Hospital at Home in Valencia

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

Hospital at Home in Valencia is an innovative service offered by the Hospital La Fe with the aim to optimize resources and better respond to population's new requirements. It is a transient service provided by specialized units to patients that otherwise would be inpatients. The innovation achieved its main objectives of acceptability, feasibility and quality although access to the service and coordination with other levels of care can be improved. It migh help system sustainability.

Purpose of health policy or idea

 We present the experience of Hospital La Fe (Valencia) in providing Hospital at Home services carried out by specialized units called Hospital at Home Units (HHU). The main objectives of this program are:

1. To reduce or avoid hospital admissions, replacing hospital care entirely or partially by home care. The main services provided are specialized home care provided to patients discharged early or to provide high tech care schemes at home.  Examples are COPD patients with an acute respiratory infection
2. To provide specialized high technology support care for patients with complex conditions who are cared for at home: Support Team scheme. Such patients are for instance those that require parenteral nutrition at home.
3. To reduce costs and to optimize the use of resources.
4. To develop pre- and postgraduate education and training for health personnel, boosting research for improving its outcomes.
5. To guarantee the quality of provided care in terms of safety, effectiveness, efficacy and equity.

HHUs provide specialized medical care based on diagnostic and therapeutic procedures addressed to "hospital-like" patients with acute or transitory health problems. Hospital at home patients live close to the Hospital and receive one or more daily regular scheduled or urgent home visits. At any purpose  (legal or administrative) these patients are considered in-patients of Hospital La Fe. 

 The expected outcomes would be:

• to improve Hospital La Fe service to the community;
• to increase population's acces to the service, the number of patients admitted and their confidence with the health outcome as well as icreasing the personalization of care;
• to improve the productivity of the hospital and to optimize cost-effectiveness.

This service is part of a broader innovation project of chronic conditions care through disease management, health services research and the use of new technologies.

The main incentives are to reduce costs and to optimize the use of resources for better meeting new population health needs (due to aging, immigration, chronic conditions), for promoting new health care delivery trends (more self care and more decentralized care) as well as for taking advantage of new technologies available. 

Main points

Main objectives

The main objectives are: to reduce or avoid hospital admissions, to support community care providing services for complex patients requiring high technology interventions, to reduce costs and to optimize resources with a high level of quality of the service. At the same time, the HHU will perform research and provide undergraduate and postgraduate training for health personnel.

The main features of HHU activity are:

1. a time-limited service (scheduled or urgent);
2. provision of "hospital-like" complex procedures, 
3. limited to the geographical area close to the hospital; 
4. patients admitted have the same rights and duties as inpatients in the hospital

Type of incentives

Incentives for the Hospital at Home service are indirect: to reduce or avoid hospital admissions in order to reduce costs and optimize the use of resources. Improving efficiency of healthcare delivery is a priority of the health Services of Valencia, especially since the region has full autonomy in the Health Sector.

Groups affected

Patients, health personnel of the service, primary care and other community services, Valencian Health Service (Valencian Agency for Health Care)

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

The acute and hospital-based nature of care provided by HHUs are characteristics that make this system innovative in comparison with other experiences from abroad. This innovation affects the overall health system. It is currently not fully accepted by other hospital wards and primary care services, although there are efforts to solve these problems.

Political and economic background

Hospital at Home appeared together with other innovations in the provision of care in Valencia since 1990 when the full responsibility of health was transferred from the national Ministry of Health to the government of the region. The Valencian Government has boosted this option of care through the Regional Health Ministry and today, 18 out of the 23 hospitals in the region have a HHU.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

Hospital at Home began with the experience by Dr. E.M. Bluestone at Guido Montefiore Hospital of New York with the purpose of clearing hospital beds, finding a more comfortable psychological environment for patients and alleviating the difficulties associated with the lack of a public health system in the lowest society strata. In the next years, several countries like Great Britain, Canada, Sweden, Italy and Germany, although under different names, followed this example.

In Spain, it was introduced in 1981 at the Provincial Hospital of Madrid, being subsequently extended to other regions. In 1983, a pilot project started in Bilbao, becoming the first Hospital at Home experience in the INSALUD-managed network  (the largest public provider) and achieving in 1986 the recognition of a hospital specific unit with its own professional structure and budget like the other hospital services.

Other main Spanish hospitals launched units with similar characteristics during the following years.

The subsequent transfer of health competences from the state government to the autonomous regions allowed great development of this approach in Valencia since 1990. The Valencia Government has boosted this care option through the Regional Health Ministry. Today, Hospital at Home is available in 18 out of the 23 hospitals in the Region of Valencia.

