The hospital at Home Service of Torino

The hospital at Home Service of Torino - hospital at home

 

 

The knowledge of where an elderly person to go is essential, but the choice should always be done in respect to the fundamental principle which the house is best when possible.
       

Prof. Fabrizio Fabris  

 

 

 

 

 

The Hospital at Home Service of Torino

In October 1984, with Resolution N. 1134/41/84, the Management Committee of the Local Health Unit 1/23 of Turin set up the ‘Experimental Project of Home Hospitalisation’.

In October 1985 a team of doctors and nurses of the Turin Department of Geriatrics started an experiment that was unique in Italy at that time: medical treatment (including examinations and related medical and nursing services) at home rather than in hospital for patients with severe chronic or relapsing illnesses.

The Hospital at Home Service (HHS) is operating in Torino at S. Giovanni Battista Hospital, a large urban University teaching and tertiary-care hospital

The HHS is a service that provides diagnostic and therapeutic treatments by health care professionals, in the patient’s home, of a condition that otherwise would require acute hospital in-patient care. A quick admission to hospital is possible for examinations or interventions that cannot be carried out at home. Transport and acceptance are free for these patients, as part of the HHS service.

The HHS normally operates 12 hours a day (from 8 am to 8 pm), seven day a week. At night our Regional Emergency Unit (“118”) can be contacted. For selected patients, medical staff is on-call 24 hours a day. Caregivers are instructed in the emergency plan and encouraged to telephone if problems arise.

The HHS team, equipped with 7 cars, is multidisciplinary and consists of 4 geriatricians, 13 nurses, 1 nurse coordinator, 2 physiotherapists, 1 social worker, 1 counsellor.

The main feature of HHS is that physicians and nurses work together as a team with daily meeting to discuss the needs of each patient and to organize individualized medical care plans and day-to-day work. The three most important aspects of the nursing activity are:

- home visits to outpatients to give medical care as agreed with the doctors

- daily team meeting

- secretarial work, receiving applications for hospitalization, stocking pharmaceuticals and sanitary material, sending and collecting laboratory analysis, transporting patients for specialistic consultations or exams which can be done only in hospital.

The team looks after 25 patients per day and 500 patients per year, on average. The most common diseases treated at home are cardiac, respiratory, cerebrovascular, metabolic and neoplastic diseases.

The HHS can be activated by a direct request of the general physician of the patient as an alternative to traditional hospital care, or by a request from hospital wards doctors to allow early and protected discharge from hospital.

Since 2001, a close collaboration has been started between the HHS and the Emergency Department (ED) of San Giovanni Battista Hospital, to propose, where possible, home care as an alternative to the traditional admission to hospital.

Now, approximately 60% of our patients are referred by the ED, 25% by hospital wards and 15% by specialist or general physicians in the community.

The relationship between the ED team and the “HHS mobile team” made up of 1 geriatrician and 1 nurse is very important. By using a multidimensional case sheet, the HHS mobile team” carries out an assessment of the patient and his caregiver to evaluate the possibility of hospitalization at home and in order to give information on the service.

A “Module of interview with the family” was conceived and implemented to discover the willingness of the family to work together with HHS team, as a part of the patient’s healthcare system.

When the availability is established, an “Informative Card” with information on the service has been given to the patient and his caregiver.

Then, the “HHS mobile team” together with the ED doctor writes a rough copy of patient’s case sheet, which will be completed at home during the first HHS visit. In the ED all the Hospital at Home for Elderly Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease necessary diagnostic tests (e.g., blood tests, radiography, ECG) are provided and then the patient moves home by ambulance, usually within a few hours.

Entry criteria for home hospitalization are: informed consent of patient and caregiver; stable, diagnosed medical conditions needing hospitalization but not expected to require emergency intervention; appropriate care supervision; telephone connection; living in the hospital catchment area (all the southern part of the city).

Exclusion criteria are: need of intensive monitoring or mechanical ventilation, a monitoring more frequent than every 2 hours of blood pressure or haemogasanalysis, patients with an heart attack or with very low levels of oxygen in the blood or with a serious acidosis or alkalosis or with a suspect of pulmonary embolism.

Many services or treatments can be provided at home: Assessment in Emergency Department and transport home via ambulance

Services and treatment provided:

Physician and nursing visits

Standard blood tests

Pulse oximetry

Electrocardiogram

Spirometry

Echocardiogram

Internistic ecographies and Doppler ultrasonographies

Oral and intravenous medication administration, including antimicrobials and cytotoxic drugs

Oxygen therapy

Blood product transfusion

Central venous access (PICC, Midline)

Surgical treatment of pressure sores

X rays

Telemonitoring

Physical therapy

Occupational therapy

Counselling

 Hospital-at-home patients are considered hospital patients, and all services are provided by the hospital, which retains legal and financial responsibility for care.

A case history is made up for each patient and is always available at the patient’s home, with an updated report available in the HHS office. Medical consultation with other hospital specialists is possible in the hospital or at the home of the patient.

HHS has continued to increase its activity since its inception in 1985. Until now about 11000 admissions have been recorded. In 2010, 550 admissions were recorded, 9113 nursing visits  and 4317 medical visits were conducted. The mean age of our patients was 80 years (range 30-101). Mean length of stay was 14 days.

In 2010 the Piedmont Region issued a decree to regulate this HHS model and acknowledged a refund of 165 Euros/day for DRG included in MDC number 1, 4, 5, 16, 17 (neurological, respiratory, cardiovascular, haematologic and neoplastic diseases), and 145 Euros for the other diseases.

 

 

 

 - hospital at home