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HTA of Integrated Homecare for Elderly, Frail, Somatic Patients


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HTA of Integrated Homecare for Elderly, Frail, Somatic Patients.

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HTA of Integrated Homecare for Elderly, Frail, Somatic Patients

  1. 1. HTA of Integrated Homecarefor Elderly, Frail, Somatic Patients Torben Larsen University of Southern Denmark, CAST. Email:
  2. 2. Definition of IHC • Takes partly place in the home of the patient in collaboration with the patient • Integrates hospital services and social and/or primary care services – clinically, financially and administratively • Is executed by a multidisciplinary hospital-based team passing possible general care needs to the community and/or primary care setting • Focuses on effectiveness, quality, access and user satisfaction in an economic way and uses tele-facilities as far as they serve these goals Based on: Kodner D, 20022 TLarsen HTAi 2012
  3. 3. Effect of IHC IHC as Limbic relaxation: (BP declines 5-7 mmHg increasing cognition from E1 to E2) • Coping effect explains improved ADL- efficacy for stroke patients ↓↑ Subjective values of IHC: • Perceived control over their care (feeling safe) • Great involvement in decision-making (participation) • Knowledge about their illness and coping in home-conditions (primary feedback) Based on Larsen T, Acta Systemica, 20103 TLarsen HTAi 2012
  4. 4. Patients’ and Caregivers’ Perspectives “Hospitalization might result in loss of control, loss of abilities for carrying out daily activities, increased burden of care, insecurity of the future and isolation. Including the context of the home and the families in preparing discharge and in follow-up support seems to enhance patient participation and satisfaction without increasing the burden of caregivers. IHC is facilitated by a relational process between the patient and healthcare professionals including information, knowledge, communication and trust.” Results from Homecare-222954 Focus group interviews by Ann Lee, principal investigator, CAST/SDU4 TLarsen HTAi 2012
  5. 5. IHC Stroke Guide • Patient pathway Early home-supported discharge (EHSD) complementing the GP • Patients Best results for moderately disabled patients (Admission BI: 12-17; About 30% of all Strokes) • Content and dose Early identifying and dealing with barriers to ADL to meet the patients agreed upon goals (In average up to 10 home visits) • Staff and organisational competencies An outreach multidisciplinary hospital-based team Mostly, occupational therapists or physiotherapists are case manager Reference: Langhorne P, Jepsen G et al 20125 TLarsen HTAi 2012
  6. 6. IHC HF Guide • Patient pathway It resembles that of IHC Stroke in the way that part of rehabilitation is transferred from hospital to the home. Also, the pathway rather complements than substitute GPs • Patients The majority of patients are moderately disabled (NYHA II+III; About 30% of all as a minority rejects the offer) • Content and dose Important components are: 1) Early intervention at decompensation, 2) Flexible prescription of diuretic intake, 3) Joint care plans, 4) Written ’indi- vidualized’ education of patient and carers (Up to 10 contacts (half by phone)) • Staff and organisational competencies The multidisciplinary team has usually a nurse case manager Reference: Jaarsma T, Strömberg A et al 20126 TLarsen HTAi 2012
  7. 7. IHC COPD Guide • Patient pathway Major phases are 1) case identification, 2) case evaluation, 3) work plan definition and 4) post-discharge follow-up • Patients In principle are all exacerbated patients eligible. However, here we focus on moderately disabled (30%<FEV1<70%; About 25% of all as a minority rejects) • Content and dose Besides pharmacological treatment attention is paid to co-morbidity, social aspects and self-management education . Often services are supplemented by tele-medicine (Up to 10 contacts (most by phone)) • Staff and organisational competencies Multidisciplinary team has often a nurse-case-manager who may be from community nursing Reference: Alonso A, Roca J et al 20127 TLarsen HTAi 2012
  8. 8. IHC effects on non-fatal endpoints • Stroke Death or dependence OR=0.75 (CI: 0.61-0.92) / LoS: -5 days • HF All-cause readmissions OR=0.60 (CI: 0.4-0.92) • COPD Readmissions COPD OR=0.5 (CI: 0.25-0.80) Minimal safety problems for all IHC interventions Reference: Larsen T et al 2012, HTA of IHC8 TLarsen HTAi 2012
  9. 9. Economic Evaluation of IHC (€) • IHC interventions are health economic dominant CEA-component Stroke HF COPD Outcome 1 home help h/w 1 All-cause 1 readmission 5 bed days readmission Value: 2820 Value: 1320 Value: 1160 Cost of intervention 1220 470 360 Average net result 1600 850 800 Worst-case-scenario 520 10 100 Best-case-scenario 4000 1200 1000 Share of patients 30% 30% 25% Per 100,000 population 60 70 40 No. of patients in China 600,000 700,000 400,0009 TLarsen HTAi 2012
  10. 10. What is the organisational challenge? IHC as a pathway complementary to coordination by GP:10 TLarsen HTAi 2012
  11. 11. Barriers and Facilitators in Horizontal Integrated Pathways Barriers Facilitators Moderate medical support Patients and carers appreciate IHC Mutual scepticism acroos Outreach teams appreciate disciplines and settings IHC very much Short term cash preference in Multidisciplinary collaboration administration is already developed in a number of hospital wards11
  12. 12. A meso-strategy of dissemination• National implementation pilots of IC in NL (and UK) by “Bundle-payment” of GPs show poor results (Struijs et al, NEJM 2011)• ”Free” funding of local medical IC-projects in Ger is very expensive with undocumented effects (Amelung V et al, IJIC 2012)• Keypoints of a meso-strategy to integrate bottom-up dynamics with organized central planning: o County hospitals as the meso-level of dissemination organizing discharge pathways complementary to GP practice o “Bundle-payment” to hospitals corresponding to about 33% of the expected benefit is required to accelerate dissemination• ”Market test” by HOPE of hospital interest in IHC: In a fortnight more than 50 European hospitals have committed themselves to a future IHC-project12 TLarsen HTAi 2012
  13. 13. References Alonso A, Roca J, Rodriguez J, Vilaró J, Larsen T (2012). Practical Guide on Home Health COPD, FP7-HOMECARE-222954, Deliverable 11, Amelung V et al (2012). Integrated care in Germany – a stony but necessary road. IJIC 16 Jaarsma T, Strömberg A & Larsen T (2012): Practical guide on Home Health HF, FP7- HOMECARE-222954, Deliverable 10, Kodner DL & Spreeuwenberg C (2002). Integrated care: meaning, logic, applications, and implications – a discussion paper. IJIC, Vol 2. Langhorne P & Jepsen BG (2011). Early Home Supported Discharge (EHSD) services for Stroke Patients. A practical problem-based guide linking clinical evidence to clinical rehabilitation, FP7-HOMECARE-222954, Deliverable 9, Larsen T et al. (2012). Health Technology Assessment of Integrated Homecare in Europe – focusing on stroke, heart failure and COPD as prototypes. FP7-HOMECARE-222954, Deliverable 12, Larsen T (2010). Neuroeconomics and Public Health. Acta Systemica, Volume X - No. 1 IIAS International Journal Struijs JN et al. (2011). Integrating Care through Bundled Payments – Lessons from the Netherlands. NEJM 364 (11):990-91.13 TLarsen HTAi 2012