Exploring the Safewards Programme to Reduce Restrictive Practices in Residential Aged Care: Protocol for a Pilot and Feasibility Study.

INTRODUCTION: Restrictive practice use in residential aged care homes internationally is unacceptably high. Although policies and legislation mandate the reduction or elimination of restrictive practices, there remains a gap in knowledge regarding strategies that have been effective in achieving a sustained reduction in restraint use. There is an urgent need to identify effective and feasible interventions that aged care staff can implement in everyday practice to reduce restraint use. Safewards is an evidence-based programme that has demonstrated effectiveness in reducing conflict and restrictive practice use in inpatient psychiatric settings and has the potential to address the issue of restraint use in aged care homes. This study aims to evaluate the feasibility of Safewards in reducing restrictive practices in residential aged care homes. METHODS: This pilot and feasibility study will adopt a mixed methods process and outcomes evaluation. Safewards will be implemented in two Australian residential aged care homes. The Reach, Effectiveness, Adoption, Implementation and Maintenance framework will be used to evaluate implementation outcomes. Additionally, the Consolidated Framework for Implementation Research will be used to guide qualitative data collection (including semi-structured interviews with residents/family members, aged care leaders and staff) and explain the facilitators and barriers to effective implementation. CONCLUSION: This study will provide pilot evidence on the feasibility of the Safewards programme in residential aged care homes. Understanding the processes and adaptations for implementing and evaluating Safewards in residential aged care will inform a future trial in aged care to assess its effectiveness. More broadly, the findings will support the implementation of an international aged care policy of reducing restrictive practices in residential aged care. PATIENT OR PUBLIC CONTRIBUTION: A person with lived experience of caring for someone with dementia is employed as a Safewards facilitator and is a member of the steering committee. Residents and family members will be invited to participate in the project steering committee and provide feedback on their experience of Safewards. TRIAL REGISTRATION: ACTRN12624000044527.

The process of co-designing a model of social prescribing: An Australian case study.

INTRODUCTION: Social needs such as housing, employment, food, income and social isolation are having a significant impact on individuals, families and communities. Individuals are increasingly presenting to health settings with social needs, which are ill-equipped to address nonmedical needs. Social prescribing is a systematic approach connecting the health, social and community sectors to better address social needs and improve health and wellbeing. Social prescribing interventions are being implemented world-wide. With variability in health and social care systems internationally, it is important that social prescribing interventions are co-designed with key stakeholders to ensure they can be implemented and sustained within local systems. METHODS: This Australian case study provides a detailed description of the process undertaken to co-design a social prescribing service model in a regional area. Four co-design workshops were undertaken, two with health and social care professionals and two with community members. The project followed an iterative process of resourcing, planning, recruiting, sensitising, facilitation, reflection and building for change across the workshops. RESULTS: Through this process, key stakeholders were able to successfully co-design a social prescribing model of care for the region. CONCLUSION: By demonstrating the process and materials used in our project, we aim to open the 'black box' of co-design for social prescribing and provide ideas and resources for others to adapt and utilise. PATIENT OR PUBLIC CONTRIBUTION: The project was designed and undertaken by a steering committee comprising university-based researchers (authors C. O. and S. B.), local government (author D. A.) and health, social and community services (authors B. G., M. W., J. O. and S. R.). Members of the steering committee participated in project design, participant recruitment, workshop facilitation, data analysis and interpretation.

A systematic review of the measurement properties of aspects of psychological capacity in older adults.

OBJECTIVE: to examine the measurement properties of instruments that have been used to measure aspects of psychological capacity in adults aged 60 years and over. METHODS: the databases PsycINFO, MEDLINE, EMCARE and Scopus from 2010 were searched using search terms related to psychological capacity, older persons and measurement properties. Both data extraction and risk-of-bias assessment were conducted using the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) criteria using Covidence software. RESULTS: the full text of 326 articles were reviewed and a total of 30 studies were included, plus two further articles identified from reference lists (n = 32). No single instrument measuring psychological capacity was identified. Twenty (n = 20) instruments were identified that measure seven constructs of psychological capacity: Resilience; Sense of coherence; Hope; Mindfulness; Optimism; Attachment to life; Emotional regulation. CONCLUSIONS: this systematic review identified potential measures of psychological capacity in older adults. The review will inform further work to develop a single comprehensive measure of psychological capacity in older adults.

