Authors:

Abstract

Introduction: If possible, most older adults prefer to receive healthcare at home. Conversely, most healthcare systems are mainly oriented to a bed-based model which is not optimal for older adults with complex needs. Hospital at home services are expanding but generally offer an acute ""diagnosis-treatment"" approach, and most lack a comprehensive and interdisciplinary approach. 

In 2017, Parc Sanitari Pere Virgili, a public provider of intermediate care in Barcelona, Spain, implemented a geriatric Hospital at Home (H@H) service as an alternative to hospitalization as part of the continuum of intermediate care. H@H is delivered by an integrated interdisciplinary team able to perform both step-down (early supported discharge) and step-up (admission avoidance) care. Based on comprehensive geriatric assessment, the multidisciplinary approach combines, diagnosis, individualized treatment plan and rehabilitation.

Aims and Methods: To describe the profile of the geriatric H@H team and casemix of older adults who received H@H for acute health crisis or exacerbations of chronic conditions and functional impairment.

To assess outcomes achieved in terms of Pre-post functional improvement (Barthel Index (BI) discharge-admission) and discharge destination.  

To compare outcomes achieved pre pandemic (before February 2020) and during the COVID-19 pandemic (from February 2020) periods. 

Results: Each H@H team for 15 virtual beds is supported by one geriatrician, two nurses, one physical and one occupational therapists, one social worker, and virtual speech therapy support (since 2021). H@H operates 24/7 (remote advice at night hours), provides IV treatments and basic diagnostic testing as well as treatment and rehabilitation. Referrals decreased February-October 2020 in the early stage of the pandemic.  H@H bed capacity increased to 45 across 3 H@H teams to manage increased activity and acuity as referrals resumed.

From December 2017 to October 2021, H@H managed 527 patients (57% women, mean age=82.4years) with moderate multimorbidity (mean Charlson Index=2); 51% lived with a partner, 32% had a caregiver or support. 51.6% were managed pre pandemic.

Primary admission diagnoses were orthopedic conditions (34.5%), decompensated heart failure (17%) and respiratory/urine infections (11%). Half of H@H patients had polypharmacy (8+ drugs), 57.2% had fallen in the previous six months and 26% had dementia. 51% were referred  from an acute hospital and 32% directly from primary care. Mean admission BI was 52.2 points, with a mean increase of 7.3 points at discharge. Discharge from H@H destinations were home (73%), intermediate-care hospital (7%), acute hospital (14%); mortality was 5.0%.

Changes in admission diagnosis during the pandemic were mainly due to post-stroke (from 2.9% to 10.0%) and COVID-19 (3.0%). During the pandemic, patients had higher rates of baseline walking impairment (57% Vs 21%; p<0,001), a reduction of functional gain (5.7% Vs 8.8%; p=0.014) and increased length of H@H episode (36 Vs 33 days; p=0.012) and mortality (7.8% Vs 2.7%; p=0.005).

Conclusions: A polyvalent (step-up+step-down) comprehensive geriatric assessment and management H@H provided an alternative to conventional hospitalization during the COVID-19 pandemic. Bed capacity was progressively tripled to meet increased demand for a safe and effective alternative to hospital care. This model and practice will be sustained post pandemic.