A SWOT Analysis of Hospitals’ and HMO Representatives’ Opinions regarding Hospital at Home in Israel

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Introduction
Hospital care was once considered the "gold standard" for delivery of acute medical care [1].However, the hospital environment might harbor risks, including falls, delirium, infections, and pressure sores [2,3].Community care is more easily accessed and less hazardous but limited in stafng and types of interventions available [4].Hospital at home (HaH) might combine the best of two worlds: intensive medical care in the home environment [5].
Healthcare systems defne acute HaH (AHaH) in several diferent ways.Casteli et al. [6] performed a meta-analysis of AHaH studies in English, French, Spanish, and Portuguese and evaluated diferent defnitions of HaH.Tey chose the operational defnition: ". ..a service that provides in-home hospital care to patients with complex clinical conditions who would be hospitalized in conventional facilities due to an acute episode, and require 24/7 monitoring and follow-up that is only available in the hospital."Tis concurs with the British [7] and Israeli defnitions [8].
Te concept of AHaH has been known for several decades.However, despite demonstrated benefts [18], it has not created widespread change in hospitalization preferences [19,20].Terefore, obtaining the opinions of healthcare professionals directly involved in AHaH might provide insights regarding barriers and facilitators to expanding AHaH.Tis study used a questionnaire based on the SWOT model (strengths, weaknesses, opportunities, and threats) to obtain this information.
SWOT is used to explore healthcare organizations [21][22][23][24].Te World Health Organization proposed a SWOT situation analysis of entire health sectors [25].SWOT healthcare studies often analyze a single healthcare entity facing an exterior challenge, such as COVID-19 [26][27][28].Tis study used the SWOT model to evaluate and compare attitudes of healthcare managers toward AHaH from the perspectives of individuals who represent hospitals or HMOs.

Research Design.
Tis is a qualitative, grounded theory [29,30], exploratory study.Te methodology is suitable for understanding attitudes and constructing theory.Te SWOT questions, which seek multidimensional aspects of a phenomena, correspond well with this.Participants were asked: "What are the strengths, weaknesses, opportunities, and threats of AHaH for patients and healthcare providers?"We compared the answers of HMO and hospital representatives to observe similarities and diferences between the positions of these two stakeholder groups.

Sample.
Te stakeholders in this study were the HMOs and general hospitals who choose to operate AHaH in Israel.Te aim was to interview clinical and administrative professionals from each healthcare organization type, who are involved daily with AHaH.One HMO and one hospital had only one representative in charge of both clinical and administrative operations.A total of 14 participants, representing the four government-mandated HMOs and four general hospitals, were interviewed.
Te HMO participants included three medical doctors (two in charge of AHaH and one in charge of primary medicine), three registered nurses (two in charge of regional HaH and one in charge of national HaH), and one economist in charge of purchasing and auditing.
Among the hospitals that ofer AHaH, four medical doctors were interviewed, including two hospital CEOs (one of a virtual hospital that is part of a large hospital), one doctor who oversees an internal medicine ward and an AHaH program, and one doctor who oversees AHaH and a COVID-19 ward.In addition, two registered nurses were interviewed, one in charge of the "virtual hospital" operations and one in charge of AHAH in a general hospital.One hospital chief fnancial ofcer was interviewed as well.Hospitals varied in size, geographic location, and ownership.

2.3.
Questionnaire.An open-ended questionnaire was developed that contained three sets of questions: six regarding demographics (name, employer, years in organization, job description, years in job, and afliation to HaH services); one defnition question: "How does your organization defne AHaH"; and four SWOT questions: "What are the strengths, weaknesses, opportunities, and threats regarding AHaH for the patient and the organization?"Each interview took up to 30 minutes.
Interviews were conducted by researcher 1 (NH) and reviewed by researcher 2 for guidance, comparison, and consistency.At the beginning of each interview, the researcher explained the SWOT model.A benchmark question regarding the defnition of AHaH was used to ensure all respondents were referring to the same type of service.
All interviews were conducted via telephone or Zoom and typed in Word format in Hebrew, during July and August 2022.Before the interviews, two healthcare service professionals who were not part of the research were interviewed by both researchers separately, to establish the coherence and validity of the questionnaire.

