The economic case for hospital discharge services for people experiencing homelessness in England: An in-depth analysis with different service configurations providing specialist care.

There are long-standing concerns that people experiencing homelessness may not recover well if left unsupported after a hospital stay. This study reports on a study investigating the cost-effectiveness of three different 'in patient care coordination and discharge planning' configurations for adults experiencing homelessness who are discharged from hospitals in England. The first configuration provided a clinical and housing in-reach service during acute care and discharge coordination but with no 'step-down' care. The second configuration provided clinical and housing in-reach, discharge coordination and 'step-down' intermediate care. The third configuration consisted of housing support workers providing in-reach and discharge coordination as well as step-down care. These three configurations were each compared with 'standard care' (control, defined as one visit by the homelessness health nurse before discharge during which patients received an information leaflet on local services). Multiple sources of data and multi-outcome measures were adopted to assess the cost utility of hospital discharge service delivery for the NHS and broader public perspective. Details of 354 participants were collated on service delivery costs (salary, on-costs, capital, overheads and 'hotel' costs, advertising and other indirect costs), the economic consequences for different public services (e.g. NHS, social care, criminal justice, housing, etc.) and health utilities (quality-adjusted-life-years, QALYs). Findings were complex across the configurations, but, on the whole, there was promising evidence suggesting that, with delivery costs similar to those reported for bed-based intermediate care, step-down care secured better health outcomes and improved cost-effectiveness (compared with usual care) within NICE cost-effectiveness recommendations.

A qualitative exploration of the views of patients and their relatives regarding interventions to minimize the distress related to postoperative delirium.

BACKGROUND: Postoperative delirium (POD) is common in older people and can be distressing for patients and their relatives. This study aimed to describe the experience of postoperative delirium and explore the views of patients and relatives in order to inform the codesign of an intervention to minimize distress related to postoperative delirium. METHODS: Qualitative study using a thematic analysis of semistructured interviews in patients (n = 11) and relatives (n = 12) who experienced and witnessed POD, respectively. RESULTS: Patients and relatives find POD distressing and desire information on the cause and consequences of delirium. This information should be delivered pre-emptively where possible for patients and relatives during the episode for relatives and in post episode follow up for patients and their families. Information should be provided in person by a health care professional who has experience in managing delirium, supplemented by written materials. In addition, participants suggested training to improve staff and public awareness of delirium. CONCLUSIONS: This qualitative study showed that patients and relatives find delirium distressing, report the need for an intervention to minimize this distress, and enabled codesign of a pilot intervention. Refinement and evaluation of this intervention should form the next step in this program of work.

Measuring the distress related to delirium in older surgical patients and their relatives.

OBJECTIVES: Delirium is a common postoperative complication with implications on morbidity and mortality. Less is known about the psychological impact of delirium in patients and relatives. This study aimed to quantitatively describe distress related to postoperative delirium in older surgical patients and their relatives using the distress thermometer, examine the association between degree of distress and features of delirium on the Delirium Rating Scale (DRS), and examine the association between recall of delirium and features of delirium on the DRS. METHODS: This prospective study recruited postoperative patients and their relatives following delirium. The distress thermometer was used to examine the degree of distress pertaining to delirium and was conducted during the hospitalization on resolution of delirium and then at 12-month follow-up. Associations between delirium-related distress in patient and relative participants and severity and features of delirium (DRS) were examined. RESULTS: One hundred two patients and 49 relatives were recruited. Median scores on the distress thermometer in patients who recalled delirium were 8/10. Relatives also showed distress (median distress thermometer score of 8/10). Associations were observed between severity and phenotypic features of delirium (delusions, labile affect, and agitation). Distress persisted at 12 months in patients and relatives. CONCLUSION: Distress related to postoperative delirium can be measured using a distress thermometer. Alongside approaches to reduce delirium incidence, interventions to minimize distress from postoperative delirium should be sought. Such interventions should be developed through robust research and if effective administered to patients, relatives, or carers.