Evaluating Person-Centred Integrated Care to People with Complex Chronic Conditions: Early Implementation Results of the ProPCC Programme.

Introduction: The evaluation of integrated care programmes for high-need high-cost older people is a challenge. We aim to share the early implementation results of the ProPCC programme in the North-Barcelona metropolitan area, in Catalonia, Spain. Methods: We analysed the intervention with retrospective data from May 2018 to December 2021 by describing the cohort complexity and by showing its 6-months pre-post impact on time spent at home and resources used: primary care visits, emergency department visits, hospital admissions and hospital stay. Findings: 264 cases were included (91% at home; 9% in nursing homes). 6-month pre vs. 6-months post results were (mean, p-value): primary care visits 8.2 vs. 11.5 (p < 0.05); emergency department visits 1.4 vs. 0.9 (p < 0.05); hospital admissions 0.7 vs. 0.5 (p < 0.05); hospital stay 12.8 vs. 7.9 days (p < 0.05). Time spent at home was 169.2 vs.174.2 days (p < 0.05). Conclusion: Early implementation of the ProPCC programme results in an increase in time spent at home (up to 3%) and significant reductions in emergency department attendance (-37.2%) and hospital stays (-38.3%). The increased use of primary care resources is compensated by the hospital resources savings, with a result in the average total cost of -46.3%.

The interplay between infection risk factors of SARS-CoV-2 and mortality: a cross-sectional study from a cohort of long-term care nursing home residents.

BACKGROUND: Covid-19 pandemic has particularly affected older people living in Long-term Care settings in terms of infection and mortality. METHODS: We carried out a cross-sectional analysis within a cohort of Long-term care nursing home residents between March first and June thirty, 2020, who were ≥ 65 years old and on whom at least one PCR test was performed. Socio-demographic, comorbidities, and clinical data were recorded. Facility size and community incidence of SARS-CoV-2 were also considered. The outcomes of interest were infection (PCR positive) and death. RESULTS: A total of 8021 residents were included from 168 facilities. Mean age was 86.4 years (SD = 7.4). Women represented 74.1%. SARS-CoV-2 infection was detected in 27.7% of participants, and the overall case fatality rate was 11.3% (24.9% among those with a positive PCR test). Epidemiological factors related to risk of infection were larger facility size (pooled aOR 1.73; P < .001), higher community incidence (pooled aOR 1.67, P = .04), leading to a higher risk than the clinical factor of low level of functional dependence (aOR 1.22, P = .03). Epidemiological risk factors associated with mortality were male gender (aOR 1.75; P < .001), age (pooled aOR 1.16; P < .001), and higher community incidence (pooled aOR 1.19, P = < 0.001) whereas clinical factors were low level of functional dependence (aOR 2.42, P < .001), Complex Chronic Condition (aOR 1.29, P < .001) and dementia (aOR 1.33, P <0.001). There was evidence of clustering for facility and health area when considering the risk of infection and mortality (P < .001). CONCLUSIONS: Our results suggest a complex interplay between structural and individual factors regarding Covid-19 infection and its impact on mortality in nursing-home residents.

Designing a Person-Centred Integrated Care Programme for People with Complex Chronic Conditions: A Case Study from Catalonia.

INTRODUCTION: The prevalence of people with complex chronic conditions is increasing. This population's high social and health needs require person-centred integrated approaches to care. METHODS: To collect data about experiences with the health system and identify priorities for care, we conducted 2 focus groups and 15 semi-structured interviews involving patients with multimorbidity and advanced conditions, caregivers, and representatives of patients' associations. To design the programme, we combined this information with evidence-based recommendations from local healthcare and social care professionals. RESULTS: Patients' and caregivers' main priorities were to ensure (a) comprehension of information provided by healthcare professionals; (b) coordination between patients, caregivers, and professionals; (c) access to social services; (d) support to caregivers in managing situations; (e) perceived support throughout the healthcare process; (f) home care, when available; and (d) a patient-centred approach. These dimensions were included in 37 of 63 clinical actions of the programme to cover the whole care trajectory: identifying high needs, defining, and providing care plans, managing crises, and providing transitional care and end-of-life care. CONCLUSION: We developed an evidence-based integrated care programme tailored to high-need patients combining input from patients, caregivers, and healthcare and social care professionals.

The provision of hospital at home care: Results of a national survey of UK hospitals.