Mental health outcome measures in the Australian context: what is the problem represented to be?

BACKGROUND: There is growing interest in the use of routine outcome measures (ROM) in mental health services worldwide. Australia has been at the forefront of introducing ROM in public mental health services, with the aim of improving services and consumer outcomes. METHODS: An in-depth policy and document analysis was conducted using Carol Bacchi's 'What is the problem represented to be?' approach to critically analyse the use of ROM. This approach was used to identify and analyse the problem representations relating to the need for, and the choice of, outcome measures in Australian public mental health services, and the potential consequences of policy and practice. Data included in the analysis were seven policy documents, four reports on the introduction of outcome measures in Australia, the Australian Mental Health Outcomes and Classifications Network website, and the content of the outcome measures themselves. RESULTS: Two dominant representations of the 'problem' were identified: 1) the 'problem' of mental health service quality and accountability, relating to the need for mental health outcome measures; and 2) the 'problem' of addressing deficits in biopsychosocial functioning of mental health consumers, which relates to the choice of outcome measures. Framing the 'problem' of mental health outcomes in these ways locates the problem within individual health providers, services, and consumers, ignoring the broader socioeconomic conditions underpinning mental health and effective service provision. CONCLUSIONS: This critical analysis of the introduction and use of ROM in public mental health services in Australia highlights the need to consider the role of the social determinants of mental health, mental health service funding, and recovery-oriented care in ensuring services are meeting consumer needs and expectations. Broader governmental engagement is central to genuine change and opportunities.

Models of social prescribing to address non-medical needs in adults: a scoping review.

BACKGROUND: The health and wellbeing consequences of social determinants of health and health behaviours are well established. This has led to a growing interest in social prescribing, which involves linking people to services and supports in the community and voluntary sectors to address non-medical needs. However, there is considerable variability in approaches to social prescribing with little guidance on how social prescribing could be developed to reflect local health systems and needs. The purpose of this scoping review was to describe the types of social prescribing models used to address non-medical needs to inform co-design and decision-making for social prescribing program developers. METHODS: We searched Ovid MEDLINE(R), CINAHL, Web of Science, Scopus, National Institute for Health Research Clinical Research Network, Cochrane Central Register of Controlled Trials, WHO International Clinical Trial Registry Platform, and ProQuest - Dissertations and Theses for articles and grey literature describing social prescribing programs. Reference lists of literature reviews were also searched. The searches were conducted on 2 August 2021 and yielded 5383 results following removal of duplicates. RESULTS: 148 documents describing 159 social prescribing programs were included in the review. We describe the contexts in which the programs were delivered, the program target groups and services/supports to which participants were referred, the staff involved in the programs, program funding, and the use of digital systems. CONCLUSIONS: There is significant variability in social prescribing approaches internationally. Social prescribing programs can be summarised as including six planning stages and six program processes. We provide guidance for decision-makers regarding what to consider when designing social prescribing programs.

Development and validation of a self-report social determinants of health questionnaire in Australia.

Social determinants of health have a significant effect on health and wellbeing. There is increasing recognition of the need for health professionals to measure and address the social determinants affecting the health and wellbeing of their clients, yet efforts to do so are hampered by the lack of a validated, brief self-report measure that covers a range of determinants in a single measure. This study aimed to develop and conduct initial validation of a measure of social determinants of health, the Steps to Better Health Questionnaire (STBH-Q). Construct validity was assessed via factorial validity using exploratory factor analysis and second order confirmatory factor analysis (CFA), followed by convergent validity against the EQ-5D-5L quality of life measure. Reliability was assessed by exploring internal consistency. A convenience sampling approach was used, and 330 Australian adults aged 18 and over completed the survey. This initial validation suggests an underlying structure of STBH-Q consisting of Access; Employment, Finances & Education; Safety; Physical & Mental Health; and Family & Childhood, confirmed by second-order CFA. Results of convergent validity testing with the EQ-5D-5L demonstrated significant correlations of modest to moderate strength with the instrument as a whole and with the sub-scales in the expected direction. Cronbach's alpha for the five scales ranged from 0.561 to 0.827. Further development and validation of the STBH-Q is needed to explore alternative questions regarding social connection and habits/addictions and add additional items to factors with only two items.

