Business Accent

Measuring Quality of Hospital in Home Care

The development of quality assessment and improvement in HIH has been hampered by several factors, despite 'usual' hospital approaches to quality adopted in HIH

Dr Vivek Verma

Hospital In the Home (HIH) refers to the delivery of acute hospital care to patients at home. This includes the delivery of intravenous therapy, low molecular weight heparin, complex wound care and rehabilitation or monitoring that would otherwise necessitate hospital admission.

The development of quality assessment and improvement in HIH has been hampered by several factors, despite 'usual' hospital approaches to quality adopted in HIH, such as monitoring of incident reports, complaints and chart reviews. The challenge in quality assessment is attributable to the fact that HIH delivers care in diverse settings, to patients with many conditions and is delivered by a range of delivery models and providers, which makes the process of agreement on quality standards difficult. Furthermore, the autonomy and control vested in patients during their HIH stay means that compliance cannot be assured.These factors further complicate randomised clinical trials in this area.

There could be two main structured approaches to quality assessment in home care. The first one is practical, based on an accreditation programme with a focus on processes of care in setting minimum requirements for accreditation. The other theoretical development in HIH quality of care assessment could be the Quality Indicator Groups.

Previous work in measuring implicit global outcomes and quality of HIH care explored the use of certain indicators for HIH care. These are unexpected number of patient telephone calls, unscheduled staff call-outs and unplanned returns to hospital during a HIH admission.

In descriptive studies of HIH, outcome and adverse events in a single centre, it was suggested that these indicators were objective, meaningful as quality measures in themselves, sensitive to a range of adverse outcomes and may indicate areas of process within a HIH that require attention. They are specific to outcomes in acute home based care. The main reasons for these incidents, and their possible links to quality of HIH care are listed below.

The approach to quality assessment through the use of clinical indicators is well known. A clinical indicator is defined by the Australian Council of Healthcare Standards (ACHS) as 'A measure of the clinical management and/or the outcome of a case'. The requirements for developing a clinical indicator are:

• Relevance to clinical practice, either in frequently managed conditions or in major complications of treatment.
• The availability of relevant data.
• That the measure or standard is achievable.

A high unexpected call rate does not imply less than optimal care, particularly the HIH units may actively encourage patients and carers to contact the unit if they are unsure of any aspect of their care. However, a threshold of concern must be reached before patient's telephone. This threshold may be influenced by the level of anxiety on the part of the patient as a result of poor selection or education, or a lapse in communication between the staff and the patient.

Call outs generally relate to clinical events, and these are not always predictable or related to poor care. The rate of call outs does not bear any significant relationship to the rate of returns to the hospital, the extent to which the rate of unscheduled staff call outs was influenced by any restriction placed on after hours support needs deliberation.

Unplanned return to hospital during HIH admission is the most important outcome as it can highlight difficulties with the eligibility criteria, care choice, skill of assessor, poor initial choice of therapy and misdiagnosis. High rates of unplanned returns could result in patient anxiety, added cost and possible deterioration of condition. Alternatively, a return to hospital maybe the best outcome of a vigilant system of clinical supervision by both nursing and medical HIH staff, which prevent negative outcomes from a complication.

Patient refusal of HIH care is not very common; the literature strongly supports patient consent as an essential criterion to participation in a HIH programme. Patient refusal may be influenced by general community attitudes to HIH or community-based care, past personal experiences of difficulties with such care, or the confidence in the model for delivery of care as presented to the patient at the time of referral. Procedural and definition difficulties exist with this indicator. Refusal of HIH treatment could be influenced by the consultant, hospital medical officer, general practitioners or the carer. Refusal by patient before a formal referral or assessment might result in the reported result being an underestimate of true rate. This indicator may have an important role in formal evaluation or research into differences between models of HIH care provision, or where a new or experimental technology may be introduced into the HIH environment.

Due to the acute nature of the patient's conditions and sites of delivery, there is a predictable level of unexpected clinical interventions. This needs to be considered in any hospitals ability to deliver safe, effective and acceptable HIH care. A minimum level of clinical infrastructure is required. Round-the-clock telephone support is necessary for HIH patients, using staff who know the patients and the HIH. Similarly, nursing and medical staff must, in addition to routine visits to deliver care, be available outside these times to attend to patients with unexpected problems, which may or may not require return to hospital.

A proportion of unscheduled visits does not result in return to hospital, and probably prevent that occurrence. A structured process for the return of HIH patients to hospital must be in place. The existence of telephone support and after-hours visiting capability by nursing staff in isolation to equivalent access to medical advice, leadership and physical availability would render the support less effective.

The complexity of the cases between different hospitals will be reflected in, and confound, clinical indicator outcomes. Although allowances may be made for the size of the hospital, or the activity of HIH, this may not necessarily translate into a meaningful adjustment for clinical case severity and complexity. In HIH care, there may be ways by which case load or severity could be measured by proxy. One such proxy could be the proportion of the total admission episode spent in the HIH unit (measured in days). It may be argued that the earlier a patient is transferred to the HIH in their hospital stay, the more and well or potentially unstable the condition managed and the greatest strain on the HIH unit to provide care.

The writer is a Healthcare Quality Consultant New Delhi
Email: drvverma@hotmail.com