HAH-OP: Hospital at home for older people

Why was this example implemented?

HAH was set up in the late fifties in order to solve the issue of “cancer bed blockers” in acute hospitals (6). It was gradually extended to patients suffering from complex and severe acute or chronic care conditions. It was expected that services when delivered at home rather than in hospitals would be less costly (5, 7). HAH is now also considered as a necessary complement to other home care providers (nursing and home care agencies) or disease specific networks which do not work in close harmony with hospital staff, are not able to care for patients with co-morbidities and cannot altogether ensure continuity of care over a long term period as patients’ needs evolved. A new care organisation was envisaged, able to bridge all these gaps by organising and delivering a comprehensive set of hospital-level services provided by an integrated team at home, closely linked to hospitals (1.b). Patients and their families as well as health and social professionals’ satisfaction is globally high (8, 9). Its more recent expansion (16, 17) independently of the aging of the population, has been favoured by legal incentives (relaxation of administrative constraints for opening HAH and of payment barriers (1)), making the market more profitable for all types of providers. Technological breakthroughs that make possible the safe delivery of more complex and/or intensive care at home to a growing and ageing population with multiple needs have also influenced its constant development.

Description

HAH structures stand as independent not-for-profit organisations or as specific departments inside a hospital but benefiting from a high degree of autonomy in staff management and the population that they target.

HAHOP targets the 65+ population suffering from acute or chronic and unstable diseases and complex and/or intensive medical as well as nursing, personal and social care needs. Orthopedic or post-surgical care as well as palliative care, are also included (13, 17).

HAH is “initiated” by a hospital physician for inpatients (90%) and by the referring GP for outpatients (10%) (17). The HAH team assesses the patient’s medical needs while the team social worker is responsible for setting up all cash benefits or in-kind services the patient is entitled to. HAH cannot be implemented without the patient’s and family’s agreement and the contractual agreement of the GP (1.b).

Services are then provided by a multi-professional team under the supervision of a coordinating physician responsible for setting the care plan, while the coordinating nurse is responsible for its implementation by the HAH team (nurses, physiotherapist, occupational and speech therapist, psychologist). The nurse also coordinates care with others (if needed) self-employed professionals and with technical assistance providers (respiratory assistance, cardio monitoring, specific drugs and medications) (5, 15). A specific electronic record is used for follow up information. The coordinating team can be reached 24 hours a day. Depending on the patient’s health status, but at least once a week, the team and both coordinators regularly assess the patient and make appropriate decisions, whilst the GP is supposed to visit the patient and communicate with the medical coordinator at least once a week.

The care team provides patients with information so they can comply with treatments. The family receives some training for specific tasks relating to technical or personal care; HAH can also organise respite care for families if necessary.

HAH has received finance since 2005 according to a specific case mix system (HAH-DRGs) (3, 11) with 200 medical groups representing 80% of the stays.

There is a gradient of 31 day tariffs, one of them applying to each group (so some have the same tariff) with the value of the highest being ten times the lowest one. This value is based on type and intensity of services delivered and on the patient’s disability level; this value is applied both for public or private organizations. As the medical group to which a patient is allocated initially may change during his stay, the global cost of the HAH stay is the sum of each day’s tariff weighted by its specific medical group.

What are/were the effects?

• HAH primarily addressed palliative care and cancer treatment with wide variation in clinical conditions (17). Only 30% of users are moderately to highly dependent. Older people aged 65+ account for 56% of the cases and 38% of the stays in 2007 (corresponding figures for the 80+ being 24% and 14%), showing that older patients have longer stays (but not necessarily higher costs).
• Operating through a unique access point (‘one-stop’ approach), and simplifying the steps for the patient (5, 15, 16), assessments showed that HAH is appreciated by patients in that care for all need (health and social) is delivered in the comfort of the home. So patients and their families as well as health and social professionals’ satisfaction is universally high (8, 9). Recent assessments showed that one hospitalisation day costs less when similar services are provided by HAH than when delivered to similar patients in acute and/or rehabilitation hospitals (10). Substituting 10,000 rehabilitation hospital beds by HAH beds could save €350 million per year (13). These results gave a strong impetus to overall HAH development: from 2006 to 2009, the number of HAH initiatives grew from 166 to 271 and “home beds” from 5,878 to 10,015 (4). The volume of number of HAH stays rose from 85,889 to 139,430 and correspondingly the volume of days (activity) grew from 1,948,210 to 3,298,104.
• Financial revenue grew from €385,979,339 to €652,368,093.
• However as development proceeded more slowly than expected, the initial target of 15,000 beds expected for 2010 was postponed to 2015 (1.g).