Health and wellbeing are influenced by a range of factors, including the circumstances in which we are born and live our lives, called social determinants of health. It is important to measure social determinants of health at an individual level so they can be addressed, yet existing questionnaires tend to focus on a limited number of determinants or are time consuming and complex for individuals to fill in. We developed a simple measure of social determinants of health that can be easily completed and conducted a study to determine the validity and reliability of the questionnaire. We found that the questionnaire is a valid and reliable measure of social determinants of health.

The impacts of unmet supportive care needs of cancer survivors in Australia: A qualitative systematic review.

INTRODUCTION: Cancer incidence and survivorship are increasing worldwide. With more people living through and beyond cancer, there is a subsequent increase in their supportive care needs. This systematic review of qualitative studies aimed to describe the impacts of unmet supportive care needs on cancer survivors in Australia. METHODS: Databases MEDLINE, EMBASE and Scopus were searched, and after screening and applying eligibility criteria, 27 qualitative studies were included. Findings were synthesised according to the Supportive Care Framework for Cancer Care, including informational, physical, practical, emotional, psychological, social and spiritual need domains. RESULTS: The systematic review identified impacts of unmet informational, physical, practical, emotional and psychological needs. Frequently identified impacts of unmet informational needs were feelings of abandonment and isolation, distress, confusion and regret. Common impacts of unmet physical and practical needs were financial burden and return-to-work difficulties. Over half of all unmet supportive care needs caused emotional and psychological impacts. CONCLUSIONS: Findings identify the detrimental emotional and psychological impacts resulting from a range of unmet supportive care needs. The review highlights the interconnections between supportive care need domains thereby enhancing the understanding of the impacts of unmet SCNs. Findings may inform policy and practice change to improve supportive cancer care.

Chemical restraint: A qualitative synthesis review of adult service user and staff experiences in mental health settings.

With an imperative to reduce or eliminate the use of coercive practices in mental health care it is important to understand the experience of service users and staff. This review aimed to synthesize qualitative studies, published between 1996 and 2020, reporting on mental health service users' and staff's experiences of chemical restraint. The databases PsycINFO, CINAHL, MEDLINE, Embase, Emcare, Web of Science, and Scopus were searched. Three analytic themes were identified from 17 included articles, synthesizing the experiences of service users and staff. These were "Unjustified versusjustified," "Violence versus necessity," and "Reflecting back: Positives and negatives." Service users viewed chemical restraint as an unjustified response to "behaviors of concern" and experienced it as a violent act with negative outcomes, although some saw it as necessary in retrospect and preferred it to other forms of coercion. Staff generally viewed it as a justified response to "behaviors of concern" and experienced it as appropriate within the constraints of staff numbers and limited alternatives. These findings identify nuances not apparent in the literature, which has generally conflated all forms of coercive practices.

Role of security guards in Code Black events in medical and surgical settings: A retrospective chart audit.

The prevalence of security guards in health care settings is growing worldwide. There is a need to explore and understand their role and actions to inform policy and training and support least restrictive practices in health care. The aim of this study was to conduct a retrospective chart audit of security guard logs to investigate security guard involvement in Code Blacks, called in emergency situations of personal threats including patient and/or visitor violence, in medical and surgical wards in a large metropolitan health network in South Australia. Security guards attended 1664 Code Blacks (0.63% of admissions) over the 2.5-year study period. Events were more frequently reported in medical than surgical wards. The most common reasons for security guard attendance were patients threatening/harming staff and patients threatening/harming themselves. The most frequent security guard actions were "Attend only/standby," "Physical restraint," and "Patient located and returned to the ward." The most frequent outcomes were physical restraint, chemical restraint, and de-escalation respectively. Results highlight the imperative that health services maintain and increase efforts to support least restrictive practice through policy directives and staff training.

The role of rehabilitation in patients undergoing oesophagectomy for cancer and pre-malignant disease: A qualitative exploration of the views of patients, carers and healthcare providers.

OBJECTIVE: Oesophagectomy for cancer is associated with significant morbidity and mortality, and reduced quality of life. Structured rehabilitation potentially offers improved physical and psychological outcomes. We aimed to explore patient, carer and healthcare provider attitudes and preferences towards the role of rehabilitation. METHODS: We interviewed 15 patients who had undergone an oesophagectomy, 10 carers and 13 healthcare providers about perceived impacts of treatment; preferred components of a rehabilitation program; barriers/enablers of support provision; and participation in rehabilitation programs. Data were analysed using framework analysis. RESULTS: The overarching theme was "Getting back to normal." Diagnosis of disease signified a disruption to the normal trajectory of patients' lives and the post-treatment period was characterised as striving to return to normal. Patients and carers focused on rehabilitation needs post-treatment including dietary support, physiotherapy and healthcare provider support. Healthcare providers described rehabilitation as potentially beneficial from the pre-treatment phase and, along with carers, highlighted the importance of psychological support. Barriers included access to services, cost of service provision and appointment burden. CONCLUSION: A need for rehabilitation services was identified by healthcare providers from the point of diagnosis, rather than only after surgery. Implications include improved service provision by healthcare institutions for patients undergoing oesophagectomy.

