Demand for patient care.

A study was performed to determine the extent to which patients of all types were receiving inappropriate levels of care. The needs of patients in acute and supporting hospitals, people in residential homes, and patients cared for at home were assessed. A sixth of the hospital inpatients did not need hospital care, while 5% of those in residential homes and 5% of those at home did need hospital services. These findings indicate that a realistic provision of hospital beds would be 4 per 1000 population for all specialties except regional specialties, psychiatry, mental subnormality, obstetrics, and paediatrics. About a third of these beds need to be acute, while the rest may be in supporting or community hospitals. Thus the current provision of acute beds (2-0 to 2-5 per 1000 population) exceeds actual need.     

Medical home care services for the housebound elderly.

In our health jurisdiction the proportion of elderly people is more than double the national average, and there is a severe shortage of both home care services and long-term care beds. To help the many elderly housebound people without primary medical care we initiated a medical services home care program. The goals were patient identification, clinical assessment, medical and social stabilization, matching of the housebound patient with a nearby family physician willing and able to provide home care and provision of a backup service to the physician for consultation and help in arranging admission to hospital if necessary. In the program''s first 2 years 105 patients were enrolled; the average age was 78.9 years. More than 50% were widowed, single, separated or divorced, over 25% lived alone, and more than 40% had no children living in the city. In almost one-third of the cases there had never been a primary care physician, and in another third the physician refused to do home visits. Before becoming housebound 15% had been seeing only specialists. Each patient had an average of 3.2 active medical problems and was functionally quite dependent. Thirty-five of the patients were surveyed after 1 year: 24 (69%) were still at home, and only 1 (3%) was in a long-term care institution; 83% were satisfied with the care provided, and 79% felt secure that their health needs were being met. One-third of the patients or their families said that it was not easy to reach the physician when necessary. We recommend that programs similar to ours be set up in health jurisdictions with a high proportion of elderly people. To recruit and retain cooperative physicians hospital geriatric services must be willing to provide educational, consultative and administrative support.     

Changing patterns of resource allocation in a London teaching district.

The health plans of the Tower Hamlets district management team were studied to determine what effects the report of the Resource Allocation Working Party and the White Paper "Priorities in the Health and Social Services" have had on resource allocation in a teaching district. The study showed that at present acute services are allocated a greater proportion of the district budget than occurs nationally, while geriatrics, mental health, and community services receive proportionately less. In the next three years spending on acute services is expected to decrease, while spending on geriatric facilities and community services will increase. Nevertheless, cuts in acute services will take place mainly through a reduction in the number of beds serving a community function, concentrating all acute services in the teaching hospital. Services to the district might be better maintained by creating a community hospital to meet the needs of patients who would otherwise need to be accommodated in acute beds with unnecessarily expensive support services.     

Primary care development zones.

Most commentators on the Tomlinson report have agreed with its emphasis on improving primary and community care. The three elements of such a strategy are a remedial programme to bring primary care up to national standards, a programme to provide such services to people with non-standard needs such as mobile Londoners, ethnic minorities, and homeless people, and the development of an expanded model of primary care. No one model will be appropriate across all of London. The process should start with an audit of existing resources and services within each community, together with an analysis of needs. From this would develop a local programme with specific plans for investment in premises, staffing, training, and management. New contractual mechanisms may be needed to attract practitioners, improve their premises, secure out of hours services, and provide medical cover for community beds. There should also be incentives for closer working between primary and secondary services. No developments on the scale needed for London have been carried out in primary care within the lifetime of the NHS--but their success will be critical to the calibre of health services for Londoners into the next century.     

Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data

Background

Avoidance of admission through provision of hospital care at home is a scheme whereby health care professionals provide active treatment in the patient''s home for a condition that would otherwise require inpatient treatment in an acute care hospital. We sought to compare the effectiveness of this method of caring for patients with that type of in-hospital care.

Methods

We searched the MEDLINE, EMBASE, CINAHL and EconLit databases and the Cochrane Effective Practice and Organisation of Care Group register from the earliest date in each database until January 2008. We included randomized controlled trials that evaluated a service providing an alternative to admission to an acute care hospital. We excluded trials in which the program did not offer a substitute for inpatient care. We performed meta-analyses for trials for which the study populations had similar characteristics and for which common outcomes had been measured.

