A Systematic Review of Patient Safety Outcomes and Contributory Factors in Hospital-at-home Care for Older People

A Systematic Review of Patient Safety Outcomes and Contributory Factors in Hospital-at-home Care for Older People | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review A Systematic Review of Patient Safety Outcomes and Contributory Factors in Hospital-at-home Care for Older People Toyosi Ganiyu, Raabia Sattar, Natalia Malecka, Alishba Hussain, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9186305/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background Hospital-at-Home (HaH) delivers hospital-level care to acutely unwell individuals in their usual place of residence and is increasingly adopted to address rising healthcare demands. While HaH may improve patient experience and reduce hospital admissions, patient safety outcomes for older people and the factors influencing patient safety in the context of care at home remain insufficiently understood. This review aimed to identify patient safety outcomes assessed in HaH care for older adults and to examine how the clinical work system factors influence these outcomes. Methods CINAHL, EMBASE, and MEDLINE databases were searched from inception to September 2024. Eligible studies included participants aged 65 and older receiving HaH care, with documented care processes and reported patient safety outcomes. Data extraction was guided by the Safety Engineering Initiative for Patient Safety 3.0 framework (SEIPS), the Yorkshire Contributory Factors Framework (YCFF), and established patient safety outcome measures. Reporting adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Results Fourteen studies were included, covering conditions such as respiratory and urinary tract infections, heart failure, and musculoskeletal disorders. Patient safety outcomes assessed included falls, mortality, readmissions, and infections. Key contributory factors influencing patient safety included multimorbidity, staffing models, communication pathways, and variability in leadership and supervision. Care was delivered by multidisciplinary teams using face-to-face and virtual methods, supported by remote monitoring via smartphones and wearable devices. Unsafe home environments were a common exclusion criterion. Conclusions Safety outcomes in HaH were generally comparable to hospital-based care. However, no safety outcomes specific to acute care delivered in the home were identified. Exclusion based on home environment suitability was common. These findings highlight the need for context-specific frameworks and safety outcome measures to support and evaluate acute care delivery for older people in the home. “Virtual ward ” “hospital-at-home ” “older people ” “patient safety ” and “safety outcomes”. Figures Figure 1 Background Health systems across Europe face increasing demand driven by population ageing, multimorbidity, rising costs, and constrained resources [ 1 ]. Key challenges include over-reliance on hospitals, limited bed capacity, fragmented care for older patients with chronic conditions, and poor information sharing between care settings [ 2 ]. As hospital utilisation increases, so do risks associated with inpatient care, including nosocomial infections and iatrogenic complications [ 3 ]. Older adults are particularly vulnerable to these adverse outcomes, with prolonged waiting times and hospital stays associated with increased mortality, deconditioning, confusion and loss of independence [ 4 , 5 ]. These pressures have driven interest in alternative models of care that aim to improve integration, quality, and efficiency while reducing reliance on hospital-based services [ 6 ]. In England, the NHS Long-term Plan prioritises care closer to home, greater use of technology, and prevention-focused approaches [ 7 ]. HaH has emerged as one response to these priorities. HaH delivers hospital-level care to selected individuals in their usual place of residence, including care homes, by replicating hospital resources such as multidisciplinary staff, medical equipment, medications and digital technologies [ 8 ]. HaH may be used to prevent hospital admissions (step-up) or facilitate early discharge from the hospital (step-down) [ 9 ]. International policymakers describe HaH as a safe and effective alternative to inpatient care [ 8 , 10 , 11 ], although robust empirical evidence remains limited [ 12 ]. Existing studies largely rely on traditional hospital safety outcomes, including mortality, length of stay, and readmissions [ 13 , 14 ], which may not be appropriate measures of safety and are less meaningful in the context of safety of acute care in the home. To address this gap, this review applies the Safety Engineering Initiative for Patient Safety (SEIPS 3.0) model [ 15 ], a systems engineering framework that examines how interactions between people, tasks, technologies, organisational factors, external environment and the patient’s journey influence care processes and patient safety across the care continuum. The Yorkshire Contributory Factors Framework (YCFF) [ 16 ] was also adapted to categorise factors contributing to safety outcomes in HaH care for older people. Together, these frameworks enable examination of the clinical work system underpinning HaH care and the factors that contribute positively or negatively to patient safety outcomes. Research Question : What are the patient safety outcomes and the potential contributory factors in the provision of HaH care to older people? Objectives To map out the clinical work system, its safety-related processes, and patient safety outcomes reported in the literature based on the SEIPS 3.0 model [ 15 ]. To use the YCFF [ 16 ] to identify the contributory factors to patient safety outcomes reported in the literature. The reporting of this systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review protocol was registered with Prospero (CRD42024591849). Methods Search strategy and selection criteria A comprehensive literature search was conducted across electronic databases, Medline, EMBASE, and CINAHL, encompassing all available years up to September 2024. A supplementary search using Google Scholar was also performed, limited to the first 100 results. Medical Subject Headings (MeSH) and keyword search terms were created based on clinical and research expertise, with help from a subject librarian and information specialist. Key search concepts included: “virtual ward,” “hospital-at-home,” “older people,” “patient safety,” and “safety outcomes”. Study Selection All search results were imported into Covidence, where duplicates were removed. Title and abstract screening was performed by five reviewers (TG, EB, AH, NM, TF). Full-text articles were independently evaluated for eligibility by two reviewers (TG and EB), with 10% of the articles checked for consistency. Inclusion and exclusion criteria Table 1 outlines the inclusion and exclusion criteria used to select studies for this systematic review, based on the population, intervention, comparator, and outcomes (PICO) framework. Table 1 Inclusion and exclusion criteria Inclusion criteria • Exclusion criteria Population : Adults (males and females) 65 years and above. Intervention : HaH models, including step-up (hospital admission avoidance) and step-down (early discharge from hospital), delivering acute care in the patient’s usual place of residence using face-to-face care with or without remote monitoring Comparator : Traditional care settings, such as hospital-based care, primary care, and community-based care. Outcome : Patient safety and care effectiveness outcomes, including mortality, hospital admissions/readmissions, length of stay, falls, delirium, infections, safeguarding concerns, adverse drug events, incident reports, patient and carer experience, carer burden and functional outcomes (e.g. mobility, deconditioning). Study Design : Qualitative, quantitative, mixed methods available in full text, including grey and unpublished literature. • Studies that include only remote monitoring/telemonitoring as an intervention. • Studies that include patients on long-term care pathways, including end-of-life and palliative care, cancer. • Studies that focus on patients based in nursing and residential homes. • Languages other than English. • Systematic reviews. • Studies that focus on COVID-19 as a specific morbidity. Data Extraction A structured form was designed to extract information from the selected articles, including the author’s name, journal publication year, country, study objectives, study design, participant characteristics, and domains adapted from the SEIPS 3.0 framework [ 15 ] and the contributory factors reported in the literature. Data were extracted onto the designed form and the results were synthesised deductively against the components of the SEIPS 3.0 [ 15 ] and domains within the YCFF [ 16 ]. TG completed 90% of the extraction, while EB finished 10%. These frameworks facilitated the categorisation of findings from the literature to answer the review question. Preliminary findings were discussed with the research team and presented during meetings. Quality assessment The Quality Assessment for Diverse Studies (QuADS) tool [ 17 ] was used for quality assessment of the studies in this review. This tool was used because of its appropriateness for studies with different methodological approaches. The quality assessment was carried out by one author (TG) and independently reviewed by another (EB). All discrepancies were resolved through discussion between the reviewers. No studies were excluded based on quality. Data Synthesis and analysis Fourteen studies were included in this review, employing differing study designs, including seven randomised controlled trials [ 14 , 18 – 23 ], three retrospective cohort studies [ 13 , 24 , 25 ], one prospective case series [ 26 ], one prospective quasi-experimental study [ 27 ], one matched control quasi-experimental study [ 28 ], and one quantitative service evaluation [ 29 ]. The studies were conducted across various countries worldwide, including the United Kingdom, the United States, Singapore, Australia, France, and Hong Kong. Eleven studies investigated step-up HaH, [ 13 , 14 , 18 – 20 , 22 , 23 , 25 – 27 , 29 ] and three examined step-down HaH [ 21 , 24 , 28 ]. This information is detailed in Table 2 which provides a comprehensive overview of the studies, including the study designs, countries where the studies were conducted, the types of HaH models reviewed, sample sizes, and the primary study outcome. The rest of the results are described below in section 5.1 based on the SEIPS 3.0 [ 15 ] and YCFF [ 16 ] frameworks. Stakeholder workshops Following completion of the systematic review, stakeholder workshops were conducted to disseminate the findings and to elicit their feedback on the relevance of the outcomes and their implications for practice and future research. The stakeholder workshops consisted of two groups: patients and carers with experience of care on HaH services, and healthcare professionals. The two groups were convened separately and employed different meeting formats appropriate to each stakeholder group. The workshops were conducted after completion of the review and did not inform study eligibility, data extraction, or synthesis. Table 2 Characteristics of articles included in the systematic review First author Publication year Country Study design Age (Mean) Health Conditions Type of Virtual Ward Sample Size Main Study Outcomes Patient Safety Outcomes Caplan 2005 Australia RCT 70 Acute infections (pneumonia, urinary tract infections (UTI), Cellulitis, Deep Vein Thrombosis (DVT), Cardiac Failure, Subacute endocarditis and Osteomyelitis. Step-up 100 Physical and cognitive function Physical and cognitive decline. Caplan 1999 Australia RCT 73 (article reported in median) Pneumonia, Cellulitis, UTI, Osteomyelitis, and DVT. Step-up 100 Geriatric complications -confusion, falls, urinary incontinence, faecal incontinence or constipation), phlebitis, pressure areas, patients and carer