Recovery college as a transition space in the journey towards recovery: An Australian qualitative study.

Recovery colleges are formal learning programs that aim to support people with a lived experience of mental illness. In this study, we aimed to explore the experiences of participants in a pilot recovery college that opened in Adelaide, South Australia, in 2016. A qualitative exploratory study was conducted involving interviews with learners (n = 8) and focus groups with lived experience facilitators (course facilitators with a lived experience of mental illness, n = 5), Clinician facilitators (mental health service staff facilitators, n = 4), and care coordinators (staff providing case management support, n = 5). Three main themes (hope, identity, and the recovery college as a transition space) and two subthemes (recovery college experience and outcomes) were identified. The results showed that the recovery college provided a transition space for shifting learners' identities from patient to student, facilitated by the experiences and outcomes of the recovery college, providing hope for the future. This study highlights the importance of providing mentally healthy and non-stigmatizing learning environments to promote and cement recovery for people with a lived experience of mental illness.

Regional responses to the challenge of delivering integrated care to older people with mental health problems in rural Australia.

OBJECTIVE: Integrated care has been identified as means of managing the demands on the healthcare budget while improving access to and quality of services. It is particularly pertinent to rural health services, which face limited access to specialist and support services. This paper explores the capacity of three rural communities in South Australia to deliver integrated mental health support for older people. METHODS: Thirty-one interviews were conducted with local health and social service providers from mental health, community health, general practice, residential aged care, private practice, NGOs and local government as part of a larger action research project on service integration. RESULTS: Participants highlighted differences in service delivery between the communities related to size of the community and access to services. Three structural barriers to delivery of integrated care were identified. These are as follows: fragmentation of governmental responsibility, the current funding climate, and centralisation and standardisation of service delivery. CONCLUSION: We conclude that despite a focus upon integrated care in mental health policy, many features of current service delivery undermine the flexibility and informal relationships that typically underpin integration in rural communities.

E-learning for self-management support: introducing blended learning for graduate students - a cohort study.

BACKGROUND: E-learning allows delivery of education in many diverse settings and researchers have demonstrated it can be as effective as learning conducted in traditional face-to-face settings. However, there are particular practices and skills needed in the area of providing patient self-management support (SMS), that may not be achievable online. The aim of this study was to compare three approaches in the training of university students regarding the preparation of a Chronic Condition Self-Management Care Plan: 1) traditional face-to-face delivery of SMS training, 2) an e-learning approach and 3) a blended approach (combining e-learning and face-to-face teaching). METHODS: Graduate entry physiotherapy students and medical students at Flinders University were recruited. Depending on the cohort, students were either exposed to traditional face-to-face training, e-learning or a blended model. Outcomes were compared between the three groups. We measured adherence to care plan processes in the preparation of an assessment piece using the Flinders Program Chronic Care Self Management tools. A total of 183 care plans were included (102 traditional, 52 blended, 29 e-learning,). All students submitted the Flinders Program Chronic Care Plan for university assessment and these were later assessed for quality by researchers. The submission was also assigned a consumer engagement score and a global competence score as these are integral to successful delivery of SMS and represent the patient perspective. RESULTS: The blended group performed significantly better than the traditional group in quality use of the Flinders Program tools: Problem and Goals (P < 0.0001). They also performed significantly better in the total care plan score (P < 0.0001) and engagement score (P < 0.0001). There was no significant difference between the groups for the Partners in Health tool. CONCLUSIONS: In this pilot study, the blended learning model was a more effective method for teaching self-management skills than the traditional group, as assessed in the development of a chronic condition self-management care plan. We anticipate that future research with identical groups of students would yield similar results but in the meantime, academics can have confidence that blended learning is at least as effective as traditional learning methods.

The health and wellbeing needs of veterans: a rapid review.

