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      Implementation of Home Hospitalization and Early Discharge as an Integrated Care Service: A Ten Years Pragmatic Assessment

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          Abstract

          Home Hospitalization has proven efficacy, but its effectiveness and potential as an Integrated Care Service in a real world setting deserves to be explored.

          Objective:

          To evaluate implementation and 10 years follow-up of Home Hospitalization and Early Discharge as an Integrated Care Service in an urban healthcare district in Barcelona.

          Methods:

          Prospective study with pragmatic assessment. Patients: Surgical and medical acute and exacerbated chronic patients requiring admission into a highly specialized hospital, from 2006 to 2015. Intervention: Home-based individualized care plan, administered as a hospital-based outreach service, aiming at substituting hospitalization and implementing a transitional care strategy for optimal discharge. Main measurements: Emergency Department, readmissions and mortality. Patients’ and professionals’ perspectives, technologies and costs were evaluated.

          Results:

          4,165 admissions (71 ± 15 yrs; Charlson Index 4 ± 3). In-hospital stay was 1 (0–3) days and the length of home-based stay was 6 (5–7) days. The 30-day readmission rate was 11% and mortality was 2%. Patients, careers and health professionals expressed high levels of satisfaction (98%). At the start, the service was reimbursed at a flat rate of 918€ per patient discharged, significantly lower than conventional hospitalization (2,879€) but still allowing the hospital to keep a balanced budget. At present, there is no difference in the payment schemes for both types of services.

          Conclusions:

          The service freed an average of 6 in-hospital days per patient. The program showed health value generation, as well as potential for synergies with community-based Integrated Care Services.

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          Most cited references 30

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          Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs.

          Persons with continuous complex care needs frequently require care in multiple settings. During transitions between settings, this population is particularly vulnerable to experiencing poor care quality and problems of care fragmentation. Despite how common these transitions have become, the challenges of improving care transitions have received little attention from policy makers, clinicians, and quality improvement entities. This article begins with a definition of transitional care and then discusses the nature of the problem, its prevalence, manifestations of poorly executed transitions, and potentially remediable barriers. Necessary elements for effective transitions are then presented, followed by promising new directions for quality improvement at the level of the delivery system, information technology, and national health policy. The article concludes with a proposed research agenda designed to advance the science of high-quality transitional care.
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            Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial.

            Comprehensive discharge planning by advanced practice nurses has demonstrated short-term reductions in readmissions of elderly patients, but the benefits of more intensive follow-up of hospitalized elders at risk for poor outcomes after discharge has not been studied. To examine the effectiveness of an advanced practice nurse-centered discharge planning and home follow-up intervention for elders at risk for hospital readmissions. Randomized clinical trial with follow-up at 2, 6, 12, and 24 weeks after index hospital discharge. Two urban, academically affiliated hospitals in Philadelphia, Pa. Eligible patients were 65 years or older, hospitalized between August 1992 and March 1996, and had 1 of several medical and surgical reasons for admission. Intervention group patients received a comprehensive discharge planning and home follow-up protocol designed specifically for elders at risk for poor outcomes after discharge and implemented by advanced practice nurses. Readmissions, time to first readmission, acute care visits after discharge, costs, functional status, depression, and patient satisfaction. A total of 363 patients (186 in the control group and 177 in the intervention group) were enrolled in the study; 70% of intervention and 74% of control subjects completed the trial. Mean age of sample was 75 years; 50% were men and 45% were black. By week 24 after the index hospital discharge, control group patients were more likely than intervention group patients to be readmitted at least once (37.1 % vs 20.3 %; P<.001). Fewer intervention group patients had multiple readmissions (6.2% vs 14.5%; P = .01) and the intervention group had fewer hospital days per patient (1.53 vs 4.09 days; P<.001). Time to first readmission was increased in the intervention group (P<.001). At 24 weeks after discharge, total Medicare reimbursements for health services were about $1.2 million in the control group vs about $0.6 million in the intervention group (P<.001). There were no significant group differences in post-discharge acute care visits, functional status, depression, or patient satisfaction. An advanced practice nurse-centered discharge planning and home care intervention for at-risk hospitalized elders reduced readmissions, lengthened the time between discharge and readmission, and decreased the costs of providing health care. Thus, the intervention demonstrated great potential in promoting positive outcomes for hospitalized elders at high risk for rehospitalization while reducing costs.
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              Integrated care prevents hospitalisations for exacerbations in COPD patients.

              Hospital admissions due to chronic obstructive pulmonary disease (COPD) exacerbations have a major impact on the disease evolution and costs. The current authors postulated that a simple and well-standardised, low-intensity integrated care intervention can be effective to prevent such hospitalisations. Therefore, 155 exacerbated COPD patients (17% females) were recruited after hospital discharge from centres in Barcelona (Spain) and Leuven (Belgium). They were randomly assigned to either integrated care (IC; n = 65; age mean+/-sd 70+/-9 yrs; forced expiratory volume in one second (FEV(1)) 1.1+/-0.5 L, 43% predicted) or usual care (UC; n = 90; age 72+/-9 yrs; FEV(1) 1.1+/-0.05 L, 41% pred). The IC intervention consisted of an individually tailored care plan upon discharge shared with the primary care team, as well as accessibility to a specialised nurse case manager through a web-based call centre. After 12 months' follow-up, IC showed a lower hospitalisation rate (1.5+/-2.6 versus 2.1+/-3.1) and a higher percentage of patients without re-admissions (49 versus 31%) than UC without differences in mortality (19 versus 16%, respectively). In conclusion, this trial demonstrates that a standardised integrated care intervention, based on shared care arrangements among different levels of the system with support of information technologies, effectively prevents hospitalisations for exacerbations in chronic obstructive pulmonary disease patients.
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                Author and article information

                Contributors
                Journal
                Int J Integr Care
                Int J Integr Care
                1568-4156
                International Journal of Integrated Care
                Ubiquity Press
                1568-4156
                16 May 2018
                Apr-Jun 2018
                : 18
                : 2
                Affiliations
                [1 ]Hospital Clínic de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en red, Enfermedades Respiratorias, University of Barcelona, Catalonia, ES
                [2 ]Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Catalonia, ES
                [3 ]Hospital Clinic, Barcelona, Catalonia, ES
                [4 ]Centre de Recerca en Epidemiologia Ambiental. Centro de Investigación Biomédica en red de Epidemiologia y Salud Pública, Universitat Pompeu Fabra, Barcelona, Catalonia, ES
                Article
                10.5334/ijic.3431
                6095082
                Copyright: © 2018 The Author(s)

                This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.

                Categories
                Research and Theory

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