'Hospital in the home' is one of several projects funded by the Commonwealth Government in recent years aimed at providing alternatives to inpatient care in public hospitals and at improving the hospital/community interface. The driving force behind these projects is to provide less costly care, less hazardous care and, perhaps, care more acceptable to the patient than hospitalisation. Pessimists might argue that this is just another example of cost shifting from government-funded care to informal family carers. The costs to family carers are difficult to measure. Costs which are likely to be hidden include:

  • degree of physical and emotional burden on carers
  • carer ill health
  • loss of paid work time for the carer
  • carer use of additional resources for own care needs and for care needs of others in the extended family network whose supports are sacrificed to provide the `hospital patient' care at home.

At a service delivery level, such government-funded projects cut across already well established community care systems: the usual professional carers in the community (general practitioners and district nurses) are displaced by hospital staff. This does not bode well for integrated care and ignores the expertise of the community health services in delivering care. They are able to educate patients about care, assess patient capacity for self care in the home and monitor the burden on carers. Hospital in the home presupposes that community nurses and general practitioners are unable to give particular forms of treatment (intravenous) and that such treatments are superior to other forms of treatment (e.g. oral or subcutaneous). This is not always true, even for the conditions listed in the paper.

Appropriate selection of patients for hospital in the home is essential for its success. In particular, the need for intravenous antibiotics is not always established, and oral therapy may well be appropriate.

These Government projects are generously funded initially, and are established with adequate supporting infrastructure. Most of these projects are funded as pilots, with short time frames, little planning or development on a local basis and with inadequate designs to allow any scientific conclusions about effectiveness to be established. The appointed staff embrace the new idea with enthusiasm and the level of activity is high. Early in such projects it is easy to demonstrate that the project appears to work: evaluations are usually carried out by the providers of the care and depend on soft end-points such as subjective feeling or on complications which are unlikely if patient selection has been appropriate. Few projects undergo the rigour of a randomised allocation comparative study with some attempt at blinded evaluation. The design required for such is complex and few studies have shown better outcomes for at home versus hospital treatment. It is difficult to avoid biases when the treatments include one with novelty on its side, while the other may involve an under-resourced and overworked public hospital, and where the patient is patently aware of which treatment arm was used. As acknowledged by the author, there are also few evaluations of the comparative costs and benefits.

Arguments for hospital in the home then hinge on provider savings and patient perceptions, which are difficult to measure and easy to influence. From the provider's perspective, hospital care using casemix and leaving out the bed (hotel services) costs is likely to be cost effective. However, the true costs to the broader community may be considerable. Aside from the hidden costs to informal carers, there are costs to other government sectors. Further resources may be taken from the already overburdened Home and Community Care services for services such as meal provision or personal care. Such shifts in costs may lead to institutionalisation of other disabled persons who are no longer able to stay in the community because of a shortage of community services. In many areas of Australia, there is a growing trend towards more community resources being spent on fewer people, as the level of support for more disabled persons is increased. Shifting the acutely ill into the community could exacerbate this trend.

When reasonably evaluated community pilot programs are expanded across the general community, studies have shown that the pilot model is rarely maintained. When required to be self funding and/or staffed as a routine service with minimalist infrastructure support, the costings can unwittingly escalate or the standards of care change. At this point, the original goals and achievements driving the establishment of the new service can be lost.

It is reasonable to continue to explore new options for care. The appropriate models of community development and the rigour of scientific evidence need to be considered. Descriptive narrative should not be the dominant method of evaluation and enthusiasm for a new idea should not be the main force for continuation.

Helen Creasey

Senior Staff Geriatrician, Centre for Education and Research on Ageing, Concord Repatriation General Hospital, Sydney