Post on 26-Jul-2020
Hospital at HomeA model of acute community care to reduce the burgeoning demand on Acute Hospitals
Karen Titchener MS APRN Strategic Director, Huntsman at Home Email:Karen.titchener@hci.Utah.eduTwitter: @karen_titchener
International evidence on HITH Hospital at home ( HaH) is an established method of delivering community based care in several countries
including Canada, Japan, Spain and Australia with published studies highlighting the benefits
In Australia, a review of HaH programmes in 2008-09 recorded 32,462 admissions across all the programmes with HaH which represented 5% of all bed-days in the state of Victoria(1)
Caplan Et al 2012 meta analysis (2)
showed unequivocally that HaH is safer and more efficient.
A 19% reduction in mortality
For every 50 patients treated in HaH, one life will be saved
A 23% reduction in readmission to hospital
Across the developed world there has been a proliferation of HaH type schemes representing an significant shift in the delivery of acute medical services normally correlating to an acute hospital bed (1).
HaH schemes have been reported to be at least equivalent to standard acute hospitalisation in terms of patient mortality and morbidity (3)
Patients often report improved patient satisfaction whilst associated with reductions in mortality, readmission and cost. (4)
RCA literature review findings LOS significantly reduced, reduced costs compared to hospital care (5)
Rational for developing HaH in the UK
Within the NHS, the last few years has seen unprecedented demands on the service.
Hospital in the home is a relatively new concept within the UK healthcare system
There is mismatch between funding, demand and activity
This leaves NHS hospitals needing to achieve a step change in productivity growth and find ways to moderate demand, or overspend against budget.
As the number of older people continues to increase and live longer (over 11 million are over 65 years with 3 million of these over 80 years), many require regular healthcare in both acute and community settings (6)
Chronic disease increased prevalence is placing significant pressure on the NHS. Caused by:-
I. an ageing population II. multiple co-morbiditiesIII. Between 2013/4 and 2015/16, the number of attendances at major A&Es increased by
18 per cent, from 12.7 million to 15 million. This represents an average annual increase of 1.4 per cent.
Rational for Developing HaH in the UK
The total number of admissions to hospital increased by 3% in quarters 1 and 2 of 2016/17 compared to the first two quarters of 2015/16. (7)
The UK has a growing hunger for developing services that reduce demand on Emergency Departments (ED) and drive care closer to home (8)
This is mainly in an attempt to control burgeoning health care costs and a realisation that many older patients do not do well in acute hospital settings (9)
There are approximately 4 million people over 65 years with a longstanding illness in the UK and this equates to 40% of all individuals over 65 years (10)
Notwithstanding this era of financial austerity and an ever-increasing demand on NHS resources there is a need for better alignment of primary, community and acute care to reduce avoidable hospital admissions and length of hospital stay. (11)
Acute care
(Admission Avoidance)
CARE ACROSS THE CONTINUUM
Supported by Hospital specialists + Community based care team
Palliative and EOL Care(Admission avoidance or early discharge)
Early discharge
Hospital at Home
Principles of HaH
The multi disciplinary clinical management of the patient varies within models from having their own medical cover to having medical cover from the referring consultant
The approach to describing HaH service delivery models is firstly identify defining elements that differentiate one model from the others:
Patient- centred, continuing, comprehensive and interdisciplinary care
The system of initial needs assessment will inform the selection to HaH to ensure safety and quality of the service
Policies practices and pathways are developed dependant on the service model
Time limited care with rapid response and transfer to other services
High quality care safe care carried out my appropriately skilled workforce
An individual requiring at least daily clinical care and assessment of their treatment needs will be classified as clinically equivalent to an admitted patient.
Daily HaH substitutes for inpatient care must have access to medical care available 24 hours per day, in the home or other setting
HAH Interventions include
For patients with confirmed diagnosis we can offer:
High intensity clinical monitoring, with short-term intervention in an acute episode of ill health in a safe and timely manner
Provide urgent clinical assessment for acutely unwell patients, ECG, urgent bloods
Initiating treatment and ongoing monitoring, IV therapy, sub cut hydration, ongoing blood monitoring, oxygen therapy, nebulisers
Physiotherapy and Occupational Therapy intervention
Environment check- micro environment set up
Main interventions for HaH patients
Falls
Chronic Obstructive Pulmonary Disease
Unstable Diabetes
Dehydration
Palliative Care
EOL
Gastroenteritis
Community Acquired Pneumonia
Heart Failure
Renal failure
Deep Vein Thrombosis
Infected Foot Ulcers
Post-operative surgery
Urinary Tract Infection
Viral Illness
Benefits of having a HaH Service
Benefits to the system
Effective and efficient integrated partnership working
Without a HaH service a hospital bed would be inevitable
Reducing A&E attendances
Reducing costs on LOS
Frees ambulances to go to next emergency call
Reduced inappropriate hospital admissions
Patient Benefits
Improved health outcome for patient
Reduced risk of hospital acquired infection
Meets preference for home care over hospital
Enhances patient choice
Psychological and social benefits of comfort own home
Reduced pain and anxiety
Reduced confusion, delirium
Reduced functional disturbance
How to establish a successful Hospital At Home
1. Design the service model based on need
2. Strategic Stakeholder engagement
3. Clinical pathway development
4. Documented Systems and process
5. Team Skill mix
6. Enablers to success
Filling the gaps in care between acute and community care (scope the need)
Where are the biggest pressures to the health system (demand)
What is the low hanging fruit and therefore “quick Wins”
Who is commissioning the program?
