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

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. Impact statement We certify that this work is confirmatory of Admission Avoidance (AA) as a value-based service by analyzing, with a population-based approach, a five-year period after regional adoption of AA in Catalonia. The research indicates the need for implementing quality assurance programs after service adoption and provides clear insights on how shape quality monitoring. The current study outcomes add novel knowledge to previous reports in the field, such as: 1. Leff B, DeCherrie L v., Montalto M, Levine DM. A research agenda for hospital at home. J Am Geriatr Soc . 2022;70(4):1060-1069. doi:10.1111/JGS.17715 2. Levine DM, Ouchi K, Blanchfield B, et al. Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Ann Intern Med . 2020;172(2):77-85. doi:10.7326/M19-0600 3. Montalto M, McElduff P, Hardy K. Home ward-bound: features of hospital in the home use by major Australian hospitals, 2011-2017. Med J Aust . 2020;213(1):22-27. doi:10.5694/mja2.50599 4. Hecimovic A, Matijasevic V, Frost SA. Characteristics and outcomes of patients receiving Hospital at Home Services in the South-West of Sydney. BMC Health Services Research . 2020;20(1):1090. doi:10.1186/s12913-020-05941-9 5. LEONG MQ ET AL. Comparison of Hospital-at-Home models: a systematic review of reviews. BMJ Open . 2021;11:43285. doi:10.1136/bmjopen-2020-043285 The current manuscript covers relevant knowledge gaps well-identified in the nine dimensions for future research in the field of hospital at home reported by Leff B et al, 2022. Moreover, the population-based approach of the research provides a valuable approach for quality assurance of the different service modalities. #### Key Points Key Points #### Why does this paper matter? Why does this paper matter? The population-based approach of the study design allows identification of key elements for service improvement after consolidated regional adoption of Hospital at Home Key strengths of the research are: i) demonstration of healthcare value generation of AA in large scale adoption of the service; and ii) generation of insightful recommendations for enhanced service delivery and continuous quality monitoring. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This article was funded by JADECARE project- HP-JA-2019 - Grant Agreement number 951442, an European Union Health Program 2014-2020. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Ethical Committee for Human Research at Hospital Clinic de Barcelona approved the study on September 8, 2021 (HCB/2021/0768) in the context of the EU project Joint Action on implementation of digitally enabled integrated person-centered care (JADECARE). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors * AA : Admission Avoidance AMG : Adjusted Morbidity Groups APR-DRG : All-Patient Refined Diagnosis Related Groups CHSS : Catalan Health Surveillance System CMI : Case Mix Index ESD : Early Supported Discharge LoS : Length of Stay HaH : Hospital at Home KPI : Key Performance Indicator PSM : Propensity Score Matching