satisfaction, adverse events and death. Falls, Confusion, Phlebitis, Pressure ulcers, and Mortality. de Stampa 2023 France Retrospective cohort study 83.4 Pain management, post-surgery care, palliative care, complex dressing, artificial nutrition and complex nursing care. Step down 75108 30-day hospital re-admission Hospital readmission and Mortality Ko 2022 Singapore Retrospective cohort study 67.9 Skin and soft tissue infections UTI, gastroenteritis, Rhabdomyolysis, pneumonia and fluid overload. Step up 108 Length of stay, 30- day emergency department re-attendance, 30-day hospital readmission, mortality, escalation to acute hospital, Infections – C-diff, pressure ulcers, catheter associated urinary tract infection, falls, adverse drug reactions. Mortality, adverse drug reaction, fall, pressure ulcer, venous thromboembolism, new catheter associated UTI (CAUTI), and hospital re-admission. Leff 1999 United States Prospective case series 74.4 Congestive heart failure, community acquired pneumonia, cellulitis, and chronic obstructive airway disease. Step up 17 Length of stay, cost effectiveness, and emergency clinical situations. Acute deterioration requiring emergency admissions and mortality. Leff 2005 United States Prospective Quasi experimental 77 Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Cellulitis and Congestive Heart Failure (CHF). Step up 455 Clinical process measure, standards of care, satisfaction with care, functional status and costs of care. Fall, incident delirium, nosocomial infection, and death. Leung 2015 Hong Kong Matched-control Quasi experimental 80 COPD, CHF and Cancer. Step down 78 Emergency attendance, medical readmissions and Quality of Life (QoL) Emergency readmissions. Levine 2019 United States RCT 80 Pneumonia, skin and soft tissue infection, complicated UTI/pyelonephritis, diverticulitis, heart failure, asthma, COPD, palliative care, and exacerbation of gout. Step up 91 Total direct cost of the acute care episode secondary outcomes included with healthcare use (laboratory orders, radiology studies and length of stay) and physical activities during the acute care episode. Medication errors, cognitive decline -delirium and functional status. Richards 1998 United Kingdom RCT 79 (median) Fractured neck of femur (NOF), hip replacements, knee replacements, cerebrovascular accidents, falls without fracture, and chest infections. Step down 241 Patient’s quality of Life, Satisfaction and physical function Mortality, functional status Shepperd 2021 United Kingdom RCT 83.3 Respiratory conditions including infections and COPD, cellulitis, gastrointestinal (GI) disorders including GI infections, UTI, and musculoskeletal disorders. Step up 1055 Healthcare costs, people’s experience of healthcare at home Mortality, cognitive decline -delirium, readmission or transfer to hospital, pressure ulcers and falls. Shepperd 2022 United Kingdom RCT 83.3 Delirium, functional decline, falls, dependence, history of dementia presenting with physical disease. Step up 1032 Clinical effectiveness, new admission to long term, residential care, death, delirium and patient satisfaction. Mortality, Cognitive decline -delirium, acute deterioration requiring hospital transfer. Tierney 2022 United Kingdom Quantitative -service evaluation 83.5 Respiratory infection, COPD, UTI, falls, volume depletion and sepsis. Step up 505 Mortality, readmission rate, length of stay, and functional ability Mortality, readmission rate, and functional decline. Tsiachristas 2019 United Kingdom Retrospective cohort study 82 Arthritis, asthma, cancer, HF, COPD, Dementia, Parkinson’s disease, diseases of the digestive system and renal failure. Step up 20,151 Healthcare costs and mortality. Mortality Wilson 1999 United Kingdom RCT 84 (median) Cardiovascular and respiratory conditions Step up 199 Mortality, and change in health status Mortality, functional decline. Results based on the SEIPS 3.0 framework Persons Healthcare professionals Studies described multidisciplinary teams delivering HaH care, with both common and context-specific features across countries. Core roles across most models included physicians, registered nurses (RNs), physiotherapists (PTs), and occupational therapists (OTs) [ 13 , 14 , 18 , 20 – 25 , 27 , 28 ]. In the United States, teams typically included general internists, nurse coordinators, and home health agency staff, with additional support from private partners such as home health aides and social workers [ 20 , 26 , 27 ]. UK models similarly involved district nurse coordinators, PTs, OTs, and support workers, with some also employing therapy technicians [ 21 , 22 , 29 ]. Australian models ranged from nurses and general practitioners (GPs) led models [ 19 ] to those incorporating hospital doctors and community outreach teams [ 18 ]. Broader team composition was reported in France and Singapore, where psychologists, dietitians, pharmacists, and speech therapists were involved as required [ 13 , 24 ]. Some models in Hong Kong and the UK were geriatrician-led teams and underpinned by Comprehensive Geriatric Assessment (CGA) [ 14 , 23 , 25 ], while another was consultant-led services with limited detail on team composition [ 29 ]. Patients Most studies included frail older adults admitted with defined acute medical conditions who were considered physiologically stable for management at home [ 13 , 14 , 18 – 20 , 22 , 23 , 25 – 27 ] In most models, patients were admitted to HaH following an initial hospital admission or emergency department assessment [ 13 , 14 , 18 – 20 , 22 , 23 , 25 – 27 ]. However, one study reported that patients with chronic complex conditions, including palliative patients, were admitted to HaH [ 24 ], another study admitted patients from the hospital who needed rehabilitation [ 21 ] and another admitted patients from nursing homes [ 29 ]. Tasks Across studies, HaH models delivered a broadly consistent set of clinical tasks, including administration of parenteral medications, blood transfusion, venepuncture and cannulation, vital-signs monitoring, point-of-care diagnostics (e.g., portable ultrasound, radiography, and electrocardiography), oxygen administration and respiratory therapies, mobility and falls monitoring, clinical assessment, prescribing, and discharge documentation [ 13 , 14 , 18 – 20 , 23 , 25 – 27 ]. Some programmes reported additional tasks aligned with service focus, including complex nursing and palliative care, artificial nutrition, chemotherapy and post-chemotherapy care, rehabilitation, pain management and post-surgical care [ 24 ]. Nurses commonly undertook patient assessment, 1:1 supervision, health education, and psychosocial support for patients and carers [ 26 – 28 ]. Medical leadership varied by model, with geriatrician-led CGA services [ 14 , 23 ], physicians led daily or urgent reviews [ 20 ], and GPs held overall medical responsibility [ 22 ]. Limited domestic assistance was reported in one study [ 21 ]. Tools and Technology Across studies, commonly used tools included cannulas, intravenous and central venous access devices, oxygen cylinders, thermometers, blood pressure monitors, and other durable medical equipment [ 13 , 14 , 18 , 23 , 25 , 27 ]. One model reported the use of the National Early Warning Score (NEWS) and patient hoists [ 29 ]. Technology-enabled care included telehealth consultations, lifeline devices, electrocardiography and radiography equipment [ 26 ], and remote monitoring using wearable skin patches to detect falls and movement, with algorithm-generated alerts reviewed by clinicians [ 20 ]. Communication was supported through telephone, encrypted video, and short message services [ 14 , 20 , 23 ]. Organisation Organisation of HaH services varied across studies in care hours, leadership, and service delivery models. Some services provided daily home visits with 24-hour physician availability [ 20 , 22 , 26 ], while others operated extended daytime or evening hours with emergency cover from existing services [ 14 , 21 , 29 ]. Clinical leadership ranged from physician or GP-led models [ 13 , 20 , 21 , 24 ] to Geriatrician-led services underpinned by CGA [ 14 , 23 ]. Two studies reported that admission and discharge processes were structured, with care handed back to their primary physicians once patients stabilised [ 26 , 27 ]. Out-of-hours care was typically provided by existing primary care services [ 14 , 25 ]. Internal environment Home environment suitability was a key determinant of eligibility for HaH care, although not all studies reported criteria in detail. When reported, exclusion factors included a lack of basic amenities (running water, electricity, and indoor toilet) and environmental hazards such as dangerous pets [ 18 , 19 ]. Availability of formal or informal caregiver support was frequently required, with patients lacking such support excluded from HaH services [ 18 , 19 , 24 ]. Additional considerations included adequate heating, accessibility, and safety in relation to disability [ 21 ]. One model classified homes where delirium, falls risk, unsafe layouts, or poor housing conditions posed safety or public health concerns [ 23 ]. The other studies did not specify environmental criteria, limiting the assessment of consistency across models. External Environment Some diagnostics, including computerised tomography (CT scan), Magnetic Resonance Imaging (MRI) and endoscopy, could not be delivered at home, requiring brief hospital visits [ 26 ]. Limited resources restricted 24-hour nursing availability, constraining patient capacity and HaH bed numbers [ 13 , 26 ]. Core services-nursing, durable medical equipment, oxygen therapy, skilled therapies, and pharmacy support were provided through partner home health agencies [ 27 ]. Processes of care Core processes included clinical assessment, prescribing and medication administration, including oxygen delivery and regular home visits by nurses and clinicians [ 14 , 18 , 19 , 27 ]. Patient education, discharge decision-making, and post-discharge planning were also integral [ 13 , 20 ]. Some services integrated rehabilitation, with radiological investigations arranged as needed [ 23 , 25 ]. Patient Journey in the HaH clinical work system SEIPS 3.0 highlights the patient journey across care stages [ 15 ]. Studies described patient transitions via hospital step-down or community step-up pathways, with variable detail on how these were navigated. One model conducted initial emergency department assessments before home transfer[ 18 ], while others initiated care directly at home [ 20 , 27 ]. The patient journey was influenced by caregiver availability, home suitability, and the use of remote monitoring technologies [ 18 , 20 , 21 , 24 ]. Potential contributory factors identified Domain 1: Situational Factors (Patient factors, individual factors and task characteristics) Patient factors: Patients admitted to the HaH service were predominantly older adults with co-morbidities[ 13 , 14 , 18 – 20 , 22 , 23 , 25 – 27 ], often with a poor functional baseline, complex conditions, or residence in nursing homes with frequent admissions [ 24 , 29 ]. Task characteristics HaH tasks focused on core acute care, including medication administration, vital signs monitoring, point-of-care diagnostics, and clinical assessment, with limited capacity for advanced diagnostics or continuous monitoring in the home [ 13 , 14 , 18 – 20 , 23 , 25 – 27 ]. Individual staff factors Individual factors were poorly reported. Most models identified physicians or geriatricians as clinically responsible, including CGA-led services, with limited detail on staff training or experience [ 13 , 14 , 18 – 20 , 23 , 25 – 29 ], except in one study [ 20 ]. Domain 2: Local Working Conditions (staffing issues and workload) Staffing workload was inconsistently reported. Some services provided initial one-to-one nursing care or capped caseloads for high-dependency patients [ 21 , 27 ] while staffing constraints limited HaH capacity [ 13 ]. Structured care pathways and clear admission and discharge criteria supported safer, standardised care [ 