Results

We included 10 randomized trials (with a total of 1327 patients) in our systematic review. Seven of these trials (with a total of 969 patients) were deemed eligible for meta-analysis of individual patient data, but we were able to obtain data for only 5 of these trials (with a total of 844 patients [87%]). There was no significant difference in mortality at 3 months for patients who received hospital care at home (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.54–1.09, p = 0.15). However, at 6 months, mortality was significantly lower for these patients (adjusted HR 0.62, 95% CI 0.45–0.87, p = 0.005). Admissions to hospital were greater, but not significantly so, for patients receiving hospital care at home (adjusted HR 1.49, 95% CI 0.96–2.33, p = 0.08). Patients receiving hospital care at home reported greater satisfaction than those receiving inpatient care. These programs were less expensive than admission to an acute care hospital ward when the analysis was restricted to treatment actually received and when the costs of informal care were excluded.

Interpretation

For selected patients, avoiding admission through provision of hospital care at home yielded similar outcomes to inpatient care, at a similar or lower cost.In many countries, programs in which hospital care is provided in the patient''s own home continue to be a popular response to the increasing demand for acute care hospital beds. Patients who received care through such programs, after assessment in the community by their primary care physician or in the emergency department, may avoid admission to an acute care ward. Alternatively, patients may be discharged early from hospital to receive hospital care at home. We have conducted a parallel systematic review and meta-analysis of individual patient data related to hospital care at home for patients who have received early discharge, which we will report separately. Recently, the emphasis has been on avoiding admission to hospital, which reflects the relatively limited gain from discharging patients early after a stay in hospital, given the universal trend for shorter lengths of stay in hospital.The types of patients receiving hospital care at home differ among schemes, as does the use of technology. Some schemes are designed to care for patients with specific conditions, such as chronic obstructive pulmonary disease, or to provide specific skills, such as parenteral nutrition. However, many schemes for the provision of hospital care at home lack such clear functions and have an “open door” policy covering a wide range of conditions. These schemes may build on existing community resources, or they may operate as hospital outreach services, with hospital staff making home visits. In particular, “hospital-at-home” programs are defined by the provision, in patients'' own homes and for a limited period, of a specific service that requires active participation by health care professionals. The care tends to be multidisciplinary and may include technical services, such as intravenous services.Cutting costs by avoiding admission to hospital altogether is the central goal of such schemes. Other perceived benefits include reducing the risk of adverse events associated with time in hospital¹ and the potential benefit of receiving rehabilitation in the home environment. However, it is not known if patients covered by a policy of avoiding admission through the provision of hospital care at home have health outcomes better than or equivalent to those of patients who receive inpatient hospital care. Furthermore, it is not known if the provision of hospital care at home results in a reduction or an increase in costs to the health service. We conducted a systematic review and meta-analysis, using individual patient data and published data, to determine the effectiveness and cost of managing care of patients through the provision of hospital care at home relative to inpatient hospital care. The meta-analysis of individual patient data allowed us to investigate whether the strategies were associated with key events happening after different periods of time, rather than simply whether or not those events occurred.     

The health and cost effects of substituting home care for inpatient acute care: a review of the evidence

BACKGROUND: There is much interest in reducing hospital stays by providing some health care services in patients'' homes. The authors review the evidence regarding the effects of this acute care at home (acute home care) on the health of patients and caregivers and on the social costs (public and private costs) of managing the patients'' health conditions. METHODS: MEDLINE and HEALTHSTAR databases were searched for articles using the key term "home care." Bibliographies of articles read were checked for additional references. Fourteen studies met the selection criteria (publication between 1975 and early 1998, evaluation of an acute home care program for adults, and use of a control group to evaluate the program). Of the 14, only 4 also satisfied 6 internal validity criteria (patients were eligible for home care, comparable patients in home care group and hospital care group, adequate patient sample size, appropriate analytical techniques, appropriate health measures and appropriate costing methods). RESULTS: The 4 studies with internal validity evaluated home care for 5 specific health conditions (hip fracture, hip replacement, chronic obstructive pulmonary disease [COPD], hysterectomy and knee replacement); 2 of the studies also evaluated home care for various medical and surgical conditions combined. Compared with hospital care, home care had no notable effects on patients'' or caregivers'' health. Social costs were not reported for hip fracture. They were unaffected for hip and knee replacement, and higher for COPD and hysterectomy; in the 2 studies of various conditions combined, social costs were higher in one and lower in the other. Effects on health system costs were mixed, with overall cost savings for hip fracture and higher costs for hip and knee replacement. INTERPRETATION: The limited existing evidence indicates that, compared with hospital care, acute home care produces no notable difference in health outcomes. The effects on social and health system costs appear to vary with condition. More well-designed evaluations are needed to determine the appropriate use of acute home care.     

