Effectiveness of integrated intervention in the hospital-home transition to improve quality and safety of care for frail older adults

Older adults (OA) who receive Home Based Primary Care (HBPC) have complex needs, a high level of functional and/or cognitive dependency and are also vulnerable to changes in the hospital-home transition. Hospital care usually focuses on balancing acute decompensation of chronic issues, through episode-related actions, which are fragmented, uncoordinated, and highly variable. These factors expose the patient to adverse events’ risks, resulting in poor health during hospitalizations with prolongated length of stays (LOS) as well as after being discharged (unscheduled readmissions and/or death). In January 2019 an integrated intervention was implemented to improve the quality of the discharge planning process of OA admitted to HBPC from a high-complexity university hospital. We reached out to the participating areas of such care process (clinical practice, geriatrics, rehab, social services, palliative care, home care services, pharmacy, ER, nursing, and the patient and his caregivers). The OA with complex needs were identified in an early stage, and through a comprehensive and multidisciplinary approach, we planned the discharge through a customized care plan. Before and after quasi-experimental study. The people in charge of the pre-intervention stage group (control group; n.=235) examined adults 64-year-old frail patients, enrolled in our institution’s health insurance, who had been admitted to HBPC after clinical hospitalization, between 10/2019 and 1/2020. The people in charge of the post-intervention group (experimental group; n=275) examined patients who had been admitted to HBPC between 11/2019 and 1/2020. There were no differences in the clinical and sociodemographic characteristics among both groups. The median age was 86. Predominantly, we found high functional and cognitive dependency and pluripathology (Charlson 6). More than 60 % needed a palliative approach and had, at least, one previous hospitalization and/or three visits to the ER during the previous year. Before being admitted to HBPC, during the stage prior to the intervention, the hospitalization LOS average was 8 days (5 to 12 IQR). After controlling the results, due to the potential confounder effect of the differences in functionality, comorbidity, and amount of previous hospital admissions among both groups, this hospitalization was reduced by 2 days (95 % CI -2.94 to -0.93, p=0.0001) after implementing the integrated intervention, which represents a 19 % cost reduction. The intervention did not modify either the time patients remained alive outside of the hospital after being admitted to HBPC (0.98 RRI; 95 % CI 0.95 to 1), the 30 days readmission rate (24.25 % vs. 22.54 %), or the 90 days mortality rate (1.09 OR; 0.71 to 1.67). A comprehensive and multidisciplinary approach optimized the hospitalization LOS without increasing the readmission and mortality rates of these patients. In future projects, we could study the patient’s and his caregivers’ experiences, and the participating health team’s experiences.