12. Alternatives to hospital care

12.2. Review question: Does community-based intermediate care improve outcomes compared with hospital care?

For full details see review protocol in Appendix A.

Table 1

PICO characteristics of review question.

12.2.1. Definitions of the different alternatives to hospital care evaluated in this review

12.2.1.1. Intermediate Care (IC)

The development of IC services was set out in 2001 within the National Service Framework for Older People. The aims of IC were stated as being to:

• promote faster recovery from illness,
• support timely discharge from hospital,
• prevent unnecessary acute hospital admission,
• maximise independent living.

The expectation was of multi-agency working based on comprehensive geriatric assessment, with short-term interventions to enable users to remain or resume living at home.

Definition of intermediate care

The definition of intermediate care provided in the Department of Health paper ‘Intermediate Care - Halfway Home’⁸⁰ was used; “a range of integrated services to promote faster recovery from illness, prevent unnecessary acute hospital admission and premature admission to long-term residential care, support timely discharge from hospital and maximise independent living”. The guidance makes clear that intermediate care services involve multi-disciplinary team working. Although homecare reablement is included within intermediate care services in some areas, services that do not have a clinical health element are not included.

The National Intermediate Care Audit demonstrates that intermediate care does increase the likelihood of returning home, improve the ability to perform activities of daily living and also increases the achievement of person specific goals. However, there is significant variation in delivery between regions throughout England and unfortunately at present it is not making a difference to the whole-system due to the lack of capacity within the service.²¹⁴

Classification of Intermediate Care Schemes (as taken from the Department of Health ‘Audit of Intermediate Care’, 2008)

i. Home from hospital

A home from hospital scheme generally aims to provide short-term post-discharge care at a more intensive level than would normally be provided by professionals such as District Nursing. Home from hospital schemes are generally delivered in the user’s own home and led by nursing staff, sometimes with input from medical and allied health professionals.

ii. Rapid response schemes

Rapid response schemes generally aim to support a user in their own home or other location either as a means of preventing admission or as a means of facilitating discharge from the acute hospital sector. Usually led by either a nurse or allied health professional, rapid response schemes can cover a wide range of interventions including administration of intravenous therapies, peg tube and catheter replacement, crisis psychiatric care and provide enhanced care to palliative care patients.

iii. Step up/down schemes

Step up/down schemes usually provide care in a setting other than an acute hospital and this can include a residential or, more usually, a nursing home. Time limited in nature, these schemes aim to either prevent admission to hospital, or aid in the discharge and transfer back home from hospital. Step up/down schemes can be aimed at similar patients to both rapid response and rehabilitation. However, normally the users require more intensive therapy or continuous monitoring than could be provided in their own home.

iv. Rehabilitation schemes

The delivery of community rehabilitation is cognisant with the role of intermediate care which has been promoted by the Department of Health. Rehabilitation is defined as “a process aiming to restore personal autonomy to those aspects of daily life considered most relevant by patients and service users, and their family carers” (Kings Fund, 1998). It is believed that this form of care will reduce the burden on the NHS through the promotion of independence.

Rehabilitation schemes usually provide time limited therapy for patients who require on-going allied health support (generally physiotherapy or occupational therapy) to regain maximum independence. Users of rehabilitation schemes will often have sustained some form of fracture and may also have undergone surgery. Rehabilitation schemes can be delivered by a multi-disciplinary team, but are often led by physiotherapists and/or occupational therapists. These schemes may be longer-term in nature than other types of schemes.

