Characteristics of Studies
A total of 10,469 records were identified, which included 417 additional records from the gray literature. Duplicates were removed using Endnote X9’s built-in function, resulting in 6,909 records. From this, 6,284 records were excluded via their title and abstract. The remaining 625 articles underwent a full-text review, which resulted in 16 included articles (Fig. 1). Of the 16 articles, most were in English (n=15) while the one in French was translated to English using Google Translate20. The majority of the studies were from America or Europe (n=15)1,12,20,21,22,23,24,25,26,27,28,29,30,31,32. A third of these studies were based in the UK (n=5)24,25,26,27,32 and one was in Australia33. Studies were qualitative (n=14)1,12,20,21,22,23,24,26,27,28,29,30,31,33, or mixed-methods (n=2)25,32. Studies were descriptive (n=13)12,21,23,24,25,26,27,28,29,30,31,32,33, utilizing a grounded theory (n=2)1,20 or ethnographic approach (n=1)22. Most data were collected from individual interviews (n=12)1,21,22,23,24,25,26,27,28,31,32,33, focus group interviews (n=2)20,30, or both (n=1)12. The remaining study employed open-ended questionnaire29. Studies employed thematic analysis (n=9)12,21,22,24,25,26,30,32,33, content analysis (n=3)23,28,29, ground theory analysis (n=2)1,20, normalizing process theory analysis (n=1)27, or retrospective analysis (n=1)31. Most HaH provided early discharge (n=9)12,22,25,26,28,29,30,31,33 compared to admission avoidance (n=1)27, while the remaining studies did not specify. The HaH studies included patients who had multiple diagnosis (n=6)1,12,20,23,30,32, COPD (n=3)24,29,31, cancer (n=1)33, renal diseases (n=1)22, and mental illnesses (n=1)26, and also geriatric (n=2)21,27 and orthopedic patients (n=2)25,28. All HaH involved multidisciplinary teams or units, and some involved community service providers (e.g., community healthcare practitioners, community nurses, community social care managers, healthcare agency partnerships)1,12,23,24,27,28,29,30,33. Table 1 summarizes the studies’ characteristics and Table 2 depicts the types of participants interviewed.
Findings were meta-synthesized to form an overarching theme, “the intricacies of developing HaH,” pillared by four main themes: (1) factors influencing patient selection, (2) advantages of HaH, (3) challenges of HaH, and (4) enablers for HaH development (Fig. 2).
Factors Influencing Patient Selection
This theme consisted of four subthemes to describe the characteristics of patients and caregivers that make them suitable for HaH: (1) strong social support, (2) positive health behaviors, (3) confidence in receiving care at home, and (4) conducive home environment.
Various studies reported that strong social support assisted patients in home recovery1,24,26,27. Social support was mainly provided by caregivers in the form of moral support for the patients1,27, ensuring patient safety, and liaising with the healthcare professionals27. HaH was reportedly less favorable for patients who did not cohabit with their caregivers27 or for patients going through divorces24. HaH was found suitable for patients who lived alone and relied on other social connections like “friends” and “neighbors.”27
HaH was found to be suitable for patients with positive health behaviors and self-efficacy22,24,25,30. This included displaying self-restraint from negative health behaviors (e.g., smoking, drinking, consuming drugs)24,30, and self-efficacy in independently performing vital sign monitoring at home22. Some studies reported that HaH was perceived to be less favorable among those who were not confident with remote care and “prefer to be in a cocoon of a hospital environment” with “someone seconds away from them.”1,24
Lastly, suitable patients should have a conducive home environment for recovery24,28,30,33. Some studies reported difficulty in performing care when patients’ pets disrupted administration of intravenous medication30,33, the living space was small 24, or the home environment was unhygienic30. Places lacking adaptive home features for safe mobility were also not ideal for home rehabilitation28.
Advantages of HaH
This theme captured the positive experiences of stakeholders with HaH across different settings. The subthemes were as follows: (1) more comfortable and patient-centered care, (2) perceived better patient clinical outcomes, (3) more family engagement with patients, (4) improved care continuity during and beyond HaH, and (5) increased hospital bed capacity.
HaH provided patients and caregivers with a more comfortable and personalized hospitalization experience1,20,24,27,28,29,30,33. All stakeholders from various studies expressed that “being in your own home” helped preserve some sense of normalcy for patients to “follow own daily rhythm,”29 and “walk around more freely.”24 This reduced anxiety for some and boosted their morale and confidence1,24,30,33. Other studies mentioned that some healthcare professionals and caregivers felt that a sense of normalcy was essential for “end-of-life patients” and their loved ones20,27. HaH also removed the need for patients and caregivers to travel to the hospital to receive care or visit their loved ones, respectively24,33.