Data Analysis.
Researchers 1 (NH) and 2 (RM) analyzed the data using an adaptation of the four-stage thematic analysis [31][32][33].Tis consisted of (1) familiarization with and organization of transcripts, (2) identifcation of themes, (3) review and analysis of themes to identify structures, and (4) construction of a theoretical model, constantly checking against new data.
Both authors read all interviews and coded them separately.Codes were identifed and divided into categories and subcategories.Data from each interview were compared between both authors and other interviews [30].Tis revealed core issues and their frequency of expression.Tus, this study used an exploratory, pragmatic, mixed-method analysis [25,34], analyzing qualitative data for subjective views and for frequency [35,36].
Tables were constructed to refect categories and subcategories, their SWOT dimensions, relevant citations, and frequency.Since 14 respondents were interviewed, seven from hospitals and seven from HMOs, each subcategory could be expressed by 0 to 7 representatives from each group.
Te interview responses were translated from Hebrew to English while attempting to maintain the tone of the original response.

Ethics.
Ethics approval was obtained from the Faculty of Social Sciences, Bar Ilan University, in April 2022.Signed consent to participate in this study was obtained from all participants.

Results
Four aspects of HaH were identifed: patient clinical care, HMO and hospital organization, macro-health systems, and stafng.All respondents gave the same answer and the same legal boundaries to the benchmark question of what is AHaH (namely, acute care replacing an internal medicine ward in a hospital), in agreement with the Israeli Ministry of Health's (MOH) [37] directive and defnition.
Table 1 presents aspects pertaining directly to patient care.All respondents viewed AHaH as benefcial for patients in terms of experience, medical outcomes, commitment to adherence, and avoiding risks and side efects related to hospitalization.

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Health & Social Care in the Community Some respondents mentionedAHaH as encouraging patients and family to take more active roles in the healing process, whereas other respondentswere leery of the burden on caregivers.Another perceived weakness was that this service is not for everyone, due to home and family conditions, geographic proximity, and clinical ft.Tis was followed by a concern, expressed by both groups, of the risk of a patient not being monitored 24/7 and the need to develop additional standards and quality tools for home care.
Table 2 focuses on the impact on the healthcare organization.Some respondents viewed AHaH as an improvement in service, in terms of the hospital-community care continuum, institutional prestige, and professional development.
A weakness presented primarily by the HMO representatives was the limited access to on-site testing, imaging, and telemedicine, which may indicate that AHaH provides fewer supportive services compared to hospitals.Worth mentioning is the concern that doctors will refer patients to AHaH when they are not sure what they need.Hospital and HMO representatives thought hospitals were neither wellintegrated nor reimbursed sufciently within the national model of AHaH.
Table 3 expresses the respondents' general observations about AHaH and the healthcare system.Among the 14 respondents, 5 from each group perceived AHaH as an opportunity for HMOs and hospitals to develop new services.Six of seven HMO representatives also perceived it as potentially cost-saving for the healthcare system, although large investments were needed to develop AHaH operated by in-house HMO staf.
Table 4 presents the strengths and opportunities for staf, which included increasing professional expertise and gaining insight into the home sphere, enabling seasonal and fexible recruiting, and extra work for those interested.

Discussion
Tis study presents issues pertaining to AHaH care from the perspectives of 14 individuals who play major roles in the public healthcare system in Israel.All respondents agreed that AHaH is benefcial for the patient and that it is a positive development for the medical provider.Tis concurred with other studies that stressed quicker recovery, fewer side efects, and a better overall experience [18,38].Concerns brought up regarding fnancing, standards, and safety concur with previous research [39,40], as does the limited availability of on-site technology in AHaH [11].Issues requiring more deliberation are risks, fnancial incentives, implications and burdens, quality assessment, evaluation and comparison, and exclusion.

