**5. The Hospital at Home Service of Torino**

In October 1984, with Resolution N. 1134/41/84, the Management Committee of the Local Health Unit 1/23 of Turin set up the 'Experimental Project of Home Hospitalisation'.

In October 1985 a team of doctors and nurses of the Turin Department of Geriatrics started an experiment that was unique in Italy at that time: medical treatment (including examinations and related medical and nursing services) at home rather than in hospital for patients with severe chronic or relapsing illnesses*.* 

The Hospital at Home Service (HHS) is operating in Torino at S. Giovanni Battista Hospital, a large urban University teaching and tertiary-care hospital (Aimonino Ricauda et al., 2004, 2005, 2008; Tibaldi et al., 2004, 2009).

The HHS is a service that provides diagnostic and therapeutic treatments by health care professionals, in the patient's home, of a condition that otherwise would require acute hospital in-patient care. A quick admission to hospital is possible for examinations or interventions that cannot be carried out at home. Transport and acceptance are free for these patients, as part of the HHS service.

The HHS normally operates 12 hours a day (from 8 am to 8 pm), seven day a week. At night our Regional Emergency Unit ("118") can be contacted. For selected patients, medical staff is on-call 24 hours a day. Caregivers are instructed in the emergency plan and encouraged to telephone if problems arise.

The HHS team, equipped with 7 cars, is multidisciplinary and consists of 4 geriatricians*,* 13 nurses*,* 1 nurse coordinator*,* 2 physiotherapists, 1 social worker, 1 counsellor.

The main feature of HHS is that physicians and nurses work together as a team (Figure 1), with daily meeting to discuss the needs of each patient and to organize individualized medical care plans and day-to-day work. The three most important aspects of the nursing activity are:


The team looks after 25 patients per day and 500 patients per year, on average. The most common diseases treated at home are cardiac, respiratory, cerebrovascular, metabolic and neoplastic diseases.

Hospital at Home for Elderly Patients

**Services and treatment provided**: Physician and nursing visits Standard blood tests Pulse oximetry Electrocardiogram Spirometry Echocardiogram

Oxygen therapy

Telemonitoring

Physical therapy Occupational therapy

Counselling

of the patient.

X rays

Blood product transfusion

Central venous access (PICC, Midline) Surgical treatment of pressure sores

with Acute Exacerbation of Chronic Obstructive Pulmonary Disease 383

necessary diagnostic tests (e.g., blood tests, radiography, ECG) are provided and then the

Entry criteria for home hospitalization are: informed consent of patient and caregiver; stable, diagnosed medical conditions needing hospitalization but not expected to require emergency intervention; appropriate care supervision; telephone connection; living in the

Exclusion criteria are: need of intensive monitoring or mechanical ventilation, a monitoring more frequent than every 2 hours of blood pressure or haemogasanalysis, patients with an heart attack or with very low levels of oxygen in the blood or with a serious acidosis or

Oral and intravenous medication administration, including antimicrobials and cytotoxic drugs

Hospital-at-home patients are considered hospital patients, and all services are provided by the

A case history is made up for each patient and is always available at the patient's home,

Medical consultation with other hospital specialists is possible in the hospital or at the home

HHS has continued to increase its activity since its inception in 1985. Until now about 11000 admissions have been recorded. In 2010, 550 admissions were recorded, 9113 nursing visits

Many services or treatments can be provided at home, as shown in Table 1.

Assessment in Emergency Department and transport home via ambulance

patient moves home by ambulance, usually within a few hours.

hospital catchment area (all the southern part of the city).

alkalosis or with a suspect of pulmonary embolism.

Internistic ecographies and Doppler ultrasonographies

hospital, which retains legal and financial responsibility for care.

Table 1. Features of the Hospital at Home Service

with an updated report available in the HHS office.

Fig. 1. Hospital at Home Service: doctor and nurse at patient's home

The HHS can be activated by a direct request of the general physician of the patient as an alternative to traditional hospital care, or by a request from hospital wards doctors to allow early and protected discharge from hospital.

Since 2001, a close collaboration has been started between the HHS and the Emergency Department (ED) of San Giovanni Battista Hospital, to propose, where possible, home care as an alternative to the traditional admission to hospital.

Now, approximately 60% of our patients are referred by the ED, 25% by hospital wards and 15% by specialist or general physicians in the community.

The relationship between the ED team and the "HHS mobile team" made up of 1 geriatrician and 1 nurse is very important. By using a multidimensional case sheet, the "HHS mobile team" carries out an assessment of the patient and his caregiver to evaluate the possibility of hospitalization at home and in order to give information on the service.

A "Module of interview with the family" was conceived and implemented to discover the willingness of the family to work together with HHS team, as a part of the patient's healthcare system.

When the availability is established, an "Informative Card" with information on the service has been given to the patient and his caregiver.

Then, the "HHS mobile team" together with the ED doctor writes a rough copy of patient's case sheet, which will be completed at home during the first HHS visit. In the ED all the

Fig. 1. Hospital at Home Service: doctor and nurse at patient's home

early and protected discharge from hospital.

has been given to the patient and his caregiver.

healthcare system.

as an alternative to the traditional admission to hospital.

15% by specialist or general physicians in the community.

