Five years of Hospital at Home adoption in Catalonia: impact and challenges

BackgroundHospital at home (HaH), either admission avoidance (AA) or early supported discharge (ESD), was increasingly implemented in Catalonia (7.7 M, Spain) for selected patients, achieving regional adoption within the 2011-2015 Health Plan. This study aimed to assess population-wide HaH outcomes over five years (2015-2019) in a consolidated regional HaH program and provide context-independent recommendations for service quality assurance. MethodsA mixed-methods approach was adopted, combining population-based retrospective analyses of registry information with qualitative research. AA and ESD were separately compared with conventional hospitalization groups using propensity score matching techniques. In the analysis, we evaluated the 12-month period before the acute episode, the admission, and use of healthcare resources at 30 and 90 days after discharge. A panel of experts discussed the results and provided recommendations for monitoring HaH services. ResultsThe adoption of AA steadily increased from 5,185 to 8,086 episodes/year (total episodes 31,901; mean age 73 (SD 17) years; 79% high-risk patients), whereas ESD remained stable over the study period, averaging 5,329 episodes per year (total episodes 26,646; mean age 68 (SD 16) years; 71% high-risk patients). Mortality rates were similar in HaH and conventional hospitalization within the episode (AA: 0.31% vs. 0.45%; ESD: 0.18% vs. 0.45%) and at 30-days (AA: 3.94% vs. 3.24%; ESD: 4.50% vs. 4.07%). Likewise, the frequency of patients requiring hospital re-admissions or ER visits 30 days after discharge was similar in HaH (AA and ESD) and the corresponding controls. The 27 healthcare providers assessed showed high variability in patients age, multimorbidity, severity of episodes, recurrences, and length of stay of AA episodes. Recommendations aiming at enhancing service delivery were produced. ConclusionsBesides confirming safety and value generation of AA, we found that this service is delivered in a case-mix of diferent scenarios, encouraging provider-profiled monitoring of the service, particularly for ESD modalities. Impact statementWe certify that this work is confirmatory of Admission Avoidance (AA) as a value-based service by analyzing, with a population-based approach, a five-year period after regional adoption of AA in Catalonia. The research indicates the need for implementing quality assurance programs after service adoption and provides clear insights on how shape quality monitoring. The current study outcomes add novel knowledge to previous reports in the field, such as: O_LILeff B, DeCherrie L v., Montalto M, Levine DM. A research agenda for hospital at home. J Am Geriatr Soc. 2022;70(4):1060-1069. doi:10.1111/JGS.17715 C_LIO_LILevine DM, Ouchi K, Blanchfield B, et al. Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Ann Intern Med. 2020;172(2):77-85. doi:10.7326/M19-0600 C_LIO_LIMontalto M, McElduff P, Hardy K. Home ward-bound: features of hospital in the home use by major Australian hospitals, 2011-2017. Med J Aust. 2020;213(1):22-27. doi:10.5694/mja2.50599 C_LIO_LIHecimovic A, Matijasevic V, Frost SA. Characteristics and outcomes of patients receiving Hospital at Home Services in the South-West of Sydney. BMC Health Services Research. 2020;20(1):1090. doi:10.1186/s12913-020-05941-9 C_LIO_LILEONG MQ ET AL. Comparison of Hospital-at-Home models: a systematic review of reviews. BMJ Open. 2021;11:43285. doi:10.1136/bmjopen-2020-043285 C_LI The current manuscript covers relevant knowledge gaps well-identified in the nine dimensions for future research in the field of hospital at home reported by Leff B et al, 2022. Moreover, the population-based approach of the research provides a valuable approach for quality assurance of the different service modalities. O_TEXTBOXKey PointsO_LILarge scale adoption of Admission Avoidance shows value generation in real-world settings C_LIO_LIImplementation of continuous quality assurance monitoring after service adoption is highly recommended. C_LI Why does this paper matter?The population-based approach of the study design allows identification of key elements for service improvement after consolidated regional adoption of Hospital at Home Key strengths of the research are: i) demonstration of healthcare value generation of AA in large scale adoption of the service; and ii) generation of insightful recommendations for enhanced service delivery and continuous quality monitoring. C_TEXTBOX