BACKGROUND: For the majority of serving members, life in the military has a positive effect on wellbeing. However, the type, intensity and duration of service, along with the transition from fulltime military to civilian life, may have a negative effect on veterans' wellbeing. Such negative consequences, alongside the growing veteran population, indicate the need for greater exploration of veterans' physical, mental and social wellbeing. METHODS: The current paper reports on the findings of a rapid review of the literature on the health and wellbeing needs of veterans, commissioned by the Australian Department of Veterans' Affairs to inform future programs and services. The databases Embase, Medline, Cinahl, PubMed, Web of Science and Cochrane Database were searched for systematic reviews reporting on veterans' physical, mental and social wellbeing published in English in peer-reviewed journals. RESULTS: A total of 21 systematic reviews were included. The reviews reported on a range of mental, physical and social health problems affecting veterans. While there was limited information on prevalence rates of physical, mental and social health problems in veterans compared to civilian populations, the reviews demonstrated the interconnection between these domains and the effect of demographic and military service factors. CONCLUSIONS: A key finding of the review is the interconnection of the mental, physical, and social health of veterans, highlighting the importance that an integrated approach to veterans' wellbeing is adopted. It is suggested that understanding key factors, such as demographic factors and factors relating to military service, can support improved service provision for veterans.

Risk assessment and absconding: perceptions, understandings and responses of mental health nurses.

AIMS AND OBJECTIVES: This paper reports mental health nurses' perspectives of absconding. The aims of the study were to explore nurses' perceptions of risk assessment and management practices regarding absconding from acute inpatient psychiatric settings, and their affective responses when patients absconded. BACKGROUND: Nurses are directly involved in managing the risk of patients leaving hospital while acutely unwell, as well as dealing with the implications of an absconding event. However, despite their key role, few studies have explored nurses' perceptions of absconding. DESIGN: An interpretive inquiry was undertaken using a systematic thematic approach. METHODS: Mental health nurses (n = 11) from three acute inpatient mental health units in Australia took part in semi-structured interviews, with a focus on the nurses' experiences of working with patients who had absconded. Data were analysed using systematic thematic coding procedures. RESULTS: Nurses' assessment of a patient's risk of absconding involved the use of clinical judgement, focusing on markers of absconding including the patient's history and clinical presentation. The acuity of the perceived risk determined the type of risk management strategy implemented, which could include support, observation and/or the use of containment procedures. Nurses responded with a myriad of affective reactions when patients absconded depending on their assessment of the patient's risk. CONCLUSIONS: Support and debriefing is required for mental health nurses following an absconding event. Additional research is vital to identify alternative absconding assessment and management strategies to ensure the best possible outcome for patients and nurses. RELEVANCE TO CLINICAL PRACTICE: Mental health nurses play a central role in risk assessment and management for absconding, with fear of repercussions a significant consequence for them. This research highlights the importance of both clinical judgment and standardised instruments in assessing absconding risk. Further research is needed to identify alternative evidence-based absconding management strategies to support nursing practice.

Service provision for older people with mental health problems in a rural area of Australia.

OBJECTIVES: Unmet mental health care needs of older people (aged 65 and over) have been identified as a serious problem internationally, particularly in rural areas. In this study we explored the views of health and social care providers of the barriers to effective mental health care for older people in a rural region in Australia. METHOD: Semi-structured interviews were conducted with 19 participants from 13 organisations providing care and support to older people in a rural region of Australia. A framework analysis approach was used to thematically analyse the data. RESULTS: Two main themes were identified: 'Recognising the Problem' and 'Service Availability and Access'. In particular the participants identified the impact of the attitudes of older people and health professionals, as well as service inadequacies and gaps in services, on the provision of mental health care to older people in a rural region. CONCLUSION: This study supports previous work on intrinsic and extrinsic barriers to older people with mental health problems accessing mental health services. The study also offers new insight into the difficulties that arise from the separation of physical and mental health systems for older people with multiple needs, and the impact of living in a rural region on unmet mental health care needs of older people.

The use of restrictive measures in an acute inpatient child and adolescent mental health service.

There are significant issues associated with the use of restrictive measures, such as seclusion and restraint, in child and adolescent mental health care. Greater understanding of how restrictive measures are used is important for informing strategies to reduce their use. In this brief report we present a 12-month audit (1/1/2010-31/12/2011) of the use of restrictive measures (seclusion, physical restraint) in one child and adolescent acute inpatient mental health unit in Australia. The study highlights the need for continued efforts to reduce the use of restrictive measures in child and adolescent mental health services.

