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Hospital at Home Services

Literature Review & Jurisdictional Scan

PREPARED BY

TRACY BYRNE, PHD

JENNY WESTON, PHD

JENNEKA JANZEN, PHD

JULY 2020

InsideOut Policy Research, 2020

www.insideoutresearch.ca info@insideoutresearch.ca

Table of Contents

EXECUTIVE SUMMARY .................................................................................................................. I

INTRODUCTION ........................................................................................................................... 1

FOCUSED LITERATURE REVIEW ..................................................................................................... 4

Introduction .............................................................................................................................. 4

Summary of Findings ................................................................................................................ 4

Conclusions from the Research Literature .......................................................................... 12

NHS ENGLAND ........................................................................................................................... 15

Context .................................................................................................................................... 15

Key Legislation ........................................................................................................................ 16

Definitions of Hospital at Home ............................................................................................ 17

H@H Services in Select NHS Trusts ......................................................................................... 18

Independent Expert Panel on Clinical Care in the Home ................................................ 23

NHS SCOTLAND ......................................................................................................................... 28

Context .................................................................................................................................... 28

Key Legislation ........................................................................................................................ 29

Supporting Policy Framework ............................................................................................... 32

Definition of Hospital at Home .............................................................................................. 33

National Guidance on the Design and Implementation of Hospital at Home Services 35 Hospital at Home in Practice - Service Models and Lessons Learned ............................ 43

FRANCE ...................................................................................................................................... 48

Ministry of Health - Definition of HAD ................................................................................... 48

Key Legislation ........................................................................................................................ 49

Best Practices and Key Focus Areas .................................................................................... 57

Reported Outcomes Data .................................................................................................... 61

Observations ........................................................................................................................... 63

COMMONWEALTH GOVERNMENT OF AUSTRALIA .................................................................. 65

Department of Health - Definition of HAD .......................................................................... 65

National Legislation ............................................................................................................... 65

National Safety and Quality Health Service Standards ..................................................... 67

National Data Collection ...................................................................................................... 67

Observations ........................................................................................................................... 68

VICTORIA, AUSTRALIA ............................................................................................................... 69

Department of Health - Definition of HITH .......................................................................... 69

Key Legislation and Policy ..................................................................................................... 69

Hospital in the Home Guidelines (2011) ............................................................................... 70

Reported Outcomes .............................................................................................................. 76

Observations ........................................................................................................................... 77

NEW SOUTH WALES, AUSTRALIA ............................................................................................... 78

Department of Health - HITH Definition ............................................................................... 78

Key Legislation ........................................................................................................................ 78

Adult and Paediatric Hospital in the Home Guideline (2018) .......................................... 79

Reported Outcomes .............................................................................................................. 87

Observations ........................................................................................................................... 87

QUEENSLAND, AUSTRALIA ........................................................................................................ 89

Definition and Overview of HITH ........................................................................................... 89

Key Legislation ........................................................................................................................ 90

Hospital in the Home Best Practice Guideline (2017) ........................................................ 91

HITH Data Collection ............................................................................................................. 95

Reported Outcomes .............................................................................................................. 95

Hospital in the Nursing Home (HiNH) .................................................................................... 95

Observations ........................................................................................................................... 96

SUMMARY OF KEY FINDINGS .................................................................................................... 98

WORKS CITED .......................................................................................................................... 103

APPENDIX : RESEARCH STUDIES EXAMINED ........................................................................... 107

i

Executive Summary

Background

The BC Ministry of Health, Hospital Services Branch, commissioned InsideOut Policy Research to conduct a limited literature review and jurisdictional scan on the topic of Hospital at Home. The research identified: • 'Best practices' and evidence of patient ou tcomes, as docum ented in select scholarly literature; and • Key approaches to the development and implementation of Hospital at Home services, reported patient- and system-level outcomes, and supporting legislation, as documented in government sources for select jurisdictions. The jurisdictions in scope were: NH S England; NHS Scot land; France; and Australia (Commonwealth Government, and the states of Victoria, New South Wales and Queensland). The following questions guided the research process: • Best practices and outcomes: For the jurisdictions that have implemented Hospital at Home services, what have been the best practices and outcomes of using the model?

• Supporting legislation: For the jurisdictions that have implemented Hospital at Home services,

what are the legislative structures that have enabled them to treat patients in their own homes while

still considering them to be hospital patients?

