Enhancing the hospital at home experience

Abstract

Background

Hospital at Home programs have demonstrated to be safe, feasible and cost effective. However, challenges such as infection control, cleanliness, space constraints and insufficient resources may hamper the adoption and effectiveness of such programs.

Aims

To understand the challenges of providing and receiving healthcare in the community, design a solution to meet the challenges, and to pilot and evaluate the solution.

Methods

This is a three-phase mixed method study. Phase 1, nurses, patients and caregivers were surveyed to understand their challenges in providing or receiving healthcare at home. Results of the survey in Phase 1 were used in Phase 2 to design a solution. In phase 3, an integrated structure was designed and piloted for stakeholders’ evaluation.

Results

Twenty nurses and 50 patient-caregiver dyads responded to Phase 1 survey. Physical home environment was most cited by the nurses as their main challenge, particularly the lack of a dedicated and clean space to conduct nursing procedures. Medication management was the greatest challenge faced by the patient-caregiver dyads. Based on these findings, a prototype of an integrated structure was fabricated in Phase 2. Ten patient-caregiver dyads and nine community nurses tested the prototype in Phase 3. The participants found the structure useful to store and organize their healthcare items, and there was ample clean workspace to carry out nursing procedures.

Conclusion

An integrated structure that can fulfil the physical, spatial and interpersonal needs at an affordable price could be useful in facilitating the delivery of hospital care in the home setting.

Patient Contribution

Patient-caregiver dyads were key stakeholders in our study. They provided valuable feedback and suggestions on the prototype and design of the integrated structure.

Background

Singapore is facing a rapidly aging population with the number of people aged 65 years and above is expected to increase three to fourfold over 25 years from the year 2017. ¹ The aging population is a strong driver for healthcare demand, ² with the elderly likely to be hospitalized more frequently and stay longer than the younger population. ¹ The impact of the aging population may be seen in the frequent occurrence of bed crunch situations in acute hospitals. ² Hence, there is an opportunity to relook at the way healthcare is currently being delivered and innovate to meet future healthcare needs and demands.

An example of such healthcare innovation, is the ‘Hospital at Home’ care model where patients whom are relatively stable and do not require complicated treatment, receive care in the comfort of their own home. The Hospital at Home concept is not new and has been implemented in several centers such as the Presbyterian Health Services in Albuquerque, New Mexico; Cedars Sinai Medical Center in Los Angeles; and in 11 Veterans Affairs Medical Centers across the United States. ³ Hospital at Home programs have resulted in lower costs, less stress and higher patient and family satisfaction. ³ There were also similar effects to clinical outcomes such as mortality and readmission rates when compared to hospital care. ⁴ Hence, caring for patients at home seems to be able to improve satisfaction without a negative impact on health outcomes.

In Singapore General Hospital (SGH), one of the largest tertiary hospitals in Singapore, the Hospital at Home program was initiated in September 2021, with the aim of providing acute and subacute hospital level treatment in the patient’s home for conditions that would normally have required continued hospital admission. To date, the program has served more than 1000 patients, and saved more than 2800 hospital bed days. Through collaborations with various disciplines, such as General Medicine, Renal, Infectious Disease, Vascular and Cardiology, patients that have an established diagnosis and are medically stable are referred to the Hospital at Home program for continued monitoring and medical treatment at home. Typical conditions include infections requiring continuation of intravenous antibiotics, complex wound/s, monitoring of electrolytes, functional rehabilitation, titration of medications, among others. Although the Hospital at Home model is relatively new and unfamiliar to the Singapore population, most patients reported an overall positive experience. ⁵

While it is feasible to deliver hospital care at home, the healthcare team, primarily the community nurses may encounter certain challenges. For instance, nurses often perform patient care alone, posing risk to their safety and well-being, or the home environment may not meet certain safety or sanitary requirement critical in providing effective hospital care at home. ⁶ When under great duress, there may be an increased risk of human error when executing these tasks. ⁷ Tasks performed in the home care setting can range in complexity, from simple task such as measuring vital signs to more challenging and complex tasks such as administering intravenous medication/s or intravenous hydration, insertion of tubes and drains, and complex wound care (Appendix 1: Picture 1). Incidence of home care patients experiencing at least one safety-related event was found to be between 5.5% and 13.2%. ⁸ In the home setting, there is a need to look beyond the safety of the patient alone and to also consider the healthcare provider’s safety, well-being and psychosocial interactions.^6,8

There is a conceptual model of safety in home care to encompass these concerns; physical, spatial and interpersonal concerns. ⁸ Physical safety concerns relate to the experience or the potential risk for physical harm such as falls or communicable diseases; Spatial concerns relates to concerns based on the inadequacy of the home environment or the safety of the neighborhood; Interpersonal concerns arise from interactions between the patient and family or healthcare workers. ⁸

There are intensifying and mitigating factors to address these concerns. Mitigating factors help relieve patients of their concerns, while intensifying factors aggravate the worries. ⁸ The presence of home modifications and equipment was seen to mitigate the stress of caring for patients at home, while the cost of such modifications and equipment are intensifying factor. ⁸ Additionally, while home modifications may suite one party, it may not necessarily be well received by another party in the household.