Rehabilitation is defined as the process of restoration of skills by a person who has had an illness or injury so as to regain maximum self-sufficiency and function in a normal or as near normal manner as possible. Rehabilitation is a process aiming to restore personal autonomy to those aspects of daily life considered most relevant to patients, service users and their carers. It can be delivered at a community hospital, residential home or within a patient’s own home.

v. Stroke schemes

Stroke schemes tend to provide a high level of support for those patients who have undergone a cerebrovascular accident (CVA) and to provide a high level of rehabilitation, usually in the users own home, to assist them in gaining an increased level of independence. Stroke schemes can be delivered by a multi-disciplinary team that includes medical, nursing, allied health and social work, and also can include the assistance of generic rehabilitation assistants (covering physiotherapy and occupational therapy). These schemes may be longer-term in nature than other types of schemes.

vi. Community hospital schemes

Community hospital schemes usually provide acute hospital ward type care, but generally under the management of GPs rather than consultants. Community hospital schemes can provide nursing, rehabilitation or step up/down type care and are generally aimed at those users who require a high level of supervision or the administration of medicines or interventions which would not be suitable for a nursing home or a users’ own home setting.

vii. Miscellaneous schemes

These schemes included a range of schemes which did not directly fit into one of the classifications previously described. They included an ED assessment team, a twilight nursing team, and a long-term behaviour support team. It could be debated whether these schemes can truly be classified as intermediate.

Within the Intermediate tier there is distinction between:

viii.

Enabling Homecare - which provides the fundamental building block of a care system where optimised independence and choice is a primary goal. This is aimed at ensuring such skills are maintained by the individual and will be found across the whole care system including any homecare delivered as part of an intermediate tier.

ix.

Reablement - for people with poor physical or mental health or disability where there is potential to improve independence and choice by learning or re-learning the skills necessary for daily living; and:

When referring to reablement in this context it is also helpful to distinguish between:

• Intake reablement - where all new referrals to adult social services (in particular home care) are considered for reablement; and
• Targeted reablement - where referrals to reablement are received from specific sources, normally hospital discharge or to prevent hospital admission.

x.

Hospital-at-home care is generally defined as the community based provision of services usually associated with acute inpatient care.

“Hospital-at-home” programs are defined by the provision, in patients’ own homes and for a limited period, of a specific service that requires active participation by health care professionals. The care tends to be multidisciplinary and may include technical services, such as intravenous services.

Many disparate models have been developed under the hospital-at-home label, leading to difficulties in evaluating their effectiveness.

Key features of the Johns Hopkins “hospital-at-home” model:

• A substitutive model providing hospital-level care for patients living in a specified geographic catchment area delineated by 30 minute travel time.
• Eligible patients are those with certain acute illnesses that require hospital-level care who also meet previously validated medical eligibility criteria.
• Robust input from physicians (at least daily visits and 24 hour coverage) and nurses (initial continuous nursing care following by intermittent visits and 24 hour coverage).
• Patient retains inpatient status and the hospital or health system retains responsibility for the acute care episode.
• Care is provided in a coordinated manner similar to that in an inpatient ward.

xi. The Virtual Ward

Virtual wards are a form of preventive hospital-at-home for patients at high predicted risk of unplanned hospital admission.

A model of home-based coordinated care with the aim of reducing hospital admissions in a relatively low-cost manner. The “virtual ward” program provides multidisciplinary case management services to people who have been identified, using a predictive model, as high risks for future emergency hospitalisation. Virtual wards use the systems, staffing and daily routine of a hospital ward to deliver preventive care to patients in their own homes. The Virtual Wards work just like a hospital ward, using the same staffing, systems and daily routines, except that the people being cared for stay in their own homes throughout.

Virtual wards seek to improve integration through a number of strategies, including a shared record, multidisciplinary team meetings (“ward rounds”) and an automated alert system for informing virtual ward staff when a patient accesses another care service, such as attending local ED. Another strategy for promoting integration was to include a social worker as a core member of the virtual ward staff. In this regard, it could be argued that virtual wards are an adaptation of the public health model of chronic disease management described by Kendall and colleagues but rather than integrating health and education, virtual wards instead aim to provide patients with a well organised and coordinated service that crosses the health care and social care sectors.

