This is, to the best of our knowledge, the first study which evaluates both health care provider’s roles and satisfaction of all health care providers involved in a community-based, early discharge, hospital-at-home scheme. In general, providers evaluate the early assisted discharge scheme as positive. Coordination of care and continuity of care need attention, and the possibility for primary care providers to contact the hospital and discuss patients is valued as very important. The transfer of patients from hospital to primary care does have impact on nurses’ roles, as they described their role in hospital-at-home to be different from usual care. However, providers are satisfied with their roles and generic community nurses feel they have sufficient knowledge and skills to monitor patients at home.
The positive results on health care providers’ satisfaction with a community-based hospital-at-home scheme are confirmative to previously published results [9–11]. However, these were results on selected professionals, where our study included all professionals involved in the hospital-at-home scheme.
Except for general practitioners, who were not officially involved in the scheme, roles were clear for health care professionals. This is confirmed by the similarity to the predetermined according to the protocol and the description the professionals gave. Hospital and community nurses experienced their role to be different from usual care. Although hospital respiratory nurses reported an intensified contact with patients on the ward, differences to their roles were associated to the activities for the randomised controlled trial, whereas reported differences by community nurses were indeed associated to the patient transfer. Community nurses state that their roles changed from mainly physical activities (washing, medication dispense etc.) to more (disease specific) guiding, counselling and controlling.
Satisfaction with the different roles was high and providers did not want to make major changes. Nonetheless, there were remarkable differences between providers in primary care, who are less satisfied, and providers in secondary care. This may partly be explained by the extremely low satisfaction scores of general practitioners, but also by the changes that are opposed on primary care (i.e. community nurses). In secondary care the population treatment did not change, whereas community nurses were confronted with a ‘new’ group of patients.
The majority generic community nurses, who in practice were the professional that performed the home visits and monitored the patient, felt they had sufficient knowledge and skills for this. This contrasts with the responses of specialised community nurses. Specialised community nurses felt certain skills and knowledge lacked in generic community nurses. There seem to be different interpretations of what is necessary to monitor patients at home. As a result of more training, specialised nurses may know the specific needs of COPD patients better, and are better able to judge whether generic community nurses can monitor patients at home. However, previously performed studies on the effectiveness of early assisted discharge showed that the use of generic community nurses had no effects on patient outcomes [18, 19]. In addition, another study showed that in post-rehabilitation COPD patients, delivery of home care by specialised nurses showed no superior results over care delivered by generic nurses . Any deficits in the disease-specific knowledge of generic community nurses could be solved by a special education program focussing on COPD, as was done in the study of Davison et al. . Due to changes in the Dutch reimbursement system, the number of specialised community nurses is decreasing. Specific and tailored training for generic nurses working with patients who are early discharge could be a good way to improve disease specific knowledge in generic community nurses and continue their work in the hospital-at-home scheme. Furthermore, specialised nurses, either working in the hospital or in the community, could be used on a consultation basis for generic community nurses. For example, when setting up a scheme it could be arranged that for each patient there is contact between the generic community nurse and a specialised nurse after the first or second home visit. In this arrangement generic community nurses receive coaching on the job, which can be reduced gradually once the scheme is running for a longer period.
It can be debated, also from a legal point of view, who should have clinical responsibility for patients that are discharged early from hospital, but still receive treatment that substitutes the hospital admission within the hospital-at-home scheme. Arguments to hold either general practitioner or hospital doctor responsible were similar among general practitioners and hospital doctors, but pulmonologist were more likely to hold responsibility at the hospital. It is possible that not only medical and safety arguments are the foundation of this opinion, but that financial issues are of importance as well . However, it can be concluded that in the future it is possible that general practitioners have clinical responsibility during the treatment at home. However, although patients appreciate practitioners’ involvement after hospital stay , it can be debated whether this is advisable. Early discharge in our scheme was possible for a limited percentage of patients (25-30%)  and it would have required large involvement of general practitioners to cover the care for these patients while being treated at home. Most general practitioners from the region did not have had any patients in the schemes and those who had patients in scheme had on average 1–2 patients during the study period of 3.5 years. A shared-care model, which is the most described hospital-at-home model in the United Kingdom , with possibilities for fast and direct consultation of pulmonologists, could be a satisfying model for both physicians and patients. The exact design of shared-care would depend on regional arrangements between general practitioners and pulmonologists.
