• Lorelle Louise Dismore, Carlos Echevarria, Anna van Wersch, John Gibson, and Stephen Bourke.
• Department of Research and Development, Northumbria Healthcare NHS Foundation Trust, North Shields, UK.
• BMJ Open. 2019 Apr 4; 9 (4): e026609.

ObjectiveHospital at home (HAH) for chronic obstructive pulmonary disease exacerbation selected by low-risk Dyspnoea, Eosinopenia, Consolidation, Acidaemia and atrial Fibrillation (DECAF) score is clinical and cost-effective; DECAF is a prognostic score indicating risk of mortality. Up to 50% of admitted patients are suitable, a much larger proportion than earlier services. Introduction of new models of care is challenging, but may be facilitated by informed engagement with stakeholders. This qualitative study sought to identify facilitators and barriers to implementation of HAH.DesignSemistructured interviews, data were analysed using thematic-construct analysis.SettingInterviews were conducted within patients' homes and hospitals in North East England.Participants89 participants were interviewees; 44 patients, 15 carers, 15 physicians, 11 specialist nurses and 4 managers.ResultsFacilitators include the following: (1) availability of home comforts and maintaining independence (with positive influences on perceived rate of recovery, sleep quality and convenience for friends, family and carers) and (2) confidence in the continuity of HAH care. Barriers include the following: (1) fear of being alone at home; (2) privacy issues and not wanting visitors and (3) resistance to change. Clinician concerns occasionally delayed return home, principally during the early phase of the trial. Nurses cited higher workload and greater responsibility, but with additional resource and training; overall, they viewed HAH positively. Operational concerns included keeping medical records in a patient's home and inability to capture activity within current payment systems.ConclusionHAH selected by DECAF was preferred to inpatient care by most patients and their families. Implementation in other hospitals will require education, training and service planning, tailored to overcome the identified barriers.Trial Registration NumberISRCTN29082260.© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.

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