Background: Yishun Health (YH) is a regional hospital system in the north of Singapore under the National Healthcare Group. In 2019, YH launched the Medical Home (MH) service, a Hospital-at-Home (HAH) service, aimed at delivering multi-disciplinary integrated acute medical care in patients' homes. Subsequently, the “Expand Acute Care Beyond Hospital” initiative was adopted as one of the four Strategic Priorities of YH to accelerate development of HAH integrated care services. This study evaluates the patient outcomes and cost-effectiveness of the MH integrated care service compared to traditional inpatient care.

Methods: This mixed-method quasi-experimental study compared 125 patients under the MH service with 125 patients receiving usual hospital care (control group). Data were collected from July 2021 to May 2023. Patient clinical, functional and experience outcomes were measured from index admission until 90-day post discharge. Health services utilized and costs during the same period were extracted from electronic medical records. Costs were adjusted to 2024 using the Singapore consumer price index and reported in Singapore dollars (SGD). Multiple linear regressions estimated incremental differences in cost, quality-adjusted life-year (QALY), and net monetary benefit (NMB) between the two groups, adjusting for age, gender, education level, Charlson Comorbidity Index (CCI), Clinical Frailty Score (CFS), and Patient Acuity Category Scale (PACS). One GDP per capita in Singapore (SGD113,779) was used as a proxy for the willingness-to-pay (WTP) threshold.

Results: MH patients had comparable clinical outcomes such as 90-day readmission rate (35% v.s. 36%, p>0.999), mortality (8.0% v.s. 5.6%, p=0.617) and length of stray (5.7 v.s. 6.8, p=0.053) with the control group but incurred significantly lower costs (SGD8,624 v.s. SGD12,140, p<0.001). Functional outcomes measured by Modified Barthel Index (MBI) and EQ5D were also comparable between both groups. Caregivers in the MH group reported lower stress levels and higher satisfaction, particularly in involvement and empowerment in patient care. The ICER (SGD1,578,000/QALY) and positive incremental NMB of 2,860 (95% CI: 2,125, 3,596) for index admission suggests the MH group is cost-effective compared to the control group.

Conclusion: The MH integrated care service demonstrated comparable clinical and functional outcomes to traditional inpatient care up to 90-day post-discharge, with significant cost savings and higher patient and caregiver satisfaction. The MH integrated care service is identified as a preferred strategy for maintaining outcomes and reducing costs, suggesting it could serve as a sustainable alternative to traditional acute care models. Future studies should examine the broader impact of mainstreaming the hospital-at-home model on healthcare delivery, patient outcomes, and cost savings at the health system level.

In 2008, WHO already considered wounds and all related problems as a new hidden epidemic, affecting millions of people around the world. Due to its high prevalence, 1 to 2% in developed countries, it constitutes a public health problem and still, today, a challenge for healthcare professionals, but above all a heavy burden for healthcare systems. In Portugal it is estimated that there are 3.3 people with wounds per thousand inhabitants.
On the other hand, it is known that 70% of these users are followed in the community.
Until now, there were no integrated and differentiated responses available at the Portuguese NHS.
As a result of the training activity and acquisition of professional skills in the area of tissue viability and wound treatment, 3 nurses submitted an application for international certification to the Grupo Nacional para el Estudio y Asesoramiento en Úlceras por Presión y Heridas Crónicas, in 2022. It was the starting point for planning and implementing a differentiated and proximity response.
We identify other valuable hospital's human resources, such as nutritionist, psychologist, orthopedist or social service technician for a multidisciplinary response. We held several meetings with the Board of Directors to define the necessary spaces, processes and equipment. We visited all primary care and 3rd sector units to disseminate the project. In the Execution phase, we monitored the gradual increase in referrals with readjustment of opening hours. The implementation process was progressive and continuous, taking into account people's nosological reality with wounds. In the Control phase, carried out quarterly, it was necessary to readjust the referral criteria (from 6 to 10 weeks) so that primary care teams could refer the most complex cases.
In 2023, around 1600 treatments were carried out. Discharge rate is 65%. 76% of referred users come from Primary Care. The treatment of each user from hospitalization to clinical discharge cost, on average, €807.83. There was a median of 7 weeks of treatment until clinical discharge. This was the organizational unit with the highest number of compliments recorded at the Hospital.
With this health response, it has been possible to closely monitor the population with stagnant chronic injuries. In parallel, interdisciplinarity allows the evaluation and treatment of other comorbidities. As a team with specific knowledge in the area, it is possible to reduce healing times and refer appropriately to other differentiated services. This is an opportunity for a clear improvement in healthcare provided in the context of Local Health Units.
The sustainability of the project will be guaranteed by the relationship of trust established between the LHU Board of Directors, CWU health professionals, primary healthcare and patients. The proximity of care allows greater user confidence, facilitating continuous monitoring, promoting adherence to treatment, significantly improving clinical results and satisfaction levels.
With the creation of Coimbra LHU, in 2024, we will now expand the activity of Cantanhede’s CWU, with a total of 5 specialized units in more distant locations and get closer to the populations, promoting improved accessibility and the reduction of global costs.

