ABSTRACT
INTRODUCTION: Multiple Cochrane Reviews have demonstrated 'hospital at home' (HaH) as a promising healthcare model to be explored, with benefits such as higher care quality, reduced readmissions, shorter lengths of stay, lower cost and greater patient satisfaction. While there have been many reviews focusing on the quantitative clinical outcomes of HaH, there is generally a lack of collation of qualitative insights from stakeholders and lessons learnt from past HaH implementation. METHODS: We performed a systematic literature search on four databases and included 17 papers involving the provision of acute and/or subacute care by healthcare professionals in patients' homes. Review characteristics and relevant outcomes were extracted from the reported findings and tables in the reviews, and these included stakeholder attitudes and factors contributing to the success of HaH implementation. RESULTS: Factors relating to patients and caregivers included home setup, preference for care and death settings, and support for caregiver. Factors involving the healthcare professionals and intervention included a multidisciplinary care team, accessibility to emergency care and support, training of providers and patients, adequate manpower allocation, robust eligibility and referral criteria, sufficient awareness of the HaH referral pathway, communication and medication management. CONCLUSION: HaH presents a promising alternative care model, and many of the success factors identified, including the strong push for multidisciplinary single care teams, existing frameworks for data sharing and strong community network, are already present today. As such, Singapore appears to be well positioned to adopt a new care model like HaH.
ABSTRACT
Objectives: Given the shift towards value-based healthcare and the increasing recognition of generalist care, enacting value-based healthcare for generalist care is critical. This work aims to shed light on how to conduct performance management of generalist care to facilitate value-based care, with a focus on medical care of hospitalised patients. Design and setting: A scoping review of published literature was conducted. 30 publications which were relevant to performance management of generalist medical inpatient care were included in the review. Outcome measures: The performance measures used across the studies were analysed and other qualitative findings were also obtained. Results: We report an overall lack of research on performance management methods for generalist inpatient care. Relevant performance measures found include both outcome and process of care measures and both clinical and reported measures, with clinical outcome measures the most frequently reported. Length of stay, readmission rates and mortality were the most frequently reported. The insights from the papers emphasise the relevance of process of care measures for performance management, the advantages and disadvantages of types of measures and provide suggestions relevant for performance management of generalist inpatient care. Conclusion: The findings of this scoping review outline a variety of performance measures valuable for generalist inpatient care including clinical outcome measures, reported outcome measures and process of care measures. The findings also suggest directions for implementation of such performance management, including emphasis on physician level performance management and the importance of documentation training. Further research for selecting and operationalising the measures for specific contexts and developing a comprehensive performance management system involving these measures will be important for achieving value-based healthcare for generalist inpatient care.
ABSTRACT
Introduction: With the increasing complexity of healthcare problems worldwide, the demand for better-coordinated care delivery is on the rise. However, current hospital-based practices remain largely disease-centric and specialist-driven, resulting in fragmented care. This study aimed to evaluate the effectiveness and feasibility of an integrated general hospital (IGH) inpatient care model. Methods: Retrospective analysis of medical records between June 2018 and August 2019 compared patients admitted under the IGH model and patients receiving usual care in public hospitals. The IGH model managed patients from one location with a multidisciplinary team, performing needs-based care transition utilizing acuity tagging to match the intensity of care to illness acuity. Results: 5,000 episodes of IGH care entered analysis. In the absence of care transition in intervention and control, IGH average length of stay (ALOS) was 0.7 days shorter than control. In the group with care transition in intervention but not in control, IGH acute ALOS was 2 days shorter, whereas subacute ALOS was 4.8 days longer. In the presence of care transition in intervention and control, IGH acute ALOS was 6.4 and 10.2 days shorter and subacute ALOS was 15.8 and 26.9 days shorter compared with patients under usual care at acute hospitals with and without co-located community hospitals, respectively. The 30- and 60-days readmission rates of IGH patients were marginally higher than usual care, though not clinically significant. Discussions: The IGH care model maybe associated with shorter ALOS of inpatients and optimize resource allocation and service utilization. Patients with dynamic acuity transition benefited from a seamless care transition process.