Aims

To understand the challenges of providing and receiving healthcare in the community, design a solution to meet these challenges, and to pilot and evaluate the solution.

Methods

This is a three-phase mixed method study implemented from July 2022 to November 2022.

Phase 1 is a survey with stakeholders providing or receiving healthcare at home to understand their challenges and needs.

Phase 2 is to design a solution to meet the needs identified in Phase 1.

Phase 3 is to pilot and evaluate the solution.

Participants

Convenient sampling was used for this study. Patients enrolled under the Homecare program or their caregivers or family members, aged 21 years and above, with no history of cognitive impairment and able to converse in English were invited to participate in the study. This group of participants were identified by the community nurses caring for them.

All community nurses were included in Phase 1 of the study. For Phase 3, community nurses who cared for patients who used the integrated structure were recruited for the study.

Implementation

Phase 1: A total of 20 community nurses and 50 patient-caregiver dyads participated in the survey to understand their challenges and needs in delivering and receiving healthcare at home.

The dyad’s questionnaire components consisted of:

• demographic details such as housing type, role/relationship with the patient

• challenges and needs in receiving healthcare at home

The nurse’s questionnaire components consisted of:

• demographic details such as years of experience working as a community nurse

• common nursing tasks performed in the home

• concerns for self or patient while providing healthcare at home

• challenges faced during home visits

• what limits or restrict their work during care delivery at patient’s home

• has these challenges affected their morale as a community nurse

• suggestions for improvement or how can they be better supported to provide the best care that they are capable of

Phase 2: Taking into account the survey findings and suggestions, the study team brainstormed for an innovative and creative solution. A prototype of an integrated structure (a movable, cabinet like structure designed to meet the needs by those providing or receiving healthcare in the community) was considered. The structure was named “HaH Buddy”. The study team obtained a grant approval and funding to co-design and fabricate the HaH Buddy prototype in Phase 2 with the design team.

Phase 3: The final prototype was piloted in 10 patients’ home to gather their feedback and user experience. The HaH Buddy was kept at the patient’s home for a minimum of 2 days to give users ample time to use, maneuver and evaluate. A minimum of 2 days was recommended by most users as adequate duration for evaluation, in addition to meeting the study’s timeline.

When it was due for the HaH Buddy to be removed from the dyads home, a post evaluation interview was conducted by a study team member on its feasibility, preferences and meeting stakeholder’s needs. The structured interview took place at the patient’s home, and lasted a maximum of 1 hour. Participant’s consent was obtained for the session to be audio recorded, and dyads received a token of appreciation for their participation upon completion of the study.

Ethical consideration

Ethical approval was obtained from the SingHealth Centralised Institutional Review Board (CIRB). Participants were assured that their decision to participate in this study would not affect their medical care in any manner.

A waiver of consent was granted for phase 1 as the data collected contained no identifiers. For phase 3 where the HaH Buddy was piloted in patient’s homes and patients, caregivers or family members were interviewed for feedback and suggestions on the HaH Buddy, written consent was sought prior to placing the HaH Buddy in their home.

Data analysis

For Phase 1, descriptive statistics were used to analyze the survey results.

In phase 3, the audio recordings were transcribed verbatim before content analysis was performed on the qualitative data.

Results

Phase 1

A total of 70 participants responded to the survey; fifty patient-caregiver dyads (30 patients, 10 family members and 10 caregivers), and 20 community nurses.

Majority of patient-caregiver dyads interviewed were age 70 and above (54%). There was no difference in gender. Majority lived in a 3-bedroom housing development board (HDB) apartment. Almost half (38%) of patients had some form of mobility issues requiring assistance in their activities of daily living (ADL). Patient’s healthcare needs included administration of oral medications (92%), requiring help in their ADL such as showering (32%), mobility (32%), dressing (22%) or wound care (18%).

Medication management such as polypharmacy, storage, clean space for medication preparation and pill minding (54%) were the greatest challenge faced by the dyads (Appendix 2: Table 2). Other challenges included mobility (32%), wound care (18%), urine catheter care (10%), and showering (10%).

The community nurses interviewed work experience ranged from 7 months to 7 years. Common nursing task performed in the home setting includes medication consolidation (100%), patient education (90%), wound care (80%), urine catheter management (65%), performing comprehensive physical examination (75%), enteral tube feeding management (50%), and others.

Physical home environment; cluttered home (38%), space constraint (17%) and cleanliness (14%) were most cited by the nurses as their main challenge when providing healthcare at home, particularly the lack of a dedicated and clean space to conduct nursing procedures. Other challenges included no proper or insufficient equipment (7%), lack of help from family members (7%), no proper furniture to place their medical items (7%), and patients’ compliance (3%) (Appendix 2: Table 1).

Phase 2:

Based on the main challenges faced by nurses, patients and caregivers of family members, the project team decided that an integrated structure that could serve as a dedicated clean space for storage of medical equipment, medications and for conducting nursing procedures will be able to solve multiple challenges raised via the survey. The team also wanted to ensure that the structure would provide a space for patients to secure their urinary catheter bag as well as wound drain/s as these were also challenges raised by the patients.

