Study Design
In this retrospective observational cohort study, we focused on a sample of 380 subjects aged 64 years and older who were discharged from the hospital "S. Giovanni Bosco" in Turin, Italy. Among these patients, 273 received a hospital discharge planning in a DPCH, while 107 patients received routine discharge care. We included in the study patients discharged between March 1st, 2005 and February 28th, 2006, whose age at hospital discharge was 64 years and over. All patients were discharged alive from the hospital and they were observed for a minimum of six months.
Before hospital discharge, a team composed of a geriatrician, a district nurse and social workers determined the medical, psychological, and functional capabilities of the elderly person in order to develop an integrated plan for treatment and follow-up after hospital discharge [29–32]. The evaluation was carried out through the use of instrumental scales (Activity of Daily Living – ADL, Instrumental ADL – IADL, Short Portable Mental Status Questionnaire – SPMSQ) and it was needed to identify the level of complexity of care. In addition, an evaluation of the presence of care givers, family network, presence of voluntary association and housing conditions lead to the definition of the appropriate social care. After the need of medical, social and rehabilitative treatments were taken into account, patients were assigned to receive either DPCH for about 30 days [19] or routine care at home. Patients were referred to DPCH mainly when there was the need of monitoring the effect of new prescribed therapies and/or they needed physical rehabilitation. The care-home setting consisted of 2 residential homes, with a total of 43 beds.
For subjects who received DPCH, individualised care pathways were provided by a multidisciplinary team involving nurses, physical therapists, occupational therapists, geriatricians, community care officers and social workers on a 24-hour basis. A nurse "case manager" was in charge of patient safety and monitored the implementation of the care plan, with the aims of improving patients' level of autonomy and supporting the creation of an adequate care network. Physical and occupational therapists were mostly engaged in developing patients' skills for daily living activities. After a period of about 30 days, a further Operative Care Centre assessment was performed. The pre-post comparison of scores for DPCH patients showed a slight improvement, especially for IADL scores, although this was not statistically significant at the 0.05 level. Patients could then be entitled to receive a long-term care intervention (LTCI) within the same residential setting. This included health and social interventions, which were carried out without a pre-defined duration in time, mainly by nurses, community care officers and social workers. These interventions supported individuals in the activities of daily living. They were provided on the basis of an individual plan, implemented by the same multidisciplinary team, and managed by the same nurse "case manager" that had intervened in the intermediate phase.
In the case of routine care, patients were discharged from hospital to home after the needs assessment, and received the usual health and social care they would ordinarily receive. At home, they were periodically visited by their general practitioner, nurses, physiotherapists, geriatricians, community care officers and social workers. Patients received nursing interventions of varying levels of complexity and frequency, and the appropriate social care, without the coordination of a specific nurse "case manager". When required, medical specialists provided their services. In case of palliative care a nurse specialized in palliative treatments was added to the nursing team.
Data sources
Data were extracted from different electronic databases that included:
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Hospital discharge records of S. G. Bosco Hospital containing International Classification of Diseases IX-Clinical Modification (ICD IX-CM) pathology codes and readmissions date;
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Data on discharge planning of the Operative Care Centre of Local Health Unit N°4 of Turin containing demographic variables (gender, age, etc) as well as physical and mental disability scales, such as ADL, IADL, and SPMSQ;
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Data from the registrar's office of the municipality of Turin in order to verify deaths and date of event;
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Data from the social services of the municipality of Turin containing social variables (family network, pension, etc).
Information on socio-demographic characteristics was collected for the following variables: gender, age at hospital admission (64–74, 75–84, 85+), living arrangements (living alone, living with at least a relative, caregiver), pension (< 750 euro, ≥ 750). Information on care needs, evaluated before hospital discharge, was categorised as follows: ADL scale (independent, partially dependent, and heavily dependent), IADL scale (independent, partially dependent, heavily dependent), and SPMSQ scale cognitive deterioration (absent-light, moderate and severe). The main reason for hospitalization was coded using the ICD-IX CM and then categorised according to the Major Disease Category in cardio-circulatory diseases, injury and poisonings, cancer, diseases of the respiratory system, and diseases of the digestive system. A further category was created for diseases not included in the previous Major Disease Category. The prescription and implementation of LTCI were derived from Operative Care Centre archives.
Statistical analyses
Descriptive and inferential analyses were performed using SPSS 13.0. All subjects were followed up for a minimum of 6 months. Log-rank test with significance level of alpha = 0.05 was used to evaluate associations between type of care and each dependent variable (mortality and readmission) over the follow-up period. Two separate Cox regression analyses were applied to estimate adjusted Hazard Ratio (HR) with 95% Confidence Interval (95% CI) of death and hospital readmission, respectively. The variables that were significant at the univariate analysis at the alpha = 0.20 level were included in the Cox regression models. The p-value of log partial ratio test was evaluated to assess the significance of fitted models. Assumptions of hazards proportionality for Cox regression model were checked by Schoenfeld residuals and Log-Minus-Log plots.
Since the follow-up period was longer than the duration of stay in DPCH (i.e. 30 days at maximum), we took into account a relevant factor intervening after this period, which might have affected our outcome measures, that is the implementation of a LTCI plan. Therefore, the comparison is not limited to two groups (i.e. DPCH vs. routine care) but instead it is made among three groups (two subgroups of DPCH, according to the implementation of a long-term care plan during the follow-up period, vs. routine care).
Ethics
Approval of the ethics committee was not required for the study. Data were extracted from routinely collected administrative databases and there was no need to obtain additional data from individual patients. The interventions under study were performed in ordinary or "natural" conditions, irrespective from the conduct of the present study. Because this was an observational retrospective study, patients had already been treated when the study protocol was written. Data linkage was performed by the team directly involved in patients' care using numerical codes. For the present study, researchers had access only to an anonymous dataset, which ensured patients' privacy. For these reasons, no personal informed consent to the present analysis was requested from study participants.
