Supported Discharge Teams for older people in hospital acute care: a randomised controlled trial

Supported Discharge Teams for older people in hospital acute care: a randomised controlled trial Abstract Background Supported Discharge Teams aim to help with the transition from hospital to home, whilst reducing hospital length-of-stay. Despite their obvious attraction, the evidence remains mixed, ranging from strong support for disease-specific interventions to less favourable results for generic services. Objective To determine whether older people referred to a Supported Discharge Team have: (i) reduced length-of-stay in hospital; (ii) reduced risk of hospital readmission; and (iii) reduced healthcare costs. Methods Randomised controlled trial with follow-up to 6 months; 103 older women and 80 men (n = 183) (mean age 79), in hospital, were randomised to receive either Supported Discharge Team or usual care. Home-based rehabilitation was delivered by trained Health Care Assistants up to four times a day, 7 days a week, under the guidance of registered nurses, allied health and geriatricians for up to 6 weeks. Results Participants randomised to the Supported Discharge Team spent less time in hospital during the index admission (mean 15.7 days) in comparison to usual care (mean 21.6 days) (mean difference 5.9: 95% CI 0.6, 11.3 days: P = 0.03) and spent less time in hospital in the 6 months following discharge home. Supported discharge group costs were calculated at mean NZ$10,836 (SD NZ$12,087) compared to NZ$16,943 (SD NZ$22,303) in usual care. Conclusion A Supported Discharge Team can provide an effective means of discharging older people home early from hospital and can make a cost-effective contribution to managing increasing demand for hospital beds. early supported discharge teams, intermediate care, hospital capacity, readmissions to hospital, older people Introduction A UK department of health report in 2016 [1] highlighted the impact of discharge delays for older people (65+ years) on acute hospital bed-days. The report estimated that 1.15 million bed-days (an increase of 31% since 2013) could be saved annually if transfers occurred in a timely fashion. Understanding and remedying this growing problem is of importance, particularly in relation to the sustainability of health services in the developed world. As numbers of older people increase, viable alternatives to hospitalisation become increasingly important, as it is simply not possible to continue to match population growth with hospital beds. Furthermore, research highlights that hospital is not always the best location for older people. Older people experience a rapid deterioration in strength [2] and function [3] as well as increased infection risk [4] when in hospital. The need for greater investment in rehabilitation has been recognised for some time in New Zealand [5] and internationally [6, 7]. Continuity of care between hospital and community has long been identified as important [8] and of equal significance is the need to co-ordinate, review and establish effective links [5]. Achieving safe discharge as soon as possible after the initiating illness has resolved is important both to the patient and the acute hospital service. Identifying a means to reduce the time an older person spends in hospital and to avoid readmission is of considerable importance to all. Supported Discharge Teams (SDT) may protect the older person from risks of hospitalisation [9–12], allowing cost-effective use of scarce resources and be preferred by older people themselves [13]. Despite the obvious attractions of such, the evidence remains mixed, ranging from strong support for disease-specific interventions such as for stroke [14, 15], to less favourable results for generic services [16, 17]. Further, it is difficult to draw conclusions from meta-analyses. The scarcity of robust SDT trials coupled to confusion around the distinct operational aspects of these services make definitive inferences problematic. It is challenging, for example to draw meaningful interpretations from a meta-analysis that combines discrete community teams with in-patient coordinated discharge roles or care planning [17–19]. Few trials have evaluated interventions that have a focus on generic needs so that, despite their age, the original work by Martin et al. [12] in relation to the ‘Home Treatment Team’ in London and the ‘Discharge of Elderly from the Emergency Department’ service evaluated by Caplan et al. [20] in Sydney are still regularly cited. Notwithstanding the difficulties in drawing definitive conclusions from the available evidence, since 2003 the UK Department of Health has advocated the establishment of SDT [21]. The population of New Zealand, like that of many other ‘new world’ countries, is comparatively young; the population of older people (65+) in 2016 is 14.3%, significantly lower than the UK at 18.5%. As such, the healthcare pressures, such as hospital capacity issues observed in more ‘aged’ countries such as the UK and Europe are only recently being experienced. This study seeks to generate new robust evidence concerning the impact of SDTs for older people with generic needs, it explicitly describes the intervention, allowing replication and has immediate applicability for growing hospital capacity issues in demographically younger countries. Methods We conducted a randomised controlled trial of an early SDT (START, Supported Transfer & Accelerated Rehabilitation Team) in comparison to usual care in Waikato, New Zealand. The trial is reported according to the CONSORT statement for parallel groups [22]. Older people were eligible for the study if they met the START inclusion criteria: >65 years; in hospital at time of referral and did not require ongoing acute hospital based treatment (in the judgement of the consultant geriatrician); consented to being treated at home; and agreed with the objectives set by the referring inter-disciplinary team. Further, following assessment by the referring team, the participant was considered to have potential for partial or complete recovery with suitable home rehabilitation within 6 weeks; was able to stand and transfer with 1-person (with or without the help of a resident carer); and the participant had a recent acute illness or injury or was at a borderline level of function with an associated reduction in Activities of Daily Living (ADL) and/or Instrumental ADL (IADL) and who without input from the team was considered likely to fail to recuperate full potential of functional recovery or was likely to fail to manage satisfactorily at home despite conventional community support and therefore would be at risk of hospital readmission or institutionalisation. Once START eligibility was confirmed, the contact details of potential participants were forwarded to the research registered physiotherapist who then contacted participants and gained written informed consent from participants or family members or legal guardians. The multi-disciplinary team had no influence on the randomisation allocation. Recruitment occurred over 18 months and all participants entered the study between May 2012 and October 2014. The study was approved by the National Health and Disability Ethics Committee (NTX/11/09/088) and registered on the Australian New Zealand Clinical Trials Registry (ACTRN12611000982910). Initial interviews were undertaken in a quiet hospital room and subsequent interviews via telephone by a registered health professional (speech and language therapist) employed by the researchers and independent of the health services at 3 and 6 months and lasted approximately 90 min. The primary outcome was number of days in hospital during the initial hospital episode (the index admission). Secondary endpoints included: (i) days in hospital during the 6 months period following randomisation (readmissions); (ii) health related costs, calculated from routine hospital administrative records; and (iii) function, as ascertained using the interRAI Contact Assessment (interRAI-CA) [23]. The interRAI-CA assesses multiple domains of the older person and has several sub-scales. The ADL self performance scale assesses across the domains of bathing, personal hygiene, dressing lower body, locomotion and toilet use; and the Instrumental ADL Capacity scale measures meal preparation, ordinary housework, managing medications and stairs. Several other key demographic variables were collected and presented in Table 1. All have been validated [24]. Table 1. Demographics Measure  Intervention (n = 97)  Control (n = 86)  n (%)  n (%)  Gender   Female  59 (60.8)  44 (51.2)   Male  