There is robust evidence that caring for the older population with long-term conditions in a home-based healthcare model is safe and as effective as an admission to an inpatient hospital bed.
Patients being treated at home report very positively on the experience, with over 90% stating that they were pleased with being offered home-based care and that they felt less stressed than being in a hospital. Patients feel that treatment at home interferes less with their daily activities and that it is less disruptive for friends and carers, leading to greater overall satisfaction.
The people most likely to benefit from home-based care are the older population, as they have some predictable health needs from their long-term conditions and are most likely to experience negative impacts if admitted to a hospital. Our local acuity audit shows that patients admitted to a community hospital are on average over 10 years older than the population admitted to an acute hospital.
In 2011, two reviews of previous work on the hospital-at-home model of care were issued by the Cochrane Collaboration, the world-leading centre for assessing the evidence that underpins effective healthcare. The reviews looked at the use of hospital at home so people could avoid going into hospital or get home earlier after being in hospital.
Each review was a ‘meta-analysis’, bringing together the range of existing evidence from around the world to address five specific areas:
- Whether patients treated by hospital-at-home services had different health outcomes when compared to those treated as hospital in-patients
- Whether rates of readmission or transfers to other hospitals were different
- Whether patient satisfaction differed
- Whether costs altered
- Whether the workload of doctors working in primary care differed
Ten studies were included in the meta-analysis for admission avoidance, and 26 studies for early discharge.
There are different models for hospital at home, so direct comparison is complex, with most of the data coming from patients who are in their 70s or 80s. Some services were excluded from the meta-analysis, including obstetric care, paediatric patients and mental health.
The admission-avoidance review, having looked at the data from 1,333 individual patients, concluded that there was no evidence to suggest admission avoidance leads to outcomes that differ from inpatient hospital care.
The ‘at home’ services may reduce the chances of dying, although readmissions may increase. Patients expressed increased satisfaction with the hospital at home care. Not all studies looked at impact on primary care, and where they did the response rate was low and showed no difference for GPs between the models.
Carers’ views were sought and there was some evidence from carers that they felt the upheaval of visiting hospitals was greater than the additional burden of care with the patient at home.
Only two of the included studies had full economic analysis. These showed admission- avoidance hospital at home to be less expensive than an acute hospital ward.
The review of hospital at home to aid early discharge concluded that there was insufficient evidence that providing services to people at home after being discharged home early may increase the risk or death or readmission. Additionally, patients may be more satisfied with their care at home, and carers did not report additional burden. This review found little evidence of cost savings.
Shepperd S, Doll H, Angus RM, Clarke MJ, Iliffe S, Lalra L, Ricauda NA, Wilson AD Hospital at home admission avoidance (Review) Cochrane Database of Systematic Reviews 2011.