Avoidable referrals? Analysis of 170 consecutive referrals to secondary care.

OBJECTIVE--To determine appropriateness of referrals from primary care to secondary care. DESIGN--Retrospective evaluation of appropriateness of referrals from a single-handed general practice: evaluations carried out independently by referring doctor and by second general practitioner who worked in same area and had access to similar secondary care services. SUBJECTS--168 referrals made between 1 October 1990 and 31 March 1991 and followed up for up to 12 months by matching with available information on outcome of episode of care. MAIN OUTCOME MEASURES--Appropriateness of referral and reasons for inappropriate referrals. RESULTS--110 referrals were agreed to be appropriate and 58 were considered avoidable. The reason for 32 of the inappropriate referrals was lack of resources: 10 were due to lack of information (mainly failure of hospitals to pass on information to general practitioner), nine were due to a deficient primary health care team; five were due to insufficient use of home care nurses, three were due to absence of direct access to day hospital, and five were due to lack of access to general practitioner beds or other facilities. Most of the remaining 26 avoidable referrals were because available resources had not been fully used, because recognised management plans had not been followed, or because of lack of skills to perform certain procedures. CONCLUSIONS--Many theoretically avoidable referrals were due to managers'' and politicians'' decisions about allocation of resources, but some inappropriate referrals could be avoided by assessment of general practitioners'' needs for further knowledge and skills.     

Is London overbedded?

OBJECTIVE--To examine whether there are too many hospital beds in London. DESIGN--Analysis of data from the Hospital In-Patient Enquiry, Mental Health Enquiry, health service indicators, and Emergency Bed Service. SETTING--England, London, and inner London. RESULTS--Hospital admission rates for acute plus geriatric services for London residents were very similar to the national values in all age groups. In the special case considered in the Tomlinson report--acute services in inner London--the admission rate was 22% above the value for England. However, the admission rate of inner deprived Londoners was 9% below that of comparable areas outside London. For psychiatry, admission rates in London roughly equalled those in comparable areas. When special health authorities were excluded, in 1990-1 there were 4% more acute plus geriatric beds available per resident in London than in England. Bed provision has been reduced more rapidly in London than nationally. Extrapolating the trend of bed closures forward indicates that beds (all and acute) per resident in London are now at about the national average. Data from the Emergency Bed Service indicate that the pressure on available hospital beds in London has been increasing since 1985. CONCLUSIONS--Data regarding bed provision and utilisation for all specialties by London residents do not provide a case for reducing the total hospital bed stock in London at a rate faster than elsewhere. Bed closures should take account of London''s relatively poorer social and primary health care circumstances, longer hospital waiting lists, poorer provision of residential homes, and evidence from the Emergency Bed Service of increasing pressure on beds. Higher average costs in London, some unavoidable, are forcing hospital beds to be closed at a faster rate in London than nationally.     

Terminal care: present services and future priorities.

Since 1975 hospices and other specialist services for terminal cancer have expanded rapidly. In December 1980 this survey found 72 such services in Britain providing 58 inpatient units, 32 home care teams, and eight hospital support teams. Many were outside the NHS. Inpatient units provided 1297 beds (modal size 21-25 beds) and dealt with under 7% of deaths from cancer. Home care teams provided 76.5 full-time equivalent nurses (modal size two nurses). Regional variations were considerable: from 10.9 beds/million population in Trent to 48.5 beds/million in South-west Thames; no home care nurses in Mersey and Wales, and 5.1 nurses/million in Wessex. Of 58 more services being planned, the 17 starting in 1981 will not substantially alter these regional imbalances. Respondents'' opinions suggest a target of 40-50 inpatient unit beds/million population. This might be reduced if hospitals were better equipped to deal with these patients. Suggested priorities are to redress regional inequalities, develop home care and hospital support teams rather than inpatient units, and improve teaching and training. Co-ordination of plans between the NHS and the voluntary sector is needed.     