Methodology

The InsideOut team conducted a limited literature review that focused primarily on systematic reviews published within the last five years. Recent studies on Hospital at Home services in the jurisdictions in scope were also examined. For the selected jurisdictions, the InsideOut team conducted a thorough (though not necessarily exhaustive) search for relevant, publi cly-available government sources, includ ing legislation, policy frameworks, best practice guidelines, and reports on specific Hospital at Home services and their outcomes. All sources were carefully reviewed and analyzed, and the pertinent information synthesized.

Key Findings: Limited Literature Review

Service Design and Implementation

There are a range of Hospital at Home service models with varied goals and intended outcomes. These include admission avoidance, early discharge, and end of life care programs. Each model relies on varying levels of i nvolvement by hospital, community, and pri mary healthcare professionals to provide an appropriate and safe level of care. ii Multidisciplinary collaboration between clinicians , specialists, nurse s, and allied health professionals is a key element of successful service delivery, enabling delivery of patient-centred, integrated care. Additional clinical training, or 'upskilling' may be needed to optimize the skill mix of Hospital at Home teams. Comprehensive patient data collection and continuous program evaluation are cornerstones of Hospital at Home programs t hat successfully meet the nee ds of patien ts, hospitals, an d communities.

Patient Health Outcomes

The lite rature examined suggests that Hospital at Home is a safe alternat ive to trad itional inpatient treatment for patien ts who meet the eligibility requirem ents. There is litt le to no difference in health outcomes among patient populations for whom admission avoidance and early discharge Hospital at Home are commonly utilized as an alternative to treatment in an acute hospital ward. Hospital at Home is also associated with a reduced risk of hospital-acquired complications and functional decline among some patient populations. End-of-life Hospital at Home increases the likelihood that terminal patients will die, as wished, in their homes rather than in a hospital or hospice. Caregivers consistently report high levels of satisfaction with Hospital at Home, but due to the

burden of caring for acutely ill patients, active support for their wellbeing and capacity to care for

the patient is an important component of service delivery.

Healthcare System Outcomes and Cost Benefits

There is evidence to suggest that Hospital at Home services may improve hospital patient flow, reduce pressure on acute hospital ward beds, and reduce the risk of patients having unnecessarily long hospital stays or being discharged to long-term residential care facilities. With regard to finance, studies have been found to present inaccurate assessments of actual Hospital at Home program costs. Some research suggests that Hospital at Home services may offload costs onto patients and informal/family caregivers, or to other parts of the healthcare system. Therefore, a holistic approach to cost assessment is recommended.

Key Findings: Jurisdictional Scan

Legislation

The legislative framework for Hospital at Home varies considerably from one jurisdiction to another. France is the only jurisdiction studied that has specific legislation for Hospital at Home services. The legislative history is extensive and includes ongoing introduction of new laws to support various changes to the provision of Hospital at Home services. In Australia, England and Scotland, there is no specific or explicit legislation that addresses the provision of Hospital at Home servi ces. In Australia, national healthcare l egislation uses definitions of "hospital treatment" and "hospital-substitute treatment" that appear to be broad iii enough to apply to Hospital at Home services. In Scotland, the main National Health Service legislation recognizes the patient's home as a location for the delivery of medical, nursing and other health services. In addition, Scotland's Public Bodies Act 2014, which is designed to support more integrated, patient-centred healthcare, is being retrospectively interpreted as an enabling piece of legislation for the national roll-out of Hospital at Home services. The fact that in Australia Hospital at Home is well-established, and in Scotland it is on the verge of being rolled out nationally, suggests that Hospital at Home services can be widely offered without the need to amend or create new legislation.

Supporting Policy and Governance

Guidelines

NHS Scotland and the Australian states examined all have published guidance in place for the provision of Hospital at Home services. NHS Scotland has recently published a set of evidence- informed "guiding principles" to support the national roll-out of Hospital at Home. The principles deliberately allow for a considerable degree of flexibility to meet local Health Board needs and contexts. New South Wales, Victoria and Queensland have detailed (and somewhat uniform) state-level guidelines to support the development and implementation of Hospital at Home. The NSW

guideline stands out for its attention to the needs of Aboriginal Peoples, and for its description of

different clinical governance and staffing models that can be applied to particular contexts.

