[State of knowledge: hospital at home, an alternative to conventional hospitalization]

Lorthios-Guilledroit A, Dugas M
Record ID 32018001694
Original Title: État des connaissances - L’hospitalisation à domicile : une alternative à l’hospitalisation conventionnelle
Authors' objectives: “Hospital at home” is one of the solutions advocated by many individuals and organizations to address the need to relieve hospital overcrowding, whether in the context of a pandemic or not. This approach involves offering hospital-level acute treatments in the patient’s home, delivered by health professionals for a condition that would otherwise require conventional hospitalization. In this report, the concept of hospital at home includes both services managed by a hospital for which the patient would be considered “admitted” at home and under the responsibility of a hospital physician, and community-operated hospital-at-home services for which the patient would be considered “enrolled,” for example, in an outpatient clinic. It is in this context that the ministère de la Santé et des Services sociaux (MSSS) gave the Institut national d’excellence en santé et en services sociaux (INESSS) the mandate to synthesize the scientific knowledge and the challenges that need to be considered in order to establish hospital-level care at home in general and in the specific context of the COVID-19 pandemic.
Authors' results and conclusions: RESULTS: The retrieved systematic reviews show that hospital at home is a safe alternative to conventional hospitalization, as it achieves at least equivalent outcomes in terms of readmissions, service utilization and mortality, without increasing the number of complications or adverse events. This finding appears to be generalizable to many types of patients who require hospitalization, provided that patients are well selected and meet additional criteria for safe home care - e.g., regarding clinical stability, the physical environment, and logistical aspects. This hospitalization option also appears to be satisfactory from the patient’s perspective; however, there are fewer data on the perspective of informal caregivers who play an important role in supporting the patient. Hospital at home may also be associated with reduced costs compared with conventional hospitalization, but the heterogeneity of the studies and health care systems examined limits the generalizability of this finding. Regarding organizational aspects, the review of the literature reveals the absence of a standardized approach to organizational models for hospital at home. Certain trends are observed, however. For example, these services are generally linked to hospitals, rather than being provided by family doctors, which thus allows access to specialized staff and equipment. They include daily visits by a nurse supported by a physician and, in most cases, by a multidisciplinary team. Although data are still too limited to determine whether one model of hospital at home is superior to another, it is recognized that close collaboration, good coordination and clear communication mechanisms between the different stakeholders are essential for the successful functioning of this service. 3 The literature also reveals various challenges related to the implementation of a hospital at-home service, such as staff recruitment and the selection of eligible patients. Logistical challenges will also need to be addressed, as the goal is to ensure that services are available 24 hours a day, 7 days a week in the event of an emergency, including in situations of difficult weather conditions or geographic constraints. The feasibility of implementing such a service also depends on the legal framework in effect in the given jurisdiction. The COVID-19 pandemic setting poses additional challenges related to, for example, the implementation of protective measures for caregivers and hospital-at-home patients, the availability of personal protective equipment (e.g., gloves, masks), the increased use of telemedicine tools, and the need for ongoing knowledge transfer. Increasing staff shortages related to the pandemic pose the risk of closure of this service, particularly when personnel are reassigned to units dedicated to the treatment of COVID-19 patients. Finally, the results of three studies suggest that patients with COVID-19 can be effectively and safely hospitalized at home, at least those whose condition is not considered severe or following a short conventional hospitalization. However, these studies have small sample sizes. Further research is needed to determine the true feasibility of hospital at home for the management of patients with COVID-19 on a larger scale, taking available resources into account. It is also conceivable that this management approach raises organizational issues (organization of care in cohorts or “bubbles”), safety issues for those living in the same household, and clinical issues related to the restriction of procedures that generate aerosols under certain conditions CONCLUSIONS: Hospital-at-home services appear to be safe and appreciated by patients, but their implementation seems to present a number of organizational challenges. In order to guide consideration of the possible implementation of such a service in Québec, additional analyses could be carried out. The feasibility of implementing this service model will depend, in particular, on the legal framework that would apply to hospital at home. Some initiatives already in place in Québec, which resemble this type of hospitalization, offer a starting point for reflecting on the organizational, logistic and legal aspects of its implementation. Moreover, although hospital at home has been proposed as a way to tackle the COVID-19 pandemic, the current public health crisis could represent an opportunity to examine the potential for developing sustainable solutions for the health care system in general. The implementation of hospital at home in Québec is worth considering, given its potential to increase hospital capacity and relieve overcrowding in the long term by addressing various issues in the health care system.
Authors' methods: The evaluation questions examined were the following: 1) What is the recent evidence on the effectiveness, safety and efficiency of hospital at home? 2) For which clientele and types of intervention is hospital at home indicated? 3) What are the different organizational models for hospital at home? 4) What are the challenges related to the implementation of a hospital-at-home service in general and in the specific context of the COVID-19 pandemic? Given the time constraints associated with this mandate, the present knowledge synthesis was conducted using a rapid review approach. Information was retrieved using strategies developed in collaboration with a scientific information counsellor. The PubMed, EMBASE, CINAHL and EBM Reviews bibliographic databases were searched, and the grey literature was retrieved by consulting various websites (belonging to governmental bodies, professional organizations, etc.). Only publications on hospital-athome services (admission avoidance or early supported discharge) for adults or older adults whose condition required acute care and hospitalization were included.
Project Status: Completed
Year Published: 2021
English language abstract: An English language summary is available
Publication Type: Other
Country: Canada
Province: Quebec
MeSH Terms
  • Home Care Services, Hospital-Based
  • Home Care Services
  • Hospitals, Community
  • COVID-19
  • Coronavirus Infections
  • SARS-CoV-2
Organisation Name: Institut national d'excellence en sante et en services sociaux
Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369
Contact Name: demande@inesss.qc.ca
Contact Email: demande@inesss.qc.ca
Copyright: Gouvernement du Québec
This is a bibliographic record of a published health technology assessment from a member of INAHTA or other HTA producer. No evaluation of the quality of this assessment has been made for the HTA database.