COFFEY Alice, et al
Increasing pressure on limited healthcare resources has necessitated the development of measures promoting early discharge and avoiding inappropriate hospital (re)admission. This systematic review examines the evidence for interventions in acute hospitals including (i) hospital-patient discharge to home, community services or other settings, (ii) hospital discharge to another care setting, and (iii) reduction or prevention of inappropriate hospital (re)admissions. Academic electronic databases were searched from 2005 to 2018. In total, ninety-four eligible papers were included. Interventions were categorized into: (1) pre-discharge exclusively delivered in the acute care hospital, (2) pre- and post-discharge delivered by acute care hospital, (3) post-discharge delivered at home and (4) delivered only in a post-acute facility. Mixed results were found regarding the effectiveness of many types of interventions. Interventions exclusively delivered in the acute hospital pre-discharge and those involving education were most common but their effectiveness was limited in avoiding (re)admission. Successful pre- and post-discharge interventions focused on multidisciplinary approaches. Post-discharge interventions exclusively delivered at home reduced hospital stay and contributed to patient satisfaction. Existing systematic reviews on tele-health and long-term care interventions suggest insufficient evidence for admission avoidance. The most effective interventions to avoid inappropriate re-admission to hospital and promote early discharge included integrated systems between hospital and the community care, multidisciplinary service provision, individualization of services, discharge planning initiated in hospital and specialist follow-up.
CARE AND REPAIR CYMRU
An evaluation of the Hospital to a Healthier Home pilot scheme, delivered by Care and Repair, which ran from 11 hospitals between January and March 2019. The scheme aimed to support older people to be safely and more quickly discharged from hospitals to their homes and prevent them being re-admitted by making their homes safe and more accessible. This evaluation describes how the Hospital to a Health Home case worker service started, what type of interventions have been provided to patients and hospital staff, costs, benefits and the difference it has made to patient well-being, quicker safe discharges, and preventing re-admissions. The pilot involved dedicated Care and Repair case workers based at each hospital to facilitate practical improvements to a patient’s home and offer practical support on issues such as benefits entitlements. During the evaluation period: 626 patients were referred through Hospital to a Healthier Home service; 508 patients received work that helped quicker safe discharge. Based on a local assessment of bed day savings, the evaluation found that service costs are fully substantiated, and return £2.80 for every £1 invested (both revenue and capital). NHS frontline staff interviewed for the evaluation study also felt the service was of significant benefit and had the potential to deliver more.
DAMERY Sarah, FLANAGAN Sarah, COMBES Gill
Objective: To summarise the evidence regarding the effectiveness of integrated care interventions in reducing hospital activity.
Design: Umbrella review of systematic reviews and meta-analyses.
Setting: Interventions must have delivered care crossing the boundary between at least two health and/or social care settings.
Participants: Adult patients with one or more chronic diseases.
Data sources: MEDLINE, Embase, ASSIA, PsycINFO, HMIC, CINAHL, Cochrane Library (HTA database,DARE, Cochrane Database of Systematic Reviews), EPPI-Centre, TRIP, HEED, manual screening of references.
Outcome measures: Any measure of hospital admission or readmission, length of stay (LoS), accident and emergency use, healthcare costs.
Results: 50 reviews were included. Interventions focused on case management (n=8), chronic care model (CCM) (n=9), discharge management (n=15), complex interventions (n=3), multidisciplinary teams (MDT) (n=10) and self-management (n=5). 29 reviews
reported statistically significant improvements in at least one outcome. 11/21 reviews reported significantly reduced emergency admissions (15–50%); 11/24 showed significant reductions in all-cause (10–30%) or condition-specific (15–50%) readmissions; 9/16 reported LoS reductions of 1–7 days and 4/9 showed significantly lower A&E use (30–40%). 10/25 reviews reported significant cost reductions but provided little robust evidence. Effective interventions included discharge management with post-discharge support, MDT care with teams that include condition-specific expertise, specialist nurses and/or pharmacists and self-management as an adjunct to broader interventions. Interventions were most effective when targeting single conditions such as heart failure, and when care was provided in patients’ homes.
Conclusions: Although all outcomes showed some significant reductions, and a number of potentially effective interventions were found, interventions rarely demonstrated unequivocally positive effects. Despite the centrality of integrated care to current policy, questions remain about whether the magnitude of potentially achievable gains is enough to satisfy national targets for reductions in hospital activity.
ROYAL VOLUNTARY SERVICE
A summary of the achievements of the Royal Voluntary Service Hospital 2 Home service during its first year. Leicestershire County Council launched the scheme in hospitals in six districts, including the three university hospitals in Leicester in summer 2012. The service provides practical help and support following a discharge from hospital; helps users to regain confidence and reduce anxiety; reduces social isolation; promotes independent living and choice; helps users to maintain day to day activities; provides information/signpost to other organisations; and helps prevent readmissions to hospital. Designed to be short-term, friendly and confidential and people-centred, the service is provided free of charge and is normally available for up to six weeks. Over 600 people have been referred. Among the participants readmission rates to hospital have been very low, with readmissions of older people approximately half national rates.