Post tracheostomy and post intubation tracheal stenosis: Report of 31 cases and review of the literature

Background

There is increasing evidence that patients with low-risk community acquired pneumonia (CAP) can be effectively treated as outpatients. This study aimed to explore patients' experiences of having pneumonia and seeking health care; their perceptions of the information provided by health professionals; how they self managed at home; their information and support needs; and their beliefs and preferences regarding site of care.

Methods

We conducted qualitative, semi-structured interviews with 15 patients who had a confirmed diagnosis of low-risk CAP and had received fewer than 3 days hospital care. Interviews were audio recorded and transcribed, and data were analysed thematically.

Results

Most patients left hospital with no clear understanding of pneumonia, its treatment or follow-up and most identified additional-other specific information needs when they got home. Some were unable to independently address their activities of daily living in their first days at home. Main concerns after discharge related to the cause and implications of pneumonia, symptom trajectory and prevention of transmission. Most sought advice from their GP in their first days at home, and indicated they would have appreciated a follow-up phone call or visit to discuss their concerns. Patients' preferences for site of care varied and appeared to be influenced by beliefs about safety (fear of rapid deterioration at home or acquiring an infection in hospital), family burden, access to support, or confidence in home-care services. Those who received intravenous (IV) medication were more likely to state a preference for hospital care.

Conclusion

Trends to support community-based treatment of CAP should be accompanied by increased attention to the information and support needs of patients who go home to self-manage. Although some information needs can be anticipated and addressed on diagnosis, specific needs often do not become apparent until patients return home, so some access to information and support in the community is likely to be necessary. Our finding that patients who received IV treatment for low-risk CAP were concerned about the relative safety of home-based care highlights the potential importance of the inferences patients make from treatment modalities, and also the need to ensure that patients' expectations and understandings are managed effectively.     

Secondary care beyond Tomlinson: an opportunity to be seized or squandered?

The Tomlinson report''s emphasis on primary care and its essentially quantitative analysis of hospital care in London leaves little space for a picture of how secondary care for Londoners should look. In this article Fiona Moss and Martin McNicol argue that most outpatient work does not need to be done in hospitals. With proper organisation and better premises a genuinely specialist consultative service can be provided in primary health care centres, with benefit to patients and communication between primary and secondary care doctors. Hospitals would then house those outpatient services that needed major investigative facilities and much reduced inpatient capacity. It may no longer be necessary for each acute unit to offer a full range of services. Such a pattern of secondary care will have implications for the organisation of accident and emergency services and for postgraduate training. Above all Moss and McNicol argue that Tomlinson''s recommendations demand that general practitioners and specialists should re-examine the services hospitals provide and agree on the best settings for different sorts of health care and the most appropriate skills to provide it.     

Needs for care from a demand led community psychiatric service: a study of patients with major mental illness.

OBJECTIVE--To measure needs for care of patients aged 18-65 years with major mental illness. DESIGN. Identification of everyone in one area seen by a health professional within the previous five years because of a psychotic disorder. Interview of a one in three sample of patients and their main carers with the cardinal needs schedule. SETTING--Hamilton, a socially deprived district of Scotland. SUBJECTS--71 subjects were interviewed from the original sample of 263 patients. MAIN OUTCOME MEASURES--"Cardinal problems" in seven clinical and eight social areas of functioning; these are defined as problems requiring action. "Needs"-cardinal problems for which suitable interventions exist but have not been tried recently. RESULTS--High levels of morbidity were found. 30 interviewed patients (42%; 95% confidence interval 31% to 54%) had one or more clinical needs. 35 (49%; 38% to 61%) had one or more social needs. Skills to deal with all but seven needs in the sample were available at the time of investigation. Patients not being seen by the community mental health team were similar in severity and levels of need to those who were on the community team''s caseload. Care was unequivocally and severely inadequate for four patients. Shortcomings in service delivery usually arose from failure to monitor some patients at home. Problems were not due to shortage of acute psychiatric beds nor the absence of an elaborate assertive community care team. CONCLUSIONS--Systematic assessment of needs with research instruments can give valuable insights into the successes and failures of community care of people with major mental illness. Most needs could be dealt with in these patients but in our area (and probably most other parts of the United Kingdom) this would entail diversion of resources from people with less severe disorders.     

Allocating resources to health authorities: development of method for small area analysis of use of inpatient services.