Furthermore, HaH promoted patient-centered care23,24,27,29,30,31,32. Patients noted that there was “time to develop rapport” for more “personal and individual” relationships with their healthcare professionals24. Similarly, healthcare professionals commented that they had more opportunities to collaborate with their patients23,27. Some healthcare professionals noted a power shift between themselves and their patients when there was change in environment (i.e., from ward to home setting). They were no longer just medical staff but were invited as “a guest” at patients’ homes with their “permission”30. Since healthcare professionals were able to assess patients in their natural home environment, both parties highlighted that medical advice was more fine-tuned to specific situations in their everyday life29,31.
HaH was perceived to improve clinical outcomes1,24,27,28,30,31,32. Patients reported having improved sleep24,32, better appetite1,24,28, and speedier recovery24,28. From healthcare professionals’ perspectives, the familiarity and privacy of home encouraged patients to “reveal something they would never mention while in the hospital”30,31 that might help tailor better care to their patients.
Patients reported that HaH allowed them to be closer to their family24,32. Recuperating at home was “easier for my family to visit,”24 and couples emphasized the importance of being together at home32. Similarly, caregivers agreed that HaH provided relief to their loved ones who depended heavily on their support32.
Some HaH focused on care continuity during and beyond the intervention itself. For these programs, healthcare professionals noted that they helped to integrate acute care into long-term care management strategies27,30,31. Caregivers commented that HaH was “the best hospital experience because there seems to be aftercare.”27 Healthcare professionals were able to provide patient education that was helpful in the long run, such as advising patients on how to cope with their disease by using their home environment to their advantage31, and providing adequate medication reconciliation for them30. Having patients undergoing treatment at home also releases hospital beds to others who need more acute care28.
Challenges of HaH
This theme captured the challenges faced by HaH stakeholders. The subthemes were as follows: (1) lack of round-the-clock patient supervision compared to the hospital; (2) increased caregiver burden; (3) unclear and underdeveloped workflows; (4) difficulty in screening, identifying, and recruiting HaH patients; (5) increased staff burden.
All stakeholders recognized safety as a priority for HaH. Some healthcare professionals and caregivers expressed that HaH lacked the 24-h physical care provided in the hospital27,28. This was more prominent for caregivers who did not live with the patients as provision of care was “difficult from a distance.”27 Remote care also made some patients “rigid with nerves” especially at night when they felt most “alone.”29,32 This sense of vulnerability was often expressed by COPD patients who were afraid of “being alone at night when I am breathless,”29 or for patients with renal diseases who feared blood loss during home hemodialysis. Lastly, mothers with acute severe mental illnesses from the included studies were mostly overwhelmed with managing distress at home and parenting responsibilities. Hence, they preferred the 24-h care provided in the hospital26.
While a few caregivers acknowledged that HaH freed time “spent in the hospital visiting” to “rest at home,”32 the transfer of care responsibility from hospital to caregivers was burdensome to some1,12,24,26,27,28. Those who experienced caregiver burden felt that there was a strong reliance on them to facilitate HaH. They were often tasked with coordinating care, standing by for eventual emergencies, or providing assistance during home treatment. This is especially so for caregivers caring for demented27 or mentally ill patients26. Caregivers reported the need to help coordinate care between healthcare professionals and the patients as “a multifunction maid.”1 Particularly at night, caregivers were reportedly “sleeping with one eye open” to provide 24-h support27 or had their “imagination runs riot” when their confused patients “tried to get out the window,” demonstrating difficulties for the family to contain the risk at home for acutely sick patients27. Moreover, some caregivers had full-time jobs and household chores1. Children of mentally ill patients were reportedly swamped with “emotional responsibilities.” Seeing patients sick all the time was a “horrible” or “frightening” experience for others1,24,26. Despite the transfer of care responsibility from hospital to caregivers, not all HaH have in place efforts to recognize caregiver stress, leaving some caregivers burnt out during HaH. Furthermore, the decision for HaH was often determined by the healthcare professionals and patient’s preference, and less influenced by caregivers or family decisions (agreement among several family members).