13 , 14 , 18 – 27 , 29 ]. Domain 3: Organisational factors (physical environment and staff training and education) Physical environment Home environments posed safety challenges, particularly for managing delirium, due to limited containment, variable layouts, and a lack of clinical infrastructure [ 14 ]. Despite this, patients reported high satisfaction, citing reduced sleep disruption, greater privacy, maintained routines, and access to a healthier diet [ 13 , 14 , 20 , 23 ]. Domain 4: Staff training and education Staff training was rarely reported. One study described an intensive one-day programme with supervised shadowing by experienced home-based physicians to prepare staff for delivering acute care at home [ 20 ]. Domain 5: Communication and culture Communication systems were variably reported, with challenges including delayed care initiation, inconsistent information sharing, unclear contact pathways, and limited patient and carer involvement [ 23 ]. Some models addressed this through extended hours, hotline access, and digital communication via telephone, encrypted video, and messaging [ 20 , 28 ]. Post-review stakeholder workshop findings This systematic review identified that safety outcomes for HaH services are commonly assessed using measures developed for inpatient hospital care, such as falls, hospital readmission, mortality and healthcare-associated infections. Given the substantial differences between hospital and home environments, the post-review stakeholder workshops explored how safety is perceived in HaH care and identified outcomes considered meaningful by stakeholders. Patients and carers identified outcomes not fully captured within the review’s safety outcomes for HaH, including carer well-being and burden, patient confidence and perceived safety, social isolation, comfort, independence, and maintenance of routine. These reflect experiential and relational outcomes aligned with the review’s aim to identify patient-centred safety outcomes in HaH care. Stakeholders identified several additional factors affecting the safety of care delivered at home, including limited monitoring, delayed emergency response, medication management risks, infection and environmental hazards, delays in equipment provision, and unclear service responsibilities. Clinicians further emphasised the importance of robust risk assessment processes, clear communication pathways, effective governance structures, family involvement, and the use of remote monitoring technologies as key system-level contributors to safe HaH care. Discussion This review identified patient safety outcomes, contributory factors, and the clinical work system underpinning HaH care, using the SEIPS 3.0 model [ 15 ] and the YCFF [ 16 ]. Findings show that the HaH work system–shaped by people, tasks, technologies, organisational processes, and the home environment – can both support and threaten patient safety. Multidisciplinary teams and digital tools enable timely monitoring and treatment; however, variation in team composition, admission criteria, and service hours introduces inconsistency across models. Across YCFF domains [ 16 ], persistent risks included patient complexity, staffing pressures, communication gaps, and limited reporting of staff practices. Although patient satisfaction with HaH care was high, this may mask safety vulnerabilities that are less visible in home-based care than in hospital settings. The patient’s environment The home environment is the defining feature of HaH and has implications beyond comfort to core safety concerns. Unlike standardised hospital settings, homes vary in layout, hygiene, equipment suitability, and availability of informal caregivers, influencing task delivery, monitoring, and emergency response [ 30 ]. While familiarity may enhance patient experience [ 31 ], the home must also be recognised as a potential source of risk requiring structured assessment. A few studies applied exclusion criteria based on unsuitable home conditions [ 14 , 18 , 19 , 21 , 23 ]. Even in suitable homes, limited space and non-clinical layouts hindered management of acute conditions such as delirium and reduced the effectiveness of monitoring and emergency response, exposing patients and staff to unpredictable risks and tensions between autonomy and safety [ 32 ]. Ongoing environmental assessment has been proposed to mitigate these risks [ 33 ], though its feasibility in time-critical acute care remains uncertain. Unlike hospital care, HaH lacks standardised infrastructure and rapid response systems, increasing vulnerability to contextual factors [ 34 ]. Medication Safety Medication administration was a core component of HaH care across studies [ 13 , 14 , 18 – 20 , 23 , 25 – 27 ]. However, no studies reported how medications were stored or prepared in the home, raising concerns given the absence of controlled storage and preparation systems routinely embedded in hospitals [ 35 ]. Medication stability and appropriate storage are essential for safety and efficacy, yet home environments are variable and largely unregulated, particularly for temperature or light-sensitive drugs [ 36 , 37 ]. These risks are amplified in HaH populations, who commonly live with multimorbidity and polypharmacy [ 13 , 14 , 18 – 20 , 22 , 23 , 25 – 27 ]. Complex regimens increase error risk, particularly when multiple caregivers are involved [ 38 ], and adverse drug reactions may be missed due to limited professional presence in the home [ 39 ]. Overall, transferring medication processes into domestic settings introduces safety vulnerabilities that remain underexplored and weakly regulated. Organisational variability This review found marked organisational variability across HaH models, particularly in team composition, service hours, and leadership. Similar heterogeneity in the literature highlights the absence of standardised guidance as a barrier to consistent and safe care [ 31 , 40 ]. Variation in protocols and staffing may contribute to unequal outcomes and limit scalability [ 41 , 42 ], underscoring the need for context-sensitive yet standardised implementation frameworks. Technology integration and patient-led monitoring This review found an inconsistent reporting of patient-led tasks such as self-monitoring and vital signs reporting in HaH care, with limited data on adherence, accuracy, or clinical oversight. This raises concerns about the safety of technology-enabled care when patients or informal caregivers undertake clinical tasks without continuous supervision [ 12 , 43 ]. Technological integration varied widely across models, from advanced remote monitoring to basic communication tools, limiting generalisability and obscuring effectiveness [ 44 ]. Assumptions that older adults can reliably engage with digital monitoring may be unrealistic, particularly given cognitive or physical impairment. Evidence on accuracy and adherence remains limited [ 45 ], while digital literacy and usability challenges among caregivers further increase risk [ 46 ]. Without robust training, support, and verification processes, technology may introduce new safety vulnerabilities. Variation in healthcare staffing This review found marked variation in healthcare team composition and leadership across HaH models, shaped by national systems and priorities. UK services are often geriatrician-led and underpinned by CGA [ 14 , 23 ], whereas US models rely more on general internists and private providers [ 20 ]. While flexibility supports local adaptation, the absence of standardised guidance raises concerns about consistency, equity, and safety. Team composition influences care quality and outcomes, highlighting the need for strategic workforce planning and minimum staffing standards to support safe and scalable HaH implementation [ 42 , 47 , 48 ]. Strengths and Limitations This review synthesises patient safety outcomes and contributory factors in HaH care for older adults, supported by a robust search strategy and use of SEIPS 3.0 and YCFF frameworks. Inclusion of diverse HaH models across multiple conditions, rather than disease-specific models, provides a broad view of safety in diverse HaH contexts. Integration of stakeholder perspectives strengthens interpretation by highlighting safety concerns that are not routinely captured in quantitative outcomes. Limitations include exclusion of non-English studies and heterogeneity in study design and quality, which may limit generalisability. Nevertheless, the predominance of randomised control trials strengthens the evidence base. The findings highlight gaps in underreported safety areas, including medication management and the role of the home environment, and point to the need for standardised yet adaptable frameworks to support safe and scalable HaH care for older people. Implications for research HaH services should be targeted to carefully selected older adults with explicit consideration of clinical complexity, home environment suitability, and availability of informal support. Standardised criteria for admission, escalation, and discharge are needed to reduce variability and support consistent decision-making. Structured assessment of the home environment and caregiver capacity should be embedded within HaH pathways, alongside clear safety netting processes. Medication safety requires dedicated protocols adapted to domestic settings, including storage, preparation, and monitoring. Where patients or caregivers undertake clinical tasks, appropriate training, support, and oversight are essential. Similarly, digital technologies should be matched to patients’ cognitive and functional abilities, with non-digital alternatives available. Finally, workforce models should support multidisciplinary collaboration, clear clinical leadership, and manageable caseloads, underpinned by minimum service standards to ensure safe and equitable HaH delivery. Conclusion HaH offers a promising alternative to inpatient care for selected older adults, but its safety depends on how care is organised and delivered in the home. This review shows that while outcomes are broadly comparable to hospital care, important safety risks remain underexplored, particularly in relation to medication management, home environments, staffing and patient-led monitoring. Variability in service models and limited reporting of work system factors make it difficult to draw firm conclusions about best practice. Developing clearer, standardised frameworks while allowing for local flexibility is essential to support safe, equitable, and scalable HaH care for older people. Abbreviations CGA Comprehensive Geriatric Assessment GP General Practitioner HaH Hospital-at-Home MESH Medical Subject Headings OT Occupational Therapist PT Physiotherapist QuADs Quality Assessment for Diverse Studies RN Registered Nurse SEIPS Safety Engineering Initiative for Patient Safety UK United Kingdom US United States YCFF Yorkshire Contributory Factors Framework Declarations Ethics approval and consent to participate None required as a systematic review Consent for publication Not applicable Competing interests The authors declare no competing interests. Author details 1 School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK. 2 NIHR Yorkshire and Humber Patient Safety Research Collaboration, Bradford Teaching Hospitals Foundation Trust, Bradford, UK. 3 . NIHR Yorkshire and Humber Patient Safety Research Collaboration, Bradford Teaching Hospitals Foundation Trust, Bradford, UK. 4 NIHR Yorkshire and Humber Patient Safety Research Collaboration, Bradford Teaching Hospitals Foundation Trust, Bradford, UK. 5 NIHR Yorkshire and Humber Patient Safety Research Collaboration, Bradford Teaching Hospitals Foundation Trust, Bradford, UK. 6 . Centre for Digital Innovations in Health and Social Care, University of Bradford, Bradford, UK. 7 . NIHR Yorkshire and Humber Patient Safety Research Collaboration, Bradford Teaching Hospitals Foundation Trust, Bradford, UK. Funding Not applicable Author Contribution TG conceptualised and designed the study with input from RS, EB, RR and BF. Screening was conducted by TG, NM, AH, TF, and EB. Data extraction and quality assessment was conducted by TG and EB. The manuscript was drafted by TG and all authors provided intellectual content to the manuscript, critical feedback and approved the final version. Acknowledgements This research was supported by the National Institute for Health and Care Research (NIHR) Yorkshire and Humber Patient Safety Research Collaboration (PSRC). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Data Availability The datasets used and analysed during the current study are available from the corresponding author on reasonable request. References de Vale S. Hospital at Home: An Overview of Literature. Home Health Care Manage Pract. 2020;32(2):118–23. Corbella X, et al. Hospital ambulatory medicine: A leading strategy for Internal Medicine in Europe. Eur J Intern Med. 2018;54:17–20. Bodenheimer T, Chen E, Bennett HD. Confronting The Growing Burden Of Chronic Disease: Can The U.S. Health Care Workforce Do The Job? Health Aff. 2009;28(1):64–74. Sheasby L. 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What do virtual wards look like in England? 2024 13 April 2024]; Available from: https://www.health.org.uk/publications/what-do-virtual-wards-look-like-in-england Kanagala SG, et al. Hospital at home: emergence of a high-value model of care delivery. Egypt J Intern Med. 2023;35(1):21–5. Walsh DW, et al. Safety and Cost-Effectiveness of Hospital at Home in Patients with COVID-19. South Med J. 2025;118(3):177–80. McGowan LJ, et al. The Views and Experiences of Integrated Care System Commissioners About the Adoption and Implementation of Virtual Wards in England: Qualitative Exploration Study. J Med Internet Res. 2024;26:e56494. Ko SQ, et al. Treating acutely ill patients at home: Data from Singapore. Ann Acad Med Singapore. 2022;51(7):392–9. Shepperd S, et al. Hospital at Home admission avoidance with comprehensive geriatric assessment to maintain living at home for people aged 65 years and over: a RCT. Volume 10. Health and Social Care Delivery Research; 2022. pp. 1–124. 2. Carayon P, et al. SEIPS 3.0: Human-centered design of the patient journey for patient safety. Appl Ergon. 2020;84:103033–103033. Lawton R, et al. Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: A systematic review. BMJ Qual Saf. 2012;21:369–80. Harrison R, et al. Quality assessment with diverse studies (QuADS): an appraisal tool for methodological and reporting quality in systematic reviews of mixed- or multi-method studies. BMC Health Serv Res. 2021;21(1):144. Caplan GA, et al. Effect of hospital in the home treatment on physical and cognitive function: a randomized controlled trial. Journals Gerontol Ser A: Biol Sci Med Sci. 2005;60(8):1035–8. Caplan GA, et al. Hospital in the home: a randomised controlled trial. Med J Australia. 1999;170(4):156–60. Levine DM, et al. Hospital-level care at home for acutely ill adults: A qualitative evaluation of a randomized controlled trial. J Gen Intern Med. 2019;34(2):S241–2. Richards SH, et al. Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care. BMJ. 1998;316(7147):1796–801. Clinical research ed.. Wilson A, et al. Randomised controlled trial of effectiveness of Leicester hospital at home scheme compared with hospital care. BMJ. 1999;319(7224):1542–6. Clinical research ed.. Shepperd S, et al. Is comprehensive geriatric assessment admission avoidance hospital at home an alternative to hospital admission for older persons? A randomized trial. Ann Intern Med. 2021;174(7):889–98. de Stampa M, et al. Thirty-day hospital readmission predictors in older patients receiving hospital-at-home: a 3-year retrospective study in France. BMJ open. 2023;13(12):e073804. Tsiachristas A, et al. Should I stay or should I go? A retrospective propensity score-matched analysis using administrative data of hospital-at-home for older people in Scotland. BMJ open. 2019;9(5):e023350. Leff B et al. Home hospital program: a pilot study. J Am Geriatr Soc, 1999: pp. 697–702. Leff B, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005;143(11):798–56. Leung DYP, et al. The effect of a virtual ward program on emergency services utilization and quality of life in frail elderly patients after discharge: A pilot study. Clin Interv Aging. 2015;10:413–20. Tierney B, Todd S, Melby V. SERVICE EVALUATION COMPARING ACUTE CARE AT HOME FOR OLDER SEOPLE SERVICE AND CONVENTIONAL ACUTE HOSPITAL CARE OF THE ELDERLY WARD. Age Ageing. 2022;51:iii10. Towle RM et al. Enhancing the hospital at home experience. Proceedings of Singapore Healthcare, 2023. 32: p. 20101058231209200. Nikmanesh P, Arabloo J, Gorji HA. Dimensions and components of hospital-at-home care: a systematic review. BMC Health Serv Res. 2024;24(1):1458. Schildmeijer K, Wallerstedt B, Ekstedt M. Healthcare Professionals' Perceptions of Risk When Care Is Given in Patients' Homes. Home Healthc now. 2019;37(2):97–105. Shahrestanaki SK, et al. Patient safety in home health care: a grounded theory study. BMC Health Serv Res. 2023;23(1):467. Yin G, Lin S, Chen L. Risk factors associated with home care safety for older people with dementia: family caregivers’ perspectives. BMC Geriatr. 2023;23(1):224. Ghezeljeh TN, et al. Home Healthcare Medication Safety risks among older adults with chronic diseases: a qualitative study. BMC Nurs. 2025;24(1):73. Rosengren K, Szemberg C. Ensuring Safe Medication Assessment for Older Adults: A Pilot Study. Home Health Care Manage Pract. 2025;37(2):87–93. Provenzani A, Di S, Maria. Medication stability: from pharmacies to patients’ homes—is consistent storage achievable? Eur J Hosp Pharm. 2025;32(1):1–2. Lee M, et al. Exploring the challenges of medical/nursing tasks in home care experienced by caregivers of older adults with dementia: An integrative review. J Clin Nurs. 2019;28(23–24):4177–89. Gil-Hernández E, et al. Enhancing safe medication use in home care: insights from informal caregivers. Front Med. 2024;11:1494771. Goh C et al. Hospital-at-home care in Singapore: A review of overseas protocols and guidelines to support implementation and policy redesign (systematic review). PLoS One, 2025. 20(6): p. e0325662. Sultani K, et al. Transforming acute care: a scoping review on the effectiveness, safety and implementation challenges of Hospital-at-Home models. BMJ Open. 2025;15(8):e098411. Denecke K. Mapping the landscape of Hospital at home (HaH) care: a validated taxonomy for HaH care model classification. BMC Health Serv Res. 2025;25(1):84. Wong A et al. Supporting older people through Hospital at Home care: a systematic review of patient, carer and healthcare professionals' perspectives. Age Ageing, 2025. 54(2). Tan SY, et al. A systematic review of the impacts of remote patient monitoring (RPM) interventions on safety, adherence, quality-of-life and cost-related outcomes. NPJ Digit Med. 2024;7(1):192. Olofsson S, et al. Patient participation in self-monitoring regarding healthcare of heart failure: an integrated systematic review. BMC Prim Care. 2025;26(1):60. Zainal H, et al. Exploring caregiver challenges, digital health technologies, and healthcare support: a qualitative study. Front Digit Health. 2025;7:1587162. Truong T-T, Siu AL. Scaling Hospital at Home Beyond the Original Studies. JAMA Netw Open. 2025;8(5):e2510622–2510622. Vleminckx S, et al. Factors influencing the formation of balanced care teams: the organisation, performance, and perception of nursing care teams and the link with patient outcomes: a systematic scoping review. BMC Health Serv Res. 2024;24(1):1129. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9186305","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":631932173,"identity":"06831e51-bdb6-495c-ab2f-bac45d334498","order_by":0,"name":"Toyosi 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14:08:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9186305/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9186305/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108408927,"identity":"7a4fd240-62fe-452b-abd6-cb06b64f8b47","added_by":"auto","created_at":"2026-05-04 09:56:28","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":117323,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003ePRISMA CHECKLIST\u003c/u\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9186305/v1/9f9392294f4968fd01e967ea.jpg"},{"id":109203975,"identity":"8bbbd931-23a2-49ae-b264-d82ab2cad1c9","added_by":"auto","created_at":"2026-05-13 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People\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eHealth systems across Europe face increasing demand driven by population ageing, multimorbidity, rising costs, and constrained resources [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Key challenges include over-reliance on hospitals, limited bed capacity, fragmented care for older patients with chronic conditions, and poor information sharing between care settings [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. As hospital utilisation increases, so do risks associated with inpatient care, including nosocomial infections and iatrogenic complications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Older adults are particularly vulnerable to these adverse outcomes, with prolonged waiting times and hospital stays associated with increased mortality, deconditioning, confusion and loss of independence [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese pressures have driven interest in alternative models of care that aim to improve integration, quality, and efficiency while reducing reliance on hospital-based services [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In England, the NHS Long-term Plan prioritises care closer to home, greater use of technology, and prevention-focused approaches [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. HaH has emerged as one response to these priorities. HaH delivers hospital-level care to selected individuals in their usual place of residence, including care homes, by replicating hospital resources such as multidisciplinary staff, medical equipment, medications and digital technologies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. HaH may be used to prevent hospital admissions (step-up) or facilitate early discharge from the hospital (step-down) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. International policymakers describe HaH as a safe and effective alternative to inpatient care [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], although robust empirical evidence remains limited [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Existing studies largely rely on traditional hospital safety outcomes, including mortality, length of stay, and readmissions [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], which may not be appropriate measures of safety and are less meaningful in the context of safety of acute care in the home.\u003c/p\u003e \u003cp\u003eTo address this gap, this review applies the Safety Engineering Initiative for Patient Safety (SEIPS 3.0) model [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], a systems engineering framework that examines how interactions between people, tasks, technologies, organisational factors, external environment and the patient\u0026rsquo;s journey influence care processes and patient safety across the care continuum. The Yorkshire Contributory Factors Framework (YCFF) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] was also adapted to categorise factors contributing to safety outcomes in HaH care for older people. Together, these frameworks enable examination of the clinical work system underpinning HaH care and the factors that contribute positively or negatively to patient safety outcomes.\u003c/p\u003e\n\u003cdiv class=\"Heading\"\u003e\u003cb\u003eResearch Question\u003c/b\u003e:\u003c/div\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eWhat are the patient safety outcomes and the potential contributory factors in the provision of HaH care to older people?