Every year about 22 billion pounds is allocated to health authorities for hospital and community services in England. The distribution of most of these funds is based on a formula developed to reflect the population''s needs, but the existing formula has been criticised on several grounds. This paper describes the development of a method to determine the health needs for small geographical areas. Data from the hospital episodes statistics and 1991 census together with information on vital statistics and supply of health care facilities were used in the model. Two stage least squares regression was used to identify true indicators of need, and these were entered into a multilevel model to take account of variations in practice in different health authorities. The resulting formula should be more statistically robust and more sensitive to needs than previous approaches.     

Intravenous antimicrobial therapy in the community: underused,inadequately resourced,or irrelevant to health care in Britain?

The NHS Executive is keen to promote "hospital at home" services in Britain, as part of its philosophy of keeping more care in the community and also to relieve the increasing demand for hospital beds. One such service is the provision of intravenous antimicrobial therapy in the community. Yet, compared with the United States, where home or outpatient intravenous antimicrobial therapy programmes are well developed, experience in Britain and Europe is limited, reflecting a difference in cultural attitudes and healthcare structures between the two continents. Only a few units in Britain currently run home intravenous antimicrobial therapy programmes, and several issues need to be addressed if more treatment is to be provided outside hospital. These include an assessment of the need for community intravenous antibiotic treatment and which patient groups many benefit. The main motive for community intravenous treatment should be better patient care and not simply a reduction in healthcare costs. At present the pace of change is being set by a few clinical enthusiasts and by commercial organisations, whereas the NHS deserves a more organised strategy for purchasing treatment with intravenous antibiotics in the community.     

Community care and social services.

The aim of community care is to enable people with various types of disability to live in their own homes, rather than in institutions. This involves the provision of support and services at home by various agencies. After a critical report in 1986 identified problems with coordination and flexibility of community care services, the white paper Caring for People (1989) stated the government''s aim to provide a "needs led," responsive range of services, promoting maximum independence of those wishing to live at home rather than enter institutional care. New arrangements were introduced in 1993, involving a formal assessment procedure and the production of a personalized care plan for each individual, incorporating services provided by private and voluntary agencies as well as by social services departments. This article describes the components of community care services supplied by local social services authorities, including housing adaptations, equipment, telephones and alarms, home care, meals, and respite care.     

Care of the terminally ill at home.

Care of the terminally ill at home demands the attention of the medical and paramedical community. Patients who choose to remain at home while death approaches must be given full physical, emotional and psychological support by the attending physician and home care services personnel. In 1974 the Vancouver early hospital discharge home care service provided such care to 47 patients. Generally both patient and family were happy with the program. A few families were unable to cope for more than a few days but most continued the care almost to the end, a large number (14) keeping the patient at home until death occurred. Added benefits are the lower costs and the freeing of hospital beds.     

Reduction in hospital readmission stay of elderly patients by a community based hospital discharge scheme: a randomised controlled trial.

STUDY OBJECTIVE--To compare a community support scheme using care attendants with standard aftercare for their effects on independence and morale of elderly patients discharged from hospital and on their use of health and social services. DESIGN--Randomised controlled study of cohort of patients over 75 discharged to their own homes. SETTING--District general hospital and community. PATIENTS--Total of 903 patients (mean age 82, 25% over 85). INTERVENTIONS--Total of 464 patients received support from care attendants on first day at home and for up to 12 hours a week for two weeks. Support comprised practical care, help with rehabilitation, and organising social help. The remaining 439 patients received standard aftercare. END POINT--Difference between two groups of 7% in hospital readmission rates or one point on activities of daily living scale (power 80%, significance level 5%). MEASUREMENTS AND MAIN RESULTS--Three months after the initial discharge 763 patients were interviewed (84%). There were no significant differences between the two groups in physical independence (activities of daily living scale), in measures of morale (Philadelphia scale), or in death rates. Hospital readmission rates within 18 months of discharge, however, were significantly higher in the control group and they spent more days in hospital (mean; control group 30.6 days, support group 17.1 days; p = 0.014). Of the patients living alone who were followed up for 18 months 21 (15%) receiving standard aftercare were readmitted more than twice compared with 6 (5%) supported by care attendants (p less than 0.01). CONCLUSIONS--If the findings are confirmed, and the policy extended to all patients over the age of 75 living alone, an average health district might expect either to save about 23 hospital beds at a net annual saving of about pounds 220,000 in the short term or to increase available beds by this number.     

Developing primary health care.