Community matrons

Community matrons are highly experienced senior nurses who work closely with patients in the community to provide, plan and organise their care. They mainly work with those with a serious long term or complex range of conditions. They therefore have an important role in the management of chronic long-term disease and multi-morbidity. These patients account a large consumption of NHS resources. Clear leadership, guidance and communication between the many services which are involved in the patient care is important to avoid mishaps. Therefore, the community matron is ideally placed to deliver this with the appropriate training and support. This review will determine if increasing the remit of community matrons and increasing the number of locations where community matrons can be accessed improves patient outcomes.

12.3. Clinical evidence

We searched for systematic reviews and randomised trials comparing the effectiveness of alternatives to hospital care (hospital at home, step-up/down care, rapid response schemes and virtual wards) with hospital care to improve outcomes for patients.

Thirty four randomised controlled trials were identified that compared alternatives to hospital care with hospital care. We identified 3 Cochrane reviews evaluating different alternatives to hospital care. All the reviews were assessed for relevance to the review protocol and methodology and were adapted and updated as part of this systematic review. The classification of interventions of the studies included in the Cochrane reviews did not match the definitions of interventions pre-specified by the guideline committee. We re-classified the studies included in the Cochrane reviews according to the definitions of the interventions (see section 12.2.1). Data for the studies presented in the Cochrane reviews has been included in the analysis. We have updated the Cochrane reviews with randomised controlled trials found from the search.

The studies have been classified in 2 strata- admission avoidance and early discharge. Admission avoidance is a service that provides active treatment by health care professionals outside hospital for a condition that otherwise would require acute hospital in-patient admission. Early discharge is a service that provides active treatment by health care professionals outside hospital for a condition that otherwise would require continued acute hospital in-patient care.

Within each strata, the studies have been grouped according to the type of service provided: hospital at home led by primary care, hospital at home led by secondary care, hospital at home led by primary and secondary care, step-up/down care and virtual wards.

12.3.1. Individual patient data (IPD) analysis

Two Cochrane reviews that met the protocol criteria for the alternatives to hospital care review (1 in the strata for early discharge and 1in the strata for admission avoidance) presented IPD analysis as well as RCT level meta-analysis.

Details of analyses presented in both Cochrane reviews are:

• Review strata 1 –Admission avoidance: Cochrane review on hospital at home admission avoidance. The review includes 10 trials.

  • 4 trials were included in the IPD analysis (hazard ratios and log hazard ratios presented for 2 of our protocol outcomes; mortality and admissions).
  • All 10 trials were included in the RCT meta-analysis. The RCT meta-analyses included RCT data from the 4 trials included in the IPD meta-analysis.
• Review strata 2- Early discharge: Cochrane review on hospital at home early discharge. The review includes 26 trials.

  • 13 trials were included in the IPD analysis (hazard ratios and log hazard ratios presented for 2 of our protocol outcomes; mortality and admissions).
  • All 26 trials were included in the RCT meta-analysis. The RCT meta-analyses included RCT data from the 13 trials included in the IPD meta-analysis.

The results of the IPD analysis have been presented as part of this evidence review (see section D.3, Appendix D).

See also the study selection flow chart in Appendix B, study evidence tables in Appendix E, forest plots in Appendix D, GRADE tables in Appendix G and excluded studies list in Appendix H.

12.3.2. Summary of included studies

Following is a summary of the number of studies included for each of the interventions:

• Hospital at home (led by primary care):

  • Number of studies identified in Cochrane reviews: 10.
  • Number of studies identified from search: 4.
• Hospital at home (led by secondary care):

  • Number of studies identified in Cochrane reviews: 4.
  • Number of studies identified from search: 3.
• Hospital at home (led by primary and secondary care):

  • Number of studies identified in Cochrane reviews: 7.
  • Number of studies identified from search: 1.
• Virtual wards:

  • Number of studies identified in Cochrane reviews: 0.
  • Number of studies identified from search: 2.
• Step up/down care:

  • Number of studies identified in Cochrane reviews: 0.
  • Number of studies identified from search: 5

See Table 2 below for details of the PICO characteristics of the studies included in the review.