Some hospital specialties (cancer, palliative care, orthopedist, rehabilitation, hemodialysis) use HAHOP frequently as a main element of their patient’s pathway. So, even if it could be used more (two thirds of rehabilitation hospital days could have been safely performed in HAH) (13), HAH is not to be considered as a tool to reduce hospitals beds but rather as enabling a more efficient use of various possible care settings (acute/rehabilitation hospitals, generic home care/HAHOP) during the patient care pathway.

The HAH (and especially HAHOP) programme is still considered a national priority and has become a mandatory section for the newly created regional Health agencies (HPST Act) planning missions (1.i).

What are the strengths and limitations?

Strengths

• One single organisation sets up and delivers all complex services that are needed for a specific population at home;
• Hospital substitution (avoiding/delaying hospital admission and earlier/safer home discharge);
• Comprehensive care plan;
• Care continuity (through integration within team and coordination with other care providers);
• Quality:  through HAH accreditation process; 
• Lower costs;
• Positive impact on patient and family satisfaction.

Weaknesses

• Not known well enough (by older persons and family);
• Not used enough by GPs as they feel they are not well trained to follow HAH patients even when supported by the HAHOP team;
• Biased payment and organisational incentives acting as barriers for self-employed specialists and for GPs as they are not adequately compensated for their contacts with HAH staff;
• Hospital biased funding principles leading them to deliver similar services in day care ward instead of using HAH;
• The HAHOP team must technically and psychologically be strong enough to intervene alone in the user’s home. As their intervention has a positive impact on patients’ well-being and quality of life, the care team would benefit from psychological support (14);
• Difficulties controlling the appropriate classification of the patient: risk of applying codes of a higher value which increases HAH spending.

Opportunities

• As the main barriers to open HAH structures have been overcome, all types of providers (public and private) are more eager to participate;
• Changes in the tariff scheme could over-ride the payment bias;
• New power regarding LTC given to the regional health agencies (ARS) may enhance their ability to facilitate HAHOP development.

 Threats

• Without a continuous HAH team training process in order to integrate technical innovations, cost savings may be achieved at the expense of deteriorating care quality;
• The trend for acute (also for rehabilitation) hospitals to use “early discharge” as a cost containment measure means that HAH is overcrowded with highly complex cases, thus with less opportunity to provide services to outpatients, leading the latter to be more frequently hospitalised, so creating a “vicious circle”;
• As informal carers age whilst the cared-for persons have more needs, the former may be unable to sustainably provide their necessary work as co-carers. Thus a specific support policy for informal carers will be needed (19).