There were clear differences between community nurses and hospital nurses in the valuation of coordination and continuity of care. Hellesø and Fagermoen found that cultural differences between hospital and community nurses may affect coordination and continuity of care . Cultural differences may influence the assessment of patients’ care needs or affect beliefs on which information is important when transferring patients from hospital to home. In addition, insufficient existing information transfer systems (i.e. transfer forms) often cause insufficient coordination and continuity of care . In our study, several community nurses made comments on the inadequate information transfer and the content of the information. This may explain the different responses of community nurses and hospital nurses. A convenient, mutual designed (electronic) transfer form that covers all aspects, or an electronic patient file accessible for all professionals involved could improve coordination and continuity of care.
As in any study, there are limitations Firstly, the low response rate in some groups of professionals jeopardises the precision and generalisability of the results. In surveys there is no scientific agreement on what is considered to be the minimal response rate, but in general a response rate of 60% is considered to be the threshold for an acceptable response rate . Several methods to reduce nonresponse have been applied. The length of the questionnaire has been discussed with representatives of the groups of professionals in order to minimise the burden of completing the survey. In addition, we tailored the methods for invitation and completion to the groups of professionals. Despite an electronic questionnaire to facilitate easy and fast answering and reminders to complete the questionnaire, the response rate among community nurses and residents was lower than in other groups. There are no details available on characteristics of both responders and non-responders, which complicates the assessment of reason for nonresponse and the implications of the nonresponse . Possible reasons for nonresponse could be a negative attitude towards hospital-at-home. However, answers to the survey were diverse and discerning, we therefore believe that responders were representative of the study population. The larger the number of individual professionals in a group (e.g. in residents, generic community nurses and general practitioners), the lower the number of patients that the individual professionals have had contact with. This because of the distribution of patients over a larger number of professionals and, in case of community nurses, a larger working area. This may explain the lower response rates in these groups. In addition, in some cases there was a long recall period between the actual care for the early discharged patient(s) and the assessment of the questionnaire which may have some professionals decide not to fill in the questionnaire. Secondly, the measurements we used in our survey were not validated. Furthermore, it is possible that other important aspects were not addresses. For example feeling safe treating patients at home. However, other results from the effectiveness evaluation , patient evaluation  and informal caregiver evaluation [Utens et al., Informal caregiver strain, preference and satisfaction in hospital-at-home and usual hospital care for COPD exacerbations: results of a randomised controlled trial. Submitted] are positive and suggest that this probably will not be a large issue. Thirdly, (health care provider) satisfaction is a multidimensional construct that is difficult to measure. There is no gold standard for measuring this and, as we already stated, no questionnaire available to evaluate providers’ opinions on hospital-at-home schemes. Therefore, results should be interpreted with some caution, because of possible measurement error. Nonetheless, we believe that the inclusion of health care providers in the development of the questionnaire has led to an acceptable survey, representing issues that are of importance to the health care providers. Fourthly, although we evaluated important aspects of early assisted discharge, results cannot just be transferred to other countries or schemes. Transferability depends on the design of the schemes, the providers involved and the culture in organisations and among providers. More specific research should be done on more detailed aspects of hospital-at-home schemes. This could help to improve the design of the hospital-at-home schemes and to ensure care activities are executed by the most suitable professional. This creates the platform that is necessary for implementation of community-based early assisted discharge schemes.
Whether or not new health care programs should be implemented or not depends on several factors. The health care program needs to provide at least the same outcomes as usual care and from a societal perspective, cost should not be larger than in the usual care program. Furthermore, how patients and their informal caregivers evaluate the health care program is of importance. Finally, successful operation of the program depends on the acceptance of health care providers involved. In addition to positive evaluations from the perspective of patients, society and informal caregivers, this study suggests that a community-based hospital-at-home scheme is acceptable.