Acute Hospital Admissions Among Care Home Residents

Background and aim
Care home residents have a high risk of experiencing acute hospital admissions due to their advanced age, concomitant diseases and general frailty. When admitted to hospitals, the care home residents face an increased risk of adverse events such as delirium, falls, fractures and hospital-acquired infections, compared to older adults living in the community. Lying still in a hospital bed can induce a loss of functional capacity, leaving the care home resident more dependent on help from others than before the admission. At the same time, acute admissions of care home residents are often deemed inappropriate or preventable. There is, therefore, a focus on how the treatment of acutely ill care home residents can be improved. This PhD thesis contributes to the discussion on how to improve conditions for acutely ill care home residents by uncovering the care home residents of Southern Jutland’s morbidities, their acute hospital admissions and readmissions, and by evaluating the effect of having a care home physician attend to the care home residents. 

Method
The four studies in the thesis are based on register data from the Danish National Health Registries. The Danish Health Data Authority launched a new register called Care Home Data in 2020, which is to be a more accurate way of identifying care home residents through national registers than the previous method. By gathering information from the four municipalities of Southern Jutland on all their care home residents, we were able to evaluate the validity of Care Home Data in Study I. In Study II, we assess the morbidities of care home residents, their acute hospital admissions, and the risk factors for acute admissions. Study III investigates the extent of readmissions within 30 days of discharge and which factors are associated with an increased risk of being readmitted. The fourth and last study examines the effect of having a care home physician on the care home residents’ contacts with PCPs and hospitals. A care home physician is a PCP who provides weekly scheduled visits at the care home and attends to the residents who have chosen a registration with this physician.

Results
The new register, Care Home Data, provided by the Danish Health Data Authority, proved to be a highly valid tool for identifying care home residents in Southern Jutland through national registers.

Study II found that the care home residents of Southern Jutland have a high age when moving to care homes, a high prevalence of especially dementia, diabetes, cardiovascular diseases, COPD (chronic obstructive pulmonary disease)/asthma and osteoporosis, along with a short survival after moving to care homes with a median survival of a little less than two years. Two-thirds of the care home residents were women, and we found a higher disease burden and shorter survival among male residents. We saw approximately one acute hospital admission for every second resident per year and one ED treat-and-release visit for every fourth resident annually. Acute admissions were more frequent among males and among residents with a medical history of cancer, diabetes, cardiovascular diseases, COPD/Asthma and osteoporosis, while dementia was associated with a lower risk of acute admission. 

Study III shows that around 15% of care home residents are readmitted within 30 days of discharge from an acute admission, while 14% die after discharge without being transferred to the hospital. Half of the readmissions occurred within seven days of discharge, and many were readmitted during evenings, nights or on weekends. Residents who recently moved to the care home (within three months) and residents with another recent hospital contact, such as a short ED visit, have a higher risk of experiencing readmission. We also saw an increased risk of readmission among residents with a medical history of cancer, diabetes, atrial fibrillation and COPD/asthma. At the same time, dementia is associated with a lower risk of readmission. 

Study IV found an increase in the number of care home physicians in Southern Jutland in 2018-2021, along with an increase in the proportion of care home residents registered with a care home physician. Still, in 2021, one-third of residents of care homes offering registration with a care home physician were registered with another PCP. Residents of care homes with a care home physician received more home visits from their PCP and had fewer e-mail contacts between PCP and care home staff. Residents of care homes with a care home physician tended to use the out-of-hours PCPs less. We found no differences in hospital admissions among residents of care homes with and without a care home physician.

Conclusion
The care home residents of Southern Jutland are multimorbid, and acute admissions and readmissions are frequent. Although often deemed preventable or avoidable in a retrospective view, avoiding an acute admission is complicated when the care home resident is acutely ill. Instead of focusing only on disease prevention, studies should also focus on alternatives to traditional hospital admissions. Diagnostic assessment and treatment in the home can help prevent some avoidable admissions of care home residents in the future.