What are the positive drivers and potential barriers to implementation of hospital at home selected by low-risk DECAF score in the UK: a qualitative study embedded within a randomised controlled trial

Abstract

Objective: Hospital at home (HAH) for chronic obstructive pulmonary disease exacerbation selected by low-risk Dyspnoea, Eosinopenia, Consolidation, Acidaemia and atrial Fibrillation (DECAF) score is clinical and cost-effective; DECAF is a prognostic score indicating risk of mortality. Up to 50% of admitted patients are suitable, a much larger proportion than earlier services. Introduction of new models of care is challenging, but may be facilitated by informed engagement with stakeholders. This qualitative study sought to identify facilitators and barriers to implementation of HAH.

Design: Semistructured interviews, data were analysed using thematic-construct analysis.

Setting: Interviews were conducted within patients' homes and hospitals in North East England.

Participants: 89 participants were interviewees; 44 patients, 15 carers, 15 physicians, 11 specialist nurses and 4 managers.

Results: Facilitators include the following: (1) availability of home comforts and maintaining independence (with positive influences on perceived rate of recovery, sleep quality and convenience for friends, family and carers) and (2) confidence in the continuity of HAH care. Barriers include the following: (1) fear of being alone at home; (2) privacy issues and not wanting visitors and (3) resistance to change. Clinician concerns occasionally delayed return home, principally during the early phase of the trial. Nurses cited higher workload and greater responsibility, but with additional resource and training; overall, they viewed HAH positively. Operational concerns included keeping medical records in a patient's home and inability to capture activity within current payment systems.

Conclusion: HAH selected by DECAF was preferred to inpatient care by most patients and their families. Implementation in other hospitals will require education, training and service planning, tailored to overcome the identified barriers.

Trial registration number: ISRCTN29082260.

Keywords: COPD; exacerbation; qualitative; service development.

Conflict of interest statement

Competing interests: SCB reports grants from NIHR: Research for Patient Benefit programme, during the conduct of the study; HTA funding, grants from Philips Respironics, grants from Pzifer Open Air, personal fees from Pzifer and AztraZeneca outside the submitted work. AvW reports grants from NIHR: Research for Patient Benefit programme, during the conduct of the study.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.