The HHS can be activated by a direct request of the general physician of the patient as an alternative to traditional hospital care, or by a request from hospital wards doctors to allow

Since 2001, a close collaboration has been started between the HHS and the Emergency Department (ED) of San Giovanni Battista Hospital, to propose, where possible, home care

Now, approximately 60% of our patients are referred by the ED, 25% by hospital wards and

The relationship between the ED team and the "HHS mobile team" made up of 1 geriatrician and 1 nurse is very important. By using a multidimensional case sheet, the "HHS mobile team" carries out an assessment of the patient and his caregiver to evaluate the possibility of hospitalization at home and in order to give information on the service.

A "Module of interview with the family" was conceived and implemented to discover the willingness of the family to work together with HHS team, as a part of the patient's

When the availability is established, an "Informative Card" with information on the service

Then, the "HHS mobile team" together with the ED doctor writes a rough copy of patient's case sheet, which will be completed at home during the first HHS visit. In the ED all the necessary diagnostic tests (e.g., blood tests, radiography, ECG) are provided and then the patient moves home by ambulance, usually within a few hours.

Entry criteria for home hospitalization are: informed consent of patient and caregiver; stable, diagnosed medical conditions needing hospitalization but not expected to require emergency intervention; appropriate care supervision; telephone connection; living in the hospital catchment area (all the southern part of the city).

Exclusion criteria are: need of intensive monitoring or mechanical ventilation, a monitoring more frequent than every 2 hours of blood pressure or haemogasanalysis, patients with an heart attack or with very low levels of oxygen in the blood or with a serious acidosis or alkalosis or with a suspect of pulmonary embolism.

Many services or treatments can be provided at home, as shown in Table 1.


Table 1. Features of the Hospital at Home Service

A case history is made up for each patient and is always available at the patient's home, with an updated report available in the HHS office.

Medical consultation with other hospital specialists is possible in the hospital or at the home of the patient.

HHS has continued to increase its activity since its inception in 1985. Until now about 11000 admissions have been recorded. In 2010, 550 admissions were recorded, 9113 nursing visits

Hospital at Home for Elderly Patients

with Acute Exacerbation of Chronic Obstructive Pulmonary Disease 385

attitudes, promoting health education to the patient and the family and finally enabling them to better cope with the situation*.* The counsellor do not provide standardized information to increase the caregiver's skill in caregiving; rather, counselors focused on

In the first days after admission in HHS each patient is visited at home on a daily basis by physicians and nurses. In the following days the patients is seen every day by a nurse and at intervals of 2-3 days or less by the doctor, as required by the patient's clinical condition. Hospital at home staff is available at all times for urgent home visits, which occur within 20- 30 minutes by the telephone call. Home visit include: physical examination, measurement of vital signs (pulse, blood pressure, respiratory rate, temperature, oxygen saturation), administration and revision of therapy, if necessary. Essential skills for members of the HHS team are the ability to take a comprehensive clinical history and assess clinical condition, familiarity with pharmacological and non-pharmacological approaches, good

Upon admission, for each patients are recorded: blood pressure, spirometric parameters (FEV1, FVC, FEV1/FVC%), hematocrit, blood glucose, serum creatinine concentration, serum hepatic enzymes, serum nutritional parameters (e.g, total proteins, albumin, transferrin, lymphocytes) and electrolytes, arterial blood gas levels (pH, partial pressure of oxygen, partial pressure of carbon dioxide, bicarbonate, pulse oximetry), sputum culture if possible. During the HHS admission clinical assessment and routine observations are useful in assessing the rate of recovery from an exacerbation. Blood tests, including arterial blood gases measurement and spirometry are repeated according to the clinical condition of the

At home, a multidimensional geriatric assessment is conducted using validated instruments. The multidimensional geriatric assessment include the evaluation of comorbidity using the Cumulative Illness Rating Scale (Conwell et al., 1993), severity of illness using the Acute Physiology And Chronic Health Evaluation (Knaus et al., 1985), depression status using the Geriatric Depression Scale (Yesavage et al., 1982), functional status using Katz Activities of Daily Living and Lawton Instrumental Activities of Daily Living (Katz et al., 1963; Lawton & Brody, 1969), cognitive status using the Mini-Mental State Examination (Folstein et al., 1975), quality of life using the Nottingham Health Profile (Hunt et al., 1985), nutritional status using the Mini Nutritional Assessment (Guigoz et al., 1997), characteristics of caregiver with special attention to the level of stress using the Relatives' Stress Scale (Greene et al., 1982), and satisfaction using an "ad hoc" questionnaire for customer satisfaction (Figure 2). The HHS patients undergo acute rehabilitative care at home, including pulmonary rehabilitation when needed, and their caregivers are encouraged to actively participate in the rehabilitation process. Education and psychological support are important for the overall success of rehabilitation. Education improves knowledge, coping and selfmanagement, actively engaging patients to maintain strategies that reduce dyspnoea, maintain good lifestyle habits and participate in decision-making when acute exacerbation

When patients recover from an acute exacerbation of COPD the dimission is planned, making arrangements with General Pratictioner. District Health Services are activated if

helping caregivers understand and resolve their reactions to caregiving process.

communication skills, understanding of airway clearance techniques.

patient. A chest X ray at home is possible, if necessary.

occur.

required.

and 4317 medical visits were conducted. The mean age of our patients was 80 years (range 30-101). Mean length of stay was 14 days.

In 2010 the Piedmont Region issued a decree to regulate this HHS model and acknowledged a refund of 165 Euros*/*day for DRG included in MDC number 1, 4, 5, 16, 17 (neurological, respiratory, cardiovascular, haematologic and neoplastic diseases), and 145 Euros for the other diseases.