\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eTo map out the clinical work system, its safety-related processes, and patient safety outcomes reported in the literature based on the SEIPS 3.0 model [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo use the YCFF [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] to identify the contributory factors to patient safety outcomes reported in the literature.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e The reporting of this systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review protocol was registered with Prospero (CRD42024591849).\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\n\u003ch3\u003eSearch strategy and selection criteria\u003c/h3\u003e\n\u003cp\u003eA comprehensive literature search was conducted across electronic databases, Medline, EMBASE, and CINAHL, encompassing all available years up to September 2024. A supplementary search using Google Scholar was also performed, limited to the first 100 results. Medical Subject Headings (MeSH) and keyword search terms were created based on clinical and research expertise, with help from a subject librarian and information specialist. Key search concepts included: \u0026ldquo;virtual ward,\u0026rdquo; \u0026ldquo;hospital-at-home,\u0026rdquo; \u0026ldquo;older people,\u0026rdquo; \u0026ldquo;patient safety,\u0026rdquo; and \u0026ldquo;safety outcomes\u0026rdquo;.\u003c/p\u003e \u003cp\u003eStudy Selection\u003c/p\u003e \u003cp\u003eAll search results were imported into Covidence, where duplicates were removed. Title and abstract screening was performed by five reviewers (TG, EB, AH, NM, TF). Full-text articles were independently evaluated for eligibility by two reviewers (TG and EB), with 10% of the articles checked for consistency.\u003c/p\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e outlines the inclusion and exclusion criteria used to select studies for this systematic review, based on the population, intervention, comparator, and outcomes (PICO) framework.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInclusion and exclusion criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInclusion criteria\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Exclusion criteria\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePopulation\u003c/b\u003e: Adults (males and females) 65 years and above.\u003c/p\u003e \u003cp\u003e\u003cb\u003eIntervention\u003c/b\u003e: HaH models, including step-up (hospital admission avoidance) and step-down (early discharge from hospital), delivering acute care in the patient\u0026rsquo;s usual place of residence using face-to-face care with or without remote monitoring\u003c/p\u003e \u003cp\u003e\u003cb\u003eComparator\u003c/b\u003e: Traditional care settings, such\u003c/p\u003e \u003cp\u003eas hospital-based care, primary care, and community-based care.\u003c/p\u003e \u003cp\u003e\u003cb\u003eOutcome\u003c/b\u003e: Patient safety and care effectiveness outcomes, including mortality, hospital admissions/readmissions, length of stay, falls, delirium, infections, safeguarding concerns, adverse drug events, incident reports, patient and carer experience, carer burden and functional outcomes (e.g. mobility, deconditioning).\u003c/p\u003e \u003cp\u003e\u003cb\u003eStudy Design\u003c/b\u003e: Qualitative, quantitative, mixed methods available in full text, including grey and unpublished literature.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Studies that include only remote monitoring/telemonitoring as an intervention.\u003c/p\u003e \u003cp\u003e\u0026bull; Studies that include patients on long-term care pathways, including end-of-life and palliative care, cancer.\u003c/p\u003e \u003cp\u003e\u0026bull; Studies that focus on patients based in nursing and residential homes.\u003c/p\u003e \u003cp\u003e\u0026bull; Languages other than English.\u003c/p\u003e \u003cp\u003e\u0026bull; Systematic reviews.\u003c/p\u003e \u003cp\u003e\u0026bull; Studies that focus on COVID-19 as a specific morbidity.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eData Extraction\u003c/h3\u003e\n\u003cp\u003eA structured form was designed to extract information from the selected articles, including the author\u0026rsquo;s name, journal publication year, country, study objectives, study design, participant characteristics, and domains adapted from the SEIPS 3.0 framework [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and the contributory factors reported in the literature. Data were extracted onto the designed form and the results were synthesised deductively against the components of the SEIPS 3.0 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and domains within the YCFF [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. TG completed 90% of the extraction, while EB finished 10%. These frameworks facilitated the categorisation of findings from the literature to answer the review question. Preliminary findings were discussed with the research team and presented during meetings.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eQuality assessment\u003c/h3\u003e\n\u003cp\u003eThe Quality Assessment for Diverse Studies (QuADS) tool [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] was used for quality assessment of the studies in this review. This tool was used because of its appropriateness for studies with different methodological approaches. The quality assessment was carried out by one author (TG) and independently reviewed by another (EB). All discrepancies were resolved through discussion between the reviewers. No studies were excluded based on quality.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Synthesis and analysis\u003c/h2\u003e \u003cp\u003eFourteen studies were included in this review, employing differing study designs, including seven randomised controlled trials [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], three retrospective cohort studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], one prospective case series [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], one prospective quasi-experimental study [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], one matched control quasi-experimental study [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], and one quantitative service evaluation [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The studies were conducted across various countries worldwide, including the United Kingdom, the United States, Singapore, Australia, France, and Hong Kong. Eleven studies investigated step-up HaH, [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and three examined step-down HaH [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. This information is detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e which provides a comprehensive overview of the studies, including the study designs, countries where the studies were conducted, the types of HaH models reviewed, sample sizes, and the primary study outcome.\u003c/p\u003e \u003cp\u003eThe rest of the results are described below in section 5.1 based on the SEIPS 3.0 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and YCFF [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] frameworks.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStakeholder workshops\u003c/h3\u003e\n\u003cp\u003e Following completion of the systematic review, stakeholder workshops were conducted to disseminate the findings and to elicit their feedback on the relevance of the outcomes and their implications for practice and future research. The stakeholder workshops consisted of two groups: patients and carers with experience of care on HaH services, and healthcare professionals. The two groups were convened separately and employed different meeting formats appropriate to each stakeholder group. The workshops were conducted after completion of the review and did not inform study eligibility, data extraction, or synthesis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of articles included in the systematic review\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst author\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePublication year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudy design\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAge (Mean)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHealth Conditions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eType of Virtual Ward\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSample Size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMain Study Outcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePatient Safety Outcomes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaplan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute infections (pneumonia, urinary tract infections (UTI), Cellulitis, Deep Vein Thrombosis (DVT), Cardiac Failure, Subacute endocarditis and Osteomyelitis.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStep-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePhysical and cognitive function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePhysical and cognitive decline.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaplan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e73 (article reported in median)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePneumonia, Cellulitis, UTI, Osteomyelitis, and DVT.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStep-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGeriatric complications -confusion, falls, urinary incontinence, faecal incontinence or constipation), phlebitis, pressure areas, patients and carer satisfaction, adverse events and death.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eFalls, Confusion, Phlebitis, Pressure ulcers, and Mortality.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ede Stampa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRetrospective cohort study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePain management, post-surgery care, palliative care, complex dressing, artificial nutrition and complex nursing care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStep down\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e75108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e30-day hospital re-admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eHospital readmission and Mortality\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSingapore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRetrospective cohort study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSkin and soft tissue infections UTI, gastroenteritis, Rhabdomyolysis, pneumonia and fluid overload.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStep up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLength of stay, 30- day emergency department re-attendance, 30-day hospital readmission, mortality, escalation to acute hospital, Infections \u0026ndash; C-diff, pressure ulcers, catheter associated urinary tract infection, falls, adverse drug reactions.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMortality, adverse drug reaction, fall, pressure ulcer, venous thromboembolism, new catheter associated UTI (CAUTI), and hospital re-admission.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnited States\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProspective case series\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCongestive heart failure, community acquired pneumonia, cellulitis, and chronic obstructive airway disease.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStep up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLength of stay, cost effectiveness, and emergency clinical situations.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eAcute deterioration requiring emergency admissions and mortality.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnited States\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProspective Quasi experimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePneumonia, Chronic Obstructive Pulmonary Disease (COPD), Cellulitis and Congestive Heart Failure (CHF).