For many healthcare professionals and administrators, HaH was operationally challenging. Firstly, since HaH function beyond the hospital’s walls, it was difficult to capture activity within the current payment system24, and there was no system in billing patient care as a bundle or single “acute episodes.”12 Absence of a proper billing system created difficulty for organizations to assess cost and cost savings for each case, and deters insurer from covering such services12. Secondly, technology was not well integrated into HaH. While proper documentation was important in a multidisciplinary service, some organizations’ electronic health records were not nimble enough to sync, record real-time, or integrate among the different care units12,24,30. Furthermore, limited studies mentioned the use of remote monitoring system or teleconsultations in HaH. For those which did22,30, the use of a remote monitoring system was physically disruptive to users’ daily lives22, and teleconsultations yielded “technical problems.”30 Patients requiring complex medical equipment such as home hemodialysis for HaH also tend to encounter difficulties with the equipment at home. Furthermore, HaH workflows were sometimes confusing12,20. Healthcare professionals were unsure of HaH entry and exit points, and had problems identifying their clinical roles in HaH20. Healthcare professionals noted that some clinicians lacked certain skills to care for patients at home12,20,28. For example, not all clinicians could perform infusion or had sufficient experience caring for certain groups of patients, which may have hindered access to delivering timely treatment at homes12,28.
Screening, identifying, and recruiting suitable HaH patients were also challenging. Healthcare professionals felt that this process was tedious and time-consuming12,20,30. In addition to assessing patients’ conditions and their ability to self-care, they had to liaise with caregivers and assess patients’ living conditions before enrolment12,20,30. Furthermore, recruitment was limited. Although the concept of HaH is not a novel intervention, some healthcare professionals, patients, and their caregivers have reservations about the implementation of HaH since acute care is traditionally provided in the hospitals12,24,28. The reservations included perceiving the service as a means to “get you out” from the hospital to obtain “empty beds.”27,28
Some healthcare professionals reported an increase in burden to deliver hospital care to the home1,21,28,30. They found the work to be “demanding” as they had to coordinate care, plan their travel time to ensure patients received prompt treatment21,30, and adjust to the changing workflows of new HaH programs30. High staff turnover rates were reported1,28; organizations that did not address the high turnover rates caused the remaining healthcare professionals to work with “very few sick leave.”30
Enablers for HaH Development
There were four subthemes that characterized enablers of effective HaH: (1) clinicians with strong clinical and communication skills; (2) importance of maintaining quality of care while receiving treatment at home; (3) supportive operational, regulatory, and legal frameworks to promote care delivery in the home setting; and (4) integration with post-discharge care.
Healthcare professionals reported that HaH team should have strong clinical and communication skills. Firstly, competence in clinical skills is important since they have to make clinical decisions independently30. As HaH relies on remote monitoring, they should also hone their technical skills to operate such technologies23. To ensure patients are safe at home, healthcare professionals must be well trained in patient and caregiver selection before HaH enrolment27. Secondly, healthcare professionals need to have effective communication skills to “collaborate” among colleagues, patients, and their family members, and communicate well to “show our respect” in patients’ homes30. Furthermore, administrators and healthcare professionals reported that teamwork and communication among multiple partners are essential12,20,21,23,28,30. For many, HaH was not well integrated to encourage “teamwork or cross-department specialist teams.”23 Timely provision of services and referrals are required to ensure the quality of care, that is, no communication delays or missing information, and a robust referral system12,28. Studies that reported proper communication among clinicians indicated that the clinicians had better HaH experiencs12,21,28,30.
It is important to maintain quality of care during HaH as well. This can be provided in the forms of providing assurance, maintaining proper communication, letting patients and their family members be actively engaged in patient recovery24,27,28,30,31,32, communicating treatment predictability32, ensuring 24-h telephone services24, daily visits24, and instilling confidence that help will be promptly given32. Patients and caregivers expressed confidence in HaH when HaH healthcare professionals were “well trained “and “caring.”31 Furthermore, patients wanted to be engaged in their recovery27,29,30,31 by being involved in their discharge planning27, treatment decisions during HaH27, learning more about their medications29, and “getting an explanation” on their diagnosis while being at home31.
While patient-centeredness care is at the forefront of HaH, the findings revealed that the healthcare system needs to be supported by laws and regulations to maintain staff’s safety and medical legal coverage as the care setting shifts to patients’ homes12,30. Some healthcare professionals revealed that a power shift between them and their patients was observed when provision of care moved from ward to home setting; this was perceived as a challenge for healthcare professionals’ safety since they were no longer just medical staff but were “a guest” invited to patients’ homes with their “permission.”30
Finally, post-discharge care integration was seen as a priority. Patients and caregivers favored having continuity of care during and beyond HaH. Caregivers wished to know how they could “change the condition” of their loved ones27, preferred having reviews by the same specialist29, and appreciated follow-ups after HaH care31. Patients and caregivers wanted to be a part of patient recovery and form a continuous relationship with an identified healthcare professional after their HaH experience27.