Table 2

Summary of studies included in the review.

Table 3

Summary GRADE profiles for alternatives compared with hospital care.

Narrative findings

Length of hospital stay

Cotton 2000⁶⁷

Mean length of initial admission (range) for the early discharge group 3.2 (1-16) and for conventional management 6.1 (1-13).

Richards 2005²⁴²

The median number of days to discharge in the home group was 4 (range: 1-14), compared with 2 (range, 0-10) in the hospital group (p=0.004).

Wilson 1999³¹²

Analyses by intention to treat showed significantly shorter stays in care for the hospital at home group than for the hospital group (median initial stay, 8 days versus 14.5 days, p=0.026); median total days of care in 3 months, 9 days versus 16 days, p=0.031.

Donald 1995⁸⁹

At 6 months the hospital at home total days in hospital (after study entry) of 22.5 (IQR 5-30) and the control group a mean number of days of 20.2 (IQR 8-27).

Applegate 1990¹⁶

The mean length of stay in the geriatric assessment unit was 23.6 (+/-13.2) days. For the high risk stratum, the average stay was 28.6 (+/-14.4days) and for the lower risk stratum it was 21.1 (+/-11.9) days.

Zimmer 1985³²⁵

Mean length of hospital stay during first 6 months for intervention (n=81) was 12.6 days and for control was 14.3 days.

Emergency department visits

Aiken 2006⁶

In the 6 months prior to the onset of PhoenixCare intervention, PhoenixCare participants averaged 0.12 emergency department visits per month (SD=0.18). Control participants averaged 0.11 emergency department visits per month (SD=0.02). This level of utilisation remained essentially unchanged during the intervention, with averages of 0.11 (SD=0.34) and 0.10 (SD=0.31) visits per month for Phoenix Care and control participants, respectively.

Zimmer 1985³²⁵

Mean ED visits per patient per month for days at risk in the first 6 months of study; intervention (n=81) 0.26 and control (n=75) 0.05.

Quality of Life

Applegate 1990¹⁶

The group assigned to the geriatric assessment unit had significantly more improvement (p<0.05) than the control group in regard to 3 basic self-care activities (bathing, dressing and the ability to transfer) during the 6 months after randomisation.

Patient satisfaction

Richards 2005²⁴²

Patient satisfaction with medical and nursing care was high in both groups, but significantly higher in the home care group (p=0.001). In the home care group, all patients reported that they were ‘very happy’ with their care. In the hospital care group, 60% were ‘very happy’, 32% ‘quite happy’ and 8% ‘neither happy nor unhappy’.

Wilson 2002³¹⁴

Patient satisfaction was greater with Hospital at Home than with hospital. Reasons included a more personal style of care and a feeling that staying at home was therapeutic. Carers did not feel that Hospital at Home imposed an extra workload.

Skwarska²⁷⁷

Replies to the questionnaires on satisfaction with the service were received from 69% of the patients treated at home, 95% of whom said they were ‘completely satisfied’ with the services and 90% felt they had been cared for just as well or better at home than they would have been in hospital.

Young 2007³²²

The reported patient satisfaction was similar for both groups. At 1 week after hospital discharge, the community hospital group showed greater satisfaction with the statement ‘I am happy with the amount of recovery I have made’ (odds ratio=2.12, 95% CI=1.30-3.46; p=0.004).

Zimmer 1985³²⁵

Mean unadjusted patient satisfaction scores at 6 months for the community palliative group was 95.0 (n=31; p=not statically significant) and for the control group 89.3 (n=22; p=not statically significant).

Carer satisfaction

Donald 1995⁸⁹

There were 13 HAH carers and 7 control group carers, all of whom were interviewed at each assessment. A large majority of carers were happy with the timing of discharge. Questions ratings carer’s opinions of how good they were at the caring role, and how well they were coping, were answered similarly with 2 HAH carers and 1 control group carer admitting difficulties in coping. No clear differences between the groups emerged, but the numbers were small.

