Hospital in the Home: An Innovative Partnership Model
15 September 2016 Last updated:
30 September 2016
Hospital in the Home: An Innovative Partnership Model
This project developed a new model of care for its Hospital in the Home (HITH) program, by integrating the services delivered by ambulatory care and community health nursing teams.
To reduce the number of HITH patients who experience an unplanned return to hospital then return to the HITH program, by 50% by 31 May 2016.
- Provides patients with high quality, safe care in their home or close to their home.
- Allows patients to remain close to their family and carers, improving their level of care and satisfaction.
- Improves recovery time, hospital discharge times and resumption of normal activities.
- Reduces hospital admissions and associated complications such as hospital-acquired infections, falls and delirium.
- Reduces costs associated with caring for patients in the hospital, as it is more affordable to care for them in the community.
- Improves availability for hospital beds, with increased capacity for other Ambulatory Care services such as medical, surgical and outpatient clinics.
- Provides junior doctors and medical students with an opportunity to gain experience working in the community setting, in collaboration with community health services.
- Ensures that post-discharge continuity of care is provided to patients by clinicians across many specialties.
In 2013, SWSLHD conducted a review of all Community Health services in the district. This resulted in recommendations for Ambulatory Care and Community Health Nursing services to be integrated into a new HITH model at Camden and Campbelltown Hospitals. The partnership was established in August 2015, with medical governance remaining with Ambulatory Care doctors, while delivery of HITH services was shifted to Community Health Nursing.
Patient selection is a critical component of the safety, efficacy and cost-effectiveness of a successful HITH program. It requires clear admission criteria and risk assessment, to ensure only suitable patients with the right environment and social support are accepted. If these factors are not considered, there is a risk that the patient will need to return to hospital unexpectedly.
The Australian Council on Healthcare Standards (ACHS) suggests the national average for HITH patients who experienced an unplanned return to hospital in 2014 was 4%1. The rate at SWSLHD was much higher, at 11.06% in August 2015. The national average of patients who experienced an unplanned return to hospital then returned to the HITH program was 2.4% in 20141, with SWSLHD experiencing a rate of 4.06% in August 2015.
Higher rates of unplanned returns to hospital can be due to inadequate treatment plans, review, clinical supervision and assessment at admission. There can also be unexpected complications in the treatment of the patient’s condition. These factors can lead to patient anxiety, added costs and possible deterioration of the patient’s condition. While a reduction in return to hospital rates is ideal, it is important to note that for some patients, a return to hospital is the most appropriate action and can demonstrate a vigilant HITH program.
To determine the success of the new HITH program, outcomes were measured and compared to the old model, where all HITH services were provided by a standalone team at Campbelltown and Camden Hospitals.
- The project team conducted in-service training to educate staff on the changes required to implement the new model of care. The emergency department (ED) was a focus, as it’s where 80% of all HITH referrals originate. General practitioners (GPs) were made aware of the changes via Primary Health Network newsletters and local noticeboards. The project was also presented at GP medical grand rounds before implementation.
- Education was provided to key medical and nursing staff, focusing on services that most often use the HITH program, such as ED, medical and surgical services. Medical grand rounds and junior medical officer education sessions were also delivered, to ensure staff were informed of the new referral process, patient selection and risk assessment.
- The introduction of NSW Health and SWSLHD policy statements were rolled out via electronic communications, education sessions, medical and nursing grand rounds.
- HITH care pathways were developed for selected conditions such as cellulitis, community-acquired pneumonia, pyelonephritis, osteomyelitis, pulmonary embolism and deep vein thrombosis, based on best practice and therapeutic guidelines. The care pathways included a risk assessment, to guide decision making on suitability for the HITH program. The care pathways were included in HITH resource folders, which were made available to all referrers based in the hospital. Referrers outside the hospital were encouraged to use the NSW Health Guideline GL2013_0062 to select patients for the HITH program.
- The HITH electronic clinical record was updated in January 2016 to ensure that measurement of vital signs was mandatory for all Community Health Nursing staff. This helped clinicians determine whether to bring the patient to the hospital or schedule a medical review for a later stage.
- A HITH coordinator role was established and was the first point of contact for new referrals. These coordinators assisted with the referral process, assessed the patient’s risk and liaised with Ambulatory Care and Community Health Nursing teams to coordinate care. This ensured communication was maintained between both teams at all times.
- Multidisciplinary case conferences were held with Community Health Nursing, Ambulatory Care and Allied Health teams via video link. This was conducted on a bi-weekly basis, to ensure patients’ management plans and clinical progress were reviewed and updates were clearly communicated to all team members.
- All GPs were notified at the beginning of the patient’s journey with the HITH program, to avoid duplication of medical services and reduce wastage in medical resources.
- A discharge summary was completed at the end of the patient’s journey and delivered to the patient’s GP. The summary outlines the principal diagnosis, any issues identified and any follow-up appointments. Ongoing reviews are clearly communicated to the primary care physicians. This ensures a robust clinical handover to GPs, once the patient is discharged from the HITH program.