BACKGROUND: Hospital at home (HaH) replicates elements of hospital-based care in the community, to facilitate the safe management of a broad spectrum of acute illness in the patient's usual environment. The extent to which this model of care has been adopted in the United Kingdom is unknown. METHODS: The Society for Acute Medicine Benchmarking Audit is a day of care survey undertaken annually within the United Kingdom. Participation is open to all hospital in the United Kingdom receiving acutely unwell medical patients. A questionnaire is used to collect hospital-level data on the structure and organisation of acute care delivery. The survey included questions designed to quantify the number of hospitals that offered HaH. When present, further questions were asked to clarify the characteristics of the HaH service in terms of workforce, range of diagnostic test and interventions. This information was used to build a picture of HaH service provision on a national scale. RESULTS: A total of 130 hospitals contributed organisational data to SAMBA19. The capability to refer to a hospital at home service was recognised by 46.9% (n = 61) of units. The majority of these services, 83.3% (n = 50) were nurse-led. The capability to provide a physician review at home was reported in 23.3% (n = 14). The majority of services could provide intravenous antibiotics at home, but access to other simple interventions, such as intravenous diuretics or acute supplemental oxygen, is limited. CONCLUSION: At present, few acute hospitals for consitency in the United Kingdom have access to a hospital at home service capable of replicating essential elements of inpatient care. Our study suggests organisational change in acute care delivery and significant investment would be required to establish equal access to hospital-at-home care within the United Kingdom.

Clinical effectiveness of an intermediate care inpatient model based on integrated care pathways.

AIM: The aim of this study was to compare the clinical impact of two intermediate care pathways. METHODS: A prospective, uncontrolled before-after study was carried out to compare two non-synchronic intermediate care frameworks in Spain. Participants in the control group were transferred to the intermediate care center by hospital request, whereas those in the intervention group (Badalona Integrated Care Model [BICM]) were transferred based on a territory approach considering the assessment of an intermediate care team. The clinical characteristics of study participants were assessed at admission and discharge. RESULTS: Compared with participants in the control group, those in the BICM group were significantly older (mean age 81.6 years [SD 10.3] vs 78.3 years [10.1], P < 0.001) and had a lower Barthel score (mean score 32.8 [SD 25.9] vs 39.9 [28.4]; P < 0.001), and a higher proportion of participants with total dependence (38.4% vs 32.2%; P = 0.001). The length of stay in intermediate care was similar in both groups; however, stay in acute care was significantly shorter in the BICM group than in the control group (mean 21 days [SD 19.5] vs 25 days [SD 23]; P < 0.001). No significant differences were found regarding the Barthel Index at discharge, although participants in the BICM group had significantly higher functional gain. CONCLUSIONS: The implementation of a territory-based integrated care pathway in an intermediate care center shifted the profile of admitted patients toward higher complexity. Despite this, patients managed under the integrated care model reduced their dependency and the referral rate to an acute unit during their stay in the intermediate care center. Geriatr Gerontol Int 2020; 20: 366-372.

Effectiveness of a Hospital-at-Home Integrated Care Program as Alternative Resource for Medical Crises Care in Older Adults With Complex Chronic Conditions.

OBJECTIVES: To compare clinical outcomes in older patients with acute medical crises attended by a geriatrician-led home hospitalization unit (HHU) vs an inpatient intermediate-care geriatric unit (ICGU) in a post-acute care setting. DESIGN: Quasi-experimental longitudinal study, with 30-day follow-up. PARTICIPANTS: Older patients with chronic conditions attended at the emergency department or day hospital for an acute medical crisis. INTERVENTIONS: Patients were referred to geriatrician-led HHU or ICGU wards. SETTING: An acute care hospital, an intermediate care hospital, and the community of an urban area in the North of Barcelona, in Southern Europe. MEASUREMENTS: We compared health crisis outcomes (recovery from the acute health crisis, referral to an acute hospital, or death), length of stay, relative functional gain (RFG) at discharge, readmission to an acute care unit within 30 days of discharge, and mortality within 30 days of discharge. RESULTS: We included 171 older adults (57 in the HHU and 114 in the ICGU) with complex conditions at risk of negative outcomes. At baseline, HHU patients were significantly younger and less likely to be cognitively impaired and referred from an emergency department. Most patients in both groups recovered from their health crises (91.2% in the HHU group vs 88.6% in the ICGU group, P = .79). No differences were found between the 2 groups in 30-day mortality (8.6% vs 9.6%, P = >.99). There was a trend toward lower 30-day readmission to an acute care unit in the HHU group (10.5% vs 19.3% in the ICGU group, P = .19). HHU patients had higher RFG (mean 0.75 days vs 0.51 in the ICGU group, P = .01), and a longer stay in the unit (9.7 vs 8.2 days in the ICGU group, P < .01). CONCLUSIONS: These preliminary results suggest that the geriatrician-led HHU seems effective in resolving acute medical crises in older patients with chronic disease. Patients attended by the HHU obtained better functional outcomes compared to those from the ICGU, although the groups did have some baseline differences.