Patient Eligibility Criteria and Care Pathways

Clear admission / eligibility criteria and referral pathways are key to the success of Hospital at Home. In Austra lia, Hospital at Home services at the state level follow t he same hospital admission policy criteria required for in-patient hospital stays. In additio n, assessments are conducted to ensure that safe and high-quality care can be delivered in the patient's home (or other domestic care setting, e.g. nursing home). In Scotland, recommended practices for supporting seamless patient transitions include: creating patient care pathways that are specific to Hospital at Home; and ensuring that, upon discharge from the Hospital at Home service, there is clear and timely communication with the patient's GP. Monitoring, Accountability and Service Improvement NHS Scotland and some of the Australian states examined emphasize the need to measure the impact and outcomes of Hospital at Home services. NHS Scotland and the states of Queensland and New South Wales have developed performance metrics that are specific to Hospital at Home in order to support local evaluation and ongoing service improvement.

Service Delivery Characteristics

Multi-Disciplinary Care

Multi-disciplinary care is a key charact erist ic of Hospital at Home servi ces across all of the jurisdictions examined. Multi-disciplinary Hospital at Home teams typically include: physicians; nurse practitioners; nurses (including those with advanced practice skills); pharmacists; and allied iv health professionals. The patient typically remains under the care of a hospital-based physician / specialist, who is responsible for the pat ient's overal l treatment and accountable for care outcomes. In some models, the healthcare professionals constitute a dedicated, standalone Hospital at Home team; in others, there is a devolved team of practitioners that are drawn into the Hospital at Home service on an as-needed basis for a specific period of time. In addition to receiving care from a core multi-disciplinary team, patients are connected with community-based supports, as needed. Integrated practice is supported by strong linkages and relationships between hospital and community services.

Patient-Centred Care

Hospital at Home is understood to support the delivery of patient-centred care. There is an emphasis on developing individualized care plans, which can be adapted to meet the patient's evolving needs. In addition, patient safety is assured through daily contact and daily multi- disciplinary team meetings / rounds.

Recognizing Family and Other Unpaid Carers

The significant role of the patient's unpaid carer(s) is acknowledged by several of the jurisdictions

examined. In France, Hospital at Home service providers are expected to assess the capacity of the carer to support the patient safely, and to ensure that they are not over-burdened in their responsibilities. In Scotland, unpaid carers must be recognized as equal partners in the planning and delivery of care, and attention is paid to ensuring their wellbeing. The Scottish Carers Act is specifically designed to support carers' health and wellbeing, and to help make their role more sustainable.

Care Settings

In general, Hospital at Home services are provided in the patient's home or in a residential care facility. However, in Australia, services also include the provision of sub-acute care in a broader range of settings, such as schools, work places, and ambulatory clinics.

Patient and System-level Outcomes

At the patient level, reported and/or demonstrated outcomes and benefits include: • Comparable patient safety outcomes (including rates of mortality and re-admissions) with traditional hospital-based acute care; • Reduced risk of hos pital-acquired infection and the negative impacts of institutionalization (such as loss of independence and functionality); • More timely access to a variety of health and social care services (including GPs and

AHPs);

• Reduced incidences of delirium and falls among frail elderly patients; • High patient and carer satisfaction; • Less disruption to normal life for the patient; v • Families stay together; and • Patients are better rested, more comfortable, and better nourished. At the systems level, reported and/or demonstrated outcomes include: • Shorter length of stay compared with hospital-based acute care; • Increased hospital bed capacity with limited capital expenditure required; and • Lower costs compared to traditional inpatient care, with comparable patient outcomes.

Implementation Challenges

Across the jurisdi ctions examin ed, the following challenges associated wi th implementing

Hospital at Home services were reported:

• Lack of awareness of services - in particular among GPs, requiring concerted awareness- raising / communication efforts and support for GPs to identify eligible patients. • Building buy-in from hospital staff and community-based services - it may be necessary to build hospital clinici ans' confidence in the safet y of Hospital at Home, as well as reassure community-based providers that Hospital at Home will not encroach upon or conflict with their own service offerings. • Staffing - challenges related to recruiting and retaining the appropriate complement of staff include a shortage of availabl e specialist and general physicians, and fierce competition across the healthcare sector for nurses with specialized skills. Creation of clear career pathways and providing professional development opportunities for Hospital at Home practitioners can help to mitigate these challenges. • Lack of capacity in community services - may make it difficult to connect patients to needed home and community care supports. This issue may limit the number and type of patients who can be safely cared for by a Hospital at Home service. 1

Introduction

This report, commissioned by the BC Ministry of Health, Hospital Services Branch, documents

the findings of a limited literature review and jurisdictional scan on the topic of Hospital at Home.