Carer stress

Tibaldi 2009²⁹⁶

The level of stress of the caregiver was high on admission in both groups but more severe in caregivers of Geriatric Home Hospital Service (relative stress scale score, 25.4 [16.6] versus 17.1 [10.8] in the general medical ward group; p=0.003).

12.4. Economic evidence

Twelve economic evaluations, published in 13 papers, relating to hospital-at-home, virtual wards and step-up/step down community care have been included in this review.^{7,23,102,118,202,204,229,235,242,288,292,296,304} One study204 was relevant to all 3 of these strata.

These are summarised in the economic evidence profile tables (Table 4, to Table 10) and the economic evidence tables in Appendix E.

Table 10

Economic evidence profile: Rapid response scheme versus usual inpatient care.

One study²³⁹ of hospital-at-home was excluded due to very serious limitations and three more^17,165,225 were selectively excluded because there was better quality evidence available. One paper relating to step-up/step-down interventions was identified but was excluded due to the availability of more applicable evidence.²²¹ Another paper relating to virtual wards was identified but excluded due to serious limitations.¹⁸⁶ All of these are listed in Appendix H, with reasons for exclusion given.

The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B.

Table 4

Economic evidence summary - Hospital at home versus inpatient care.

Table 5

Economic evidence profile: Hospital at home versus inpatient hospital care – Admission avoidance.

Table 6

Economic evidence profile: Hospital at home versus inpatient hospital care – Early discharge.

Table 7

Economic evidence profile: Hospital at home versus inpatient hospital care – Both admission avoidance and early discharge.

Table 8

Economic evidence profile: Step up/Step-down care versus inpatient hospital care.

Table 9

Economic evidence profile: Virtual wards care versus inpatient care.

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Appendices

Appendix B. Clinical article selection

Figure 1Flow chart of clinical article selection for the review of alternatives to hospital care

Appendix C. Forest plots

C.1.1. Early discharge

Figure 2Mortality- Early discharge

Figure 3Readmissions (30 days) – Early discharge

Figure 4Admissions – Early discharge

Figure 5Presentations to ED - Early discharge

Figure 6Length of stay (initial inpatient days) - Early discharge

Figure 7Length of stay (days in treatment) - Early discharge

Figure 8Quality of life(high score is good) - Early discharge

Figure 9Quality of life (higher values better QoL) - Early discharge

Figure 10Patient satisfaction (dichotomous) - Early discharge

Figure 11Patient Satisfaction (continuous-higher values more satisfied) - Early discharge

Figure 12Carer satisfaction (dichotomous) - Early discharge

C.1.2. Admission avoidance

Figure 13Mortality - Admission avoidance

Figure 14Readmissions (< 30 days) - Admission avoidance

Figure 15Admissions(>30 days) - Admission avoidance

Figure 16Presentations to ED - Admission avoidance

Figure 17Length of stay (initial inpatient days) - Admission avoidance

Figure 18Length of stay (days in treatment) - Admission avoidance

Figure 19Quality of life (high score is good) - Admission avoidance

Figure 20Patient satisfaction (dichotomous) - Admission avoidance

Figure 21Patient Satisfaction (continuous-higher score is good) - Admission avoidance

Figure 22Days to discharge (hazard ratio) - Admission avoidance

Figure 23Carer satisfaction (continuous) - Admission avoidance

Figure 24Adverse events – Admission avoidance

C.1.3. Individual patient data analyses

Figure 25IPD generic inverse variance early discharge elderly medical mortality at 3 months

Figure 26IPD generic inverse variance early discharge readmission at 3 months

Figure 27Readmission 3 months (excluding readmissions in the first 14 days)

Figure 28Mortality 3 months

Footnotes

a

NICE has published guidelines on transition between inpatient hospital settings and community or care home settings for adults with social care needs and intermediate care including reablement