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