Time-limited intensive home care for elderly patients after discharge

Safe discharge is a type of intensive home care intervention. It is mainly offered to older people who need extra support in conjunction with discharge from the hospital. The intervention includes extra care time for the elderly for a limited period (1 to 2 weeks) by staff in special home reception teams. Safe discharge is a Swedish intervention that has emerged in recent years and is found in around half of the country's municipalities.

Question

What systematic reviews are there on the effect of intensive home care after discharge from the hospital?

Identified literature

Table 1. Systematic reviews with low/medium risk of bias
RCT = Randomised controlled trial
Included studies Population/Intervention Outcome and Results
Sempé et al, 2019, [1]
Study design: 15 studies (5 RCTs, 5 controlled pre-post studies and 3 non-controlled observational studies)

Setting: Studies were from USA (4), England/UK (2), New Zeeland (1) and Singapore (1)

Categories: Studies were categorised to either transitional care (n=8), case management (n=4) or hospital-at-home (n=3)

Risk for bias: Moderate risk for bias
Population: Older people (defined as aged over 60 years old) with multimorbidity or frailty

Intervention: Home-based interventions by any type of multidisciplinary team that aimed at reducing avoidable displacement from home
Effect: The review focused on the results from studies with low risk for bias (n=3).

Readmission rate (30 days):
I: 11.7% vs C: 17.3%; p<0.001

Readmission rate (1–10, 11–30, 31–90 days):
I: 76.8% vs C: 69.2%;p>0.05

Readmission rate (28 days)
Regression discontinuity parameter estimation:
–1.60 (SD 3.10); p=0.05
Authors' conclusion: “…the review was not able to identify robust impact evidence, either in terms of quantity or quality from the studies presented. As such, the available evidence is not sufficiently robust to inform policy or interventions for reducing avoidable displacement from home.”
Sims-Gould et al, 2017, [2]
Study design: 15 RCT-studies

Setting: from Denmark (1), Norway (2), England/UK (3), Netherlands (1), Australia (5), New Zeeland (2), USA (1)

Categories: 7 studies focused on rehabilitation, 6 on restorative, 2 studies on reablement, and none on reactivation

Risk for bias: Moderate risk for bias
Population
Community dwelling older adults (65 years+) in receipt of home care services. In total, n=2364 (range 29–750)

Mean age 76–83 years

Intervention
4R programs, i.e., reablement, reactivation, rehabilitation or restorative, delivered in the home over 4–24 weeks. A personalized and tailored approach characterizes the interventions

Comparison
Home care recipients not in receipt of any 4R interventions, but who continued to receive home care services
Functional abilities
Two studies reported no changes in functional abilities over the intervention period and seven studies found improvements that lasted several months to a year. These functional improvements included fewer activity restrictions at 3 months postintervention (1); improved ADL scores and self-assessed ability in the kitchen at 3 months, and in the execution of domestic tasks at 12 months (1); better home management and self-care (1); improvements in ADL and IADL at 6 months (1).

Clinical outcomes
Statistically significant clinical outcomes: improvement in self-reported walking im-pairments (1); improved mobility scores (1); improved physical function (1); overall score and gait speed (1) ; improved Timed-Up and Go (2) and other test scores (1).
Better rates of survival (2).
A higher number of falls both during the intervention and at 6 months’ follow-up among those who received the home care program compared with a center-based falls reduction program (1).

Older adult outcomes
No change in quality of life (1); no change in mental state (1); no statistically significant change in mood, pain, or cognition (1); no change in social support (1). An exception was improvements in mental well-being at both 3 and 6 months postintervention (1).

Care giver outcomes
No significant findings were re-ported with respect to the carers. An improvement in carers’ General Health Ques-tionnaire was found at both 3 and 12 months postintervention (1).

Service usage outcomes
Several interventions appeared to facilitate participants continuing to live at home, rather than transferring to residential care (4).
Reduced home care use at various follow-up points: number of participants requiring ongoing home care at 3 and 12 months (2), length of time receiving home care was shorter overall (1); fewer home care hours and a lower total home care cost over a 9-month period (1) and a 2-year period (1).

Health care resource utilization: cost analyses
Interventions reduced the total number of emergency room visits (2), unplanned hospital stays (1) and total hospital days (2).
Authors' conclusion: “From cost savings to improvements in clinical outcomes, 4R interventions show some promise in the home care context. However, there are several key issues across studies, including questions surrounding the generalizability of the results, in particular with respect to the ineligibility criteria for most interventions; the lack of information provided on the interventions; and lack of in-formation on staff training”.

References

  1. Sempe L, Billings J, Lloyd-Sherlock P. Multidisciplinary interventions for reducing the avoidable displacement from home of frail older people: a systematic review. BMJ Open 2019;9:e030687.
  2. Sims-Gould J, Tong CE, Wallis-Mayer L, Ashe MC. Reablement, Reactivation, Rehabilitation and Restorative Interventions With Older Adults in Receipt of Home Care: A Systematic Review. J Am Med Dir Assoc 2017;18:653-663.

SBU Enquiry Service Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

Published: 11/1/2021
Report no: ut202124
Registration no: SBU 2021/368