Outcome of Elderly Patients Enrolled in Home Health Care Program Affiliated to Al-Hada and Al-Tayef Military Hospitals Program in KSA

Home health care is a rapidly growing health care sector. An increasing older population and the desire to reduce acute health care costs have contributed to its growth. Moreover, older persons and their family members do prefer home care. A prospective cohort study was implemented to determine the outcome of elderly patients enrolled in the Home Health Care program affiliated to Al-Hada and Al-Tayef Military Hospitals program, KSA and investigate some factors associated with the outcome of those patients. A total of 131 elderly enrolled in the program were included. Sociodemographic and medical history were obtained, medical records were reviewed and full clinical assessment was conducted. The study extended for 19 months. All elderly were followedup until discharge from services, readmission to hospital, death, or end of the study. Results revealed that by the end of the study, 65.5% of the elderly were still in the service, 6.9% died, and 17.6% were readmitted to the hospital and didn’t’ return back. The factors significantly associated with death or readmission to the hospital were the principal diagnosis, higher number of comorbidities, presence of chronic obstructive pulmonary disease (COPD), atrial fibrillation (AF), presence of associated problems, and higher number and earlier timing for emergency visits to hospitals. The independent predictors for death and readmission to hospitals were altered consciousness on admission, presence of AF, COPD, and higher number of emergency visits to hospitals. Further studies including control groups receiving different modalities of care are required to assess the effectiveness of the program. Cost effective analysis of the service is recommended. Better selection of the patients for the service and assuring their stabilization before admission may improve the outcome of these patients and enhance the quality of care. INTRODUCTION An overall goal of good geriatric medical practice is to maintain older persons in the familiarity, comfort, and dignity of their own home setting for as long as possible. If attempts to reduce the functional impact of illness in old age are to be successful, it is vital that all health care professionals understand the significance of providing care in the patient’s own home. Home health care (HHC) is a rapidly growing health care sector. An 870 Bull High Inst Public Health Vol.37 No.4 [2007] increasing older population and the desire to reduce acute health care costs have contributed to its growth. Moreover, older persons and their family members do prefer home care, independent of the financial savings. The health care delivery system has undergone dramatic shifts in care settings during the past decade. More patients are receiving professional home care following discharge from hospitals, skilled-care facilities and rehabilitation centres. Several studies have shown that home based interventions for patients with chronic illness following acute hospital stays can result in fewer unplanned readmissions, lower fatality, fewer emergency department encounters, and lower cost of care. Despite the huge benefits of HHC, hospitalization and visits to the emergency department among seniors receiving homecare services is still high. Several factors were found to be significantly associated with readmission to hospitals. Among these are disease severity, functional disability level, comorbidity, and previous hospital admission. The increased use of home care services, and the provision of more sophisticated care to acutely ill patients, has prompted concern about quality assurance in home settings. Reduction in rehospitalization is one of the outcome measures used to evaluate home care services. However, practitioners and managers must carefully analyze the reasons for patients’ return to the hospital. Despite the rapid growth in home health services in industrial world, HHC programs in our Arab countries are newly Mohamed M Makhlouf 871 established. Data on outcomes of elderly patients receiving homecare services are sparse. Aims of this study are 1To determine the outcome of elderly patients enrolled in the Home Health Care program affiliated to a Military Hospitals program, KSA. 2To investigate some factors associated with the outcome of those patients. MATERIAL AND METHODS HHC program at Al-Hada and Al-Tayef Military Hospitals program HHC is a newly developed and expanding service offered to the patients working in the military service and their relatives. Patients are referred to HHC from the 4 hospitals affiliated to Al-Hada and Al-Tayef Military Hospitals program and also from the community. HHC team receives requests for admission, assesses patients, puts the care plan, and follows the patients at their homes through scheduled visits. The team includes physician, rehabilitation specialist, nurses, physiotherapists, and drivers. For enrolled, patients should have 24-hour available caregiver, and his medical condition should be stable. Care givers were given health education about the case, emergency situations, and general care for the elderly. In case of emergency situations, patients are transferred to the hospital. Study design A prospective cohort study. Target population Elderly patients (60 years or more) enrolled in the HHC of Al-Hada and AlTayef Military Hospitals program. Sampling All elderly enrolled in the HHC program during the study period (From 11/2004 till 6/ 2006) were included in the study. 