(P20) Evaluation of Emergency Room Reattendance and Re-hospitalisation Reductions with Our Hospital to Home Programme

Objectives: Many patients get readmitted post hospital discharge due to multiple factors. Home visits through Hospital-to-Home(H2) programs are targeted at these at-risk patients with complex co-morbidities and high social care needs. We aimed to review the outcome of a hospital-to-home program with regards to reducing emergency department visits and readmissions.

Background: Upon discharge from inpatient wards, patients with high risk of re-hospitailsation are followed up by a heath care team at home visits, with the purpose to identify patient care needs which range from medical to social needs, and intervene so as to prevent an avoidable readmission back to the emergency department or hospital. We also to optimise the well-being of the patient with our multi-disciplinary team approach.

Methods: A retrospective review of patients cared under the program in a tertiary hospital in Singapore from September 2020 to August 2021 was conducted. We studied the demographics of patients 3 months prior to enrolment into the H2H program and followed up with them for the period of enrolment. The enrolment consisted of 2 home visits to the patient which could be conducted virtually if deemed suitable. Thereafter the cohort was tracked for 3 more months after the last home visit and the visits to ED and hospital admissions documented for them.
During the home visits, other than following up on the medical issues, we would perform medical reconciliation, conduct Advance Care Planning conversations and attend to social/financial needs by referring them to social workers or community partners where necessary.

Results: 284 patients have complete data and were included in the analysis. 90% of the patients were above the age 60. The median length of enrolment to the program was 5 months (0 to 7 months). Compared to three-months pre-enrolment period, there was a 47.5% reduction in ED re-attendances during the enrolment of the program. The after-effect was also observed whereby there was a further 18% reduction in ED re-attendances three-months post-discharge from the program. Compared to pre-enrolment period, enrolment in H2H studied 3 months later resulted in the highest number of ED re-attendance reductions among the groups with 3 ED visits (8 patients down from 46) and 4 and above ED visits (6 down from 30).

Conclusions: Home visits through hospital-to-home program can reduce the number ED re-attendances and the benefit can still be observed after three-months post-discharge from the program.

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Funding (Optional): The study was funded by the Agency of Integrated Care Singapore.