38 (39.2)  42 (48.8)  Mean age (SD)  79.8 (7.2)  78.7 (8.2)  Ethnicity   European not further defined  8 (8.2)  2 (2.3)   NZ European  65 (67.0)  61 (70.9)   Other European  14 (14.4)  11(12.8)   NZ Māori  8 (8.2)  3 (3.5)   Not stated  2 (2.1)  9 (10.5)  Living arrangement   Alone  58 (59.2)  45 (52.3)   With spouse/partner only  27 (27.6)  28 (32.6)   With spouse/partner and other(s)  3 (3.1)  0 (0)   With child (not spouse/partner)  6 (6.1)  6 (7.0)   With sibling(s)  0 (0)  1 (1.2)   With other relative(s)/whanau  2 (2.0)  0 (0)   With non-relative(s)  2 (2.0)  2 (2.3)   Missing  0 (0)  4 (6.7)  Living   Private home/apartment/rented room  95 (96.9)  74 (86.0)   Board and care  0 (0)  2 (2.3)   Assisted living or semi-independent  living  1 (1.0)  9 (10.5)   Missing  1 (1.0)  1 (1.2)  Cognitive skills for daily decision making   Independent  84 (85.7)  70 (81.4)   Modified independent or any impairment  14 (14.3)  16 (18.6)  Comprehension (ability to understand others)   Understands  82 (83.7)  73 (84.9)   Usually understands  13 (13.3)  11 (12.8)   Often understands  3 (3.1)  1 (1.2)   Sometimes understands  0 (0)  1 (1.2)  Vision (ability to see in adequate light)   Adequate  63 (64.3)  65 (75.6)   Minimal difficulty  4 (4.1)  13 (15.1)   Moderate difficulty  5 (5.1)  6 (7.0)   Severe difficulty  1 (1.0)  1 (1.2)   Missing  25 (25.5)  1 (1.2)  Measure  Intervention (n = 97)  Control (n = 86)  n (%)  n (%)  Gender   Female  59 (60.8)  44 (51.2)   Male  38 (39.2)  42 (48.8)  Mean age (SD)  79.8 (7.2)  78.7 (8.2)  Ethnicity   European not further defined  8 (8.2)  2 (2.3)   NZ European  65 (67.0)  61 (70.9)   Other European  14 (14.4)  11(12.8)   NZ Māori  8 (8.2)  3 (3.5)   Not stated  2 (2.1)  9 (10.5)  Living arrangement   Alone  58 (59.2)  45 (52.3)   With spouse/partner only  27 (27.6)  28 (32.6)   With spouse/partner and other(s)  3 (3.1)  0 (0)   With child (not spouse/partner)  6 (6.1)  6 (7.0)   With sibling(s)  0 (0)  1 (1.2)   With other relative(s)/whanau  2 (2.0)  0 (0)   With non-relative(s)  2 (2.0)  2 (2.3)   Missing  0 (0)  4 (6.7)  Living   Private home/apartment/rented room  95 (96.9)  74 (86.0)   Board and care  0 (0)  2 (2.3)   Assisted living or semi-independent  living  1 (1.0)  9 (10.5)   Missing  1 (1.0)  1 (1.2)  Cognitive skills for daily decision making   Independent  84 (85.7)  70 (81.4)   Modified independent or any impairment  14 (14.3)  16 (18.6)  Comprehension (ability to understand others)   Understands  82 (83.7)  73 (84.9)   Usually understands  13 (13.3)  11 (12.8)   Often understands  3 (3.1)  1 (1.2)   Sometimes understands  0 (0)  1 (1.2)  Vision (ability to see in adequate light)   Adequate  63 (64.3)  65 (75.6)   Minimal difficulty  4 (4.1)  13 (15.1)   Moderate difficulty  5 (5.1)  6 (7.0)   Severe difficulty  1 (1.0)  1 (1.2)   Missing  25 (25.5)  1 (1.2)  The START service consists of healthcare assistants (HCA) trained to Level III on the New Zealand Qualifications Authority framework, registered nurses working at an advanced level of practice and allied health practitioners (physiotherapy and occupational therapy). Consultant geriatricians provide weekly input through case conferencing. HCAs provided up to 4 visits a day, 7 days a week following a programme of graduated reduction of inputs (See the Table in Appendix 2, Supplementary Information) and utilise functional rehabilitation principles to maximise recovery through incorporating exercises within ADL tasks, which has a growing evidence base [25, 26] (e.g. progressively increasing walking distance, sit-to-stands, lying-in-bed to standing, carrying groceries home from shops and putting away in cupboards). The model focuses on maximising independence rather than fostering dependence and aligns with developing research in New Zealand [26–29]. Significantly, such exercise programmes can be successfully implemented by non-health professionals rather than physiotherapists [30]. The use of HCAs to deliver direct care is a sensible strategy to developing a sustainable workforce. Once patients have returned home, direct clinical care responsibility returns to the general practitioner (GP). The team works in close collaboration with GPs and practice nurses as well as the specialist community teams and hospital services and will continue to visit the patient until their return to independence or until stable (but requiring continuing input from community nursing or home care support). Patients are limited to 6 weeks attendance, though the team on an exception basis may choose to extend this to maximise potential recovery. Patients are supported to develop meaningful distal goals which are re-interpreted into a therapy ladder to support development of a care-plan utilising functional rehabilitation principles. Participants were randomly assigned to either the intervention or control group using a computer-generated randomisation sequence. Participants assigned to the control group were provided with usual care, which involved discharge planning from the hospital to their place of residence and subsequent community-based services as required. It was not possible to conceal randomisation allocation from participants but primary endpoints were collected through routine hospital datasets and analyses were undertaken blinded to the intervention/control allocation. All enroled older people were under the care of their GP and the health services being evaluated. Adverse Events and Serious Adverse Events were monitored according to the International Conference on Harmonisation/Good Clinical Practice standards. At each data collection point, the research associate collected additional data around GP visits, hospitalisations, falls, reported episodes of abuse, infections, which was independently reviewed 3-monthly by a monitoring committee. A total sample size of 176 participants was estimated to provide a power of 90% with a 2-sided α = 0.05 to detect a 20% reduction in mean hospital length of stay (index hospital admission) from 15 to 12 days (a difference of 3 days) assuming a SD of 6.1. The changes were based on previous findings of studies exploring the impact of SDTs on hospital length-of-stay [12] and local clinical experience during delivery of a prototype service. Summaries of collected data are presented in Tables 1–3 as counts and percentages for categorical and means and standard deviations for continuous. All statistical tests were 2-tailed and a 5% significance level maintained throughout the analyses. All treatment evaluations were performed on the principle of ‘Intention to Treat’ and analyses were blinded. Analysis of variance, adjusted by age was undertaken on the primary end-point. Secondary outcomes were analysed using analysis of variance (adjusted by age) for readmission data and costs. Changes in functional status was assessed though the interRAI-CA, analysed using 2 × 2 chi squared, as presentation of the individual items of the ADL and IADL scales were considered of more value than summative scores. All analyses were performed using SAS Software 9.4. Results In total, 351 older people were screened and 184 participants entered the trial (recruitment rate 52.4%) (see Appendix 1, in Supplementary Information for Consort Flow Diagram). One participant withdrew after randomisation before the baseline assessment. Participants were mostly female, of European descent, lived in their own home either alone or with a spouse and around 15% had some level of cognitive impairment. Baseline characteristics were similar across the two groups (Table 1). Over the trial time-period, 8,700 older people were discharged across the 600-bedded tertiary hospital, which includes 81 Assessment, Treatment and Rehabilitation beds. The START intervention reduced the mean length of time a participant spent in hospital prior to discharge home, the index admission (15.7 days in START versus 21.6 days in usual care, Table 2a). Further, participants who received the START intervention spent less time in hospital in the 6 months following randomisation, readmissions (7.1 days in START compared to 12.5 days in usual care, Table 2b). Hospital data were collected in the 6 months pre-randomisation and was comparable between the two groups (mean 22.0 days [SD 20.6] in START versus mean 22.2 [SD 20.1] in usual care). Table 2a. Index hospital length of stay (primary outcome) Allocation  N  Mean hospital days (SD)  Mean days difference between groups (CI)  Significance (ANOVA)  Effect size, Partial Eta (CI)  START  97  15.7 (11.5)  5.9 (0.6, 11.3)  0.030  0.03 (0.0, 0.08)  Usual care  86  21.6 (22.9)  Allocation  N  Mean hospital days (SD)  Mean days