BACKGROUND
The Complex Care Hub (CCH) program in Calgary, Canada is based on the international hospital at home model. CCH was co-designed with an inter-professional, inter-organizational team spanning the healthcare system in Calgary, Canada. Throughout this process we also involved patient advisors to support development of materials and processes impacting patient care and transitions across the system.

APPROACH
The program evaluation leveraged the Quadruple Aim framework via a multi-methods study that included patient, caregiver and provider surveys and interviews, as well as quantitative data analysis on patient outcomes, healthcare utilization and cost. This included a comparison of CCH patients with retrospective propensity-matched controls, on the basis of demographic and clinical factors. For data from 2018-2020, 241 of 278 CCH patients were matched to contemporaneous controls, and 238 were matched to historical controls at the same site. Currently, the same analysis is being conducted for admissions between 2020-2023.

RESULTS
CCH patients and caregivers reported an overall high quality of care on CCH. In the 2 years prior to the pandemic, patients' average rating of CCH care was 9.3 out of 10 (n=169). Of CCH patients surveyed during the COVID-19 pandemic (n=91), 97% of patients (n=91) were "satisfied" or "very satisfied," 100% reported that they were treated with "respect and dignity," and 80% felt prepared to manage their conditions upon discharge. Health-related quality of life measured by the EQ-5D visual analogue scale found an average improvement of 9.8 points from admission (n=148) to 30 days post discharge.
Length of stay (in days) appeared to be twice as long for CCH patients versus controls. However, when separating by subgroups, the AA group showed no statistically significant difference in length of stay, while the EFD subgroup had a statistically significant increase in length of stay over twice that of controls. AA subgroup cost estimates suggest 35% lower cost of index admissions, with a further avoidance of 13% in the 180 days post-dishcarge with an overall reduction in cost of 22%. EFD subgroup showed 78% higher cost during the index admissions (approximately $19700 versus $11000 for controls) with but showed a dramatic cost avoidance of 65% in the 180 days post-discharge ($15800 versus $24000) with an overall equal cost over 6 months in both arms. When all patients were analyzed together, the same pattern was observed as for the EFD subgroup, which comprised 75% of admissions. At the time of writing this abstract the analysis for data from 2020 to 2023 is in progress and expected to be completed for ICIC 2025.

IMPLICATIONS
Hospital at Home is an emerging international model of care that is able to safely provide home-based acute care and enhance transitions of care via real-world care-planning. The ability to care for patients outside of hospital walls increases system capacity, with better patient and caregiver experience and outcomes, while reducing the need to build new physical infrastructure.

Background: Central Adelaide Local Health Network (CALHN) is a state government run public hospital organisation in South Australia comprised of five hospitals with two emergency departments. The population we serve is diverse in location and in their health and social care requirements. To accommodate an increasing unmet community demand, CALHN introduced a model of care that accommodates consumers with urgent non-emergency care needs.
Approach: Healthcare in Australia is largely funded by the government, with primary care covered by the Federal government's Medicare scheme and public hospitals by the states and territories. The Medicare scheme is poised for reform to ensure it meets the needs of an evolving healthcare landscape. In the meantime, increasing demand for healthcare that is not sustained by current primary care structures and services means that public hospitals - with an always open door and no out-of-pocket expenses - are being overwhelmed by demand. This mismatch in capacity and demand often sees the state-run public hospitals creating solutions that may be seen as foundationally primary care. CALHN first created a hospital avoidance model of care in 2019. It was designed as a multidisciplinary "rapid see, treat, discharge" service to accommodate consumers on a trajectory to an emergency department, but whose care needs do not require emergency medicine (typically Australasian Triage Scale categories 3 and 4). The service also focusses on the care needs of those from diverse backgrounds who may have a level of vulnerability, including older people, those with a disability, First Nations people, people experiencing homelessness or from culturally and linguistically diverse communities. The service was established in a community location, approximately 7 kilometers from the nearest emergency department. Following the success of this service, CALHN designed a second service, largely based on the original but with significant consumer engagement to inform the model. The second service was designed to be located onsite at one of its tertiary public teaching hospitals; this nuance provided both opportunities and challenges in the design.
Results: The second service has been operational since 15 July 2024 and to date has provided care for over 2,000 consumers. The original service, in the same time period, has provided care for 2,800 consumers. Collectively, this represents close to 5,000 consumers who have been redirected from CALHN emergency departments. Whilst this model of care does not solve the structural problems of healthcare in Australia, it does provide a person-centred, care-level appropriate alternative for consumers in the CALHN community whilst reducing activity presenting to the busy emergency departments.
Implications: Healthcare demand is creating opportunities for organisations to do things differently. Traditional hospital models need to evolve to meet this demand whilst governments plan an approach to system reform that will sustain growing demand. Our next steps are to review the model in early 2025, to ensure the referral pathways are capturing the right consumers, and that activity base covers the costs of the service.