Facilitators and barriers to implementing an acute geriatric community hospital in the Netherlands: a qualitative study.

BACKGROUND: there is a trend across Europe to enable more care at the community level. The Acute Geriatric Community Hospital (AGCH) in the Netherlands in an acute geriatric unit situated in a skilled nursing facility (SNF). It provides hospital-level care for older adults with acute medical conditions. The aim of this study is to identify barriers and facilitators associated with implementing the AGCH in a SNF. METHODS: semi-structured interviews (n = 42) were carried out with clinical and administrative personnel at the AGCH and university hospital and stakeholders from the partnering care organisations and health insurance company. Data were analysed using thematic analysis. RESULTS: facilitators to implementing the AGCH concept were enthusiasm for the AGCH concept, organising preparatory sessions, starting with low-complex patients, good team leadership and ongoing education of the AGCH team. Other facilitators included strong collaboration between stakeholders, commitment to shared investment costs and involvement of regulators.Barriers to implementation were providing hospital care in an SNF, financing AGCH care, difficulties selecting patients at the emergency department, lack of protocols and guidelines, electronic health records unsuited for hospital care, department layout on two different floors and complex shared business operations. Furthermore, transfer of acute care to the community care meant that some care was not reimbursed. CONCLUSIONS: the AGCH concept was valued by all stakeholders. The main facilitators included the perceived value of the AGCH concept and enthusiasm of stakeholders. Structural financing is an obstacle to the expansion and continuation of this care model.

Investigating the Effectiveness of Care Delivery at an Acute Geriatric Community Hospital for Older Adults in the Netherlands: A Prospective Controlled Observational Study.

OBJECTIVES: Hospital admission in older adults is associated with unwanted outcomes such as readmission, institutionalization, and functional decline. To reduce these outcomes, the Netherlands introduced an alternative to hospital-based care: the Acute Geriatric Community Hospital (AGCH). The AGCH is an acute care unit situated outside of a hospital focusing on early rehabilitation and comprehensive geriatric assessment. The objective of this study was to evaluate if AGCH care is associated with decreasing unplanned readmissions or death compared with hospital-based care. DESIGN: Prospective cohort study controlled with a historic cohort. SETTING AND PARTICIPANTS: A (sub)acute care unit (AGCH) and 6 hospitals in the Netherlands; participants were acutely ill older adults. METHODS: We used inverse propensity score weighting to account for baseline differences. The primary outcome was 90-day readmission or death. Secondary outcomes included 30-day readmission or death, time to death, admission to long-term residential care, occurrence of falls and functioning over time. Generalized logistic regression models and multilevel regression analyses were used to estimate effects. RESULTS: AGCH patients (n = 206) had lower 90-day readmission or death rates [odds ratio (OR) 0.39, 95% CI 0.23-0.67] compared to patients treated in hospital (n = 401). AGCH patients had a lower risk of 90-day readmission (OR 0.38, 95% CI 0.21-0.67) but did not differ on all-cause mortality (OR 0.89, 95% CI 0.44-1.79) compared with the hospital control group. AGCH patients had lower 30-day readmission or death rates. Secondary outcomes did not differ. CONCLUSIONS AND IMPLICATIONS: AGCH patients had lower rates of readmission and/or death than patients treated in a hospital. Our results support further research on the implementation and cost-effectiveness of AGCH in the Netherlands and other countries seeking alternatives to hospital-based care.

Two European Examples of Acute Geriatric Units Located Outside of a General Hospital for Older Adults With Exacerbated Chronic Conditions.

OBJECTIVE: Throughout Europe, the number of older adults requiring acute hospitalization is increasing. Admission to an acute geriatric unit outside of a general hospital could be an alternative. In this model of acute medical care, comprehensive geriatric assessment and rehabilitation are provided to selected older patients. This study aims to compare patients' diagnoses, characteristics, and outcomes of 2 European sites where this care occurs. DESIGN: Exploratory cohort study. SETTING AND PARTICIPANTS: Subacute Care Unit (SCU), introduced in 2012 in Barcelona, Spain, and the Acute Geriatric Community Hospital (AGCH), introduced in 2018 in Amsterdam, the Netherlands. The main admission criteria for older patients were acute events or exacerbations of chronic conditions, hemodynamic stability on admission, and no requirement for complex diagnostics. MEASURES: We compared setting, characteristics, and outcomes between patients admitted to the 2 units. RESULTS: Data from 909 patients admitted to SCU and 174 to AGCH were available. Patients were admitted from the emergency department or from home. The mean age was 85.8 years [standard deviation (SD) = 6.7] at SCU and 81.9 years (SD = 8.5) (P < .001) at AGCH. At SCU, patients were more often delirious (38.7% vs 22.4%, P < .001) on admission. At both units, infection was the main admission diagnosis. Other diagnoses included heart failure or chronic obstructive pulmonary disease. Five percent or less of patients were readmitted to general hospitals. Average length of stay was 8.8 (SD = 4.4) days (SCU) and 9.9 (SD = 7.5) days (AGCH). CONCLUSIONS AND IMPLICATIONS: These acute geriatric units are quite similar and both provide an alternative to admission to a general hospital. We encourage the comparison of these units to other examples in Europe and suggest multicentric studies comparing their performance to usual hospital care.