difference between groups (CI)  Significance (ANOVA)  Effect size, Partial Eta (CI)  START  97  15.7 (11.5)  5.9 (0.6, 11.3)  0.030  0.03 (0.0, 0.08)  Usual care  86  21.6 (22.9)  Table 2b. Time in hospital in the 6-month period post-randomisation (readmissions) Allocation  Mean hospital days over 6 months (SD)  Mean discrete hospital episodes (SD)  Difference between groups for mean hospital days (CI)  Significance (ANOVA)  Effect size, Partial Eta (CI)  START  7.1 (12.8)  1.3 (1.1)  5.4 (−0.2, 11.3)  0.047  0.06 (0.0, 0.1)  Usual care  12.5 (24.2)  1.7 (2.4)  Allocation  Mean hospital days over 6 months (SD)  Mean discrete hospital episodes (SD)  Difference between groups for mean hospital days (CI)  Significance (ANOVA)  Effect size, Partial Eta (CI)  START  7.1 (12.8)  1.3 (1.1)  5.4 (−0.2, 11.3)  0.047  0.06 (0.0, 0.1)  Usual care  12.5 (24.2)  1.7 (2.4)  The effect size was calculated using Partial Eta, revealing a small to moderate change for the primary outcome, the index admission (Table 2a, 0.03) and a larger change for the 6-month post-randomisation period (Table 2b, 0.06). In-patient hospital costs were NZ$680 per day and were the main contributor to overall costs. The START intervention was priced at NZ$94 a day, which totalled a mean NZ$1,618 per total episode (see Appendix 2, in Supplementary Information for detailed breakdown of START staffing inputs, by episode of care). In the 6 months prior to randomisation, participants in the START group accrued mean healthcare costs of NZ$22,766 (SD NZ$16,605) compared to NZ$23,692 (SD NZ$24,961) in usual care. Healthcare costs reduced in both groups in the 6-month post-randomisation period, though the reduction in the START group was greater (P = 0.004). The START group costs were calculated at mean NZ$10,836 (SD NZ$12,087), compared to mean NZ$16,943 (SD NZ$22,303) in usual care. Functional status at baseline/follow-up is described in Table 3. Many required support for bathing and lower body dressing (around 40%). Half required assistance with meal preparation and half were unable to negotiate stairs independently. Only 20% were able to perform their own housework. There was a trend for increasing independence across the functional domains for those participants who had received the START intervention. The interRAI-CA does not readily lend itself to statistical interpretation and therefore the independent value was redefined as ‘1’ from ‘0’ and dependent as ‘2’ from ‘1’ and the mean differences from baseline to follow-up were analysed. Table 3. Function at baseline and follow up Measure  START  Usual care  P value (mean diff. on scores)  Baseline, N (%)  Follow up, N (%)  Baseline, N (%)  Follow up, N (%)  Bathing (ADL self performance)   Independent or set-up help only  34 (34.7)  63 (65.6)  38 (44.2)  48 (55.8)  0.006   Supervision or any physical assistance  63 (64.3)  18 (18.8)  48 (55.8)  28 (32.6)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.65  1.22  1.56  1.37  Personal hygiene (ADL self performance)   Independent or set-up help only  79 (80.6)  75 (78.1)  67 (77.9)  64 (74.4)  0.400   Supervision or any physical assistance  19 (19.4)  6 (6.3)  19 (22.1)  12 (14.0)   Missing  0 (0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.19  1.07  1.22  1.16  Dressing lower body (ADL self performance)   Independent or set-up help only  59 (60.2)  71 (74.0)  58 (67.4)  59 (68.6)  0.025   Supervision or any physical assistance  38 (38.8)  10 (10.4)  28 (32.6)  17 (19.8)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.39  1.12  1.33  1.22  Locomotion (ADL self performance)   Independent or set-up help only  81 (82.7)  76 (79.2)  69 (80.2)  65 (75.6)  0.327   Supervision or any physical assistance  16 (16.3)  5 (5.2)  17 (19.8)  11 (12.8)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.16  1.06  1.20  1.14  Toilet use (ADL self performance)   Independent or set-up help only  57 (58.2)  74 (77.1)  71 (82.6)  67 (77.9)  0.545   Supervision or any physical assistance  15 (15.3)  7 (7.3)  14 (16.3)  9 (10.5)   Missing  26 (26.5)  15 (15.6)  1 (1.2)  10 (11.6)   Mean scores  1.21  1.09  1.16  1.12  Meal preparation (IADL capacity)   Independent or set-up help only  43 (43.9)  61 (63.5)  39 (45.4)  51 (59.3)  0.415   Supervision or any assistance during task  54 (55.1)  20 (20.8)  46 (53.5)  25 (29.1)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.56  1.25  1.54  1.33  Ordinary housework (dishes dusting etc.) (IADL capacity)   Independent or set-up help only  10 (10.2)  35 (36.5)  18 (20.9)  35 (40.7)  0.267   Supervision or any assistance during task  87 (88.8)  46 (47.9)  68 (79.1)  41 (47.7)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.90  1.57  1.79  1.54  Managing medications (IADL capacity)   Independent or set-up help only  65 (66.3)  64 (66.7)  55 (64.0)  59 (68.6)  0.725   Supervision or any assistance during task  33 (33.7)  17 (17.7)  30 (34.9)  17 (19.8)   Missing  0 (0)  15 (15.6)  1 (1.2)  10 (11.6)   Mean scores  1.34  1.21  1.35  1.22  Stairs (IADL capacity)   Independent or set-up help only  26 (26.5)  54 (56.3)  35 (40.7)  53 (61.6)  0.137   Supervision or any assistance during task  72 (73.5)  27 (28.1)  49 (57.0)  23 (26.7)   Missing  0 (0)  15 (15.6)  2 (2.3)  10 (11.6)   Mean scores  1.73  1.33  1.58  1.30  Measure  START  Usual care  P value (mean diff. on scores)  Baseline, N (%)  Follow up, N (%)  Baseline, N (%)  Follow up, N (%)  Bathing (ADL self performance)   Independent or set-up help only  34 (34.7)  63 (65.6)  38 (44.2)  48 (55.8)  0.006   Supervision or any physical assistance  63 (64.3)  18 (18.8)  48 (55.8)  28 (32.6)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.65  1.22  1.56  1.37  Personal hygiene (ADL self performance)   Independent or set-up help only  79 (80.6)  75 (78.1)  67 (77.9)  64 (74.4)  0.400   Supervision or any physical assistance  19 (19.4)  6 (6.3)  19 (22.1)  12 (14.0)   Missing  0 (0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.19  1.07  1.22  1.16  Dressing lower body (ADL self performance)   Independent or set-up help only  59 (60.2)  71 (74.0)  58 (67.4)  59 (68.6)  0.025   Supervision or any physical assistance  38 (38.8)  10 (10.4)  28 (32.6)  17 (19.8)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.39  1.12  1.33  1.22  Locomotion (ADL self performance)   Independent or set-up help only  81 (82.7)  76 (79.2)  69 (80.2)  65 (75.6)  0.327   Supervision or any physical assistance  16 (16.3)  5 (5.2)  17 (19.8)  11 (12.8)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.16  1.06  1.20  1.14  Toilet use (ADL self performance)   Independent or set-up help only  57 (58.2)  74 (77.1)  71 (82.6)  67 (77.9)  0.545   Supervision or any physical assistance  15 (15.3)  7 (7.3)  14 (16.3)  9 (10.5)   Missing  26 (26.5)  15 (15.6)  1 (1.2)  10 (11.6)   Mean scores  1.21  1.09  1.16  1.12  Meal preparation (IADL capacity)   Independent or set-up help only  43 (43.9)  61 (63.5)  39 (45.4)  51 (59.3)  0.415   Supervision or any assistance during task  54 (55.1)  20 (20.8)  46 (53.5)  25 (29.1)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.56  1.25  1.54  1.33  Ordinary housework (dishes dusting etc.) (IADL capacity)   Independent or set-up help only  10 (10.2)  35 (36.5)  18 (20.9)  35 (40.7)  0.267   Supervision or any assistance during task  87 (88.8)  46 (47.9)  68 (79.1)  41 (47.7)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.90  1.57  1.79  1.54  Managing medications (IADL capacity)   Independent or set-up help only  65 (66.3)  64 (66.7)  55 (64.0)  59 (68.6)  0.725   Supervision or any assistance during task  33 (33.7)  17 (17.7)  30 (34.9)  17 (19.8)   Missing  0 (0)  15 (15.6)  1 (1.2)  10 (11.6)   Mean scores  1.34  1.21  1.35  1.22  Stairs (IADL capacity)   Independent or set-up help only  26 (26.5)  54 (56.3)  35 (40.7)  53 (61.6)  0.137   Supervision or any assistance during task  72 (73.5)  27 (28.1)  49 (57.0)  23 (26.7)   Missing  0 (0)  15 (15.6)  2 (2.3)  10 (11.6)   Mean scores  1.73  1.33  1.58  1.30  Discussion The START service reduced both the index hospital admission and time in hospital in the following 6 months. Understanding the mechanism by which this was achieved requires a pragmatic interpretation. START, like any successful SDT does not operate a waiting list, can deliver intensive home-based support immediately and has the trust and confidence of the in-patient clinical teams. As such, even very frail older people can be discharged home at any point rather than waiting sometimes several days for a similarly intensive home care package to be established. There are several ways to interpret the reduction in hospital admissions