The report identifies 'best practices' and evidence of patient outcomes based on the findings of the literature review. The scan of selected international jurisdictions describes key approaches to the development and implementation of Hospital at Home services, reported patient and system- level outcomes, and supporting legislation. The following jurisdictions were included in the scan: • NHS England; • NHS Scotland; • France; and • The Commonwealth Government of Australia, and the states of Victoria, New South

Wales and Queensland.

Research Questions

The jurisdictional scan was based on the following research questions: • Supporting legislation: For the jurisdictions that have implemented Hospital at Home services, what are the legislative structures that have enabled them to treat patients in their own homes while still considering them to be hospital patients? • Best practices and outcomes: For the jurisdictions that have implemented Hospital at Home services, what have been the best practices and outcomes of using the model?

Methodology

Literature Review

The limited literature review focused on systematic reviews capturing most high-quality clinical studies published in the last five years, as well as recent literature on Hospital at Home services in the jurisdictions in scope. The primary goal of the literature review was to identify best or leading practices for the design and delivery of Hospital at Home services, and evidence of outcomes for patients and public healthcare systems. Search terms included "Hospital at Home / Hospital in the Home +": admission avoidance; early discharge; Cochrane review; systematic review; comparative stu dy; outcomes; program; feasibility ; France; England; Sco tland; and

Australia.

Jurisdictional Scan

In consultation with the Hospital Services Branch client, a number of international jurisdictions known to have established Hospital at Home services were selected for inclusion. (See list above.) For all of the selected jur isdictions, the Insi deOut team conducted a thorough (though not necessarily exhaustive) search for relevant, pu blicly-available government sources, including 2 legislation, policy frameworks, best practice guidelines, and reports on specific Hospital at Home services and their outcomes. Sources were carefully reviewed and analyzed, and the pertinent information synthesized for the report.

Structure of the Report

The report is structured as two parts:

• Part 1 - Literature Review; and • Part 2 - Jurisdictional Scan. Part 1 presents a summ ary of findings from the literature re view. The follow ing topics are addressed: patient populations; patient eligibility; the role of caregivers; program models; cost benefits; and patient and system-level outcomes. Specific research studies examined are described in detail in the Appendix to this report. Part 2 provides the findings of the jurisdictional scan. Information is structured as a series of jurisdictional "snapshots." The content of the snapshots reflects the particular approaches of and available materials for each jurisdiction; however, broadly, they address the following: • Relevant legislation and supporting policy; • Key characteristics of effective service design and delivery, drawn from guidelines and (where available) case studies of specific Hospital at Home services; and • Reported patient and system-level outcomes (where available). Part 2 concludes with a synthesis of key findings from across all jurisdictions studied, drawing particular attention to notable themes and shared approaches. 3

LITERATURE REVIEW

4

Focused Literature Review

Introduction

The jurisdictions described in the literature examined demonstrate a range of sophistication and organization with respect to Hospital at Home programs. While the terms "Hospital at Home" or "Hospital in the Home" occasionally refer to post-discharge or long-term care, in current scholarly studies, and in this limited literature review, Hospital at Home refers specifically to acute-level, hospital-equivalent, active tr eatment by healthcare professionals, carried out in the pat ient' s

home, that takes the place of inpatient hospital care. That is, if Hospital at Home were unavailable,

patients would receive treatment in an acute care hospital ward. For all intents and purposes, Hospital at Home patients are considered acute inpatients, and not ambulatory, convalescent, or long-term care patients. Literature currently identifies three primary types of Hospital at Home programs: admission avoidance; early discharge; and end-of-life Hospital at Home.

Summary of Findings

This limited literature review, focused on systematic reviews capturing the most high-quality clinical studies published in the last five years, as well as recent literature published about the targeted jurisdictions, reveals valuable findings about the past and current status of Hospital at Home from scholarly perspectives. An overview of findings with respect to patient populations, patient eligibility, the role of caregivers, program models, cost benefits, and patient and system- level outcomes is provided below.