Although all included under the term "Hospital at Home", this health innovation has different characteristics depending on the country were it has been implemented. The main difference between the hospital at home care provided by the HHUs' of Hospital La Fe and the home care provided by primary care teams in the same region is that the former is transient (time limited) and provides "hospital-like" complex services, while the later offers less intense and less complex care for an unlimited period of time.

Initiators of idea/main actors

• Government: Community health policies in Valencia are boosting home care developed by primary care teams and specialized services such as Hospital at Home.

• Providers: This is a hospital-based program with little coordination with community and primary care services.

• Payers: Valencian Agency for Health takes into account this policy in its budgets and boosts it trough several projects.

• Patients, Consumers: Patients accept and are satisfied with the service, although patients from some areas criticize the unavailability of the service in their territory.

Approach of idea

The approach of the idea is described as:
renewed: The Valencia model is innovative in Spain. Valencia and US’ Hospital at Home spectrum of services are similar.

Innovation or pilot project

Else - The experience is being extended to every hospital in the region with the following main features: 1) transient care ; 2) "hospital-like" complexity of applied procedures, not limited to specific diseases or procedures; 3) geographically limited area

Stakeholder positions

The implementation of Hospital at Home in Valencia and in other Spanish autonomous regions can be considered as a top-down process, the main promoters of which are the regional governments and HHUs managers. 

The experience shows a lack of coordination between the Hospital at Home service and the Home Care programs provided by primary care teams. The Hospital at Home service also faces difficulties in the cooperation with other services from the same hospital. The commitment of the other hospital wards in identifying suitable patients and in referring them to the Hospital at Home service is weak.

Self-evaluation of the innovation shows that internal communication is fluid, although it can be improved. Furthermore, there is resistance to change displayed by some professionals that were forced to move from providing hospital care to Hospital at Home service.

Patients report high satisfaction with the service received. Some criticism is voiced because the service is not already available to the whole region and pressure exists from some groups of citizens that want the service extended to the whole territory.

Actors and positions

Government
Regional Health Ministry	very supportive		strongly opposed
Providers
HHUs health personnel	very supportive		strongly opposed
Other hospital specialists	very supportive		strongly opposed
Primary Care (GPs)	very supportive		strongly opposed
Payers
The Valencian Agency for Health (Valencial Regional Health Service)	very supportive		strongly opposed
Patients, Consumers
Patients	very supportive		strongly opposed

Influences in policy making and legislation

The service is provided without any legal change. Patients admited to the service have the same rights and responsibilities as inpatients.

Actors and influence

Government
Regional Health Ministry	very strong		none
Providers
HHUs health personnel	very strong		none
Other hospital specialists	very strong		none
Primary Care (GPs)	very strong		none
Payers
The Valencian Agency for Health (Valencial Regional Health Service)	very strong		none
Patients, Consumers
Patients	very strong		none

Positions and Influences at a glance

Adoption and implementation

International, national, comunity and hospital health policies see home care as an emerging opotion of healthcare provision in front of the growing demand of healthcare services.  For this reason, the Health Agency of Valencia launched specific plans such as "IMAD" (Initiative for the Improvement of Home Care) , for improving the implementation of Home Care offered by primary care teams and the Hospital at Home services managed by hospitals.

Spain experienced an increase in health expenditure due to the growth of the elderly population and to the augment of the population due to immigration. Hospital at Home services are seen in Valencia as an innovation that might support the suistanability of the health system while affecting neither quality nor public finances. For this main purpose to be achieved, regional politicians want a commitment between profesionals, managers and citizens.

Monitoring and evaluation

The Valencian Agency for Health monitors the regular HHU activity through the information provided by the hospitals on a monthly basis. The reported activity includes the number of admissions, days of stay, discharges for each care scheme and the sort of activities performed according to the HHU procedures catalogue.

The HHU established a system for carrying out internal audits for checking the compliance with the 9001:2000 ISO norms and with the foreseen activities accorded in the health services contract with the Valencia Agency for Health.

HHU of Hospital La Fe in Valencia assessed the quality of his service according to the European For Quality Management Model  (EFQM) for the 2004 and 2005 periods.

Review mechanisms

Final evaluation (internal)

Dimensions of evaluation

Structure, Process, Outcome

Results of evaluation

In Spain, the 80% of HHUs' activity corresponds to the "Early Discharge from Hospital Scheme", which makes possible to shorter the average stays days at the hospital by providing at home the care that follows the acute in-patient period.  

 Self evaluation shows that the objectives of increasing patient satisfaction and improving personalized and access to care were achieved. Patients' satisfaction index  was 98%, and the average delay in the admission to the service was lower than 4 hours (only in 1.5% of cases it was higher than 48 hours).