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStep up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e455\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eClinical process measure, standards of care, satisfaction with care, functional status and costs of care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eFall, incident delirium, nosocomial infection, and death.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeung\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHong Kong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMatched-control Quasi experimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCOPD, CHF and Cancer.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStep down\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eEmergency attendance, medical readmissions and Quality of Life (QoL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEmergency readmissions.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnited States\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePneumonia, skin and soft tissue infection, complicated UTI/pyelonephritis, diverticulitis, heart failure, asthma, COPD, palliative care, and exacerbation of gout.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStep up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTotal direct cost of the acute care episode secondary outcomes included with healthcare use (laboratory orders, radiology studies and length of stay) and physical activities during the acute care episode.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMedication errors, cognitive decline -delirium and functional status.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRichards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1998\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79 (median)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFractured neck of femur (NOF), hip replacements, knee replacements, cerebrovascular accidents, falls without fracture, and chest infections.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStep down\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e241\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePatient\u0026rsquo;s quality of Life, Satisfaction and physical function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMortality, functional status\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShepperd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRespiratory conditions including infections and COPD, cellulitis, gastrointestinal (GI) disorders including GI infections, UTI, and musculoskeletal disorders.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStep up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHealthcare costs, people\u0026rsquo;s experience of healthcare at home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMortality, cognitive decline -delirium, readmission or transfer to hospital, pressure ulcers and falls.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShepperd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDelirium, functional decline, falls, dependence, history of dementia presenting with physical disease.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStep up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eClinical effectiveness, new admission to long term, residential care, death, delirium and patient satisfaction.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMortality, Cognitive decline -delirium, acute deterioration requiring hospital transfer.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTierney\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQuantitative -service evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRespiratory infection, COPD, UTI, falls, volume depletion and sepsis.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStep up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e505\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMortality, readmission rate, length of stay, and functional ability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMortality, readmission rate, and functional decline.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTsiachristas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRetrospective cohort study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eArthritis, asthma, cancer, HF, COPD, Dementia, Parkinson\u0026rsquo;s disease, diseases of the digestive system and renal failure.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStep up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e20,151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHealthcare costs and mortality.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMortality\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWilson\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e84 (median)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCardiovascular and respiratory conditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStep up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e199\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMortality, and change in health status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMortality, functional decline.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Results based on the SEIPS 3.0 framework","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePersons\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eHealthcare professionals\u003c/h2\u003e \u003cp\u003eStudies described multidisciplinary teams delivering HaH care, with both common and context-specific features across countries. Core roles across most models included physicians, registered nurses (RNs), physiotherapists (PTs), and occupational therapists (OTs) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In the United States, teams typically included general internists, nurse coordinators, and home health agency staff, with additional support from private partners such as home health aides and social workers [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. UK models similarly involved district nurse coordinators, PTs, OTs, and support workers, with some also employing therapy technicians [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Australian models ranged from nurses and general practitioners (GPs) led models [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] to those incorporating hospital doctors and community outreach teams [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Broader team composition was reported in France and Singapore, where psychologists, dietitians, pharmacists, and speech therapists were involved as required [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Some models in Hong Kong and the UK were geriatrician-led teams and underpinned by Comprehensive Geriatric Assessment (CGA) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], while another was consultant-led services with limited detail on team composition [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eMost studies included frail older adults admitted with defined acute medical conditions who were considered physiologically stable for management at home [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] In most models, patients were admitted to HaH following an initial hospital admission or emergency department assessment [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, one study reported that patients with chronic complex conditions, including palliative patients, were admitted to HaH [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], another study admitted patients from the hospital who needed rehabilitation [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and another admitted patients from nursing homes [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eTasks\u003c/h2\u003e \u003cp\u003eAcross studies, HaH models delivered a broadly consistent set of clinical tasks, including administration of parenteral medications, blood transfusion, venepuncture and cannulation, vital-signs monitoring, point-of-care diagnostics (e.g., portable ultrasound, radiography, and electrocardiography), oxygen administration and respiratory therapies, mobility and falls monitoring, clinical assessment, prescribing, and discharge documentation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Some programmes reported additional tasks aligned with service focus, including complex nursing and palliative care, artificial nutrition, chemotherapy and post-chemotherapy care, rehabilitation, pain management and post-surgical care [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Nurses commonly undertook patient assessment, 1:1 supervision, health education, and psychosocial support for patients and carers [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Medical leadership varied by model, with geriatrician-led CGA services [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], physicians led daily or urgent reviews [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], and GPs held overall medical responsibility [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Limited domestic assistance was reported in one study [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eTools and Technology\u003c/h2\u003e \u003cp\u003eAcross studies, commonly used tools included cannulas, intravenous and central venous access devices, oxygen cylinders, thermometers, blood pressure monitors, and other durable medical equipment [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. One model reported the use of the National Early Warning Score (NEWS) and patient hoists [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Technology-enabled care included telehealth consultations, lifeline devices, electrocardiography and radiography equipment [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], and remote monitoring using wearable skin patches to detect falls and movement, with algorithm-generated alerts reviewed by clinicians [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Communication was supported through telephone, encrypted video, and short message services [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eOrganisation\u003c/h2\u003e \u003cp\u003e Organisation of HaH services varied across studies in care hours, leadership, and service delivery models. Some services provided daily home visits with 24-hour physician availability [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], while others operated extended daytime or evening hours with emergency cover from existing services [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Clinical leadership ranged from physician or GP-led models [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] to\u003c/p\u003e \u003cp\u003eGeriatrician-led services underpinned by CGA [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Two studies reported that admission and discharge processes were structured, with care handed back to their primary physicians once patients stabilised [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Out-of-hours care was typically provided by existing primary care services [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eInternal environment\u003c/h2\u003e \u003cp\u003eHome environment suitability was a key determinant of eligibility for HaH care, although not all studies reported criteria in detail. When reported, exclusion factors included a lack of basic amenities (running water, electricity, and indoor toilet) and environmental hazards such as dangerous pets [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Availability of formal or informal caregiver support was frequently required, with patients lacking such support excluded from HaH services [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Additional considerations included adequate heating, accessibility, and safety in relation to disability [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. One model classified homes where delirium, falls risk, unsafe layouts, or poor housing conditions posed safety or public health concerns [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The other studies did not specify environmental criteria, limiting the assessment of consistency across models.