within the START group in the 6 months post-randomisation. The reduction in the time an individual spent in hospital reduced hospital exposure [1, 2, 4], which in the process may have contributed directly to reduced readmission rates. Further, the enhanced oversight from an experienced inter-disciplinary clinical team within START coupled to a strong focus on individualised goals and rehabilitation and the development of a partnership approach between the patient’s GP and specialist geriatric services may also have had a role. The trend for improvements in functional status were primarily within personal ADL, specifically bathing, lower body dressing and toileting. It is possible that such activities were a focus of the service as dependency in these areas invariably require ongoing community support. Lower levels of change were observed in other domains, but this may have been more due to the ceiling effect of the assessment tool or simply that a greater number of older people were independent in those areas on discharge from hospital. Although findings were positive around the costs of the intervention, most savings were made through reducing hospital bed-days. Given that hospital beds are seldom closed because of initiatives such as these, it is debateable as to whether financial savings were truly made, rather financial gains may come later through either delaying or preventing new hospital beds coming online. In this way, SDTs such as START offer a proven community-based secondary care tool to manage hospital capacity. A limitation of the study, arising in the main as a direct effect of the intention to intervene on the basis of function is that no restrictions were placed on diagnoses, opting more to focus on a population of older people who had experienced a recent decline in function, often had low morale with a level of cognitive impairment. Such inclusion criteria are common to the original SDT, still operating in Lambeth, London [12]. Conclusions from this study therefore need to be cognisant of the inclusion criteria described herein. We believe our findings can be generalised, where the same eligibility criteria apply. However, the application of the inclusion criteria could have a substantial impact on extrapolation of results to other services. Key points Supported Discharge Teams can support older people with a variety of conditions to be discharged earlier from hospital. Supported Discharge Teams can reduce risk of readmission to hospital for older people. Supported Discharge Teams have an important role to play in increasing bed capacity of hospitals. Supplementary Data Supplementary data mentioned in the text are available to subscribers in Age and Ageing online. Funding The research was funded by the Health Research Council of New Zealand (ref. 11/720). Conflicts of Interest None. Acknowledgements A huge thanks to Barb Garbutt, General Manager of Older Person Rehabilitation Services, Waikato District Health Board, without who’s wisdom and support, fundamentally important pieces of the evidence puzzle could not have been solved. To Raewyn Dean, the forever flexible, dynamic service leader who has created a wonderful team—well done! References 1 Comptroller, Auditor General. Discharging Older Patients From Hospital . London, UK: Department of Health, 2016. 26th May 2016. Report No.: Contract No.: HC18. 2 de Morton N, Keating JL, Jeffs K. Exercise for acutely hospitalised older medical patients. The Cochrane Library, 2007. 3 Covinsky KE, Palmer RM, Fortinsky RH et al.  . Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc  2003; 51: 451– 8. Google Scholar CrossRef Search ADS PubMed  4 Office for National Statistics. Deaths involving MRSA: 2008 to 2012. London: 22 August 2013. Report No. 5 Ministry of Health. Guideline for Specialist Health Services for Older People . Wellington, New Zealand: Ministry of Health, 2004. 6 Nocon A, Baldwin S. Trends in Rehabilitation Policy: A Review of the Literature . London: King’s Fund, 1998. 7 King’s Fund. Developing Rehabilitation Opportunities for Older People . London: King’s Fund, 1999. 8 King’s Fund. Treatment of stroke: consensus conference. Br Med J  1988; 297: 126– 8. CrossRef Search ADS   9 Kennedy L. Effective comprehensive discharge planning for hospitalized elderly. Gerontolgist  1987; 27: 577– 80. Google Scholar CrossRef Search ADS   10 Styrborn K. Early discharge planning for elderly patients in acute hospitals—an intervention study. Scand J Soc Med  1995; 23: 273– 85. Google Scholar CrossRef Search ADS PubMed  11 Rich M. Prevention of readmission in elderly patients with congestive heart failure. J Gen Intern Med  1993; 8: 585– 90. Google Scholar CrossRef Search ADS PubMed  12 Martin F, Oyewole A, Moloney A. A randomized controlled trial of a high support hospital discharge team for elderly people. Age Ageing  1994; 23: 228– 34. Google Scholar CrossRef Search ADS PubMed  13 Cobley CS, Fisher RJ, Chouliara N, Kerr M, Walker MF. A qualitative study exploring patients’ and carers’ experiences of Early Supported Discharge services after stroke. Clin Rehabil  2013; 27: 750– 7. Google Scholar CrossRef Search ADS PubMed  14 Langhorne P, Taylor G, Murray G et al.  . Early supported discharge services for stroke patients: a meta-analysis of individual patients’ data. Lancet  2005; 365: 501– 6. Google Scholar CrossRef Search ADS PubMed  15 Fearon P, Langhorne P, Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients. Cochrane Database Syst Rev  2012; 9: CD000443. 16 Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care. Cochrane Database Syst Rev 2001; 2: CD000356. doi: 10.1002/14651858.CD000356. 17 Hyde C, Robert I, Sinclair A. The effects of supporting discharge from hospital to home in older people. Age Ageing  2000; 29: 271– 9. Google Scholar CrossRef Search ADS PubMed  18 Dunn R. The role of post-hospital discharge schemes, Current Medical Literature. Geriatrics  1996; 9: 3– 10. 19 Bours G, Ketelaars C, Corry A. The effects of aftercare on chronic persons and frail elderly persons when discharged from hospital—a systematic review. J Adv Nurs  1998; 27: 271– 9. Google Scholar CrossRef Search ADS   20 Caplan G, Williams AJ, Daly B et al.  . A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department—The DEED II Study. J Am Geriatr Soc  2004; 52: 1417– 23. Google Scholar CrossRef Search ADS PubMed  21 Depart Discharge from Hospital. Pathway, Process and Practicement of Health United Kingdom. London, 2003. 22 Schulz K, Altman D, Moher D. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. BMC Med  2010; 8: 18. Google Scholar CrossRef Search ADS PubMed  23 Hirdes J, Curtin-Telegdi N, Poss J et al.  . interRAI Contact Assessment (CA) form and User’s manual: a screening level assessment for emergency department and intake from community/hospital. Version 9.2, 2010. 24 Morris J, Fries BE, Bernabei R et al.  . RAI—Home Care Assessment Manual . Washington, DC: InterRAI Corporation, 1996. 25 de Vreede PL, Samson MM, van Meeteren NLU, Duursma SM, Verhaar HJJ. Functional-task exercise versus resistance strength exercise to improve daily function in older women: a randomized controlled trial. J Am Geriatr Soc  2005; 53: 2– 10. Google Scholar CrossRef Search ADS PubMed  26 Parsons M, Senior H, Kerse N, Chen M-H, Jacobs S, Anderson C. Randomised trial of restorative home care for frail older people in New Zealand. Nurs Older People  2017; 29: 27– 33. Google Scholar CrossRef Search ADS PubMed  27 King AII, Parsons M, Robinson E, Jörgensen D. Assessing the impact of a restorative home care service in New Zealand: a cluster randomised controlled trial. Health Soc Care Community  2011; 20: 365– 74. Google Scholar CrossRef Search ADS PubMed  28 Parsons J, Rouse P, Robinson EM, Sheridan N, Connolly MJ. Goal setting as a feature of homecare services for older people: does it make a difference? Age Ageing  2012; 41: 24– 9. Google Scholar CrossRef Search ADS PubMed  29 Parsons M, Senior HE, Kerse N et al.  . The Assessment of Services Promoting Independence and Recovery in Elders Trial (ASPIRE): a pre-planned meta-analysis of three independent randomised controlled trial evaluations of ageing in place initiatives in New Zealand. Age Ageing  2012; 41: 722– 8. Google Scholar CrossRef Search ADS PubMed  30 Parsons J, Mathieson S, Parsons M. Home Care: an opportunity for physiotherapy. New Zeal J Physiother  2015; 43: 24– 31. © The Author 2017. Published by Oxford University Press on behalf of the British Geriatrics Society.All rights reserved. For permissions, please email: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Age and Ageing Oxford University Press

