited potential because of two main factors: the acute condition of the patient and the short available learning period, and, iv) interactive tools such as videoconference and the patient personal health folder [17] seem to be useful to reinforce remote support, but we were unable to optimize these two Information and Communication tools during the project lifetime.

(2.4)Economic analysis
The economic analysis included the impact of Home Hospitalization/Early Discharge on both healthcare provider and at health system level. The Home Hospitalization/Early Discharge program admitted between 303 and 559 patients per year over a ten-year period, from 2006 to 2015. Table 3S displays the costs of the different items and reimbursement per year. The Home Hospitalization/Early Discharge was highly efficient when the economic analysis is done at health system level due to an average saving of 6 in-hospital days per patient. Indirect costs were not included because of: 1) the payer perspective adopted; 2) the fact that the need for an additional care was a criterion of exclusion of the program, and 3) because the majority of informal careers are retired spouses.