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Knowledge, attitudes, and perceptions of residents towards Hospital-at-Home (HaH) and its role in residency training

BMC Medical Education volume 24, Article number: 953 (2024) Cite this article

Abstract

Background

With the proliferation of Hospital at Home (HaH) programmes globally, there is a need to equip junior doctors with the skills necessary for provision of HaH care. The ideal training structure and clinical requirements for junior doctors to be considered competent in providing HaH care is still poorly understood. This study examines the perceptions of junior doctors towards HaH, and aims to determine the learning needs that might be helpful for future curriculum planning.

Methods

We conducted a cross-sectional study of residents at the National University Health System (NUHS) Singapore. Using a 45-item questionnaire, we explored the knowledge, attitudes and perceptions of residents towards HaH, and their interest in participating in HaH as part of residency training.

Results

One hundred six residents responded. Overall knowledge and attitudes were mostly average. Perceptions were neutral but comparatively lower in the domains of safety, efficiency and equity. 69% of residents showed a positive attitude and interest to participate in HaH as part of residency rotations. 80% of respondents were keen to have a 2–4 week rotation incorporated into routine training. Demographic factors that influenced higher scores in various domains included type of residency programme and years of work experience.

Conclusion

Our findings suggest that residents are interested in participating in HaH. Incorporation of HaH rotations in residency training will allow juniors doctors to receive greater exposure and training in the skills specific to provision of HaH care. Further studies on the introduction of a HaH curriculum and Entrustable Professional Activities (EPAs) specific for HaH in residency training may be useful to to ensure that we have a competent HaH workforce that can support and keep up with the growth of HaH globally.

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Background

With ageing populations and rising prevalence of chronic diseases, [1,2,3,4] there is immense pressures on health systems to cope with the increasing health services demands [5,6,7,8,9,10]. There is thus a need for health systems to evolve and adapt to provide better patient care. Hospital at Home (HaH) programmes, defined as the community-based provision of services usually associated with acute inpatient care, [11] have become an accepted alternative for inpatient hospitalization. It has shown to improve patient satisfaction, reduce length of stay and utilization of health service resources and costs while providing comparable clinical outcomes [12,13,14,15,16,17,18,19]. These findings, coupled with the increasing strain on hospitals globally have led to the expansion of this service [20]. To keep up with this growth, there is also a need to increase the workforce equipped with the necessary skills to provide these services.

Despite the growing need for a trained workforce in HaH, formal physician training programs at present do not exist. Majority of internal medicine residency training takes place in the hospital or clinic setting, and a survey of Internal Medicine Residencies in the United States (US) showed that only 25% had a single home visit experience during their training [21]. Furthermore, these home visits might be done in primary care rather than acute care settings [22,23,24]. Residents therefore lacked the exposure and training in skills necessary to provide HaH care [16, 25].

To our knowledge, there are no existing studies addressing the optimal training structure and training requirements at a junior doctor level for HaH. Existing studies [24, 26,27,28] explore curricula on home medical care for residents but do not address competencies specific to HaH. This study aims to establish the current Knowledge, Attitudes, and Perceptions of residents towards HaH and their interest to include HaH as part of residency training. This could determine needs and identify gaps that would be useful for the development of future training curricula for HaH.

Methods

Setting

Singapore is a densely populated city-state where majority of the population live in high-rise public housing apartments [29]. There are 3 public integrated healthcare clusters, each with several general hospitals providing acute inpatient care and specialist outpatient services, and a set of large primary care centres, known as polyclinics, scattered around the geographical region of coverage [30]. The clusters work closely with and are supported by private primary care clinics, intermediate and long-term care institutions, and social service agencies. National University Health System (NUHS) [31] is one of these clusters in the western region of Singapore comprising 3 general hospitals, 3 specialty centres, 2 emergency departments, 1 urgent care center, 1 community hospital, and 7 polyclinics. NUHS serves a population of more than 1 million people with at least 25% aged 60 and above [31].

The residency postgraduate training system adopted by all three clusters was introduced in Singapore in 2010, modelled after that of the US, which aimed to provide a structured and formative training for junior doctors [32]. Upon completion of post-graduate year 1 (PGY1), junior doctors may opt to apply for a residency programme of their choice.