Although there was a positive trend, in providers satisfaction and patients attraction to the system the objectives were not achieved. Providers' satisfaction index was 91,6% (increasing 7,6 % respect year 2004) and patients volume, fidelity and attraction to the system was measured through the called "ambulatorización index" (home visits grew a 17% but the expected increase in daily hospital sessions was not achieved).

HHU has boosted organizational change and implemented all the planned key processes. The staff performance exceeded the foreseen objective (118.2% vs 90%).

Related to costs, HHU increased its overall productivity and optimized cost-effectiveness compared to the previous year, with an important growth of discharges (34%) and a reduction of 19% of pharmaceutical cost for each episode.

Care management was optimized too. Efficiency, measured by average stay index and visits/episode index, increased compared to the previous year. Further studies comparing hospital at home's outcomes and traditional hospitalization ones are needed.

Emergencies per episode, urgent visits per episode and percentage of urgent readmissions to the hospital meet the objective. The inclusion of patients in the diseases management program is higher than expected. The monitoring of processes trough medical record audits showed a positive trend.

The objective of innovating the provisioning of care has been achieved, carrying out 100 e-consultations, including tele-consultations and tele-monitoring. The internal information management was measured by the delay in reporting the clinical records (6.2 days) and in the coding of diagnosis and procedures at the discharge (100%).

The HHU was also involved in teaching activities and carried out research projects in collaboration with the University of Valencia. A Master of Hospital at Home has been launched trough Valencia Public Health School.

Expected outcome

When traditional inpatient care and Hospital at Home are compared in the literature (Medline and The Cochrane Library from 1996 to 2006), the results are controversial related to resource consumption and efficiency and there is a lack of evidence about its effect on patients' satisfaction.

Nevertheless these results do not directly apply to the Spanish experience. Most of the published studies come from Great Britain. In this country the provision of Hospital at Home is different from the one provided in Spain. In UK patients are included in the service for longer periods and receive procedures more similar to the one provided in Spain by primary care teams rather than by Hospital at Home teams.

Evaluations in the literature review pool the experiences from different schemes. For these reason the results do not directly apply to the Spanish experience. Despite its excellent indicators, the evaluation of the hospital at home service in Valencia does not allow us to state its superior efficiency compared to traditional hospital care. Among its current weaknesses - that will be tackled shortly - is the weak coordination with other hospital wards and with primary care services.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

The organizational innovation performed by Hospital La Fe in Valencia achieved very positive results measured by patient's satisfaction and acceptability, quality of care, and efficiency. Nevertheless, the experience faces the same difficulties as other community innovations lead by hospitals in Spain. Neither hospital nor primary care teams really accept the change. Professionals from the hospital do not like to move out of the walls of the institution and primary care teams fear to lose competences in community care. These attitudes are not in favour of the needed cooperation between different providers in order to offer a better service to the patient. These top-down innovations, apart from the investments and the organizational changes introduced in the HHUs, must also look for introducing incentives in the health services that favour cooperation among different providers.

References

Sources of Information

- Management Technical Project of  Hospital at Home Unit. Hospital La Fe (Valencia). 2006.

- González Ramallo VJ, et al. Hospitalización a Domicilio. Med Clin (Barc) 2002; 118 (17): 659-64. 

- Bluestone EM. The principles and practice of home care. JAMA 1954; 155:1379-82.

- Morris DE. Sante Service Bayonne: a French approach to home care. Age Ageing 1983; 12:323-8.  

- Donald IP, Baldwin RN, Bannerjee M. Gloucester hospital-at-home: a randomized controlled trial. Age Ageing 1995;24:434-9.  

- Iliffe S. Hospital at home: from red to amber? BMJ 1998; 316: 1761-2.  

-  Shepperd S, Iliffe S. Hospital at home. An uncertain future. BMJ 1996; 312:923-4.  

-  Bentur N. Hospital at home: what is its place in the health system? Health Policy 2001; 55:71-9.  

-  Caplan GA, Ward JA, Brennan NJ, Coconis J, Board N, Brown A. Hospital in the home: a randomised controlled trial. Med J Aust 1999; 70:156-60.  

-  Burton LC, Leff B, Harper M, Ghoshtagore I, Steinwachs DA, Grenough WB, et al. Acceptability to patients of a Home Hospital. J Am Geriatr Soc 1998;46:605-9.  

-  Parker H. Evaluation of hospital at home scheme. Despite study's positive findings the scheme faces financial constrains. BMJ 2000; 230: 1077-8.

Author/s and/or contributors to this survey

María González Ortega.

Vocational Trainee in Family and Community Medicine at the Hospital Clinic of Barcelona.

Suggested citation for this online article

María González Ortega.. "Hospital at Home in Valencia". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/es/a14/3