Characteristics and Outcomes of Patients Receiving Hospital in the Home Services in South West of Sydney.

doi:10.21203/rs.3.rs-37649/v1

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Characteristics and Outcomes of Patients Receiving Hospital in the Home Services in South West of Sydney.

https://doi.org/10.21203/rs.3.rs-37649/v1

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published 26 Nov, 2020

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Background

Hospital in the home (HiTH) provides acute or subacute care in a patient’s home, that normally would require a hospital stay. HiTH has consistently been shown to improve patient outcomes and reduce health care costs. The characteristics and outcomes of patients receiving HiTH care in the South Western Sydney Local Health District (SWSLHD) has not been well described.

Aim

This project aimed to describe the characteristics and outcomes of HiTH services across the SWSLHD.

Methods

The characteristics of patients referred to HiTH between January 2017 and December 2019, the indications for HiTH, and representation rates to hospital emergency department (ED) will be presented.

Findings

Between January 2017 and December 2019 there was 7,118 referrals to the LHDs HiTH services, among 6,083 patients (3,094 females, 51%), median age 56 years (IQR, 40 - 69). The majority of indications for HiTH were for IV medications (78%, n = 5,552), followed by post-operative drain management (11%, n = 789), rehab in the home (5%, n = 334), bridging anticoagulant therapy (4%, n = 261), and intraperitoneal medications (1%, n = 100). The requirement for presentation to an ED for care, while receiving HiTH only occurred on 172 (2%) of occasions. The average length of HiTH treatment was 7-days (IQR 4 - 16). Rates of presentation to ED for HiTH patients has decreased since 2017, 3.4% (95% CI 2.7 – 4.2%), 2018 2.1% (95% CI 1.5 – 2.8%), and 2019 1.8% (95% CI 1.3 – 2.4 %), p for trend < 0.001.

Discussion

Hospital in the Home Services across the SWSLHD are predominately for administration of IV medications, but include management of post-operative drains, bridging of anticoagulant therapy, and rehab in the home. Importantly, only a very small proportion (3%) of HiTH episodes will results in an unplanned presentation to the ED.

Conclusion

Hospital in the Home is well established, diverse, and safe clinical service to shorten or avoid hospitalisation for many patients. Importantly, avoidance of hospitalisation can avoid many risks that are associated with being cared for in the hospital setting.

Health Economics & Outcomes Research

Health Policy

Hospital in the home (HiTH)

South Western Sydney Local Health District (SWSLHD)

Problem

Hospital in the Home has been adapted world-wide and provides a diverse range of clinical care. However, the characteristics and outcomes of patients cared for by this service has not been extensively described in the Australian setting.

What is Already Known

Hospital in the Home is effective, safe and preferred by patients.

What this Paper Adds

Hospital in the Home is well established, diverse, and safe clinical service to shorten or avoid hospitalisation for many patients across our local health district. Importantly, avoidance of hospitalisation can avoid many risk that are associated with being cared for in the hospital setting, especially among older or vulnerable patients with multiple comorbid conditions.

Hospital in the home (HiTH) provides acute or subacute care in a patient’s home, that normally would require a hospital admission (Caplan et al., 2012). Substituting for hospital care, HiTH care can include hospital avoidance, fully substituting for in-hospital care, and early discharge followed by care at home, partial substitution (Shepperd et al., 2008, Shepperd et al., 2009). Importantly, HiTH has been shown to improve patients outcomes and reduce health care costs (Cryer et al., 2012, Shepperd and Iliffe, 2005, Federman et al., 2018). In the South West of Sydney, HiTH services commenced in 2008, and currently receive approximately 200–300 patient referrals each month, across the local health district (LHD). However, the characteristics and outcomes of patients receiving HiTH care in the South Western Sydney LHD has not been well described. Therefore, this project aims to describe the characteristics of patients receiving HiTH care across the LHD, and the outcomes, in particular, the duration and types of treatment, and hospital representation rates.

Subjects and Setting

South Western Sydney Local Health District delivers hospital services to a population of approximately a million people, through five acute public hospitals that between them have approximately 230,000 admissions each year. Approximately 200–300 patients are referred to HiTH each month.

Referral to Hospital in the Home services

Patients across the SWSLHD are referred to HiTH after presenting to an emergency department, or acute in hospitals setting. Patients can also be referred to HiTH by a community based General Practitioner by the Tripe I Hub (The Intake, Information and Intervention service for Primary and Community Care).