Sustained - the initiative has been implemented and is sustained in standard business.
- Campbelltown and Camden Hospitals, SWSLHD
- Rosemeadow Community Health Centre
- Oran Park Community Health Centre
- Clinical Leadership Program, Clinical Excellence Commission
- SWSLHD Community Health and Primary Health Network
- A baseline audit was conducted between August and December 2015. Medical records of 298 HITH patients were examined, with the following results:
- 135 received treatment for cellulitis
- 70 received treatment for community-acquired pneumonia, with 90% not requiring hospital admission
- 35 (11.06%) had an unplanned return to hospital
- 21 (7.04%) had an unplanned return to hospital and did not return to the HITH program
- 14 (4.06%) had an unplanned return to hospital and after review were returned to the HITH program
- 63% of patients had vital signs recorded by Community Health Nursing teams in August 2015 – a suboptimal result
- the mean age of patients was 56 years.
- A survey conducted with ED medical officers in September 2015 found that only 18% knew the correct definition of a HITH patient and only 43% knew how to make a referral to HITH.
- A survey conducted with HITH patients in September 2015 found that only 38% knew how to escalate issues such as problems with intravenous devices and only 44% knew how to contact the care team if they had any issues with their HITH condition.
- An audit was conducted between January and May 2016. Medical records of 280 HITH patients were examined, with the following results:
- 29 (10.35%) had an unplanned return to hospital
- 20 (7.14%) had an unplanned return to hospital and did not return to the HITH program (hospital admission)
- 93% of patients did not require hospital admission while in the HITH program
- 9 (3.2%) had an unplanned return to hospital and after review were returned to the HITH program
- 80% of patients had vital signs recorded by Community Health Nursing teams, an improvement of 17%.
- the mean age of patients was 57 years.
- A survey conducted with ED medical officers in January 2016 found that 99% knew the correct definition of a HITH patient and 100% knew how to make a referral to HITH.
- A survey conducted with HITH patients between January and May 2016 found that 74% knew how to escalate issues such as problems with intravenous devices and 100% knew how to contact the care team if they had any issues with their HITH condition.
- The project had no instances of infections or mortality, demonstrating its safety and efficacy.
- By treating the patients with cellulitis at home with hospital-level care, there was a saving of $383,938 (based on costings provided by Deloitte Access Economics3). With an average of 339 patients per year presenting to hospital with cellulitis, SWSLHD can potentially save $436,725.60 per year with a change in treatment location of this condition alone.
- Patient satisfaction with the partnership model was high at 91%, with 3% suggesting they were not satisfied and 3% with no response.
- Since the completion of the pilot project, Liverpool Hospital has received funding to implement a similar partnership model.
- A project involving more than one service can be complex, with many team members and different governance structures. As a result, robust communication and escalation processes are important.
- There are many uncontrollable factors that can influence the success of the program. These include:
- patient choice of treatment location (at home or in the hospital)
- patient compliance with the recommendation to be available at home while in the HITH program
- the suitability of patients selected to enter the program
- the complexity of care required to deliver treatment at home (although patients with chronic conditions are not automatically excluded, their choice of treatment and the equipment required to deliver this treatment needs to be considered).
- It is important to carefully assess each patient’s risk factors and suitability for the HITH program before the referral process is initiated, to ensure it is safe for the patient to receive acute services at home and that staff are providing care in an environment that is safe for patients and staff.
- Consumer partnerships are essential and will ensure the project is patient-led at all times.
- The Australian Council on Healthcare Standards (ACHS) Health Services Research Group, University of Newcastle. Australasian Clinical Indicator Report: 2007–2014. 16th edition. Ultimo: ACHS; 2015.
- Ministry of Health. NSW Hospital in the Home (HITH) Guideline GL2013_006. North Sydney: NSW Health; 2013.
- Hospital in the Home Society of Australasia. Economic Analysis of Hospital in the Home (HITH). Deloitte Access Economics; 2011.
- Board N, Brennan N, Caplan GA. A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients. Australian and New Zealand Journal of Public Health 2000; 24(3): 305-311.
- Caplan GA, Coconis J, Board N et al. Does home treatment affect delirium? A randomised controlled trial of rehabilitation of elderly and care at home or usual treatment (The REACH-OUT trial). Age Ageing 2006; 35(1): 53-60.
- Caplan GA, Mangin DA, Ricauda NA et al. A meta-analysis of ‘hospital in the home’. Medical Journal of Australia 2012; 197(9): 512-519.
- Department of Health. Literature Review and Background Analysis – Hospital in the Home. Melbourne: DLA Phillips Fox; 2011.
- South Western Sydney Local Health District (SWSLHD) Planning Unit. Strategic & Healthcare Services Plan: Strategic Priorities in Health Care Delivery to 2021. NSW. Liverpool: SWSLHD; 2013.
Dr Bilyana Konstantinova
Director Macarthur Ambulatory Care Unit
South Western Sydney Local Health District
Phone: 02 4634 3600
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