Experiences of Patients and Their Caregivers Admitted to a Hospital-at-Home Program in Singapore: a Descriptive Qualitative Study

Abstract

BACKGROUND: Hospital at Home (HaH) programs have been shown to improve clinical outcomes, quality of care, and patient satisfaction. However, how Asian patients experience HaH remained underexplored. OBJECTIVE: To explore the perceptions and experiences of patients and caregivers admitted to a hospital-at-home program in Singapore. DESIGN: Descriptive qualitative study design. PARTICIPANTS: Purposive sampling was used to conduct 36 interviews with 13 patients, nine Legally Acceptable Representatives (LARs), and 14 caregivers until data saturation was achieved. INTERVENTIONS: NUHS@Home is a HaH program providing care through a multi-disciplinary team, enabled by remote vital signs monitoring through a tablet and wireless blood pressure and oxygen meters. APPROACH: This study used in-depth semi-structured individual interviews. Interviews were transcribed and thematically analyzed using Braun and Clark's six-step inductive approach. KEY RESULTS: The overarching theme identified was "Enablers, difficulties, and improvements to the HaH experiences" which was supported by three key themes:(1) Perceived better care at home, (2) Importance of social support, and (3) Organizational structures required to support HaH. Participants described overall HaH experiences around factors contributing to their impeding engagement, overall satisfaction, and quality of care. CONCLUSIONS: Although HaH is unfamiliar to the Singapore population, most of the participants in this study had an overall positive experience. The key challenges found in this paper were the stress and inconvenience caused to caregivers. The enablers for positive HaH experiences were (1) consideration of patient's family members as key participants in the patients' therapeutic alliance;(2) the HaH care team must be accessible, approachable, and reassuring, and communicate frequently and timely with patients and their families; and (3) financing strategies to ensure HaH out-of-pockets costs remain affordable which are critical to keeping HaH as an option for patients and families.

Economic Evaluation of Novel Models of Care for Patients With Acute Medical Problems

“…A large proportion of the savings are attributed to a reduced burden on nursing and physician time, as well as eliminating unnecessary “bed and breakfast” services in treating these conditions of low acuity and severity. By design, these alternative models deliver treatment to patients according to existing clinical practice guidelines and are expected to result in the same clinical outcomes in addition to the decreased risk of hospital-acquired infections and improved patient-reported outcomes related to quality of sleep and increased convenience from an earlier return to home . These models that reduce inpatient bed utilization are of greater value in postpandemic Singapore as bed occupancy rates in public hospitals frequently remain above 85% …”

“…If the HaH model were operated by all acute hospitals nationally, costs would be expected to decrease as commute times decrease when patients are serviced in smaller geographical zones. Increased public familiarity with the incorporation of this service into existing public health financing schemes would decrease the time needed to counsel patients on enrollment . However, the expansion of this service to other more complex conditions would be dependent on available protocols and resources to facilitate timely return to hospitals for investigation and treatment, as well as patient and clinician acceptance of these potential “U-turns.” Unfortunately, patients who are socially isolated and who cannot recover without a caregiver would always be excluded from this service.…”

“…Patients with dengue were treated at home, in a hospital-at-home (HaH) model, where patients were admitted to an HaH service from the ED. A multidisciplinary team of physicians and nurses delivered intravenous therapy or perform simple investigations for patients, giving them round-the-clock access to health care personnel from their home . Patients with chest pain were treated in an ambulatory care team (ACT) model, where timely care was provided in a clinic-style setting at the ED.…”

“…HaH is in line with trends for digitalizing health care and increasing patient and caregiver preferences for recovering at home . However, a reliable cost analysis of these models is lacking …”

Enhancing the hospital at home experience

“…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.…”