In September 2020, the health system started its HaH programme, NUHS@Home [17]. NUHS@Home accepts referrals from treating physicians in emergency departments, primary care services, and acute care hospitals across the system. Referrals were assessed for suitability by the NUHS@Home team. Suitable patients were subsequently admitted to a comprehensive multi-disciplinary service, which included a team of doctors, nurses, pharmacists, allied health therapists, and administrative support. The service was led by a Consultant in Advanced Internal Medicine (similar to a hospitalist or General Internal Medicine attending in other health systems). From inception in September 2020 till March 2023, about 2600 patients have been treated under the NUHS@Home programme [33].

Study population

Between 11th February to 10th March 2023, residents who were currently in any NUHS residency training programme were invited to participate in this study. The survey link was disseminated to 268 residents – 174 residents from Internal medicine (IM), 68 residents from Family Medicine (FM), and 26 residents from Emergency Medicine (EM). A snowball sampling method was used. Residents who received the survey link were allowed to share the link with residents from other NUHS residency programmes if they were keen to participate. We prioritised recruiting IM, FM, and EM residents as they were more likely to have been exposed to HaH in the previous year. Participants were excluded if they were not currently in a residency programme, or if they were from other training institutions in Singapore.

Survey instrument

A 45-item questionnaire was created via FormSG, an encrypted online survey platform created by the government’s GovTech agency (Additional file 1). The survey link was disseminated via short message service and email by a point-of-contact from each of the 3 identified residency programmes (IM, FM, and ED). Information about the purpose and voluntary nature of the survey was provided, and participants who completed the survey provided implied consent to use the collected data for research.

Survey development

The content validity of the questionnaire was assessed by an expert panel consisting of the programme lead of NUHS@Home with in-depth knowledge on the programme’s needs and expectations, a health services researcher seasoned in survey design, and the Training and Education lead of NUHS@Home.

Multiple rounds of refinement were made to capture the various domains that this study intended to evaluate. To emphasise on high quality patient-centred care, we used the six domains of healthcare quality, which is a framework developed by the Institute of Medicine, [34] to guide our questionnaire development in exploring perceptions of residents towards HaH as compared to usual hospital care.

Survey design

The survey assessed the following components: demographic information, baseline exposure to HaH, and related components; Knowledge, attitudes, and perceptions (KAP); and interest of residents to include HaH as part of residency training.

Data on familiarity with and confidence in home-based care provision were gathered. The questionnaire included general questions about home care, as well as specific aspects related to HaH components, such as teleconsultations, remote vital signs monitoring, home visits, and acute care delivery at home. This approach aimed to encompass a wide range of experiences and responses, given that HaH was a relatively recent introduction to NUHS.

The KAP questionnaire included 6 questions that assessed knowledge on NUHS@Home, which mimicked what other HaH models support [35,36,37] (scores ranging from 0–16), 7 questions that assessed attitudes (scores ranging from 7–35), and 12 questions that assessed perceptions (scores ranging from 12–60). Participants were also asked to propose a suitable duration for a HaH rotation, taking into account their current rotation schedules within the residency programme, and to provide feedback on their desired learning outcomes if HaH were incorporated into residency training. (Table 1).

Table 1 Content of the KAP and interest in HaH questionnaires
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The survey utilised a combination of various response formats: 5-point Likert scale, dichotomous true/false responses, frequency scales, and multiple-answer questions.

For the section on knowledge, each correct answer was given 1 point. The first two questions required correctly picking the applicable conditions out of the 6 options. Correct selection and non-selection of the 6 options yielded 1 point each, totalling 6 points for the question. The third to sixth questions were dichotomous true/false questions, and each correct response yielded 1 point.

For the section on attitudes and perceptions, ratings were on a 5-point Likert scale: for positive attitude/perception question items, the scoring was 1 for strongly disagree to 5 for strongly agree; for negative attitude/perception question items, reverse scoring was used.

Reliability of survey instrument

The Cronbach’s alpha, which is a measure of internal consistency, was used to measure the reliability of the question items in the Attitudes and Perceptions domains. Due to mixed response formats designed for the question items in the Knowledge domain, internal consistency was not assessed for the question items in this domain. The Cronbach’s alpha with one item dropped at a time was used for item analysis to examine whether particular items affect the overall reliability of the domain. A Cronbach’s alpha coefficient of > 0.70 was considered as good measure of internal consistency and the values between 0.60 and 0.70 were considered as acceptable [39, 40].

