Facilitating and inhibiting thematic constructions of Hospital at Home care (HaH) for COPD patients

Abstract

Background: In a RCT patients admitted with an acute exacerbation of their COPD were randomised to receive Hospital at Home (HAH) or usual care (UC) identified at low risk of death by the DECAF score. DECAF allows for the inclusion of more patients than previous trials (of importance, 45-53% of hospitalised patients). In this trial we sought to identify positive drivers and potential barriers of HAH care pathway. Methods: 89 semi-structured interviews with: patients, those who declined participation, carers, clinicians, nurses and managers who were purposely selected to ensure diversity. Thematic-Construct Analysis was employed. Findings: ‘Positive drivers’ were divided into two sub-constructs ‘Availability of home comforts and maintaining independence’ and ‘Confidence in the continuity of care’. ‘Potential Barriers’ were grouped into two sub-constructs ‘Personal preferences’ and ‘Resistance to change’. Nurses cited increased workload and responsibility (with experience, viewed positively); whilst operational concerns included; keeping medical records in a patient’s home and inability to capture activity within the current payment systems. Clinicians hold preconceptions that patients prefer hospital for safety and respite for carers and raised concerns that patients may not be low risk. Despite efforts to ensure UC was not affected by trial participation patients were sent home earlier than expected. Discussion: During the trial few barriers were identified and were effectively overcome. HAH selected by DECAF allows for the inclusion of more patients than previous models, and is preferred to inpatient care by most patients and their families.