“Hurrying Home to Hospital”

Utilising Hospital in the Home (HITH)

as early as possible.

Gen Cooper : HITH Senior Project Officer

gen.cooper@health.vic.gov.au

03 9096 61332

Hospital in the Home (HITH)

The Opportunity

HITH & Discharge

Planning

The Evidence

Potential Barriers

Making a Difference

The Opportunity

The Opportunity

Hospital in the Home

• Provision of acute admitted care in the home or suitable environment

• Direct substitution - criteria as per Victorian Hospital Admission Policy

• Casemix funded

• Reported through VAED (Victorian Admitted Episode Dataset)

2012-13 Victorian HITH

• 27,647 separations

• 196,868 HITH bed days

• 2.1% all Victorian separations involve HITH

• 6.0% of Victorian multi day separations

2013-14 Q1-3 Victorian HITH (indicative data)

• 6.4% of Victorian multi day separations

The Opportunity

Most common diagnostic related groups (DRGs)

• J64B (cellulitis),

• F63B (DVT) and

• E61B (pulmonary embolus)

The most common HITH therapy

• intravenous antibiotic therapy for cellulitis, genitourinary, respiratory or

postoperative/post-traumatic infections, and

• anticoagulant therapy for deep vein thrombosis or pulmonary

embolism

• chemotherapy at home

HITH provides equivalent care that is direct substitution and can be

safely delivered at home. This allows scope for a range of care types.

HITH provides a safe and viable

alternative to hospital treatment in

an environment familiar to the

patient and with far less disruption.

HITH supports the health system by

providing an efficient and flexible

resource for hospitals

Aim is for patient to receive the

most appropriate treatment in the

most appropriate setting.

HITH & Discharge Planning

HITH & Discharge Planning

Consider direct admission to

HITH for appropriate clients

Consider HITH at the earliest

appropriate time

NEAT

A whole of system approach

Primary care Emergency department

Acute admission

Sub-acute admission

Community services

Home

Additional capacity

OPTIMISE PATIENT FLOW •Redesign •Clinical pathways •Criteria-based discharge •Weekend rounds •Rigorous bed management

ALTERNATIVES TO ED ADMISSION •Chronic disease management/ HARP •Resi-care inreach •Direct admissions •Call referral •Expanding primary care

SYSTEM COORDINATION •HITH/ PAC/ Transition Care •Health Independence Programs

EARLIEST DEFINITIVE CARE •Fast track/streaming •Short Stay Units •Senior consultants ‘up front’ •Access to diagnostic testing •Direct admitting rights •Acute medical units •Acute surgery units •Direct Access (inc Aged Care)

1

SYSTEM COORDINATION •Ambulance arrivals boards •Ambulance distribution

•NHS 111

•ED role delineation

2 3 5 6

ADDITIONAL CAPACITY •Fast-track / streaming •Short-stay units •Senior consultants •Diagnostic testing •HARP/resi-care inreach

REDUCE VARIATION IN CARE •Clinical guidelines •Clinical pathways

4

HITH Evidence

Report on evaluation of Hospital in the Home Programs

DLA Phillips Fox 2009

Commissioned by Department of Health Victoria 2009

1. Clearly safe and effective for a range of conditions

2. Cost efficient

3. Patient preference. Highly valued by consumers & carers

Report on evaluation of HITH Programs

“It is clear that there is considerable

opportunity to increase the utilisation of

HITH for a broad range of conditions.

Failure to do so represents a lost

opportunity in light of the very positive

evaluations HITH receives from patients

and carers and the literature confirming

its utility and efficiency.”

HITH Evidence

Deloitte Report: Economic analysis of HITH

Commissioned by the HITH Society 2011

Examined 6 HITH care types: cellulitis, venous thrombosis, pulmonary

embolus, respiratory infection, chronic obstructive pulmonary disease.

HITH was 32% cheaper relative to hospital care across all six AR-DRGs by

separation on average.

“Health services should be investigating

opportunities for HITH growth as a flexible way

to manage demand for appropriate patients and

care types.”

HITH Evidence- Clinical

• HITH provides a safe and viable alternative to hospital

treatment in an environment familiar to the patient and with

far less disruption.

• Comparable mortality, and adverse event rates to inpatient

care. (Montalto et al, 2010, Australian Health Review; Tran & Taylor 2009 Australian Health Review, 33 ,3; MacIntyre,

2002, International Journal for Quality in Health Car,14,4; Caplan et al, 1999, Medical Journal of Australia, 170)

• As effective as inpatient care (Deloitte Access Economics, 2011, Economic Analysis of

Hospital in the Home; Richards et al, 2005, Medical Journal of Australia, 183,5; Caplan ,2006, Medical Journal of Australia,

184,12)

• Reduction in complications frequently related to hospital

inpatient care such as falls and infections (Richards et al, 2005, Medical Journal

of Australia, 183, 5)

• For older patients – decrease in delirium, and deterioration in

continence and mobility. (Frick et al, 2009, American Journal of managed Care, 15,1; Mendoza et

al, 2009, European Journal of Heart Failure; Inouye et al,1999, New England Journal of Medicine,340,9)

HITH Evidence- Health System

HITH supports the health system by providing an

efficient and flexible resource for hospitals

• Cost Effective (Sheppard et al, 2008 ,Cochrane Library of Systematic Reviews; Wilson et al, 2005, Australian Health Review,

29,3; Richards et al, 2005, Medical Journal of Australia, 183,5)

• Impact on Health System (including capacity) (Sheppard 2009, Cochrane Library of

Systematic Reviews; Cameron et al, 2009, Medical Journal of Australia, 190, 7; O’Neill,2008, Home Healthcare –an Economic Choice for

the Health Service; Cameron et al, 2009, Medical Journal of Australia,190,7; Scott, 2010, Australian Health Review, 34,3; Ram et al,

2004,British Medical Journal,329,7461)

• Readmission rates- positive

preliminary data (DH Victoria)

HITH Evidence- Patient Preference

For appropriate patients, HTH offers the best

care in the right place.

Leff et al, 2005, Annals of Internal Medicine, 143 (11) Wilson et al, 2002, British Journal of General practice, 52

Potential Barriers- ED & Wards

• Lack of understanding of HITH and eligibility

• Difficulty making referrals after hours and weekends

• Difficulty arranging visit more than once a day

• Response and responsiveness to referrals “Long Memories”

• Completion of referral documentation

• Patients that do not meet the HITH admission criteria

• Lack of medical lead

• Process and timing of PICC line insertions

• Review process- time, place, person

• Lack of organisational protocols, clinical pathways for HITH

Potential Barriers- HITH

• Capped services ‘HITH beds’

• HITH service area, geography, subcontracting

• Limited hours, typically evening, overnight,

weekend services limited

• Time of referral (late decision)

• Lack of nursing EFT to support demand, case

finding in hospital, recruitment issues

• Lack of cars, phones, computers, clinical

equipment

• Lack of dedicated medical EFT

• Lack of space – office, review clinic, treatment

room

Making a difference

• Executive Support

• Medical governance and leadership

• Direct substitution- at start or end of

episode

• Safeguards are in place to ensure

equivalent care and quality outcomes

• Flexing resources to meet demand-

flexible workforce, cars, no capped

beds

• Staff education/ marketing

• Physical space

• Patient choice

Can I make a HITH referral please?

Making a difference

• Emergency & HITH interface

• Medical oversight & HITH bed card

• Case finding – not waiting for referrals

• Residential Aged Care In-reach

• HARP

• Clinical pathways for HITH suitable

conditions

• Streamline processes and paperwork