Statistical analysis

Categorical data are presented using frequency and percentages. Continuous data are presented using means and standard deviations if normally distributed, and medians and interquartile ranges if not normally distributed. Comparison of data between different residency groups were performed using logistic regression models. Data were analysed and interpreted using Stata 18.0 [41], and level of statistical significance was p < 0.05.

Ethics

The study was approved by the local institutional review board National Healthcare Group Domain Specific Review Board (Ref 2022/00789).

Results

We received 106 responses of which 59% (n = 63) were from IM, 19% (n = 20) from FM, and 22% (n = 23) from EM and other specialties (Haematology & Oncology, General Surgery, Orthopaedic surgery, Paediatrics, Anaesthesia and Diagnostic Imaging).

Characteristics of participants are detailed in Table 2. The baseline experience with home-based services of participants are detailed in Table 3.

Table 2 Characteristics of participants in this study (n=106)
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Table 3 Baseline experience with home-based services of participants
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Classification of scores

Knowledge, attitudes, and perceptions were classified based on the following score ranges (Additional file 2).

  1. (1)

    Good knowledge if cumulative score was 13–16, average if score 8–12, poor if score < 8.

  2. (2)

    Positive attitude if cumulative score 28–35, neutral if score 15–27, negative if score 7–14.

  3. (3)

    Positive perception if score 48–60, neutral if scores 25–47, and negative if score 12–24.

The ranges for knowledge classification were based on > 75% or better score, 50% to ≤ 75% score, and < 50% as good, average, and poor, respectively. The ranges for attitude and perception classification were based on a mean of ≥ 4, > 2 to < 4, and ≤ 2 rating across the section’s question items, for positive, neutral, and negative, respectively.

Knowledge

The mean knowledge score was 12.5 ± 1.3, from a maximum obtainable score of 16 (Table 4). 51% (n = 54) of participants had good knowledge of HaH. Within the sub-domains evaluated, participants were more familiar with the types of medical conditions supported by HaH as compared to the types of services provided and comparison with other home care services. 72% (n = 76), 49% (n = 52) and 70% (n = 74) of participants achieved a good score in these sub-domains respectively (Fig. 1).

Table 4 Breakdown of participants’ scores in the sub-domains of Knowledge, Attitudes, and Perceptions of Hospital-at-Home (HaH) programme (n=106)
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Fig. 1
figure 1

Illustration of participants’ Knowledge, Attitudes, and Perceptions of Hospital-at-Home (HaH) programme (n = 106)

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The knowledge score of HaH was associated with participants’ post-graduate year. Years post-graduate was used as a proxy for experience and training. A cut-off of 5 or more years of work experience was used to denote participants that were residents with more experience. The odds of achieving an overall good knowledge score for more experienced residents was 2.3 (95% CI: 1.0–5.3, p = 0.048) times higher than that of residents with less experience (Table 5).

Table 5 Associations between participants’ demographics and their knowledge, attitudes, and perceptions of Hospital-at-Home (HaH) programme (n=106)
Full size table

There was no significant association observed between characteristics of participants and the overall knowledge. However, we found that one of the subdomains of knowledge, i.e. comparison with other home care services, was associated with resident’s post-graduate year. Residents with more experience had 4.8 times (95% CI: 1.3–17.3, p = 0.017) higher odds of achieving a good score in the subdomain compared to residents with less experience (Table 5).

Attitudes

Participants’ attitudes towards HaH were neutral, and the mean attitude score was 26.8 ± 3.8, with a maximum attainable score of 35 (Table 4).

Majority of participants had a positive attitude in the sub-domain of interest to participate in HaH rotations (69%, n = 73) (Fig. 1). These findings were significantly associated with type of residency programme. The odds of showing interest in participation in HaH rotations were 3.8 (95% CI: 1.4–10.4, p = 0.009) times higher among internal medicine residents and 5.2 (95% CI: 1.3–20.5, p = 0.018) times higher among family medicine residents, as compared to residents from other departments. Significant association with participants’ post-graduate year was also observed. More experienced residents had 66% lower odds of showing interest in participation in HaH rotations compared to less experienced residents (OR: 0.3, 95% CI: 0.1–0.9, p = 0.033) (Table 5).

