Abstract
Introduction: Health systems are facing unparalleled volumes of individuals in hospital awaiting discharge, often because patients’ homes are not amenable to their needs or immediate care supports are unavailable. Hospital-to-home care transition programs that integrate acute and community-based care delivery can ensure home environments are safe and conducive to recovery, and provide temporary intensive support until long term community care is available or patients regain their health. They can also expedite in-hospital care for patients who need it the most by streamlining patient flow. However, care transition programs need to flexibly offer a wide range of services depending on patient needs, so resource planning is challenging. Further, understanding patient and provider experiences with transition programs will ensure they deliver sustainable, high-quality care.
Approach: We conducted a multi-methods pilot evaluation of a hospital-to-home care transition program at a community hospital in Mississauga, Canada called THP@Home. This hospital serves a large, diverse patient population, of which 14% are aged 65 years or older, and 11% are considered to have unsuitable housing. To understand the reach, required resources, and feasibility of the program, we summarized the number and characteristics of patients served by the program and the types of services provided. To explore experiences with the program and identify strengths, challenges, comparison to usual care, and potential areas for improvement, we conducted interviews with patients, caregivers, healthcare providers, and program administrators.
Results: From March 2023 to September 2024, 398 patients received THP@Home services. Of these patients, 65% were female, 53% were over 80 years of age, the average length of hospital stay for inpatients before transitioning home was 19 days, and the average length of THP@Home services provided was 37 days. Sixteen percent of patients were provided THP@Home services following an emergency department visit with no admission. Patients averaged 32 service orders each when receiving care from the program, with occupational therapy (n=531), personal support (n=579), and physiotherapy (n=539) being the most common. Ten patients, caregivers, healthcare providers, and program administrators participated in the interviews. The overwhelming consensus was that the program positively exceeded patient and caregiver expectations, providing more support and services and facilitating a quicker return home than anticipated. Healthcare providers found the program fulfilling, but faced challenges when supporting patients who needed unanticipated services to improve home safety such as decluttering or pest-control services, purchasing basic amenities (e.g., mattress, temporary phone), or handyperson services to build or install needed furniture for medical accommodations.
Implications: Overall, this evaluation suggests that the hospital-to-home transition program at our hospital is a valuable service, as it expedites discharge and supports patients to recover in a safe and comfortable environment. Next steps for this program will focus on evaluating the program’s effectiveness in facilitating timely discharge, reducing hospital re-admissions and emergency department visits, improving readiness for providing various services, and exploring how patients in highest need of THP@Home services can be prioritized.