Supported Discharge Teams for older people in hospital acute care: a randomised controlled trial

Loading next page...
 
/lp/ou_press/supported-discharge-teams-for-older-people-in-hospital-acute-care-a-f9YmIpVtf5
Publisher
Oxford University Press
Copyright
© The Author 2017. Published by Oxford University Press on behalf of the British Geriatrics Society.All rights reserved. For permissions, please email: journals.permissions@oup.com
ISSN
0002-0729
eISSN
1468-2834
D.O.I.
10.1093/ageing/afx169
Publisher site
See Article on Publisher Site

Abstract

Abstract Background Supported Discharge Teams aim to help with the transition from hospital to home, whilst reducing hospital length-of-stay. Despite their obvious attraction, the evidence remains mixed, ranging from strong support for disease-specific interventions to less favourable results for generic services. Objective To determine whether older people referred to a Supported Discharge Team have: (i) reduced length-of-stay in hospital; (ii) reduced risk of hospital readmission; and (iii) reduced healthcare costs. Methods Randomised controlled trial with follow-up to 6 months; 103 older women and 80 men (n = 183) (mean age 79), in hospital, were randomised to receive either Supported Discharge Team or usual care. Home-based rehabilitation was delivered by trained Health Care Assistants up to four times a day, 7 days a week, under the guidance of registered nurses, allied health and geriatricians for up to 6 weeks. Results Participants randomised to the Supported Discharge Team spent less time in hospital during the index admission (mean 15.7 days) in comparison to usual care (mean 21.6 days) (mean difference 5.9: 95% CI 0.6, 11.3 days: P = 0.03) and spent less time in hospital in the 6 months following discharge home. Supported discharge group costs were calculated at mean NZ$10,836 (SD NZ$12,087) compared to NZ$16,943 (SD NZ$22,303) in usual care. Conclusion A Supported Discharge Team can provide an effective means of discharging older people home early from hospital and can make a cost-effective contribution to managing increasing demand for hospital beds. early supported discharge teams, intermediate care, hospital capacity, readmissions to hospital, older people Introduction A UK department of health report in 2016 [1] highlighted the impact of discharge delays for older people (65+ years) on acute hospital bed-days. The report estimated that 1.15 million bed-days (an increase of 31% since 2013) could be saved annually if transfers occurred in a timely fashion. Understanding and remedying this growing problem is of importance, particularly in relation to the sustainability of health services in the developed world. As numbers of older people increase, viable alternatives to hospitalisation become increasingly important, as it is simply not possible to continue to match population growth with hospital beds. Furthermore, research highlights that hospital is not always the best location for older people. Older people experience a rapid deterioration in strength [2] and function [3] as well as increased infection risk [4] when in hospital. The need for greater investment in rehabilitation has been recognised for some time in New Zealand [5] and internationally [6, 7]. Continuity of care between hospital and community has long been identified as important [8] and of equal significance is the need to co-ordinate, review and establish effective links [5]. Achieving safe discharge as soon as possible after the initiating illness has resolved is important both to the patient and the acute hospital service. Identifying a means to reduce the time an older person spends in hospital and to avoid readmission is of considerable importance to all. Supported Discharge Teams (SDT) may protect the older person from risks of hospitalisation [9–12], allowing cost-effective use of scarce resources and be preferred by older people themselves [13]. Despite the obvious attractions of such, the evidence remains mixed, ranging from strong support for disease-specific interventions such as for stroke [14, 15], to less favourable results for generic services [16, 17]. Further, it is difficult to draw conclusions from meta-analyses. The scarcity of robust SDT trials coupled to confusion around the distinct operational aspects of these services make definitive inferences problematic. It is challenging, for example to draw meaningful interpretations from a meta-analysis that combines discrete community teams with in-patient coordinated discharge roles or care planning [17–19]. Few trials have evaluated interventions that have a focus on generic needs so that, despite their age, the original work by Martin et al. [12] in relation to the ‘Home Treatment Team’ in London and the ‘Discharge of Elderly from the Emergency Department’ service evaluated by Caplan et al. [20] in Sydney are still regularly cited. Notwithstanding the difficulties in drawing definitive conclusions from the available evidence, since 2003 the UK Department of Health has advocated the establishment of SDT [21]. The population of New Zealand, like that of many other ‘new world’ countries, is comparatively young; the population of older people (65+) in 2016 is 14.3%, significantly lower than the UK at 18.5%. As such, the healthcare pressures, such as hospital capacity issues observed in more ‘aged’ countries such as the UK and Europe are only recently being experienced. This study seeks to generate new robust evidence concerning the impact of SDTs for older people with generic needs, it explicitly describes the intervention, allowing replication and has immediate applicability for growing hospital capacity issues in demographically younger countries. Methods We conducted a randomised controlled trial of an early SDT (START, Supported Transfer & Accelerated Rehabilitation Team) in comparison to usual care in Waikato, New Zealand. The trial is reported according to the CONSORT statement for parallel groups [22]. Older people were eligible for the study if they met the START inclusion criteria: >65 years; in hospital at time of referral and did not require ongoing acute hospital based treatment (in the judgement of the consultant geriatrician); consented to being treated at home; and agreed with the objectives set by the referring inter-disciplinary team. Further, following assessment by the referring team, the participant was considered to have potential for partial or complete recovery with suitable home rehabilitation within 6 weeks; was able to stand and transfer with 1-person (with or without the help of a resident carer); and the participant had a recent acute illness or injury or was at a borderline level of function with an associated reduction in Activities of Daily Living (ADL) and/or Instrumental ADL (IADL) and who without input from the team was considered likely to fail to recuperate full potential of functional recovery or was likely to fail to manage satisfactorily at home despite conventional community support and therefore would be at risk of hospital readmission or institutionalisation. Once START eligibility was confirmed, the contact details of potential participants were forwarded to the research registered physiotherapist who then contacted participants and gained written informed consent from participants or family members or legal guardians. The multi-disciplinary team had no influence on the randomisation allocation. Recruitment occurred over 18 months and all participants entered the study between May 2012 and October 2014. The study was approved by the National Health and Disability Ethics Committee (NTX/11/09/088) and registered on the Australian New Zealand Clinical Trials Registry (ACTRN12611000982910). Initial interviews were undertaken in a quiet hospital room and subsequent interviews via telephone by a registered health professional (speech and language therapist) employed by the researchers and independent of the health services at 3 and 6 months and lasted approximately 90 min. The primary outcome was number of days in hospital during the initial hospital episode (the index admission). Secondary endpoints included: (i) days in hospital during the 6 months period following randomisation (readmissions); (ii) health related costs, calculated from routine hospital administrative records; and (iii) function, as ascertained using the interRAI Contact Assessment (interRAI-CA) [23]. The interRAI-CA assesses multiple domains of the older person and has several sub-scales. The ADL self performance scale assesses across the domains of bathing, personal hygiene, dressing lower body, locomotion and toilet use; and the Instrumental ADL Capacity scale measures meal preparation, ordinary housework, managing medications and stairs. Several other key demographic variables were collected and presented in Table 1. All have been validated [24]. Table 1. Demographics Measure  Intervention (n = 97)  Control (n = 86)  n (%)  n (%)  Gender   Female  59 (60.8)  44 (51.2)   Male  38 (39.2)  42 (48.8)  Mean age (SD)  79.8 (7.2)  78.7 (8.2)  Ethnicity   European not further defined  8 (8.2)  2 (2.3)   NZ European  65 (67.0)  61 (70.9)   Other European  14 (14.4)  11(12.8)   NZ Māori  8 (8.2)  3 (3.5)   Not stated  2 (2.1)  9 (10.5)  Living arrangement   Alone  58 (59.2)  45 (52.3)   With spouse/partner only  27 (27.6)  28 (32.6)   With spouse/partner and other(s)  3 (3.1)  0 (0)   With child (not spouse/partner)  6 (6.1)  6 (7.0)   With sibling(s)  0 (0)  1 (1.2)   With other relative(s)/whanau  2 (2.0)  0 (0)   With non-relative(s)  2 (2.0)  2 (2.3)   Missing  0 (0)  4 (6.7)  Living   Private home/apartment/rented room  95 (96.9)  74 (86.0)   Board and care  0 (0)  2 (2.3)   Assisted living or semi-independent  living  1 (1.0)  9 (10.5)   Missing  1 (1.0)  1 (1.2)  Cognitive skills for daily decision making   Independent  84 (85.7)  70 (81.4)   Modified independent or any impairment  14 (14.3)  16 (18.6)  Comprehension (ability to understand others)   Understands  82 (83.7)  73 (84.9)   Usually understands  13 (13.3)  11 (12.8)   Often understands  3 (3.1)  1 (1.2)   Sometimes understands  0 (0)  1 (1.2)  Vision (ability to see in adequate light)   Adequate  63 (64.3)  65 (75.6)   Minimal difficulty  4 (4.1)  13 (15.1)   Moderate difficulty  5 (5.1)  6 (7.0)   Severe difficulty  1 (1.0)  1 (1.2)   Missing  25 (25.5)  1 (1.2)  Measure  Intervention (n = 97)  Control (n = 86)  n (%)  n (%)  Gender   Female  59 (60.8)  44 (51.2)   Male  38 (39.2)  42 (48.8)  Mean age (SD)  79.8 (7.2)  78.7 (8.2)  Ethnicity   European not further defined  8 (8.2)  2 (2.3)   NZ European  65 (67.0)  61 (70.9)   Other European  14 (14.4)  11(12.8)   NZ Māori  8 (8.2)  3 (3.5)   Not stated  2 (2.1)  9 (10.5)  Living arrangement   Alone  58 (59.2)  45 (52.3)   With spouse/partner only  27 (27.6)  28 (32.6)   With spouse/partner and other(s)  3 (3.1)  0 (0)   With child (not spouse/partner)  6 (6.1)  6 (7.0)   With sibling(s)  0 (0)  1 (1.2)   With other relative(s)/whanau  2 (2.0)  0 (0)   With non-relative(s)  2 (2.0)  2 (2.3)   Missing  0 (0)  4 (6.7)  Living   Private home/apartment/rented room  95 (96.9)  74 (86.0)   Board and care  0 (0)  2 (2.3)   Assisted living or semi-independent  living  1 (1.0)  9 (10.5)   Missing  1 (1.0)  1 (1.2)  Cognitive skills for daily decision making   Independent  84 (85.7)  70 (81.4)   Modified independent or any impairment  14 (14.3)  16 (18.6)  Comprehension (ability to understand others)   Understands  82 (83.7)  73 (84.9)   Usually understands  13 (13.3)  11 (12.8)   Often understands  3 (3.1)  1 (1.2)   Sometimes understands  0 (0)  1 (1.2)  Vision (ability to see in adequate light)   Adequate  63 (64.3)  65 (75.6)   Minimal difficulty  4 (4.1)  13 (15.1)   Moderate difficulty  5 (5.1)  6 (7.0)   Severe difficulty  1 (1.0)  1 (1.2)   Missing  25 (25.5)  1 (1.2)  The START service consists of healthcare assistants (HCA) trained to Level III on the New Zealand Qualifications Authority framework, registered nurses working at an advanced level of practice and allied health practitioners (physiotherapy and occupational therapy). Consultant geriatricians provide weekly input through case conferencing. HCAs provided up to 4 visits a day, 7 days a week following a programme of graduated reduction of inputs (See the Table in Appendix 2, Supplementary Information) and utilise functional rehabilitation principles to maximise recovery through incorporating exercises within ADL tasks, which has a growing evidence base [25, 26] (e.g. progressively increasing walking distance, sit-to-stands, lying-in-bed to standing, carrying groceries home from shops and putting away in cupboards). The model focuses on maximising independence rather than fostering dependence and aligns with developing research in New Zealand [26–29]. Significantly, such exercise programmes can be successfully implemented by non-health professionals rather than physiotherapists [30]. The use of HCAs to deliver direct care is a sensible strategy to developing a sustainable workforce. Once patients have returned home, direct clinical care responsibility returns to the general practitioner (GP). The team works in close collaboration with GPs and practice nurses as well as the specialist community teams and hospital services and will continue to visit the patient until their return to independence or until stable (but requiring continuing input from community nursing or home care support). Patients are limited to 6 weeks attendance, though the team on an exception basis may choose to extend this to maximise potential recovery. Patients are supported to develop meaningful distal goals which are re-interpreted into a therapy ladder to support development of a care-plan utilising functional rehabilitation principles. Participants were randomly assigned to either the intervention or control group using a computer-generated randomisation sequence. Participants assigned to the control group were provided with usual care, which involved discharge planning from the hospital to their place of residence and subsequent community-based services as required. It was not possible to conceal randomisation allocation from participants but primary endpoints were collected through routine hospital datasets and analyses were undertaken blinded to the intervention/control allocation. All enroled older people were under the care of their GP and the health services being evaluated. Adverse Events and Serious Adverse Events were monitored according to the International Conference on Harmonisation/Good Clinical Practice standards. At each data collection point, the research associate collected additional data around GP visits, hospitalisations, falls, reported episodes of abuse, infections, which was independently reviewed 3-monthly by a monitoring committee. A total sample size of 176 participants was estimated to provide a power of 90% with a 2-sided α = 0.05 to detect a 20% reduction in mean hospital length of stay (index hospital admission) from 15 to 12 days (a difference of 3 days) assuming a SD of 6.1. The changes were based on previous findings of studies exploring the impact of SDTs on hospital length-of-stay [12] and local clinical experience during delivery of a prototype service. Summaries of collected data are presented in Tables 1–3 as counts and percentages for categorical and means and standard deviations for continuous. All statistical tests were 2-tailed and a 5% significance level maintained throughout the analyses. All treatment evaluations were performed on the principle of ‘Intention to Treat’ and analyses were blinded. Analysis of variance, adjusted by age was undertaken on the primary end-point. Secondary outcomes were analysed using analysis of variance (adjusted by age) for readmission data and costs. Changes in functional status was assessed though the interRAI-CA, analysed using 2 × 2 chi squared, as presentation of the individual items of the ADL and IADL scales were considered of more value than summative scores. All analyses were performed using SAS Software 9.4. Results In total, 351 older people were screened and 184 participants entered the trial (recruitment rate 52.4%) (see Appendix 1, in Supplementary Information for Consort Flow Diagram). One participant withdrew after randomisation before the baseline assessment. Participants were mostly female, of European descent, lived in their own home either alone or with a spouse and around 15% had some level of cognitive impairment. Baseline characteristics were similar across the two groups (Table 1). Over the trial time-period, 8,700 older people were discharged across the 600-bedded tertiary hospital, which includes 81 Assessment, Treatment and Rehabilitation beds. The START intervention reduced the mean length of time a participant spent in hospital prior to discharge home, the index admission (15.7 days in START versus 21.6 days in usual care, Table 2a). Further, participants who received the START intervention spent less time in hospital in the 6 months following randomisation, readmissions (7.1 days in START compared to 12.5 days in usual care, Table 2b). Hospital data were collected in the 6 months pre-randomisation and was comparable between the two groups (mean 22.0 days [SD 20.6] in START versus mean 22.2 [SD 20.1] in usual care). Table 2a. Index hospital length of stay (primary outcome) Allocation  N  Mean hospital days (SD)  Mean days difference between groups (CI)  Significance (ANOVA)  Effect size, Partial Eta (CI)  START  97  15.7 (11.5)  5.9 (0.6, 11.3)  0.030  0.03 (0.0, 0.08)  Usual care  86  21.6 (22.9)  Allocation  N  Mean hospital days (SD)  Mean days difference between groups (CI)  Significance (ANOVA)  Effect size, Partial Eta (CI)  START  97  15.7 (11.5)  5.9 (0.6, 11.3)  0.030  0.03 (0.0, 0.08)  Usual care  86  21.6 (22.9)  Table 2b. Time in hospital in the 6-month period post-randomisation (readmissions) Allocation  Mean hospital days over 6 months (SD)  Mean discrete hospital episodes (SD)  Difference between groups for mean hospital