872 Bull High Inst Public Health Vol.37 No.4 [2007] Methods 1All elderly patients or their caregivers were interviewed to collect sociodemographic data as age and sex, and history of the past, and present medical condition. 2Complete physical examination. All patients had complete assessment on admission to the HHC program. 3Medical records of the patients referred from the hospitals including the discharge summary and patient’s record in the HHC program were reviewed. 4Follow up of the patients during the whole period of the study. The following data were collected: Final diagnosis for the patient’ condition for which he/she was enrolled in the HHC program. Associated number and type of comorbidities as hypertension, Diabetes Mellitus (DM), ischemic heart disease (IHD), atrial fibrillation (AF) and chronic obstructive pulmonary disease (COPD). Problem list on enrollment including the state of consciousness, presence or absence of bedsores, pattern of feeding; oral, nasogastric tube feeding (NGT), or Gastrostomy tube feeding (PEG tube). It includes also whether the patient utilizes room or external oxygen, and if he has incontinence or joint contracture. Frequency of visits of the HHC team to the patient. Frequency of emergency visits of the patient to the hospital and the duration from the admission to HHC to the first emergency visit. Length of stay of the patient in the HHC program was calculated by subtracting the final outcome date Mohamed M Makhlouf 873 from date of enrollment to HHC service. The final outcome of the patients was determined as follows: AFavourable outcome: Patient is still receiving the service (active) by the end of the study. Patient was discharged from the service due to improvement or to transfer other place or on caregiver request. BUnfavourable outcome: Patient was readmitted to the hospital and didn’t return back to the HHC service. Patient died. All elderly or their caregiver included were informed about the study and their consent was taken to participate. Statistical analysis Analyses were performed using the Statistical Package for Social Sciences (SPSS, version 11.0. The differences between categorical variables were tested by Chi–Squared test; Fisher’s Exact Test (FET) and Mont-Carlo Exact test (MCE) were used in case of small frequencies. Student t test was used for comparison of mean length of stay for two independent groups. Multivariate associations were evaluated in a logistic regression model, including only significant variables in univariate analysis. Dependent variable Patient outcome was divided into two categories only: Favourable (Active/ Discharged) and Unfavourable (readmitted/died). Although it was much Better to investigate the factors associated with death and re-enrollment separately. However, due to small number of patients who died (9 patients) and those who were readmitted (23 874 Bull High Inst Public Health Vol.37 No.4 [2007] patients), and as many of those who were readmitted and didn’t return back may be died at hospital, these 2 outcome were combined under unfavourable outcome. Independent variables Reference categories were chosen according to literature review and results of the univariate analysis. For all variables, the reference category is mentioned first, and the predictor category was contrasted with the reference category. The variables included in the model were: principal diagnosis (miscellaneous vs. CVA, dementia), number of comorbidities (< 3 vs. ≥ 3), level of conscious on admission (intact vs. impaired), feeding (oral vs. PEG, NGT feeding), respiration (room vs. external oxygen) and number of emergency visits (< 2 vs. ≥ 2), and for AF, COPD, bedsore, joint contracture, incontinence (negative vs. positive). Time from enrollment to 1 emergency visits to hospital was not included due to small number of those who had visits. RESULTS The present study is a follow-up one. It included 131 elderly patients enrolled in the HHC program. Their age ranged from 60 to 100 years, with a mean of 75±10.25 years. More than half of the sample was males (53.4%). The most common cause for enrollment was cerebrovascular accidents (CVA) in 72.52% of patients followed by dementia (5.34%). Other causes included traumatic brain injuries, cancers, spinal cord injuries, and others. The minimum length of stay was one week; the maximum was 19 months, with a mean of 5.74 ± 4.71 months. Figure (1) shows distribution of the patients according to their outcome. The figure reveals that a round