Five years of Hospital at Home adoption in Catalonia: impact and challenges

Abstract

Background: Hospital at home (HaH), either admission avoidance (AA) or early supported discharge (ESD), was increasingly implemented in Catalonia (7.7 M, Spain) for selected patients, achieving regional adoption within the 2011-2015 Health Plan. This study aimed to assess population-wide HaH outcomes over five years (2015-2019) in a consolidated regional HaH program and provide context-independent recommendations for service quality assurance. Methods: A mixed-methods approach was adopted, combining population-based retrospective analyses of registry information with qualitative research. AA and ESD were separately compared with conventional hospitalization groups using propensity score matching techniques. In the analysis, we evaluated the 12-month period before the acute episode, the admission, and use of healthcare resources at 30 and 90 days after discharge. A panel of experts discussed the results and provided recommendations for monitoring HaH services. Results: The adoption of AA steadily increased from 5,185 to 8,086 episodes/year (total episodes 31,901; mean age 73 (SD 17) years; 79% high-risk patients), whereas ESD remained stable over the study period, averaging 5,329 episodes per year (total episodes 26,646; mean age 68 (SD 16) years; 71% high-risk patients). Mortality rates were similar in HaH and conventional hospitalization within the episode (AA: 0.31% vs. 0.45%; ESD: 0.18% vs. 0.45%) and at 30-days (AA: 3.94% vs. 3.24%; ESD: 4.50% vs. 4.07%). Likewise, the frequency of patients requiring hospital re-admissions or ER visits 30 days after discharge was similar in HaH (AA and ESD) and the corresponding controls. The 27 healthcare providers assessed showed high variability in patients age, multimorbidity, severity of episodes, recurrences, and length of stay of AA episodes. Recommendations aiming at enhancing service delivery were produced. Conclusions: Besides confirming safety and value generation of AA, we found that this service is delivered in a case-mix of diferent scenarios, encouraging provider-profiled monitoring of the service, particularly for ESD modalities. Keywords: Hospital at Home, Admission Avoidance, Early Supported Discharge, Implementation Science, Integrated Care.