Operations of Service

The HiTH service operates across the SSWLHD. The program is overseen by a Nurse Practitioner who also provides resource to both staff and patients. A clinical Nurse Specialist (Grade 2) works with the Nurse Practitioner as well. The service is a collaborative between 4 Ambulatory Care Services across the area who also supply much of the medical governance (Health, 2018).

Delivery of Hospital in the Home (HiTH) services

The care of HiTH patients is primarily undertaken by community health centres across the local health district, using a multi-disciplinary team of nurses, applied health and medical staff.

Outcomes of interest

Due to the nature of HiTH services being to avoid in-hospital care, or reduce length of an episode of hospital care, the main key performance indicator is hospital presentation while receiving HiTH (i.e. presentation to ED for clinical deterioration, or need for vascular access).

Statistical analysis

The characteristics of HiTH admissions are presented using descriptive statistics. Yearly rates of presentation to ED were compared using Poisson regression (Breslow and Day, 1980). All levels of statistical significance are set at 0.05, and all data management and analysis were performed using the R language for statistical computing (R Core Team, 2017).

Ethical Considerations

This project was considered by the South Western Sydney Local Health District Human Research Ethics Committee and was determined to meet the requirements of the National Statement on Ethical Conduct in Human Research (2007). Due to the use of routinely collected hospital separation data, the need for individual patient consent was waived (HREC code - ETH 08739).

The characteristics of HiTH admissions between January 1st 2017 and December 31st 2019 are presented in Table 1. During this period there was approximately 665,00 hospital separations across the SWSLHD, and 7,118 referrals to HiTH services, among 6,083 patients (3,094 females, 51%), median age 56 years (IQR, 40–69). The majority of indications for HiTH were for IV medications (78%, n = 5,552), followed by post-operative drain management (11%, n = 789), rehab in the home (5%, n = 334), bridging anticoagulant therapy (4%, n = 261), and intraperitoneal medications (1%, n = 100). The average length of HiTH treatment was 7-days (IQR 4–16). Presentation to an emergency department for care, while receiving HiTH only occurred on 172 (2%) occasions, a median of 2.3% per month (IQR 1.3, 3.1).

Table 1

Characteristics of Hospital in the Home Services, January 2017 to December 2019.
	Year of referral
	2017	2018	2019	combined
Age (yrs), median (IQR)	58 (42, 70)	58 (42, 71)	55 (38, 68)	57 (41, 70)
Females, % (n)	49% (1202)	52% (1146)	51% (1257)	51% (3605)
Indication for HiTH, % (n)
IV medications	81% (2006)	76% (1671)	76% (1875)	78% (5552)
Post-op drain	10% (243)	12% (257)	12% ( 289)	11% (789)
Rehab in the home	3% (67)	6% (125)	6% (142)	5% (334)
Bridging therapy	3% (84)	5% (99)	3% (78)	4% (261)
IP medications	2% (43)	1% (23)	1% (34)	1% (100)
Other (NP review etc.)	1% (23)	1% (20)	2% (39)	1% (82)
Length of treatment (days), median (IQR)	7 (4,17)	7 (4,18)	7 (4,15)	7 (4, 16)
Presentation to ED, % (n)	3% (84)	2% (45)	2% (43)	2% (172)

Presentation rate to emergency, between January 2017 and December 2019, based on indication for HiTH are presented in Table 2. Patients receiving HiTH for Rehab had the highest rates of presentation to ED (4.2%), and overall rates of presentation to ED for HiTH patients has decreased since 2017, 3.4% (95% CI 2.7–4.2%), 2018 2.1% (95% CI 1.5–2.8%), and 2019 1.8% (95% CI 1.3–2.4%), p for trend < 0.001.

Table 2

Presentation to emergency department, based on indication for HiTH, January 2017 to December 2019.
	Year of referral
Indication for HiTH, % (n/N)	2017	2018	2019	combined
IV medications	3.2% (64/2,006)	2.0% (33/1,671)	1.6% (30/1,875)	2.3% (127/5,552)
Post-op drain	4.9% (12/243)	2.3% (6/257)	1.4% (4/289)	2.8% (22/789)
Rehab in the home	7.5% (5/67)	3.2% (4/125)	3.5% (5/142)	4.2% (14/334)
Bridging therapy	3.6% (3/84)	2.0% (2/99)	3.9% (3/78)	3.1% (8/261)
IP medications	0.0% (0/43)	0.0% (0/23)	0.0% (0/34)	0.0% (0/100)
Other (NP review etc.)	0.0% (0/23)	0.0% (0/20)	2.6% (1/39)	1.2% (1/82)
All HiTH, rate (95% CI)	3.4% (2.7–4.2)	2.1% (1.5–2.8)	1.8% (1.3–2.4)	p for trend < 0.001

This study has been able to describe the characteristics and outcomes of patients receiving HiTH services across the SWSLHD between January 2007 and December 2019. The majority of these patients were referred to HiTH for administration of IV medications, but also included management of post-operative drains, bridging of anticoagulant therapy (before and after a surgical admission), and rehab in the home. Only a very small proportion (3%) of these patients had a change in their clinical status that resulted in them needing to present to an emergency department during HiTH.