Hospital-at-home Integrated Care Programme for the management of disabling health crises in older patients: comparison with bed-based Intermediate Care.

Objective: to analyse the clinical impact of a home-based Intermediate Care model in the Catalan health system, comparing it with usual bed-based care. Design: quasi-experimental longitudinal study. Setting: hospital Municipal de Badalona and El Carme Intermediate Care Hospital, Badalona, Catalonia, Spain. Participants: we included older patients with medical and orthopaedic disabling health crises in need of Comprehensive Geriatric Assessment (CGA) and rehabilitation. Methods: a CGA-based hospital-at-home Integrated Care Programme (acute care and rehabilitation) was compared with a propensity score matched cohort of contemporary patients attended by usual inpatient hospital care (acute care plus intermediate care hospitalisation), for the management of medical and orthopaedics processes. Main outcomes measures were: (a) Health crisis resolution (referral to primary care at the end of the intervention); (b) functional resolution: relative functional gain (functional gain/functional loss) ≥ 0.35; and (c) favourable crisis resolution (health + functional) = a + b. We compared between-groups outcomes using uni/multivariable logistic regression models. Results: clinical characteristics were similar between home-based and bed-based groups. Acute stay was shorter in home group: 6.1 (5.3-6.9) versus 11.2 (10.5-11.9) days, P < 0.001. The home-based scheme showed better results on functional resolution 79.1% (versus 75.2%), OR 1.62 (1.09-2.41) and on favourable crisis resolution 73.8% (versus 69.6%), OR 1.54 (1.06-2.22), with shorter length of intervention, with a reduction of -5.72 (-9.75 and -1.69) days. Conclusions: in our study, the extended CGA-based hospital-at-home programme was associated with shorter stay and favourable clinical outcomes. Future studies might test this intervention to the whole Catalan integrated care system.

Hospital-at-home Integrated Care Program for Older Patients With Orthopedic Processes: An Efficient Alternative to Usual Hospital-Based Care.

OBJECTIVE: To compare outcomes and costs for patients with orthogeriatric conditions in a home-based integrated care program versus conventional hospital-based care. DESIGN: Quasi-experimental longitudinal study. SETTING: An acute care hospital, an intermediate care hospital, and the community of an urban area in the North of Barcelona, in Southern Europe. PARTICIPANTS: In a 2-year period, we recruited 367 older patients attended at an orthopedic/traumatology unit in an acute hospital for fractures and/or arthroplasty. INTERVENTION: Patients were referred to a hospital-at-home integrated care unit or to standard hospital-based postacute orthogeriatric unit, based on their social support and availability of the resource. MEASUREMENTS: We compared home-based care versus hospital-based care for Relative Functional Gain (gain/loss of function measured by the Barthel Index), mean direct costs, and potential savings in terms of reduction of stay in the acute care hospital. RESULTS: No differences were found in Relative Functional Gain, median (Q25-Q75) = 0.92 (0.64-1.09) in the home-based group versus 0.93 (0.59-1) in the hospital-based group, P =.333. Total health service direct cost [mean (standard deviation)] was significantly lower for patients receiving home-based care: €7120 (3381) versus €12,149 (6322), P < .001. Length of acute hospital stay was significantly shorter in patients discharged to home-based care [10.1 (7)] than in patients discharged to the postacute orthogeriatric hospital-based unit [15.3 (12) days, P < .001]. CONCLUSION: The hospital-at-home integrated care program was suitable for managing older patients with orthopedic conditions who have good social support for home care. It provided clinical care comparable to the hospital-based model, and it seems to enable earlier acute hospital discharge and lower direct costs.