Subject(s)
Hospitals, General , Inpatients , Hospitalization , Humans , Length of Stay , Retrospective StudiesABSTRACT
INTRODUCTION: Hospital-based practices today remain predominantly disease-oriented, focusing on individual clinical specialties with less visibility on a comprehensive picture of each patient's health needs. To tackle the challenge of growing multimorbidity worldwide, practices without disease-specific focus have shown better integration of services. However, as we move away from the familiar disease-specific approaches of care delivery, many of us are still learning how to implement generalist care in a cost-effective manner. METHODS: This mixed-method case study, which centred on a specialist-led General Medicine model implemented at an acute hospital in Singapore, aimed to (1) quantitatively summarise its clinical outcomes, and (2) qualitatively describe the challenges and lessons gathered from the pragmatic implementation of the care model. Quantitative hospital data were extracted from databases and summarised. Qualitative staff-reported experiences and insights were gathered through semi-structured interviews and analysed using thematic analysis. RESULTS: Quantitative findings revealed that the generalist care model was implemented with high fidelity, where more than 75% of patients admitted were placed under General Medicine's or General Surgery's care. The mean length of stay was 2.6 days, and the 30-day post-discharge readmission rate was 15%. Inpatient mortality rate was found to be 2.8%, and the average gross hospitalisation bill amounted to SGD3,085.30. For qualitative findings, themes concerning feasibility and operational aspects of the implementation were grouped into categories- (1) Feasibility of 'One Care Team' approach, (2) Enablers required for meaningful generalist care, (3) Challenges surrounding information sharing, (4) Lack of integration with the community to facilitate care transition, and (5) Evolving roles of self-management. The findings were rich, with some being identified as barriers that could benefit from system-level de-constraining. DISCUSSION: This case study was an illustration of our pursuit for an integrated solution to rising prevalence of multimorbidity. While quantitative findings indicated that a pivot towards General Medicine might be possible, data also revealed gaps in clinical outcomes, especially in readmission rates. These findings corroborated with much of the lessons and challenges gathered from qualitative interviews, specifically surrounding the lack of receptacles in the community to facilitate care transition, training, and competency of generalists in holistic management of complex multimorbid cases, as well as inadequate infrastructure to allow information sharing between providers. Thus, a multi-pronged approach might be required to develop a new and sustainable care model for patients with multimorbidity in the long run. In the short to medium transitional period, nonetheless, the specialist-led General Medicine care model demonstrated might be a viable interim approach, especially in circumstances where trained medical generalists remained limited.
Subject(s)
Delivery of Health Care , Health Personnel , Hospitals , Inpatients , Humans , SingaporeABSTRACT
OBJECTIVES: To provide an overview of the safety and effectiveness of Hospital-at-Home (HaH) according to programme type (early-supported discharge (ESD) vs admission avoidance (AA)), and identify the model with higher evidence for addressing clinical, length of stay (LOS) and cost outcomes. METHODS: A systematic review of reviews was conducted by performing a search on PubMed, EMBASE, Cochrane Database of Systematic Reviews, Web of Science and Scopus (January 2005 to June 2020) for English-language systematic reviews evaluating HaH. Data on primary outcomes (mortality, readmissions, costs, LOS), secondary outcomes (patient/caregiver outcomes) and process indicators were extracted. Quality of the reviews was assessed using Assessment of Multiple Systematic Reviews-2. There was no registered protocol. RESULTS: Ten systematic reviews were identified (four high quality, five moderate quality and one low quality). The reviews were classified according to three use cases. ESD reviews generally revealed comparable mortality (RR 0.92-1.03) and readmissions (RR 1.09-1.25) to inpatient care, shorter hospital LOS (MD -6.76 to -4.44 days) and unclear findings for costs. AA reviews observed a trend towards lower mortality (RR 0.77, 95% CI 0.54 to 1.09) and costs, and comparable or lower readmissions (RR 0.68-0.98). Among reviews including both programme types (ESD/AA), chronic obstructive pulmonary disease reviews revealed lower mortality (RR 0.65-0.68) and post-HaH readmissions (RR 0.74-0.76) but unclear findings for resource use. CONCLUSION: For suitable patients, HaH generally results in similar or improved clinical outcomes compared with inpatient treatment, and warrants greater attention in health systems facing capacity constraints and rising costs. Preliminary comparisons suggest prioritisation of AA models over ESD due to potential benefits in costs and clinical outcomes. Nonetheless, future research should clarify costs of HaH programmes given the current low-quality evidence, as well as address evidence gaps pertaining to caregiver outcomes and adverse events under HaH care.