days (CI)  Significance (ANOVA)  Effect size, Partial Eta (CI)  START  7.1 (12.8)  1.3 (1.1)  5.4 (−0.2, 11.3)  0.047  0.06 (0.0, 0.1)  Usual care  12.5 (24.2)  1.7 (2.4)  Allocation  Mean hospital days over 6 months (SD)  Mean discrete hospital episodes (SD)  Difference between groups for mean hospital days (CI)  Significance (ANOVA)  Effect size, Partial Eta (CI)  START  7.1 (12.8)  1.3 (1.1)  5.4 (−0.2, 11.3)  0.047  0.06 (0.0, 0.1)  Usual care  12.5 (24.2)  1.7 (2.4)  The effect size was calculated using Partial Eta, revealing a small to moderate change for the primary outcome, the index admission (Table 2a, 0.03) and a larger change for the 6-month post-randomisation period (Table 2b, 0.06). In-patient hospital costs were NZ$680 per day and were the main contributor to overall costs. The START intervention was priced at NZ$94 a day, which totalled a mean NZ$1,618 per total episode (see Appendix 2, in Supplementary Information for detailed breakdown of START staffing inputs, by episode of care). In the 6 months prior to randomisation, participants in the START group accrued mean healthcare costs of NZ$22,766 (SD NZ$16,605) compared to NZ$23,692 (SD NZ$24,961) in usual care. Healthcare costs reduced in both groups in the 6-month post-randomisation period, though the reduction in the START group was greater (P = 0.004). The START group costs were calculated at mean NZ$10,836 (SD NZ$12,087), compared to mean NZ$16,943 (SD NZ$22,303) in usual care. Functional status at baseline/follow-up is described in Table 3. Many required support for bathing and lower body dressing (around 40%). Half required assistance with meal preparation and half were unable to negotiate stairs independently. Only 20% were able to perform their own housework. There was a trend for increasing independence across the functional domains for those participants who had received the START intervention. The interRAI-CA does not readily lend itself to statistical interpretation and therefore the independent value was redefined as ‘1’ from ‘0’ and dependent as ‘2’ from ‘1’ and the mean differences from baseline to follow-up were analysed. Table 3. Function at baseline and follow up Measure  START  Usual care  P value (mean diff. on scores)  Baseline, N (%)  Follow up, N (%)  Baseline, N (%)  Follow up, N (%)  Bathing (ADL self performance)   Independent or set-up help only  34 (34.7)  63 (65.6)  38 (44.2)  48 (55.8)  0.006   Supervision or any physical assistance  63 (64.3)  18 (18.8)  48 (55.8)  28 (32.6)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.65  1.22  1.56  1.37  Personal hygiene (ADL self performance)   Independent or set-up help only  79 (80.6)  75 (78.1)  67 (77.9)  64 (74.4)  0.400   Supervision or any physical assistance  19 (19.4)  6 (6.3)  19 (22.1)  12 (14.0)   Missing  0 (0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.19  1.07  1.22  1.16  Dressing lower body (ADL self performance)   Independent or set-up help only  59 (60.2)  71 (74.0)  58 (67.4)  59 (68.6)  0.025   Supervision or any physical assistance  38 (38.8)  10 (10.4)  28 (32.6)  17 (19.8)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.39  1.12  1.33  1.22  Locomotion (ADL self performance)   Independent or set-up help only  81 (82.7)  76 (79.2)  69 (80.2)  65 (75.6)  0.327   Supervision or any physical assistance  16 (16.3)  5 (5.2)  17 (19.8)  11 (12.8)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.16  1.06  1.20  1.14  Toilet use (ADL self performance)   Independent or set-up help only  57 (58.2)  74 (77.1)  71 (82.6)  67 (77.9)  0.545   Supervision or any physical assistance  15 (15.3)  7 (7.3)  14 (16.3)  9 (10.5)   Missing  26 (26.5)  15 (15.6)  1 (1.2)  10 (11.6)   Mean scores  1.21  1.09  1.16  1.12  Meal preparation (IADL capacity)   Independent or set-up help only  43 (43.9)  61 (63.5)  39 (45.4)  51 (59.3)  0.415   Supervision or any assistance during task  54 (55.1)  20 (20.8)  46 (53.5)  25 (29.1)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.56  1.25  1.54  1.33  Ordinary housework (dishes dusting etc.) (IADL capacity)   Independent or set-up help only  10 (10.2)  35 (36.5)  18 (20.9)  35 (40.7)  0.267   Supervision or any assistance during task  87 (88.8)  46 (47.9)  68 (79.1)  41 (47.7)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.90  1.57  1.79  1.54  Managing medications (IADL capacity)   Independent or set-up help only  65 (66.3)  64 (66.7)  55 (64.0)  59 (68.6)  0.725   Supervision or any assistance during task  33 (33.7)  17 (17.7)  30 (34.9)  17 (19.8)   Missing  0 (0)  15 (15.6)  1 (1.2)  10 (11.6)   Mean scores  1.34  1.21  1.35  1.22  Stairs (IADL capacity)   Independent or set-up help only  26 (26.5)  54 (56.3)  35 (40.7)  53 (61.6)  0.137   Supervision or any assistance during task  72 (73.5)  27 (28.1)  49 (57.0)  23 (26.7)   Missing  0 (0)  15 (15.6)  2 (2.3)  10 (11.6)   Mean scores  1.73  1.33  1.58  1.30  Measure  START  Usual care  P value (mean diff. on scores)  Baseline, N (%)  Follow up, N (%)  Baseline, N (%)  Follow up, N (%)  Bathing (ADL self performance)   Independent or set-up help only  34 (34.7)  63 (65.6)  38 (44.2)  48 (55.8)  0.006   Supervision or any physical assistance  63 (64.3)  18 (18.8)  48 (55.8)  28 (32.6)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.65  1.22  1.56  1.37  Personal hygiene (ADL self performance)   Independent or set-up help only  79 (80.6)  75 (78.1)  67 (77.9)  64 (74.4)  0.400   Supervision or any physical assistance  19 (19.4)  6 (6.3)  19 (22.1)  12 (14.0)   Missing  0 (0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.19  1.07  1.22  1.16  Dressing lower body (ADL self performance)   Independent or set-up help only  59 (60.2)  71 (74.0)  58 (67.4)  59 (68.6)  0.025   Supervision or any physical assistance  38 (38.8)  10 (10.4)  28 (32.6)  17 (19.8)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.39  1.12  1.33  1.22  Locomotion (ADL self performance)   Independent or set-up help only  81 (82.7)  76 (79.2)  69 (80.2)  65 (75.6)  0.327   Supervision or any physical assistance  16 (16.3)  5 (5.2)  17 (19.8)  11 (12.8)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.16  1.06  1.20  1.14  Toilet use (ADL self performance)   Independent or set-up help only  57 (58.2)  74 (77.1)  71 (82.6)  67 (77.9)  0.545   Supervision or any physical assistance  15 (15.3)  7 (7.3)  14 (16.3)  9 (10.5)   Missing  26 (26.5)  15 (15.6)  1 (1.2)  10 (11.6)   Mean scores  1.21  1.09  1.16  1.12  Meal preparation (IADL capacity)   Independent or set-up help only  43 (43.9)  61 (63.5)  39 (45.4)  51 (59.3)  0.415   Supervision or any assistance during task  54 (55.1)  20 (20.8)  46 (53.5)  25 (29.1)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.56  1.25  1.54  1.33  Ordinary housework (dishes dusting etc.) (IADL capacity)   Independent or set-up help only  10 (10.2)  35 (36.5)  18 (20.9)  35 (40.7)  0.267   Supervision or any assistance during task  87 (88.8)  46 (47.9)  68 (79.1)  41 (47.7)   Missing  1 (1.0)  15 (15.6)  0 (0)  10 (11.6)   Mean scores  1.90  1.57  1.79  1.54  Managing medications (IADL capacity)   Independent or set-up help only  65 (66.3)  64 (66.7)  55 (64.0)  59 (68.6)  0.725   Supervision or any assistance during task  33 (33.7)  17 (17.7)  30 (34.9)  17 (19.8)   Missing  0 (0)  15 (15.6)  1 (1.2)  10 (11.6)   Mean scores  1.34  1.21  1.35  1.22  Stairs (IADL capacity)   Independent or set-up help only  26 (26.5)  54 (56.3)  35 (40.7)  53 (61.6)  0.137   Supervision or any assistance during task  72 (73.5)  27 (28.1)  49 (57.0)  23 (26.7)   Missing  0 (0)  15 (15.6)  2 (2.3)  10 (11.6)   Mean scores  1.73  1.33  1.58  1.30  Discussion The START service reduced both the index hospital admission and time in hospital in the following 6 months. Understanding the mechanism by which this was achieved requires a pragmatic interpretation. START, like any successful SDT does not operate a waiting list, can deliver intensive home-based support immediately and has the trust and confidence of the in-patient clinical teams. As such, even very frail older people can be discharged home at any point rather than waiting sometimes several days for a similarly intensive home care package to be established. There are several ways to interpret the reduction in hospital admissions within the START group in the 6 months post-randomisation. The reduction in the time an individual spent in hospital reduced hospital exposure [1, 2, 4], which in the process may have contributed directly to reduced readmission rates. Further, the enhanced oversight from an experienced inter-disciplinary clinical team within START coupled to a strong focus on individualised goals and rehabilitation and the development of a partnership approach between the patient’s GP and specialist geriatric services may also have had a role. The trend for improvements in functional status were primarily within personal ADL, specifically bathing, lower body dressing and toileting. It is possible that such activities were a focus of the service as dependency in