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eExternal Environment\u003c/h2\u003e \u003cp\u003eSome diagnostics, including computerised tomography (CT scan), Magnetic Resonance Imaging (MRI) and endoscopy, could not be delivered at home, requiring brief hospital visits [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Limited resources restricted 24-hour nursing availability, constraining patient capacity and HaH bed numbers [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Core services-nursing, durable medical equipment, oxygen therapy, skilled therapies, and pharmacy support were provided through partner home health agencies [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eProcesses of care\u003c/h2\u003e \u003cp\u003eCore processes included clinical assessment, prescribing and medication administration, including oxygen delivery and regular home visits by nurses and clinicians [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Patient education, discharge decision-making, and post-discharge planning were also integral [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Some services integrated rehabilitation, with radiological investigations arranged as needed [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003ePatient Journey in the HaH clinical work system\u003c/h2\u003e \u003cp\u003eSEIPS 3.0 highlights the patient journey across care stages [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Studies described patient transitions via hospital step-down or community step-up pathways, with variable detail on how these were navigated. One model conducted initial emergency department assessments before home transfer[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], while others initiated care directly at home [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The patient journey was influenced by caregiver availability, home suitability, and the use of remote monitoring technologies [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003ePotential contributory factors identified\u003c/h2\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eDomain 1: Situational Factors (Patient factors, individual factors and task characteristics)\u003c/h2\u003e \u003cdiv id=\"Sec23\" class=\"Section4\"\u003e \u003ch2\u003ePatient factors:\u003c/h2\u003e \u003cp\u003ePatients admitted to the HaH service were predominantly older adults with co-morbidities[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], often with a poor functional baseline, complex conditions, or residence in nursing homes with frequent admissions [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eTask characteristics\u003c/h2\u003e \u003cp\u003eHaH tasks focused on core acute care, including medication administration, vital signs monitoring, point-of-care diagnostics, and clinical assessment, with limited capacity for advanced diagnostics or continuous monitoring in the home [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eIndividual staff factors\u003c/h2\u003e \u003cp\u003eIndividual factors were poorly reported. Most models identified physicians or geriatricians as clinically responsible, including CGA-led services, with limited detail on staff training or experience [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26 CR27 CR28\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], except in one study [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eDomain 2: Local Working Conditions (staffing issues and workload)\u003c/h2\u003e \u003cp\u003eStaffing workload was inconsistently reported. Some services provided initial one-to-one nursing care or capped caseloads for high-dependency patients [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] while staffing constraints limited HaH capacity [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Structured care pathways and clear admission and discharge criteria supported safer, standardised care [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eDomain 3: Organisational factors (physical environment and staff training and education)\u003c/h2\u003e \u003cdiv id=\"Sec28\" class=\"Section4\"\u003e \u003ch2\u003ePhysical environment\u003c/h2\u003e \u003cp\u003eHome environments posed safety challenges, particularly for managing delirium, due to limited containment, variable layouts, and a lack of clinical infrastructure [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Despite this, patients reported high satisfaction, citing reduced sleep disruption, greater privacy, maintained routines, and access to a healthier diet [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eDomain 4: Staff training and education\u003c/h2\u003e \u003cp\u003eStaff training was rarely reported. One study described an intensive one-day programme with supervised shadowing by experienced home-based physicians to prepare staff for delivering acute care at home [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDomain 5: Communication and culture\u003c/h3\u003e\n\u003cp\u003eCommunication systems were variably reported, with challenges including delayed care initiation, inconsistent information sharing, unclear contact pathways, and limited patient and carer involvement [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Some models addressed this through extended hours, hotline access, and digital communication via telephone, encrypted video, and messaging [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003ePost-review stakeholder workshop findings\u003c/h2\u003e \u003cp\u003e This systematic review identified that safety outcomes for HaH services are commonly assessed using measures developed for inpatient hospital care, such as falls, hospital readmission, mortality and healthcare-associated infections. Given the substantial differences between hospital and home environments, the post-review stakeholder workshops explored how safety is perceived in HaH care and identified outcomes considered meaningful by stakeholders.\u003c/p\u003e \u003cp\u003ePatients and carers identified outcomes not fully captured within the review\u0026rsquo;s safety outcomes for HaH, including carer well-being and burden, patient confidence and perceived safety, social isolation, comfort, independence, and maintenance of routine. These reflect experiential and relational outcomes aligned with the review\u0026rsquo;s aim to identify patient-centred safety outcomes in HaH care.\u003c/p\u003e \u003cp\u003eStakeholders identified several additional factors affecting the safety of care delivered at home, including limited monitoring, delayed emergency response, medication management risks, infection and environmental hazards, delays in equipment provision, and unclear service responsibilities. Clinicians further emphasised the importance of robust risk assessment processes, clear communication pathways, effective governance structures, family involvement, and the use of remote monitoring technologies as key system-level contributors to safe HaH care.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis review identified patient safety outcomes, contributory factors, and the clinical work system underpinning HaH care, using the SEIPS 3.0 model [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and the YCFF [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Findings show that the HaH work system\u0026ndash;shaped by people, tasks, technologies, organisational processes, and the home environment \u0026ndash; can both support and threaten patient safety. Multidisciplinary teams and digital tools enable timely monitoring and treatment; however, variation in team composition, admission criteria, and service hours introduces inconsistency across models.\u003c/p\u003e \u003cp\u003eAcross YCFF domains [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], persistent risks included patient complexity, staffing pressures, communication gaps, and limited reporting of staff practices. Although patient satisfaction with HaH care was high, this may mask safety vulnerabilities that are less visible in home-based care than in hospital settings.\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section2\"\u003e \u003ch2\u003eThe patient\u0026rsquo;s environment\u003c/h2\u003e \u003cp\u003eThe home environment is the defining feature of HaH and has implications beyond comfort to core safety concerns. Unlike standardised hospital settings, homes vary in layout, hygiene, equipment suitability, and availability of informal caregivers, influencing task delivery, monitoring, and emergency response [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. While familiarity may enhance patient experience [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], the home must also be recognised as a potential source of risk requiring structured assessment. A few studies applied exclusion criteria based on unsuitable home conditions [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Even in suitable homes, limited space and non-clinical layouts hindered management of acute conditions such as delirium and reduced the effectiveness of monitoring and emergency response, exposing patients and staff to unpredictable risks and tensions between autonomy and safety [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Ongoing environmental assessment has been proposed to mitigate these risks [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], though its feasibility in time-critical acute care remains uncertain. Unlike hospital care, HaH lacks standardised infrastructure and rapid response systems, increasing vulnerability to contextual factors [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section2\"\u003e \u003ch2\u003eMedication Safety\u003c/h2\u003e \u003cp\u003eMedication administration was a core component of HaH care across studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, no studies reported how medications were stored or prepared in the home, raising concerns given the absence of controlled storage and preparation systems routinely embedded in hospitals [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Medication stability and appropriate storage are essential for safety and efficacy, yet home environments are variable and largely unregulated, particularly for temperature or light-sensitive drugs [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. These risks are amplified in HaH populations, who commonly live with multimorbidity and polypharmacy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Complex regimens increase error risk, particularly when multiple caregivers are involved [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], and adverse drug reactions may be missed due to limited professional presence in the home [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Overall, transferring medication processes into domestic settings introduces safety vulnerabilities that remain underexplored and weakly regulated.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOrganisational variability\u003c/h3\u003e\n\u003cp\u003e This review found marked organisational variability across HaH models, particularly in team composition, service hours, and leadership. Similar heterogeneity in the literature highlights the absence of standardised guidance as a barrier to consistent and safe care [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Variation in protocols and staffing may contribute to unequal outcomes and limit scalability [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], underscoring the need for context-sensitive yet standardised implementation frameworks.