Hospital-at-home complex intervention tailored to older patients with disabling acute processes: evaluation of clinical factors for effectiveness on early discharge and admission avoidance strategies
- Autores: Miquel Angel Mas
- Directores de la Tesis: Marco Inzitari (dir. tes.), Ramon Miralles Basseda (tut. tes.)
- Lectura: En la Universitat Autònoma de Barcelona ( España ) en 2018
- Idioma: español
- Tribunal Calificador de la Tesis: Albert Selva O'Callaghan (presid.), Juan José Baztán Cortés (secret.), Nicolás Ignacio Martínez Velilla (voc.)
- Programa de doctorado: Programa de Doctorado en Medicina por la Universidad Autónoma de Barcelona
- Materias:
- Enlaces
- Resumen
In the last decades, an international movement worldwide has developed different schemes in the community to provide care to older adults in complex health crises based on complex interventions.
In the first part of this thesis, a literature review was done in order to analyse the main characteristics of several models of hospital-at-home care in older adults, based on two main modalities/strategies: Admission Avoidance (for providing hospital admission substitution and preventing hospital-related morbidities) and Early Supported Discharge (for shortening length of hospitalisation and facilitating community reinsertion after an acute admission).
After knowing that there is a strong international evidence on hospital-at-home interventions for several processes of care in older populations, both on Early Supported Discharge and Admission Avoidance modalities, we designed a patient-centred complex intervention, by using Comprehensive Geriatric Assessment (CGA), based on the reviewed literature, to provide care of health crises in vulnerable older patients in need of hospital care.
The Hospital-at-Home Integrated Care Programme (HaH-ICP) was piloted and evaluated in an urban area in the north of Barcelona, by a geriatrician-led multidisciplinary team. The programme was analysed using a quasi-experimental design, by comparing the results of the intervention provided in a hospital-at-home unit, linked to a department of geriatrics, with the results of contemporary matched patients that were attended by the same department in a hospital-based trajectory for several disabling health processes (medical, orthopaedics and stroke).
In both, Early Supported Discharge and Admission Avoidance modalities, the home-based scheme was found efficient based on clinical outcomes of health crisis resolution and functional resolution, in several trajectories (medical, orthopaedic and stroke processes). Overall, the clinical results were comparable to the hospital-based trajectory. In the rehabilitation process of the disabling health crises, the intervention was found associated with favourable crisis resolution, compared to usual care. In the Early Supported Discharge trajectory, in medical and orthopaedics crises, the intervention led to shortening of acute stay. In Admission Avoidance in medical crises, better functional results at discharge were evidenced, and a non significant trend in lower readmission rates up to 30-day follow-up was observed. In orthopaedic processes, a significant reduction in direct costs was evidenced.
The HaH-ICP was an adaptation of geriatrician-led hospital-at-home models of care to a local older adult population in Southern Europe. Several clinical factors from CGA at admission, such as suffering an orthopaedic process, having Barthel Index score higher than 40 points at admission, and not having pressure ulcers at admission, were found factors related with favourable crisis resolution.
The clinical research presented in this Doctoral Thesis pretends to contribute to future implementation of the geriatrician-led multidisciplinary hospital-at-home model in the Catalan integrated care system, based on future research lines summarised in the discussion section.