Health Conditions

As demon strated by Cochrane reviews, Ho spital at Home for admiss ion av oidance, early discharge, and end-of-life care is well-attested in decades of scholarly studies for a wide range of clinical conditions. The variability in Hospital at Home programs, condition treatment protocols, and health systems, however, makes it difficult to present definitive findings on the efficacy of Hospital at Home broadly, with most primary studies focusing on one of the numerous conditions for which it may be utilized. Primary studies most frequently focus on patient populations with conditions that present a relatively low-risk of death during episodic treatment; COPD, hear t failure, electiv e surgery recovery (especially orthopaedic), fractures, and stroke are among the most common. 1 Home- based care is especially favoured for the treatment of infectious disease in Australia. 2 Gathering together studies of Hospital at Home for common conditions, systematic reviews report that outcomes for most Hospital at Home patients demonstrate little to no difference compared to hospital ward inpatients with respect to mortality, readmission risk, patient reported outcomes (such as health related quality of life and functional activity), or length of stay (or, in the home 1

Shepperd et al. (2017), "Early Discharge Hospital at Home." Cochrane Database of Systematic Reviews 6: 1-102, at pp. 1-

2. 2

Montalto et al. (2020), "Home Ward Bound: Features of Hospital in the Home Use by Major Australian Hospitals,

2011-2017." Medical Journal of Australia: 1-6, at p. 5.

5 setting, length of treatment). 3 Hospital at Home patients often reported increased satisfaction with their care; 4 this finding could be biased, however, as study participants have usually chosen

Hospital at Home treatment in place of ward care.

5

Moreover, Hospital at Home patients were

more likely to continue living at home following treatment in comparison to ward patients. 6 This is an important consideration in the context of ongoing challenges with limited bed availability in long-term and residential care facilities. One condition for which patients consistently showed less certain benefits was stroke: while some

systematic reviews reported equal or little difference in mortality, length of stay, readmission, and

functionality, 7 others reported an i ncreased need for specialist hospi tal ization among stroke patients. Although faring better than stroke patients who were placed in general acute care wards, those suffering stroke had significantly greater mortality and institutionalization risks when cared for outside of specialist stroke wards. As such, in accordance with NHS England protocol, stroke patients are less likely to be suitable candidates for Hospital at Home care. 8 While admission avoidance and early discharge Hospital at Home seek patient recovery as a key outcome, end-of-life Hospital at Home naturally anticipates patient deaths while receiving care. Reviews found that patients were less likely to die in hospital or hospice - a desired result - if they had undergone palliative care at home. It may slightly increase patient satisfaction to receive in-home end-of-life care, and caregiver satisfaction, provided the care is not prolonged for more than 30 days. 9

Patient Eligibility

Determining populations suitable for Hospital at Home was identified as a concern in several reviews and studies. 10 A 2020 literature review found that less than half of included studies (21 of

48) specified the proportion of patients with studied conditions eligible for Hospital at Home.

3

Shepperd et al. (2016a). "Admission Avoidance Hospital at Home." Cochrane Database of Systematic Review 9: 1-52, at

p. 15; Conley, J. et al. (2016). "Alternative Strategies to Inpatient Hospitalization for Acute Medical Conditions: A

Systematic Review." JAMA Internal Medicine 176(11), p. 1696; Shepperd et al. (2017), p. 16; Huntley, A.L. et al. (2017).

"A Systematic Review to Identify and Assess the Effectiveness of Alternatives for People over the Age of 65 who are at

Risk of Potentially Avoidable Hospital Admission." BMJ Open 7(e016236), pp. 3-5; Vale et al. (2020). "Hospital at Home:

an Overview of Literature." Home Health Care Management and Practice 32(2): 118-123, at p. 121. 4

Conley et al. (2016), p. 1696; Huntley et al. (2017), p. 4; Shepperd et al. (2016a), p. 15; Shepperd et al. (2016b). "Hospital

at Home: Home-Based End-of-Life Care." Cochrane Database of Systematic Reviews 2: 1-27, at p. 13; Shepperd et al. (2017),

pp. 15-16; Lee, G.A. and Titchener K. (2017). "The Guy's and St Thomas's NHS Foundation Trust @ Home Service: an

Overview of a New Service." London Journal of Primary Care 9(2): 18-22, at p. 21; Dismore, L.L. et al. (2019). "What are

the Positive Drivers and Potential Barriers to Implementation of Hospital at Home selected by Low-risk DECAF Score

in the UK: a Qualitative Study Embedded within a Randomised Controlled Trial." BMJ Open 9(e026609): 1-8, at p. 3;

Rossinot et al. (2019). "The Experience of Patients and Family Caregivers during Hospital-at-Home in France." BMC

Health Services Research 19(470): 1-10, at p. 5; Vale et al. (2020), p. 121. 5

Shepperd et al. (2016a), p. 15.

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