\u003c/p\u003e\n\u003ch3\u003eTechnology integration and patient-led monitoring\u003c/h3\u003e\n\u003cp\u003eThis review found an inconsistent reporting of patient-led tasks such as self-monitoring and vital signs reporting in HaH care, with limited data on adherence, accuracy, or clinical oversight. This raises concerns about the safety of technology-enabled care when patients or informal caregivers undertake clinical tasks without continuous supervision [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Technological integration varied widely across models, from advanced remote monitoring to basic communication tools, limiting generalisability and obscuring effectiveness [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Assumptions that older adults can reliably engage with digital monitoring may be unrealistic, particularly given cognitive or physical impairment. Evidence on accuracy and adherence remains limited [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], while digital literacy and usability challenges among caregivers further increase risk [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Without robust training, support, and verification processes, technology may introduce new safety vulnerabilities.\u003c/p\u003e \u003cdiv id=\"Sec37\" class=\"Section2\"\u003e \u003ch2\u003eVariation in healthcare staffing\u003c/h2\u003e \u003cp\u003e This review found marked variation in healthcare team composition and leadership across HaH models, shaped by national systems and priorities. UK services are often geriatrician-led and underpinned by CGA [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], whereas US models rely more on general internists and private providers [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. While flexibility supports local adaptation, the absence of standardised guidance raises concerns about consistency, equity, and safety. Team composition influences care quality and outcomes, highlighting the need for strategic workforce planning and minimum staffing standards to support safe and scalable HaH implementation [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec38\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis review synthesises patient safety outcomes and contributory factors in HaH care for older adults, supported by a robust search strategy and use of SEIPS 3.0 and YCFF frameworks. Inclusion of diverse HaH models across multiple conditions, rather than disease-specific models, provides a broad view of safety in diverse HaH contexts. Integration of stakeholder perspectives strengthens interpretation by highlighting safety concerns that are not routinely captured in quantitative outcomes.\u003c/p\u003e \u003cp\u003eLimitations include exclusion of non-English studies and heterogeneity in study design and quality, which may limit generalisability. Nevertheless, the predominance of randomised control trials strengthens the evidence base. The findings highlight gaps in underreported safety areas, including medication management and the role of the home environment, and point to the need for standardised yet adaptable frameworks to support safe and scalable HaH care for older people.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec39\" class=\"Section2\"\u003e \u003ch2\u003eImplications for research\u003c/h2\u003e \u003cp\u003eHaH services should be targeted to carefully selected older adults with explicit consideration of clinical complexity, home environment suitability, and availability of informal support. Standardised criteria for admission, escalation, and discharge are needed to reduce variability and support consistent decision-making. Structured assessment of the home environment and caregiver capacity should be embedded within HaH pathways, alongside clear safety netting processes. Medication safety requires dedicated protocols adapted to domestic settings, including storage, preparation, and monitoring. Where patients or caregivers undertake clinical tasks, appropriate training, support, and oversight are essential. Similarly, digital technologies should be matched to patients\u0026rsquo; cognitive and functional abilities, with non-digital alternatives available. Finally, workforce models should support multidisciplinary collaboration, clear clinical leadership, and manageable caseloads, underpinned by minimum service standards to ensure safe and equitable HaH delivery.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eHaH offers a promising alternative to inpatient care for selected older adults, but its safety depends on how care is organised and delivered in the home. This review shows that while outcomes are broadly comparable to hospital care, important safety risks remain underexplored, particularly in relation to medication management, home environments, staffing and patient-led monitoring. Variability in service models and limited reporting of work system factors make it difficult to draw firm conclusions about best practice. Developing clearer, standardised frameworks while allowing for local flexibility is essential to support safe, equitable, and scalable HaH care for older people.\u003c/p\u003e"},{"header":"Abbreviations","content":" \u003cp\u003eCGA Comprehensive Geriatric Assessment\u003c/p\u003e \u003cp\u003eGP General Practitioner\u003c/p\u003e \u003cp\u003eHaH Hospital-at-Home\u003c/p\u003e \u003cp\u003eMESH Medical Subject Headings\u003c/p\u003e \u003cp\u003eOT Occupational Therapist\u003c/p\u003e \u003cp\u003ePT Physiotherapist\u003c/p\u003e \u003cp\u003eQuADs Quality Assessment for Diverse Studies\u003c/p\u003e \u003cp\u003eRN Registered Nurse\u003c/p\u003e \u003cp\u003eSEIPS Safety Engineering Initiative for Patient Safety\u003c/p\u003e \u003cp\u003eUK United Kingdom\u003c/p\u003e \u003cp\u003eUS United States\u003c/p\u003e \u003cp\u003eYCFF Yorkshire Contributory Factors Framework\u003c/p\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eNone required as a systematic review\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eAuthor details\u003c/h2\u003e \u003cp\u003e \u003csup\u003e1\u003c/sup\u003e School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK. \u003csup\u003e2\u003c/sup\u003e NIHR Yorkshire and Humber Patient Safety Research Collaboration, Bradford Teaching Hospitals Foundation Trust, Bradford, UK. \u003csup\u003e3\u003c/sup\u003e. NIHR Yorkshire and Humber Patient Safety Research Collaboration, Bradford Teaching Hospitals Foundation Trust, Bradford, UK. \u003csup\u003e4\u003c/sup\u003e NIHR Yorkshire and Humber Patient Safety Research Collaboration, Bradford Teaching Hospitals Foundation Trust, Bradford, UK. \u003csup\u003e5\u003c/sup\u003e NIHR Yorkshire and Humber Patient Safety Research Collaboration, Bradford Teaching Hospitals Foundation Trust, Bradford, UK. \u003csup\u003e6\u003c/sup\u003e. Centre for Digital Innovations in Health and Social Care, University of Bradford, Bradford, UK. \u003csup\u003e7\u003c/sup\u003e. NIHR Yorkshire and Humber Patient Safety Research Collaboration, Bradford Teaching Hospitals Foundation Trust, Bradford, UK.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eTG conceptualised and designed the study with input from RS, EB, RR and BF. Screening was conducted by TG, NM, AH, TF, and EB. Data extraction and quality assessment was conducted by TG and EB. The manuscript was drafted by TG and all authors provided intellectual content to the manuscript, critical feedback and approved the final version.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003e This research was supported by the National Institute for Health and Care Research (NIHR) Yorkshire and Humber Patient Safety Research Collaboration (PSRC). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ede Vale S. Hospital at Home: An Overview of Literature. 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Patient participation in self-monitoring regarding healthcare of heart failure: an integrated systematic review. BMC Prim Care. 2025;26(1):60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZainal H, et al. Exploring caregiver challenges, digital health technologies, and healthcare support: a qualitative study. Front Digit Health. 2025;7:1587162.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTruong T-T, Siu AL. Scaling Hospital at Home Beyond the Original Studies. JAMA Netw Open. 2025;8(5):e2510622\u0026ndash;2510622.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVleminckx S, et al. Factors influencing the formation of balanced care teams: the organisation, performance, and perception of nursing care teams and the link with patient outcomes: a systematic scoping review. BMC Health Serv Res. 2024;24(1):1129.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"“Virtual ward, ” “hospital-at-home, ” “older people, ” “patient safety, ” and “safety outcomes”.","lastPublishedDoi":"10.21203/rs.3.rs-9186305/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9186305/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHospital-at-Home (HaH) delivers hospital-level care to acutely unwell individuals in their usual place of residence and is increasingly adopted to address rising healthcare demands. While HaH may improve patient experience and reduce hospital admissions, patient safety outcomes for older people and the factors influencing patient safety in the context of care at home remain insufficiently understood. This review aimed to identify patient safety outcomes assessed in HaH care for older adults and to examine how the clinical work system factors influence these outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eCINAHL, EMBASE, and MEDLINE databases were searched from inception to September 2024. Eligible studies included participants aged 65 and older receiving HaH care, with documented care processes and reported patient safety outcomes. Data extraction was guided by the Safety Engineering Initiative for Patient Safety 3.0 framework (SEIPS), the Yorkshire Contributory Factors Framework (YCFF), and established patient safety outcome measures. Reporting adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFourteen studies were included, covering conditions such as respiratory and urinary tract infections, heart failure, and musculoskeletal disorders. Patient safety outcomes assessed included falls, mortality, readmissions, and infections. Key contributory factors influencing patient safety included multimorbidity, staffing models, communication pathways, and variability in leadership and supervision. Care was delivered by multidisciplinary teams using face-to-face and virtual methods, supported by remote monitoring via smartphones and wearable devices. Unsafe home environments were a common exclusion criterion.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSafety outcomes in HaH were generally comparable to hospital-based care. However, no safety outcomes specific to acute care delivered in the home were identified. Exclusion based on home environment suitability was common. These findings highlight the need for context-specific frameworks and safety outcome measures to support and evaluate acute care delivery for older people in the home.\u003c/p\u003e","manuscriptTitle":"A Systematic Review of Patient Safety Outcomes and Contributory Factors in Hospital-at-home Care for Older People","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 09:56:22","doi":"10.21203/rs.3.rs-9186305/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"103400887760369831505848994120923421404","date":"2026-05-01T10:28:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-22T16:24:08+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-30T12:06:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-30T12:05:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-28T14:14:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2026-03-28T14:09:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f662a008-5882-46d0-9fbf-6ac019d01791","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"103400887760369831505848994120923421404","date":"2026-05-01T10:28:02+00:00","index":66,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T09:56:24+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 09:56:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9186305","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9186305","identity":"rs-9186305","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}