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Intermediate care is a treatment model which bridges the interface between hospital and community care. It often involves cooperation between hospital doctors, general practitioners, nurses, physiotherapists and other healthcare professionals. A specific subtype of intermediate care is Hospital-at-Home (HaH), where 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.
In 2003 a Cochrane systematic review concluded that HaH was a safe and effective treatment approach for selected patients with exacerbations of chronic obstructive pulmonary disease (COPD), and suggested that one in four patients presenting to hospital as an emergency would be suitable for home treatment with nursing support,1 although some felt that this was an underestimate of eligibility for HaH (Stevenson, 2005).
In 2004 the National Institute for Clinical Excellence (NICE) COPD guidelines2 included appraisal of HaH in exacerbations of COPD. A distinction was made between HaH (where hospital admission was avoided) and assisted or early discharge schemes (where a short initial admission was followed by home care). We suggest that it is illogical to exclude cases of early or assisted discharge from HaH and, in this guideline, we will consider HaH as a treatment modality which encompasses both admission avoidance and early supported discharge.
The NICE guideline identified four randomised controlled trials (RCTs) and one service evaluation which were applicable to admission avoidance for patients with exacerbations of COPD, and one RCT related to early supported discharge.
The evidence statements can be summarised as follows:
There were no significant differences in forced expiratory volume in 1 second (FEV1),3–,5 readmission rates,3–,6 mortality4–,6 or number of days in care5 between HaH and hospital care.
Two studies showed no difference between the …