Credits

External Links and References

• 1. Legislative texts: Ministry of Health (MoH) - see also www.legifrance.gouv.fr:
• 1a. Ministry of Health (MoH, 1992), Decrees n°92-1101 and n°92-1102 of 2 October 1992 relative to the medical care structures alternative in the hospitalization and in the technical conditions of functioning of the medical care structures, (Hospital alternative and definition).
• 1b. Ministry of Health (MoH, 2000), MoH circular n° DH/EO2/2000/295 of 30 May 2000 on hospital at home; definition, missions of HAH, therapeutic project, etc.).
• 1c. Ministry of Health (MoH, 2003), Ordinance n° 2003-850 of 4 September 2003 relative to carrying simplification of the health system organization and functioning.
• 1d. Ministry of Health (MoH, 2004), 2007 Hospital Plan. MoH Circular DH/O/ n° 144 of 4 February 2004 relative to hospitalization at Home. It specifies the missions and the modalities of care in HAH generally, in perinatal period, in pediatrics and in psychiatry. These orientations join within the framework of the revision of the regional plans of second generation sanitary organization.
• 1e. Ministry of Health (MoH, 2004), MoH circular DHOS N°2004-101 du 5 mars 2004, relative to the SROS 3 elaboration
• 1f. Ministry of Health (MoH, 2005), MoH circular DHOS/F1/F3 n° 2005-231 of 18 May 2005 relative to the financing of the implementation of the collection and the data processing, extracted from the medicalization of information system program for the hospital at home activity in the health establishments.
• 1g. Ministry of Health (MoH, 2006), MoH circular n° DHOS/O3/2006/506 of 1st December 2006 on hospital at home.
• 1h. Ministry of Health (MoH, 2007), Decree n°2007-241 of 22 February 2007, Decree n° 2007-660 of 30 April 2007 and Circular N°DHOS/03/DGAS/2C/2007/365 of 05 October 2007 relative to the intervention of hospital at home in the establishments for dependant older people (EHPAD).
• 1i. Ministry of Health (MoH, 2009), Hospital, Patients, Health and Territories Act (HPST Act) n° 2009-879 of 21 July 2009 (JO n° 167 of 22 July 2009).
• 2. HAS (2010/12) Guide préparer et conduire votre démarche de certification V2010 - mise à jour.
• 3. ATIH (2010), Agency for Information on Hospital Care, HAH Medical Information Systems Program (HAH PMSI). 
• 4. FNEHAD, National Federation of French Hospitalization at Home Establishments.  
• 5. Com-Ruelle L., Raffy N. (1993), Le fonctionnement des services d'HAD : évolution 1980-1992, Rapport CREDES n° 958, 162 p.
• 6. Com-Ruelle L. (1993), La place des cancers en H.A.D. en 1991/1992, son évolution depuis 1982 et les perspectives, Intervention à la 11e Journée Presse Quid en Cancérologie ? Paris, 10/1993, 8 p. 
• 7. Com-Ruelle L., Raffy N. (1994), Quel avenir pour l'hospitalisation à domicile ? Analyse des freins et des facteurs en faveur de son développement, Rapport CREDES n° 998, 131 p.
• 8. Com-Ruelle L., Raffy N. (1994), Les patients hospitalisés à domicile en 1992, Rapport CREDES n° 1007, 233 p. 
• 9. Aligon A., Com-Ruelle L., Raffy-Pihan N. (2000), L'hospitalisation à domicile : un patient à satisfaire ? In " Informations Hospitalières " n°52, pp. 16-21.
• 10. Aligon A., Com-Ruelle L., Renaud T., avec la collaboration de Lebrun E, 2003/06, Le coût de prise en charge en hospitalisation à domicile (HAD). Questions d'économie de la santé IRDES n° 67.
• 11. Com-Ruelle L., Dourgnon P., Perronnin M., Renaud T. 2003/07, Construction d’un modèle de tarification à l’activité de l’hospitalisation à domicile, Questions d'économie de la santé IRDES n°69.
• 12. Chevreul K., Com-Ruelle L., Midy F., Paris V., 2004/12, The development of hospital care at home: an investigation of Australian, British and Canadian experiences, Questions d'économie de la santé n° 91. Rapport IRDES n° 1610, 2005/11. 130 pages.
• 13. Afrite A., Com-Ruelle L., Or Z., Renaud T., 2007/02, Hospital at home, an economical alternative for rehabilitative care, Questions d'économie de la santé n° 119. Rapport IRDES n° 1689, 2008/06, 166 pages et Rapport IRDES n° 1689bis, 2008/06, 134 p. 
• 14. Sentilhes-Monkam A. (2007), L’hospitalisation à domicile, une autre manière de soigner, L’Harmattan. 
• 15. Com-Ruelle L., Afrite A. (2008/08), L'HAD, une prise en charge hospitalière moderne. Paris : Elsevier-Masson, 52 pages. 
• 16. Com-Ruelle L., Chevreul K., 2009/04, The Development of Hospital at Home (HAH) in France: Implications of Research on Reasons of Admission and on the Determinants of Patients’ Costs on the Pricing Reform and the Rapid Expansion of Services.
• 17. Afrite A., Chaleix M., Com-Ruelle L., Valdelièvre H., 2009/03 (IRDES), Hospital at home (HAH), a structured, individual care plan for all patients, 2009/03, Questions d'économie de la santé n° 140. 
• 18. Chaleix M., Valdelièvre H., Afrite A., Com-Ruelle L. 2009/07, Les structures d’hospitalisation à domicile en 2006. «Etudes et Résultats », DREES, n° 697, 6 p. (www.sante.gouv.fr/les-structures-d-hospitalisation-a-domicile-en-2006.html) 
• 19. Triantafillou J./ Naiditch M./ Repkova K./ Stiehr K./ Carretero S./ Emilsson T./ Di Santo P./ Bednarik R./ Brichtova L./ Ceruzzi F./ Cordero L./ Mastroyiannakis T./ Ferrando M./ Mingot K./ Ritter J./ Vlantoni D. (2010) “Informal care in the long-term care system.” European Overview Paper for INTERLINKS project (FP7). Athens/Vienna: European Centre (http://www.euro.centre.org/interlinks)