The use of restraint in four general hospital emergency departments in Australia.

OBJECTIVE: The purpose of this study was to investigate restraint use in Australian emergency departments (EDs). METHOD: A retrospective audit of restraint incidents in four EDs (from 1 January 2010 to 31 December 2011). RESULTS: The restraint rate was 0.04% of total ED presentations. Males and females were involved in similar numbers of incidents. Over 90% of restrained patients had a mental illness diagnosis and were compulsorily hospitalised. Mechanical restraint with the use of soft shackles was the main method used. Restraint was enacted to prevent harm to self and/or others. Median incident duration was 2 hours 5 minutes. CONCLUSIONS: In order to better integrate the needs of mental health clients, consideration is needed as to what improvements to procedures and the ED environment can be made. EDs should particularly focus on reducing restraint duration and the use of hard shackles.

Barriers and facilitators to the implementation of the Flinders Chronic Condition Management Program in outpatient drug and alcohol settings in Australia.

INTRODUCTION: There has been a growing call for drug and/or alcohol dependence to be managed as a chronic condition. The Flinders Chronic Condition Management Program (Flinders Program) was implemented in a drug and alcohol service in Australia in 2019-2022 to explore the feasibility of chronic condition management in outpatient clinics. Implementation involved: adaptation of the Flinders Program; adaptation of clinical procedures; training clinicians and managers; training Flinders Program Accredited Trainers; and system integration. This study aims to explore barriers and enablers to implementation. METHODS: A qualitative formative evaluation was undertaken. Data included implementation documents (n = 7), responses to open-ended questions in post-training surveys (n = 27), and focus groups and interviews with implementation staff, clinicians, managers and a trainer (n = 16). Data were analysed using the Consolidated Framework for Implementation Research in a 'coding reliability' approach to thematic analysis. RESULTS: Participants responded positively to the Flinders Program's philosophy, processes, tools and training. However, barriers were identified across three Consolidated Framework for Implementation Research domains: (i) outer setting (client suitability and incompatibility with external policies and incentives); (ii) characteristics of individuals (low self-efficacy); and (iii) inner setting (lack of system and workflow integration). DISCUSSION AND CONCLUSIONS: Executive support and systems integration are important for the implementation of the Flinders Program in drug and alcohol services. This needs to be achieved within externally mandated key performance indicators for outpatient services. Further research is needed to fully evaluate the potential of a chronic condition management framework in Australian outpatient drug and alcohol services.

Patient experiences and outcomes in a South Australian stand-alone Hospital in the Home program.

ObjectivesThis study aimed to compare clinical outcomes for patients admitted to Hospital in the Home (HITH) and traditional (bricks-and-mortar) hospitals and explore patient and carer experiences.MethodsA mixed methods approach including triangulation of quantitative and qualitative data was used. Quantitative outcomes were compared using augmented inverse propensity weighting to adjust for differences in patient characteristics between groups. Qualitative data was collected by focus groups and interviews and analysed using reflexive thematic analysis. The study took place in metropolitan Adelaide and one adjacent regional health network in 2020-22. Participants were patients discharged from either hospital setting with 1 of 22 eligible diagnoses. Hospital administrative data informed a comparison of outcomes that included mortality, rate of emergency department re-presentations and re-admissions, length of stay and incidence of complications.ResultsPatients treated in HITH were less unwell than traditional hospital patients. There were no safety or quality concerns identified in the clinical outcomes. Of 2095 HITH patients, the in-patient mortality rate was 0.2%, and 2.3% experienced a return to a bricks-and-mortar hospital during the HITH admission. For HITH patients, the mortality rate after 30days was lower (-1.3%, 95% CI -2 to -0.5, P=0.002), as were re-presentations in 28days (-7.2%, 95% CI -9.5 to -5, P<0.0001), re-admissions in 28days (-4.9%, 95% CI -6.7 to -3.2, P<0.001) and complications (-0.6%, 95% CI -0.8 to -0.5, P<0.001). Interviews of 35 patients and six carers found that HITH was highly accepted and preferred by patients. HITH was perceived to free up resources for other, more acutely unwell patients.ConclusionsHITH was preferred by patients and at least as effective in delivering quality health care as a traditional hospital, although the potential for unobserved confounding must be acknowledged.