The initial artist impression of the structure (Appendix 3: Figure 1) by the study team differed significantly from the first prototype (Appendix 3: Figure 2) because design change took place to ensure stability of the prototype.

The clinical team evaluated the first prototype, and found it not suitable for use in the home setting as the height of the structure was too high, and the size was too big (bulky). Moreover, some of the cabinet space was not easily accessible if placed against the wall. Therefore, it was not trialed in the patients’ home.

The prototype design was reviewed again and revised to incorporate all the modifications and specifications required from various stakeholders. The final structure (Appendix 3: Figure 3) met all the requirements, providing ample storage space for the patient’s healthcare needs, space for the nurse to place the requisites for nursing care procedures and even holders for the intravenous bottles and drainage bag (Appendix 3: Figure 4).

Phase 3

Ten patient-caregiver dyads and nine community nurses completed the post evaluation interview. Most participants found the HaH Buddy useful, but had some feedback and suggestions for future enhancement and improvement.

The participants appreciated that the HaH Buddy provided ample storage space for their one-stop healthcare consumables and equipment. The small table-top provided a clean workspace for the nurses to place their laptop or medical requisites.

Common recommendation cited was to improve the design, in terms of its size and outlook. The size was too bulky especially for smaller apartments. Participants recommended to have the height and size reduced, and the drawers to slide open more easily. As for cost, most were willing to pay anything below $100; those with lower income suggested to include government subsidies to keep the price affordable.

Discussion

Providing healthcare services in the home setting will become a necessity due to the changing healthcare needs, expedited hospital discharge and ongoing care plans. ⁶ While the visiting nurse continues to provide healthcare alone in the home setting without the adequate resources that are typically available in a hospital environment, ⁹ it is key to understand the challenges and develop mitigating strategies to adequately address these challenges and optimize health care delivery in the home setting. ⁶

Through this study, we have identified several challenges that the community nurses face while carrying out safe hospital care at home, and opportunities for improvement and innovation. Improvements in home healthcare have the potential to provide increased well-being, comfort, and safety to both caregivers and recipients alike. ⁶ Our findings also suggest that the HaH Buddy can be useful and practical to use in our local home setting and layout. Stakeholders found the HaH Buddy most useful in organizing all their healthcare consumables such as wound products, medications, diapers, milk supplements, etc. The HaH Buddy also created a clean and convenient workspace for the visiting nurse.

Users’ feedback and suggestions for future modifications and enhancement are taken into consideration for continued improvement. Although the HaH Buddy provides a solution that is less costly and permanent as compared to a home modification, more work is required to further enhance the aesthetics, layout and size (it is currently challenging for one nurse to lift the structure to the patient’s apartment if the nurse were to transport it alone) of this current version of the HaH Buddy. The team is aware that with the current design, users may not have much use for such a structure if they recover from their illness and do not require medical care at home. The team hopes for the HaH Buddy to be designed to allow it to be repurposed as a common household furniture if the patient does not need it for their healthcare use anymore. This will prolong the use of the structure beyond the duration of the patient’s medical care requirements. The team is also conscious to keep it affordable as most patients are only willing to pay below $100 for such a structure. However, if the purpose can be extended beyond medical purposes, patients and families may also be more willing to pay a higher price for it.

Limitations

Our study has several limitations. Firstly, the survey was conducted on a heterogeneous group from the SGH's Homecare programme, hence it may not be generalizable to all patients receiving healthcare at home. Secondly, the feedback and evaluation gathered were primarily from dyads who consented to participate in the study. There may be other patients receiving healthcare at home requiring all the functions of the HaH Buddy but not included in the evaluation. In order to evaluate all functions, we should recruit patients with different care needs and complexity.

Conclusion

The integrated structure ‘H@H Buddy’ is useful and practical to use in a home care setting. Stakeholders found the HaH Buddy useful in organizing their healthcare and medical items and consumables such as medications, wound products, diapers, milk supplements, and creating a safe workspace for the visiting community nurse. This enhances the experience, efficiency and comfort of the patient, family and staff.

Implications for future practice

Our findings guide the design of optimal user experience in delivering and receiving hospital care at home. With knowledge of stakeholders’ preferences, we will be able to inform the design of an ideal integrated structure to facilitate delivery of hospital care at home in the future.

Implications for future research

Further studies could be performed in efforts to improve the experiences of healthcare providers and patients in the Hospital at Home programs. The HaH Buddy can be further improvised to cater to the various needs of the patients enrolled in the Hospital at Home programs.

Supplemental Material

Supplemental Material - Enhancing the hospital at home experience

Supplemental Material for Enhancing the hospital at home experience by Rachel Marie Towle, Peijin Esther Monica Fan, Juweita Arba’in, Fazila Aloweni, Siew Hoon Lim, Shin Yuh Ang and Su-Fee Lim in Proceedings of Singapore Healthcare.

Ethical statement

Ethical approval

Ethical clearance from the Central Institutional Review Board (CIRB), Singapore was obtained.

Informed consent

Participants were assured that their decision to participate in this study would not affect their medical care in any manner. Written consent for participation and audio-recorded interviews were sought.