For the seven-item Attitudes domain, Cronbach’s alpha was 0.61 and ranged between 0.51 and 0.65 when omitting one item at a time, indicating acceptable internal consistency in the domain.

Perceptions

74% of participants (n = 78) had a neutral perception of HaH, with a mean score of 43.7 ± 5.9 and a maximum attainable score of 60 (Table 4). Within the sub-domains of healthcare quality, participants had a positive perception of HaH as being patient-centred (89%, n = 94) and effective (56%, n = 59). A larger proportion of participants had concerns about the safety (neutral perception 64% (n = 68); negative perception 10% (n = 11)) and equitability (neutral perception 77% (n = 82) and negative perception 8% (n = 9)) of HaH (Fig. 1).

For the 12-item Perceptions domain, Cronbach’s alpha was 0.85 and remained at 0.83 to 0.86 when items were omitted one at a time, indicating strong internal consistency in the domain.

Interest towards HaH in residency training

Overall, participants showed a positive attitude and interest in participating in HaH as part of residency rotations. In terms of duration of HaH posting, 59% (n = 63) of participants felt that a 2-week rotation was ideal, and 21% (n = 22) opted for a 4 week posting. They were keen to participate in home visits, conduct teleconsults, and learn how to identify patients who were suitable for the programme. Participants felt that rotations through HaH would be useful in developing skills in the following domains: learning how to rationalise the use of resources and investigations (92%, n = 98), transitions of care (91%, n = 96), sharpening clinical acumen (87%, n = 92), communications with patients and their families (80%, n = 85), inter-professional communication (72%, n = 76), and hands on/procedural skills (54%, n = 57) (Table 6).

Table 6 Residents interest in HaH rotations and learning outcomes (n = 106)
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Discussion

In this cross-sectional study of medical residents in post-graduate training, we found that despite having a HaH programme in the institution for > 2 years, majority of residents had little to no experience in home-based care. Overall knowledge and attitudes of residents towards HaH were mostly average. Perceptions were neutral, but comparatively lower in the domains of safety, efficiency, and equity. Majority of residents showed a positive attitude and interest to participate in HaH as part of residency rotations. 80% of residents were keen to have a 2–4 week rotation incorporated into routine training.

Our findings build on existing literature promoting medical education to incorporate home care medicine, whether in home-based primary care, or in HaH settings.

Previous studies have shown that a greater exposure to home visits during residency training increased interest in incorporating home visits into future practice. Goroncy et al. [28] surveyed FM residents who went through a 3-year home-based primary care programme. 85% of residents showed interest in home visits as part of their future practice, and 78% indicated that they would be more likely to perform future home visits if they had more opportunities during residency to do so. Similarly, our findings showed that IM and FM residents who had more exposure to HaH in residency showed more positive attitudes and interest in participating in HaH.

Residents surveyed in our study had concerns regarding the safety, efficiency and equity of HaH, in contrast to multiple studies that suggests that for suitable patients, HaH generally results in similar or improved clinical outcomes and shorter length of stay as compared to inpatient hospitalisation [15]. Such attitudes, combined with concerns about liabilities [42,43,44] may explain physician hesitance towards referring patients to HaH, which has previously been identified as a key barrier to scaling up HaH programmes [45, 46]. Engagement of residents during training years may increase familiarisation and help to address negative perceptions in safety, efficiency, and equity, thereby increasing confidence in identifying and referring patients to a HaH programme.

Our findings also suggest that residents believe that relevant skills can be developed through rotations in HaH (Table 6). Training in the HaH setting provides residents with opportunities to develop the ACGME core competencies [47]. Mastery of multiple competencies, also referred to as Entrustable Professional Activities (EPAs), [48,49,50] is also of key importance in specialist training. The five levels of entrustment have been described by ten Cate and Taylor (Fig. 2).

