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Comprehensive Geriatric Hospital At Home: adaptation to referral and case-mix changes during the COVID-19 pandemic

Published:November 10, 2022DOI:https://doi.org/10.1016/j.jamda.2022.11.003
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      Abstract

      Objectives

      To describe the evolution of a Hospital at Home (HAH) based on comprehensive geriatric assessment (CGA), including its adaptability to changing case-mixes and pathways during the COVID-19 pandemic.

      Design

      Observational study of consecutive admissions to a combined step-up (admissions from home) and step-down (hospital discharge) HAH during three periods: pre-pandemic (2018-Feb 2020) vs. pandemic (March-Dec 2020, and Jan-Dec 2021).

      Setting and participants

      Participants were all consecutive patients admitted to a CGA-based HAH, located in Barcelona, Spain. Referrals followed acute events or exacerbation of chronic conditions, by either primary care (step-up) or after post-surgical discharge (step-down).

      Methods

      HAH intervention based on CGA and incorporated geriatric rehabilitation. Patient case-mix, functional evolution (Barthel index) and mortality were compared across periods and between pathways.

      Results

      HAH capacity expanded three-fold from 15 to 45 virtual beds and altogether managed 688 consecutive patients (mean age(SD)=82.5(9.6) years; 59% women). Pandemic case-mix was slightly older (mean age=83.5 vs 82, p=0.012) than pre-pandemic, with greater mobility impairment. Across periods, step-up increased (26.1%, 40.9%, 48.2%, p<0.01) due to medical events, skin ulcers and post-acute stroke, whereas step-down decreased; multivariable models showed no differences in functional improvement or mortality. When comparing pathways, step-up featured older patients with higher comorbidity, worse functional status and lower absolute functional gain than step-down (5.6 vs 13 points of Barthel Index, p<0.01), remaining statistically significant after adjusting for covariates (p=0.003); no differences in mortality were observed.

      Conclusions and Implications

      A multipurpose, step-down and step-up CGA HAH expanded its activity and adapted to changing case-mixes and pathways throughout COVID-19 pandemic waves. While further quantitative and qualitative studies are needed to assess the impact of this model, our results suggest that harnessing the adaptability of HAH may help advance a paradigm shift toward more person-centered, cost-effective models of clinical care aimed at older adults.

      Keywords