What KPI’s are they wanting the program to achieve?
What measurable outcomes will you capture?
What is program design: Rapid response/admission avoidance Early Supported discharge ?
Hospital at Home: 1. Designing a service based on need
Questions to consider?
Budget of program?
What is the target patient population ?
What will be expected average length of stay on the program?
What will the team makeup be?
What will hours of operation be?
Team location?
Inclusion/exclusion criteria?
Hospital at Home : Designing a service based on need
More questions to consider?
Have a communications plan
Building confidence in the program- ensure program promoted and understood
Define you target audience and stakeholders
Meet with the key strategic stakeholder pre/post program start
Involve them in service design/pathways development (clinical engagement)
Scoping the service gaps through observations on wards/ER/clinics/community
Becoming an integrated part of the health system rather than a stand alone service
Present the program to as many staff groups as possible
Hospital at Home : 2. Strategic Stakeholder engagement
For the program to succeed:-
Clinical pathways are the building blocks to a successful program
Agreed pathway with inclusion/exclusion/ escalation triggers
Specific disease groups such as
Cardiac –Heart failure
Respiratory- COPD
Renal
Infectious diseases – wounds
Unstable diabetics
Palliative and EOL
Learning difficulties
Ambulance pathways
Community pathways for step up referrals
Hospital at Home: 3. Clinical Pathway Development
A must do for successful programs :-
For Program to success
Operational policy :- clinical hub, ward rounds,
Referral process
Admission process
Documentation process
Discharge process
Inclusion/exclusion criteria
Hospital at Home: 4. Documented systems and process
Must have multidisciplinary team consisting of
Have a clinical lead for the service either Doctor or Nurse Practitioner (NP)
Acute consultant involvement
GP
NP/RN nurse prescribers
Therapists
Pharmacy
Clinical nursing assistants
Administration staff
Hospital at Home: 5.Team skill mix and education
All staff should have thorough induction to program (minimum 1 month)
Complete competencies dependent on profession
Partake in higher education
Engage with high education institutes to develop bespoke education
RN staff to have mentorship qualification
Allow the program to have student nurses/ therapists
Allow junior doctors to rotate into the program
Sustainability and growth
Transform community workforce
Hospital at Home: 5. Team skill mix and education
Strong dedicated developmental and operational leadership, with effective business support.
Stable recurrent funding to support a sustainable, rapidly developing service.
Service has regular meetings with strategic stakeholders
An integrated IT and telecommunications system that is fit for purpose
A scalable model of service delivery
Clear patient pathways for referral and expectations for length of stay
A single point of access, with a streamlined and integrated referral process
Physical presence in A&E, medical wards and discharge planning meetings
Case finders in acute hospitals
Patient involvement and feedback
Address challenges as they arise
Hospital at Home : 6. Enablers to Success
Excellent clinical nursing care combining best practice with confidence to treat more patients traditionally cared for in acute settings.
integrated multi-disciplinary and inter-disciplinary working, with clarity about medical responsibility.
A consistent service presence in acute hospitals at the right level an background, working with hospital teams (based in acute)
First dose medication kit for team
Well-placed, appropriate office accommodation, with visible presence
A ‘ready use’ equipment store, with a small number of key items
Hospital at Home: 6. Enablers to success
Questions?
Reference List 1. Montalto M. (2010) ) The 500-bed hospital that isn't there: the Victorian Department of Health review of the Hospital in the Home program. Medical Journal of Australia;
193(10): 598-601.
2. Caplan GA, Sulaiman NS, Mangin DA, et al. A meta-analysis of “hospital in the home”.
Med J Aust 2012; 197: 512-519.
3. Utens C, Goosens, L, Van Schayck O, Rutten-vanMolken M, Van Litsenburg W, Van der pouw A &Smeenk F (2013) Patient preference and satisfaction in hospital-at-home and usual hospital care for COPD exacerbations: Results of a randomised controlled trial. International Journal of Nursing Studies.50.1537-1549
4. Spiliopoulos N, Donoghue J, Clark E & Dunford M (2008) Outcomes from a respiratory coordinated care program (RCCP) providing community-based interventions for COPD patients from 1998 to 2006.Contemporary Nurse. Vol. 31. Issue 1. Pages 2-8.
5 Chetty M, MacKenzie M, Douglas D & Currie G 2006- A literature review of 6 RCTs comparing HaH and in patient . Aberdeen
6. Age UK, (2014)later Life in the United Kingdom. Age UP London
7. Murray et al 2016
8. Five Year Forward View (2014) NHS England et al 2014
9. Jester R & Hicks C (2003) Using cost-effectiveness analysis to compare Hospital at Home and inpatient interventions. Part 1. Journal of Clinical Nursing.12.13-19
10. Office for National Statistics, (2013).
11. Imison C, Poteliakhoff E, Thompson J. Older people and emergency bed use. London: The King’s Fund; 2012
CONTACT: Karen.Titchener@hci.Utah.edu