Fig. 2
figure 2

Five levels of Entrustable Professional Activities (EPA) as described by ten Cate and Taylor

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To our knowledge, there has been no established competency requirements established for HaH. We propose the development of a HaH residency curriculum that incorporates clinical exposure to address the deficiencies identified in current practices. This curriculum can be structured around EPAs tailored specifically for HaH training, which may include topics such as managing acute medical conditions in HaH, managing unstable patients in HaH, and providing HaH consultations to identify suitable patients for admission.

However, it remains uncertain at which level of post-graduate training the HaH curriculum and EPAs should be mapped into. As healthcare systems continue to evolve, the need for residents to receive adequate training and exposure to HaH is becoming more evident. However, the duration of residency training that should be dedicated to HaH remains uncertain. 80% of our participants felt that a rotation between 2–4 weeks long would be ideal, but this short duration is unlikely to allow residents to manage HaH patients unsupervised (i.e., EPA level 4) by the end of residency. Incorporating a longer HaH posting into a residency programme is also challenging, given the number of other rotations and requirements that residents must fulfil. Complicating matters further are the variety of specialists with different training programmes that have been traditionally involved in HaH care delivery, including internal medicine hospitalists, geriatric medicine, family medicine, emergency medicine and others, who have varying exposure, knowledge, perceptions and attitudes as seen in this study. These matters must be balanced with the need for a larger, trained HaH workforce to respond to the demands for rapid expansion of HaH globally.

Recently, the concept of a ‘Home Hospitalist’ has been suggested by Danielsson & Leff [51]. One possibility may be to encourage feeder specialities to incorporate short 2–4 week rotations as a core part of post-graduate education, with the objective of achieving EPA level 2–3 to facilitate future appropriate referrals to HaH programmes. Providers interested in providing HaH care should then receive additional training and clinical experience in a dedicated training programme in home-based acute care post residency training to achieve EPA level 4–5.

Limitations

This study has several limitations. First, it was a small study conducted at a single training site in Singapore. However, this represented about a third of the Singapore residency pool, and training curriculum was based on the ACGME curriculums in the US. Second, there was a higher proportion of participants from internal medicine. Although this is reflective of the size of each residency programme, it might not accurately reflect the view of all residents from other specialities and residents who did not participate in the survey. Moreover, there were variations in the level of exposure to HaH among participants, even within the same residency programme. Years post-graduate was also used as a proxy for level of experience, and might not accurately reflect the actual training and capabilities of a resident. Third, although the HaH service had been running for more than 2 years in the health system, penetration to all specialties was variable and was not yet considered standard of care. Several questions in the survey were also developed around HaH within the context of NUHS. The perspectives of residents might not be generalisable to other contexts or health systems with established HaH programmes, and could change over time as the service develops.

Conclusion

Despite the current level of exposure to HaH, our findings suggest that medical residents are interested to participate in HaH as part of residency training. A HaH residency curriculum that incorporates clinical exposure, and the introduction of the use of Entrustable Professional Activities (EPAs) may be useful as a framework for training residents in the skills required for HaH. Further studies and collaboration with experts of medical education will be beneficial to determine the optimal training structure and requirements to ensure consistency of the quality of care provided by the HaH workforce.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ACGME:

Accreditation Council of Graduate Medical Education

EPA:

Entrustable Professional Activities

EM:

Emergency Medicine

FM:

Family Medicine

GP:

General Practitioner

HaH:

Hospital at home

IM:

Internal Medicine

KAP:

Knowledge, Attitudes and Perceptions

PGY1:

Post graduate year 1

US:

United States

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Acknowledgements

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Funding

This study was supported by the Population Health Research Grant from the National Medical Research Council, Singapore (PHRGOC23Jan-0002).

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Authors and Affiliations

  1. Department of Medicine, Alexandra Hospital, National University Health System, Singapore, Singapore

    Rachel Choe & Jonathan E. Jacob

  2. Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore

    Ian Yi Han Ang & Hooi Swang Cheng

  3. Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore

    Stephanie Qianwen Ko

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Correspondence to Rachel Choe.

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Choe, R., Ang, I.Y.H., Cheng, H.S. et al. Knowledge, attitudes, and perceptions of residents towards Hospital-at-Home (HaH) and its role in residency training. BMC Med Educ 24, 953 (2024). https://doi.org/10.1186/s12909-024-05946-6

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BMC Medical Education

ISSN: 1472-6920

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