The benefit of HiTH services to avoid hospitalisation has been widely described (Caplan et al., 2012, Federman et al., 2018, Shepperd et al., 2008), and has been shown to be a safe, effective and cost saving alternative to hospitalisation for a wide range of acute problems (Shepperd and Iliffe, 2005, Shepperd et al., 2009). In particular the HiTH has been shown to be a preferred preference for acute care by patients (Federman et al., 2018), and as a result both clinical outcomes and patient reported outcomes have been proposed as measures of the quality of care. Specifically, HiTH services has been associated with lower mortality, reduced risk of hospital readmission, and greater patient and carer satisfaction (Caplan et al., 2012).

The results of this study show a similar low rate of the need for presentation to the emergency department during HiTH, among studies in the Australia setting and other parts of the world (Caplan et al., 2012, Montalto et al., 1999). And the indications for HiTH reported in this study were similar to another Australia study (Montalto et al., 1999), with the majority of patients also being referred to HiTH for IV therapy. Importantly, this study has shown a downward trend in the need for presentation to the emergency department during HiTH, and increasing number of patients being referred to HiTH for rehab services.

An overall strength of this study is the description of a wide range of HiTH patients, across a local health district, over many years. In particular, the HiTH team provides services to five major hospitals and general practitioners, that supply health services to the one million residents of the south west of Sydney. The potential to miss patient presentations to hospital during HiTH, over the study period, was minimised by both active surveillance of patients under HiTH care, by the HiTH team, and an extensive search of the hospital electronic patient records to identify ED presentations.

The results of this study highlight the diverse indications for HiTH services, and their effectiveness to avoid hospitalisation. The implications of the success of HiTH services to shorten or avoid hospital has many implications for patient safety and outcomes. In particular, avoidance of hospitalisation will lower the risk of hospital related adverse events, infections, delirium and nutritional problems. And, given the high risk of these events amongst the more vulnerable of the population, the elderly and those with multiple chronic diseases, HiTH services has many, both direct and indirect, benefits.

In conclusion, Hospital in the Home Services across the South Western Sydney Local Health District are predominately for administration of IV medications, but include management of post-operative drains, bridging of anticoagulant therapy, and rehab in the home. Importantly, only a very small proportion (3%) of HiTH episodes will include the need for patients to present to emergency. Hospital in the Home is well established, diverse, and safe clinical service to shorten or avoid hospitalisation for many patients. Importantly, avoidance of hospitalisation can avoid many risks that are associated with being cared for in the hospital setting.

Authors’ contributions

Anthony Hecimovic, conceptualization, methodology data curation, interpretation of results and preparation of manuscript; Vesna Matijasevic conceptualization, methodology data curation, interpretation of results and preparation of manuscript; Steve Frost conceptualization, methodology data management and analysis, interpretation of results and preparation of manuscript

All Authors Agree: (1) that the article is our original work; (2) the article has not received prior publication and is not under consideration for publication elsewhere; (3) that all authors have seen and approved the manuscript being submitted; (4) the authors abide by the copyright terms and conditions of Elsevier and the Australian College of Nursing.

Ethical Considerations

Competing of interests

All authors have no potential or actual competing interests to declare.

Funding

No funding was obtained to support this project.

Data

The R-code used to manage and analysis data is available from the last author. However, the actual patient data is not available.

Acknowledgments

The author wish to acknowledge the nursing, medical and allied health clinicians who care for the HiTH patients across the South Western Sydney Local Health District.

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Journal Publication

published 26 Nov, 2020

Read the published version in BMC Health Services Research →

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Submission checks completed at journal
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You are reading this latest preprint version

Characteristics and Outcomes of Patients Receiving Hospital in the Home Services in South West of Sydney.

Status:

Journal Publication

Version 1

Abstract

Summary of relevance

Introduction

Methods

Subjects and Setting

Referral to Hospital in the Home services

Operations of Service

Delivery of Hospital in the Home (HiTH) services

Outcomes of interest

Statistical analysis

Ethical Considerations

Results

Discussion

Declarations

References

Supplementary Files

Status:

Journal Publication

Version 1