**8. Conclusion**

Acute exacerbations of COPD are the most common cause of admission to hospital for respiratory illnesses. This causes an increased demand on hospital beds especially during the winter months. Increased provision of services in the community is one proposed method for reducing the pression on acute hospitals.

Intermediate care is a treatment model which bridges the interface between hospital and community care. It often involves cooperation between hospital doctors, general pratictioners, nurses, physioterapists and other healthcare professionals. A specific subtype of intermediate care is Hospital-at-home, were active treatment is provided by healthcare professionals in the patient's home for a condition that otherwise would require hospital care, always for a limited period. Providing acute hospital-level care in a patient's home can be a safe end efficacious alternative to hospital care, especially for frail elderly patients.

The physician-led substitutive "clinical unit" hospital-at home model of Torino provides care that substitutes entirely for an inpatient acute hospital admission; an intensity of care, including medical and nursing care, similar to that provided in the hospital, commensurate with the severity of illness treated; and care that usual community-based home care services cannot provide. Some prior studies of hospital at home for COPD have been of early discharge hospital at home models that treat patients at home with nursing care after they have been admitted to and stabilized in the acute hospital. Davies and collegues in their study of substitutive hospital at home care for COPD employed a nurse-based model that provided only twice daily nursing visits for a period of 3 days and although responsibility for patients rested with hospital physicians, patient's clinical condition did not necessarily require hospital physician's visits at home (Davies et al., 2000). Our intervention targeted very elderly patients with multiple comorbid illnesses, functional impairments and a fairly elevated degree of clinical severity, as shown by the APACHE mean score. These patients need frequent home visits by doctors, nurses and physiotherapists who work together as a team. In our experience HHS care was associated with a reduction in hospital readmission for COPD patients. In addition, HHS care was associated with improvements in quality of life and depression symptoms and a reduction in costs of care. HHS is appropriate for this target population that is especially susceptible to iatrogenic consequences of hospital care and to disruption in their common routines.

The importance of targeting appropriate interventions to appropriate patients has been seen in studies of home care services in which more intensive interventions that included multidimensional assessment were associated with positive outcomes.

Despite the evidence supporting hospital-at-home care, it has had relatively limited dissemination worldwide. Hospital-at-home care is a complex clinical model and, as such, faces substantial dissemination barriers (Leff, 2009).

Our experience suggests that a mature, physician-led, substitutive clinical unit model of hospital-at-home for elderly patients with acute exacerbation of COPD is feasible and is associated with reduction in hospital readmissions and better quality of life.

To date, the evidence base is focused nearly exclusively on patient-related outcomes, rather than on outcomes of interest to potential adopter organizations. There is a need for further studies that include a larger number of patients and an economic evaluation of direct and indirect costs. Moreover, the costs of implementation and the adoption process required within an health organization are to be well delineated.

Hospital at Home of Torino is a part of a comprehensive *continuum of services* at one end of which lies the hospital system and at the other end of which lie community services. Our model is well delineated from an organizational and administrative point of view, and may be considered an example for dissemination.
