Introduction

Home Hospital (HH) or hospital at home are concepts that are associated with an alternative to traditional hospital inpatient admittance. The first experience appears in the 40’s in New York’s Montefiore Hospital where, to promote quality of care and provide extra space for patients, it is put into practice the first sketch of home hospital^1-3. In Europe the first HH experience takes place in France, in 1957, and consistently during the 60’s it spreads out through the continent^2,3. It only arrives to Portugal in 2015 with the first Home Hospital unit is created at Hospital Garcia da Orta, Lisbon. In 2018 Centro Hospitalar de Vila Nova de Gaia/Espinho starts another HH unit⁴. From 2019 onwards the development of several HH units was promoted. Nowadays the presence of HH units is unanimous on the majority of Portuguese public hospitals.

Home Hospital units aim to promote quality healthcare similar to conventional inpatient in hospital settings admittance with the possibility of reducing associated risks: crossed infections, falls, acute confusion, etc. Additionally the possibility for a patient to be receiving high quality healthcare in his home promote an environment that prompts healing conditions and better psychological conditions for the patient⁴.

The main features that constitute the core of a HH unit are the commitment to substitute completely an inpatient acute hospital admission; offers and provides the same level of care that would be provided in-hospital; it provides care that is commonly provided in a acute hospital and not in usual community based home care services¹.

Health Literacy is of paramount importance for the development and quality life-styles and based on knowledge, personal skills and confidence⁵: “Health literacy represents the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health”.

Home Hospital depends greatly on informal caregivers and/or family members support while patient is admitted to HH.Their support is composed on early warning signs of deterioration, vital signs observations and recording, non-IV medication monitoring, administration and recording and a variety of data required to be provided to healthcare professionals when the visit is due. Health literacy must be one the components and should be a tool widely spread on legislation and official documents in order to be enforced by healthcare professionals. Health literacy is of paramount importance for the successful development of HH. Therefore this retrospective descriptive study analyses the legal documentation related to HH issued by Portuguese health authorities in order to seek the relevance given to Health Literacy in this context.

Methods

In order to develop this review and document analysis the authors established search on the website “Diário da República Electrónico - DRE” which is the online repository for Portuguese Legislation using the following terms: “hospitalização domiciliária” - between 01st January 2015 and 06th July 2020 and corresponding only to the “Ministério da Saúde” (Health Minister). A total of 27 documents were found (Table 1) containing the terms above mentioned and only 3 were considered for this review, after the title and purpose reading. Only laws or decree of laws were included in this search.

On the 3 documents above mentioned a discourse analysis⁶ was implemented following the “in-document” search of the terms: “literacy em saúde” (health literacy) AND/OR “educação para a saúde” (health education).

Results

The 3 legislative documents versed Home Hospital units directly: on the 17th September 2018 is nominated the national coordinator responsible for the implementation of several Home Hospital Units throughout the country. Despite the fact that this document is mainly based on logistic details, the terms “educação para a saúde” and/or “literacia em saúde” were not presented nor mentioned in this document.

On the 03rd of October of 2018 the legal document number 9329-A/2018 describes the national strategy for Home Hospital Units implementation throughout several public hospitals in the country. The document enumerates the patient’s rights and duties, medication and range of availability, units timetable and staffing, motoring and evaluation, human resources and main goals for Home Hospital units. The minister mandates the “Direcção Geral da Saúde” to produce the ground rules for Home Hospital units function. This document has no mention to “educação para a saúde” nor “literacia em saúde”.

On the 23rd December of 2019 the legal document number 12333/2019 reinforces that all public hospitals should have a working Home Hospital Unit. This document has no mention to “educação para a saúde” nor “literacia em saúde”.

Following the results above stated the author searched the “Direcção Geral da Saúde” (Directorate General Health) website for the ground rules or standard operation procedure (SOP) for portuguese Home Hospital Units: SOP 020/2018 regulates all the activities and healthcare delivered through these type of hospital admission. The SOP regulates criteria for patients inclusion/admission and refusal, diagnostic test and therapies expected too held in this type of admission, patients pathway, audit criteria and evaluation standards. Although this legal document is the pivotal for the development, regulation and daily healthcare deliver for Home Hospital units it has no mention to the expressions: “educação para a saúde” nor “literacia em saúde”. However there is indication that healthcare professionals should teach and instruct - therefore promote literacy - to patient and main carer regarding treatment being delivered, infection control strategies and, as well, to promote knowledge development in healthcare professionals through research and/or academic placements.

Discussion

Health literacy is a powerful asset that healthcare professionals may develop on their patients. Home Hospital units have the power to provide quality healthcare and decrease in hospital admission length of stay and improve patients quality of life⁷. If perceived has an asset that promotes healthy lifestyles and health seeking behaviors, health literacy can be portrayed has a powerful weapon to patients take control of their life on a healthy manner⁸. The implications on quality of life and costs savings are obvious. Empowering citizens to play an active role in improving their own health and to promote a health equity context is pivotal to abolish inequalities and disadvantages and marginalized societies(⁵⁾.

Portugal is the country that, when compared to another European countries, presents the lowest percentage (8,6%) of individuals with Excellent Health Literacy levels^8,9. The European average percentage of individuals that possessed a Sufficient level of Health Literacy is 36% whereas in Portugal is 42,4%. Portugal presents 38,1% of individuals with Problematic level of Health Literacy when compared with 35,2% of European average. The Inadequate level of Health Literacy is in Portugal of 10,9% whereas in Europe is 12,4%^8,9. The most vulnerable part of Portuguese population on Health Literacy levels are individuals with 65 or above years of age, low income and low degree of literacy, with chronic diseases, with a poor perception of their health status and with limitations due to chronic conditions^8,10.

Health Literacy is a tool crucial to promote equity on healthcare access and maintenance of quality of life. Home Hospital units seek to deliver excellent healthcare to patients, avoid iatrogenic complications, reduce costs and avoid functional decline¹. The range of pathologies that area admitted to Home Hospital is focus on chronic conditions and acute phase of chronic conditions.⁸ It is extremely important that the opportunity is seized to provide tailored healthcare to a patient when a admitted in Home Hospital setting and, as well, to establish a diagnosis and plan of intervention to overcome any possible needs on Health Literacy. Home Hospital is an emergent tool to provide Health Literacy tailored to patient needs in his own setting. These conditions are prosperous for a successful interaction and acquisition of knowledge. Additionally literature states that the majority of conditions that establish admissions to Home Hospital are chronic conditions⁷. How to manage chronic conditions and alarm signs are just two examples on how healthcare providers may promote Health Literacy on their patients. Although, with effort, one can withdraw an educational intention and inclination on the elaboration of the legal documents evaluated, this is not clear and explicit. The lack of Health Literacy dimension and wording on legal documents that support Home Hospital units regulation is presented on this analysis review. Additionally the relevance of Health Literacy on promoting equity on access to healthcare and decreasing the gap between marginalized individuals and health is well established. Therefore authors conclude that it is extremely important that legislative documentation provide support to healthcare professionals increase Health Literacy in their practice to individuals admitted in Home Hospital units.