Primary health care is best provided by a primary health care team of general practitioners, community nurses, and other staff working together from good premises and looking after the population registered with the practice. It encourages personal and continuing care of patients and good communication among the members of the team. Efforts should be made to foster this model of primary care where possible and also to evaluate its effectiveness. Community services that are not provided by primary care teams should be organised on a defined geographical basis, and the boundaries of these services should coincide as much as possible. Such arrangements would facilitate effective community care and health promotion and can be organised to work well with primary care teams. The patient''s right to freedom of choice of a doctor, however, should be retained, as it adds flexibility to the rigidity of fixed geographically based services.     

Randomised controlled trial comparing effectiveness and acceptability of an early discharge,hospital at home scheme with acute hospital care

Objective: To compare effectiveness and acceptability of early discharge to a hospital at home scheme with that of routine discharge from acute hospital. Design: Pragmatic randomised controlled trial. Setting: Acute hospital wards and community in north of Bristol, with a catchment population of about 224 000 people. Subjects: 241 hospitalised but medically stable elderly patients who fulfilled criteria for early discharge to hospital at home scheme and who consented to participate. Interventions: Patients’ received hospital at home care or routine hospital care. Main outcome measures: Patients’ quality of life, satisfaction, and physical functioning assessed at 4 weeks and 3 months after randomisation to treatment; length of stay in hospital and in hospital at home scheme after randomisation; mortality at 3 months. Results: There were no significant differences in patient mortality, quality of life, and physical functioning between the two arms of the trial at 4 weeks or 3 months. Only one of 11 measures of patient satisfaction was significantly different: hospital at home patients perceived higher levels of involvement in decisions. Length of stay for those receiving routine hospital care was 62% (95% confidence interval 51% to 75%) of length of stay in hospital at home scheme. Conclusions: The early discharge hospital at home scheme was similar to routine hospital discharge in terms of effectiveness and acceptability. Increased length of stay associated with the scheme must be interpreted with caution because of different organisational characteristics of the services.

Key messages

• Pressure on hospital beds, the increasing age of the population, and high costs associated with acute hospital care have fuelled the search for alternatives to inpatient hospital care
• There were no significant differences between early discharge to hospital at home scheme and routine hospital care in terms of patient quality of life, physical functioning, and most measures of patient satisfaction
• Length of stay for hospital patients was significantly shorter than that of hospital at home patients, but, owing to qualitative differences between the two interventions, this does not necessarily mean differences in effectiveness
• Early discharge to hospital at home provides an acceptable alternative to routine hospital care in terms of effectiveness and patient acceptability

     

A randomized controlled trial investigation of a non-stimulant in attention deficit hyperactivity disorder (ACTION): Rationale and design

Background

Patients with delirium and dementia admitted to general hospitals have poor outcomes, and their carers report poor experiences. We developed an acute geriatric medical ward into a specialist Medical and Mental Health Unit over an eighteen month period. Additional specialist mental health staff were employed, other staff were trained in the 'person-centred' dementia care approach, a programme of meaningful activity was devised, the environment adapted to the needs of people with cognitive impairment, and attention given to communication with family carers. We hypothesise that patients managed on this ward will have better outcomes than those receiving standard care, and that such care will be cost-effective.

Methods/design

We will perform a controlled clinical trial comparing in-patient management on a specialist Medical and Mental Health Unit with standard care. Study participants are patients over the age of 65, admitted as an emergency to a single general hospital, and identified on the Acute Medical Admissions Unit as being 'confused'. Sample size is 300 per group. The evaluation design has been adapted to accommodate pressures on bed management and patient flows. If beds are available on the specialist Unit, the clinical service allocates patients at random between the Unit and standard care on general or geriatric medical wards. Once admitted, randomised patients and their carers are invited to take part in a follow up study, and baseline data are collected. Quality of care and patient experience are assessed in a non-participant observer study. Outcomes are ascertained at a follow up home visit 90 days after randomisation, by a researcher blind to allocation. The primary outcome is days spent at home (for those admitted from home), or days spent in the same care home (if admitted from a care home). Secondary outcomes include mortality, institutionalisation, resource use, and scaled outcome measures, including quality of life, cognitive function, disability, behavioural and psychological symptoms, carer strain and carer satisfaction with hospital care. Analyses will comprise comparisons of process, outcomes and costs between the specialist unit and standard care treatment groups.

Trial Registration number

ClinicalTrials.gov: NCT01136148