Risk Management in the Home Environment.
AHaH requires medical staf to work with caregivers who are not professional healthcare providers.Laymen assuming professional roles may result in mistakes and misunderstandings, potentially risking patient safety.Burden and fatigue of caregivers may add to this risk.Studies that focus on the consequences and repercussions on family members of patients receiving AHaH are lacking.Time spent by professionals on instruction was not mentioned in previous research.It might be worthwhile to develop a checklist for emergency departments to gauge the true at-home treatment capacity in this regard.

Comparing "Apples to Oranges". Te fndings show that
AHaH provided by hospital staf, as an extension of ward activity, is very diferent from outsourcing or immediate referral to AHaH after an emergency department visit, or from a general practitioner referring a patient directly from home to AHaH.Most studies regarding HAH explored short-term consequences and savings.Studies exploring the medium-to-long-term efects of AHaH were not found, as well as studies comparing the types of physician/nursing visits and interventions, testing, prescribing, and time of response to urgent calls.A more in-depth comparison of AHaH operations is required.Health & Social Care in the Community

Financial Incentives.
Most studies reported fnancial benefts for systems based on private insurance [18,41] and national healthcare [38].Most evaluated daily expenditures, length of hospitalization, and immediate results.Although it may seem less expensive compared to the cost of a hospital day, this comparison often does not evaluate medium and long-term expenses incurred by deteriorating health, complications [40], and hidden costs, such as time spent on transporting staf [42], drugs, and test kits from home to labs.Our fndings refect the notion that there is potential savings on an organizational level, but investment is needed to develop a robust in-house AHaH service.Te total cost for the purchaser-insurer might seem less for some patients;   Tis study had some limitations.It evaluated opinions and attitudes, not quantitative data.It was also based on 14 interviews with professionals.Although all are experts in the feld of AHaH, it was a purposive sample.Terefore, comparing subjective opinions to data collected from the organizations could improve triangulation and compatibility.Te Israeli case of AHaH is generalizable, but information, particularly regarding fnancial considerations, is in the context of the Israeli healthcare system, mainly arrangements between hospitals, HMOs, and the MOH.

Conclusion
AHaH is perceived by healthcare service managers as a potential game changer for hospitals of the future.However, many barriers to upscaling exist, including quality management, staf development, technology and services, caregiver implications, and fnancial planning and incentives.Additional research that correlates the suitability of specifc diagnoses for AHaH, as well as specifc demographics, should be conducted.A comparison of the benefts and defcits of specifc types of AHaH service providers (HMOs, hospital, or others), to create benchmarks for technologies and interventions, is also needed.
Can AHaH survive on a large scale without governmental compensation?Which type of organization is best suited to provide it?Which patient groups are the most appropriate?Tese questions need further deliberation through more research.Last, a thorough review of patient, family and caregiver experiences, implications, and views is recommended.

Table 1 :
SWOT of patient clinical and care aspects.Comfort and satisfaction of patient and family, more active in recovery."Patients stay in their normal environment," "Treatment is provided on their schedule," "I do not remember a violent incident, I have more time, I am a guest, I am respected" S, strengths; W, weaknesses; O, opportunities; T, threats.

Table 2 :
Organizational aspects of the HMO and hospital.

Table 4 :
Staf issues and considerations.Equity vs. "Pick the Right Patient".AHaH requires careful patient selection-clinically, demographically, socially, and geographically.A patient who does not meet the criteria is excluded from AHaH.Te study results concur with the literature, since many respondents repeated the theme: "Pick the right patient."Given the fnancial incentives we referred to previously, this could be perceived as a new form of cream skimming and exclusion.When "picking the right patient" is frmly ingrained in the process, AHaH might not be an equitable service to develop compared to other service options.Clearly, the social and systemic impact of AHaH development needs further analysis.