these areas invariably require ongoing community support. Lower levels of change were observed in other domains, but this may have been more due to the ceiling effect of the assessment tool or simply that a greater number of older people were independent in those areas on discharge from hospital. Although findings were positive around the costs of the intervention, most savings were made through reducing hospital bed-days. Given that hospital beds are seldom closed because of initiatives such as these, it is debateable as to whether financial savings were truly made, rather financial gains may come later through either delaying or preventing new hospital beds coming online. In this way, SDTs such as START offer a proven community-based secondary care tool to manage hospital capacity. A limitation of the study, arising in the main as a direct effect of the intention to intervene on the basis of function is that no restrictions were placed on diagnoses, opting more to focus on a population of older people who had experienced a recent decline in function, often had low morale with a level of cognitive impairment. Such inclusion criteria are common to the original SDT, still operating in Lambeth, London [12]. Conclusions from this study therefore need to be cognisant of the inclusion criteria described herein. We believe our findings can be generalised, where the same eligibility criteria apply. However, the application of the inclusion criteria could have a substantial impact on extrapolation of results to other services. Key points Supported Discharge Teams can support older people with a variety of conditions to be discharged earlier from hospital. Supported Discharge Teams can reduce risk of readmission to hospital for older people. Supported Discharge Teams have an important role to play in increasing bed capacity of hospitals. Supplementary Data Supplementary data mentioned in the text are available to subscribers in Age and Ageing online. Funding The research was funded by the Health Research Council of New Zealand (ref. 11/720). Conflicts of Interest None. Acknowledgements A huge thanks to Barb Garbutt, General Manager of Older Person Rehabilitation Services, Waikato District Health Board, without who’s wisdom and support, fundamentally important pieces of the evidence puzzle could not have been solved. To Raewyn Dean, the forever flexible, dynamic service leader who has created a wonderful team—well done! References 1 Comptroller, Auditor General. Discharging Older Patients From Hospital . London, UK: Department of Health, 2016. 26th May 2016. Report No.: Contract No.: HC18. 2 de Morton N, Keating JL, Jeffs K. Exercise for acutely hospitalised older medical patients. The Cochrane Library, 2007. 3 Covinsky KE, Palmer RM, Fortinsky RH et al.  . Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc  2003; 51: 451– 8. Google Scholar CrossRef Search ADS PubMed  4 Office for National Statistics. Deaths involving MRSA: 2008 to 2012. London: 22 August 2013. Report No. 5 Ministry of Health. Guideline for Specialist Health Services for Older People . Wellington, New Zealand: Ministry of Health, 2004. 6 Nocon A, Baldwin S. Trends in Rehabilitation Policy: A Review of the Literature . London: King’s Fund, 1998. 7 King’s Fund. Developing Rehabilitation Opportunities for Older People . London: King’s Fund, 1999. 8 King’s Fund. Treatment of stroke: consensus conference. Br Med J  1988; 297: 126– 8. CrossRef Search ADS   9 Kennedy L. Effective comprehensive discharge planning for hospitalized elderly. Gerontolgist  1987; 27: 577– 80. Google Scholar CrossRef Search ADS   10 Styrborn K. Early discharge planning for elderly patients in acute hospitals—an intervention study. Scand J Soc Med  1995; 23: 273– 85. Google Scholar CrossRef Search ADS PubMed  11 Rich M. Prevention of readmission in elderly patients with congestive heart failure. J Gen Intern Med  1993; 8: 585– 90. Google Scholar CrossRef Search ADS PubMed  12 Martin F, Oyewole A, Moloney A. A randomized controlled trial of a high support hospital discharge team for elderly people. Age Ageing  1994; 23: 228– 34. Google Scholar CrossRef Search ADS PubMed  13 Cobley CS, Fisher RJ, Chouliara N, Kerr M, Walker MF. A qualitative study exploring patients’ and carers’ experiences of Early Supported Discharge services after stroke. Clin Rehabil  2013; 27: 750– 7. Google Scholar CrossRef Search ADS PubMed  14 Langhorne P, Taylor G, Murray G et al.  . Early supported discharge services for stroke patients: a meta-analysis of individual patients’ data. Lancet  2005; 365: 501– 6. Google Scholar CrossRef Search ADS PubMed  15 Fearon P, Langhorne P, Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients. Cochrane Database Syst Rev  2012; 9: CD000443. 16 Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care. Cochrane Database Syst Rev 2001; 2: CD000356. doi: 10.1002/14651858.CD000356. 17 Hyde C, Robert I, Sinclair A. The effects of supporting discharge from hospital to home in older people. Age Ageing  2000; 29: 271– 9. Google Scholar CrossRef Search ADS PubMed  18 Dunn R. The role of post-hospital discharge schemes, Current Medical Literature. Geriatrics  1996; 9: 3– 10. 19 Bours G, Ketelaars C, Corry A. The effects of aftercare on chronic persons and frail elderly persons when discharged from hospital—a systematic review. J Adv Nurs  1998; 27: 271– 9. Google Scholar CrossRef Search ADS   20 Caplan G, Williams AJ, Daly B et al.  . A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department—The DEED II Study. J Am Geriatr Soc  2004; 52: 1417– 23. Google Scholar CrossRef Search ADS PubMed  21 Depart Discharge from Hospital. Pathway, Process and Practicement of Health United Kingdom. London, 2003. 22 Schulz K, Altman D, Moher D. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. BMC Med  2010; 8: 18. Google Scholar CrossRef Search ADS PubMed  23 Hirdes J, Curtin-Telegdi N, Poss J et al.  . interRAI Contact Assessment (CA) form and User’s manual: a screening level assessment for emergency department and intake from community/hospital. Version 9.2, 2010. 24 Morris J, Fries BE, Bernabei R et al.  . RAI—Home Care Assessment Manual . Washington, DC: InterRAI Corporation, 1996. 25 de Vreede PL, Samson MM, van Meeteren NLU, Duursma SM, Verhaar HJJ. Functional-task exercise versus resistance strength exercise to improve daily function in older women: a randomized controlled trial. J Am Geriatr Soc  2005; 53: 2– 10. Google Scholar CrossRef Search ADS PubMed  26 Parsons M, Senior H, Kerse N, Chen M-H, Jacobs S, Anderson C. Randomised trial of restorative home care for frail older people in New Zealand. Nurs Older People  2017; 29: 27– 33. Google Scholar CrossRef Search ADS PubMed  27 King AII, Parsons M, Robinson E, Jörgensen D. Assessing the impact of a restorative home care service in New Zealand: a cluster randomised controlled trial. Health Soc Care Community  2011; 20: 365– 74. Google Scholar CrossRef Search ADS PubMed  28 Parsons J, Rouse P, Robinson EM, Sheridan N, Connolly MJ. Goal setting as a feature of homecare services for older people: does it make a difference? Age Ageing  2012; 41: 24– 9. Google Scholar CrossRef Search ADS PubMed  29 Parsons M, Senior HE, Kerse N et al.  . The Assessment of Services Promoting Independence and Recovery in Elders Trial (ASPIRE): a pre-planned meta-analysis of three independent randomised controlled trial evaluations of ageing in place initiatives in New Zealand. Age Ageing  2012; 41: 722– 8. Google Scholar CrossRef Search ADS PubMed  30 Parsons J, Mathieson S, Parsons M. Home Care: an opportunity for physiotherapy. New Zeal J Physiother  2015; 43: 24– 31. © The Author 2017. Published by Oxford University Press on behalf of the British Geriatrics Society.All rights reserved. For permissions, please email: journals.permissions@oup.com

Journal

Age and AgeingOxford University Press

Published: Mar 1, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 12 million articles from more than
10,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Unlimited reading

Read as many articles as you need. Full articles with original layout, charts and figures. Read online, from anywhere.

Stay up to date

Keep up with your field with Personalized Recommendations and Follow Journals to get automatic updates.

Organize your research

It’s easy to organize your research with our built-in tools.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

Monthly Plan

  • Read unlimited articles
  • Personalized recommendations
  • No expiration
  • Print 20 pages per month
  • 20% off on PDF purchases
  • Organize your research
  • Get updates on your journals and topic searches

$49/month

Start Free Trial

14-day Free Trial

Best Deal — 39% off

Annual Plan

  • All the features of the Professional Plan, but for 39% off!
  • Billed annually
  • No expiration
  • For the normal price of 10 articles elsewhere, you get one full year of unlimited access to articles.

$588

$360/year

billed annually
Start Free Trial

14-day Free Trial