Investigating the effectiveness of care delivery at an acute geriatric community hospital for older adults in the Netherlands: a protocol for a prospective controlled observational study.

INTRODUCTION: Hospital admission in older adults with multiple chronic conditions is associated with unwanted outcomes like readmission, institutionalisation, functional decline and mortality. Providing acute care in the community and integrating effective components of care models might lead to a reduction in negative outcomes. Recently, the first geriatrician-led Acute Geriatric Community Hospital (AGCH) was introduced in the Netherlands. Care at the AGCH is focused on the treatment of acute diseases, comprehensive geriatric assessment, setting patient-led goals, early rehabilitation and streamlined transitions of care. METHODS AND ANALYSIS: This prospective cohort study will investigate the effectiveness of care delivery at the AGCH on patient outcomes by comparing AGCH patients to two historic cohorts of hospitalised patients. Propensity score matching will correct for potential population differences. The primary outcome is the 3-month unplanned readmission rate. Secondary outcomes include functional decline, institutionalisation, healthcare utilisation, occurrence of delirium or falls, health-related quality of life, mortality and patient satisfaction. Measurements will be conducted at admission, discharge and 1, 3 and 6 months after discharge. Furthermore, an economic evaluation and qualitative process evaluation to assess facilitators and barriers to implementation are planned. ETHICS AND DISSEMINATION: The study will be conducted according to the Declaration of Helsinki. The Medical Ethics Research Committee confirmed that the Medical Research Involving Human Subjects Act did not apply to this research project and official approval was not required. The findings of this study will be disseminated through public lectures, scientific conferences and journal publications. Furthermore, the findings of this study will aid in the implementation and financing of this concept (inter)nationally. TRIAL REGISTRATION NUMBER: NL7896; Pre-results.

Determinants of Post-acute Care Costs in Acutely Hospitalized Older Adults: The Hospital-ADL Study.

OBJECTIVES: After hospitalization, many older adults need post-acute care, including rehabilitation or home care. However, post-acute care expenses can be as high as the costs for the initial hospitalization. Detailed information on monthly post-acute health care expenditures and the characteristics of patients that make up for a large share of these expenditures is scarce. We aimed to calculate costs in acutely hospitalized older patients and identify patient characteristics that are associated with high post-acute care costs. DESIGN: Prospective multicenter cohort study (between October 2015 and June 2017). SETTING AND PARTICIPANTS: 401 acutely hospitalized older persons from internal medicine, cardiology, and geriatric wards. MEASUREMENTS: Our primary outcome was mean post-acute care costs within 90 days postdischarge. Post-acute care costs included costs for unplanned readmissions, home care, nursing home care, general practice, and rehabilitation care. Three costs categories were defined: low [0-50th percentile (p0-50)], moderate (p50-75), and high (p75-100). Multinomial logistic regression analyses were conducted to assess the associations between costs and frailty, functional impairment, health-related quality of life, cognitive impairment, and depressive symptoms. RESULTS: Costs were distributed unevenly in the population, with the top 10.0% (n = 40) accounting for 52.1% of total post-acute care costs. Mean post-acute care costs were €4035 [standard deviation (SD) 4346] or $4560 (SD 4911). Frailty [odds ratio (OR) 3.44, 95% confidence interval (CI) 1.78-6.63], functional impairment (OR 1.80, 95% CI 1.03-3.16), and poor health-related quality of life (OR 1.89, 95% CI 1.09-3.28) at admission were associated with classification in the high-cost group, compared with the low-cost group. CONCLUSIONS/IMPLICATIONS: Post-acute care costs are substantial in a small portion of hospitalized older adults. Frailty, functional impairment, and poor health-related quality of life are associated with higher post-acute care costs and may be used as an indicator of such costs in practice.