Dr. Federico Ruggeri – Dr. Mariano Barberini* Service of Anesthesia and Intensive Care

1. May home hospitalisation (HH) improve outcome than conventional hospitalisation in patients affected with selected chronic diseases ? Dr. Federico Ruggeri – Dr. Mariano Barberini* Service of Anesthesia and Intensive Care Hospital“G.Ceccarini” Riccione AUSL Rimini *Dept. Of internal Medicine S.Salvatore Hospital Pesaro Italy

2. Home hospitalisation (HH) • In these years, the increasing number of emergency medical admissions caused higher requests of hospital beds for critically ill patients. • Improving the community services may be a method for reducing the pressure on emergency hospitals.

3. Home hospitalisation (HH) • Home hospitalisation (HH) has acquired great importance in clinical practice, because it is necessary to find alternative models of assistance in chronically ill patients, in order to reduce duration of hospital medical treatment and its cost or to avoid new hospital admissions, if they are not strictly required.

4. Home hospitalisation (HH) • If we consider our problem only under an economy point view, it’s recently demonstrated that in Italy over75 elderly people, representing the 6.5% of total, spend the 28% of the Medicare expenditures (ISTAT)

5. Statistic indexes Elderly index Over 75 Dependency index

6. Home hospitalisation (HH) • The “hospital at home” model provides cares - that are usually available only in hospital - at patient's home, such as observation, administration of drugs, respiratory and nutritionial support, nursing care, and rehabilitation.

7. Home hospitalisation (HH) • Our group’s aim is to promote health and well-being in patients affected with chronic diseases, undergoing several treatments, in order to make easier the therapeutic activity of implicated medical doctors.

8. Home hospitalisation (HH) • Usually, these patients are referred for their first HH admission after few days of hospital stay , caused by cardiovascular and/or respiratory diseases, old age disorders or cancer.

9. Home hospitalisation (HH) • HH care may be cost effective in patients who are partially self-sufficient but need drugs or technical support, such as those receiving intravenous antimicrobial therapy or artificial nutritional support

10. Home hospitalisation (HH) • Supporting old patients, keeping their independence of life, restoring and encouraging self-management in those with chronic diseases: these are ways for increasing health-related quality of life, reducing costs of National Health.

11. Home hospitalisation (HH): objectives • Patient’s satisfaction, good clinical outcomes and cost savings are the targets we must get. • Patients with chronic conditions often benefit from follow-up access by our team: during HH, integrated care was delivered by a specialised team. • Home clinical controls must be numerous and repeated, clinical cares must be individualised.

12. Home hospitalisation (HH) • In a retrospective study, we analysed the Medicare patients, affected with chronic deseases. • We collected data that described the number of home controls and hospital re-entry, the levels of home medical/nursing therapies and the results we got. • This study was necessary in order to have better educational backgrounds and to enable replies.

13. Home Artificial Nutrition Home Artificial Nutrition (HAN) is one of the aspects of the Home hosptalization ideated with the target to reduce duration of hospital medical treatment and its costs.

14. Home Artificial Nutrition Undernourishment is common in critically ill patients, in hospital and after discharge. It often develops insidiously and its diagnosis is frequently delayed or missed: in Italy recent epidemilogic studies have shonwn high under-nourish levels -20-50% in Hospitalized patients -40-50% in Hospitalized pediatrics patients -10-85% in RSA -10%-30% in Home patients New protocols of AN and a wide number of parenteral and enteral nutrition products let us to create the basis of the service of HAN

15. Home Artificial Nutrition Patients are eligible for HAN when there conditions are present: • Hypo-aphagia • Life expentancy 3 months or more • Collaboration of patient/relatives for self-management • Adequate background • Informed consent

17. Home Artificial Nutrition • HEN: nutritional liquid formulas are given through feeding tubes in patients with swallowing impairment, narrowing of the pharingeal-esophageal passage, who cannot take food orally, or to avoid aspiration pneumonia in patients in coma. • HPN:it is used when patient has a disease of guts or digestive organs which makes impossible for the patients to digest food, so nutrition is given through a central or periferical vein line.

18. NAD • We treated 302 patients in Home Enteral and Parenteral Nutrition (1999-2003), mainly applied in patients with neoplasias (36%) or neurological alterations (35%). • In enteral nutrition,the most commonly access route is the nasogastric tube, although there is an observed increase in the application of Percutaneous Gastrostomy (31%).

19. Distribution nad (302 cases)

20. NAD • In parenteral nutrition, we treated mainly neoplasias and mesenteric ischemia: the majority of patients have non tunnelled tube or periferic vein cath (67%) and 33% have an implanted tube. • There is an obseved complications index 0,05 episodes/patient-year and our index of hospitalizations is 0,56 hospitalizations/ patient-year.

21. HH: New cases/year

22. NAD • These percentages are similar in licterature, although better education and greater awareness are requred to improve the quality of care and the clinical outcome for patients treated by parenteral and enteral nutrition in hospital and at home.

23. Home Artificial Nutrition • The service has an important role at the time of passage of the patient from hospital to home • In this period, after the choice of model of nutrition, it’s necessary to teach the patient’s relatives the method of home feeding, its characteristics and possible problems, with the help of medical and nurses’ staff • Prognosis of terminally ill patients: The median physician prognosis was 75 days from hospice admission

24. Prognosis of NA • The main duration of NED is 3 years for a nerologic patient • Some months of NPD in patients wih cancer • Some years or all the life for a pediatric patient with infiammatory intestinal chronic desease

25. Home Artificial Nutrition • The main target of the service is the self-management of the AN by the patients and, if necessary, with the help of medical (experts in nutrition, intensive care and surgery, nurses) or not medical staff (relatives, supporting people, volunteers)

26. Objectives of HH • Optimization of the therapy • Therapeutic continuity between hospital and home • Decrease of costs and complication • Reduction of costs for therapeutic protocols • Integration between hospital and home • Good quality of patient’s life • Reduction of new admissions into hospital

27. Costs • We have calculated that one of these patients costs in eurs/one day (with the same patology): • 353 in intensive care • 257 in post intensive care • 197 in RSA • 55 in home hospitalization

28. Home hospitalisation (HH): conclusions • Our opinion is that HH causes better outcomes at lower costs than conventional care, in terms of patient’s satisfaction, good clinical outcome and cost saving. • This last effect is due to the shortness of patient’s hospitalisation.

29. Home hospitalisation (HH):conclusions • Furthermore, higher ratios of patients had better knowledge of their diseases, better self-management of their conditions and the level of satisfaction was greater in many of them and in their families.

30. Conclusions HH provides a well-tolerated long term support in many patients. These patients have usually poor prognosis, caused by many factors, the most important of which are age and underlying desease. To have optimal results, it is important to use accurate selection criteria and good evaluation of this impact on life quality.