Hospital in the home

Introduction
'Hospital in the home' generally refers to a unit which gives therapy, normally delivered in hospital, in a community setting.^1,2 Acute home care by hospital (or hospital-contracted) staff to admitted patients in their own homes, including nursing homes and hostels, is the model dominating the development of hospital in the home in Victoria. Other models, particularly in the U.S.A., rely more heavily on outpatient visits or self-infusion. Acute home management of postoperative and postpartum care, alcohol detoxification and acute mental illnesses has also been reported. Hospital in the home differs from facilitated discharge programs in that hospitals retain responsibility (and derive income) for the treatment of the patients. In Victoria, all costs of direct care are born by the hospital providing hospital in the home care.

Advantages of hospital in the home care
The cornerstone for the development of hospital in the home is the improvement in patient and family morale, comfort³, and feeling of control and involvement for those who face a period of hospitalisation, particularly if this is long. Second is the benefit of providing high technology hospital care more efficiently. Other advantages include the reduced risk of nosocomial infections, and the benefits to staff satisfaction and morale in treating patients at home.

Casemix of hospital in the home
Hospital in the home has been used for the long - or short-term treatment of many infections such as cellulitis, pyelonephritis, pneumonia, neutropenic and HIV-related disease, endocarditis, infected prostheses and osteomyelitis. Other conditions which can be managed at home include deep venous thrombosis, wounds, cystic fibrosis and hyperemesis. The range of conditions being treated at home is increasing.

Therapeutics of hospital in the home
There are 3 major therapeutic tools available to hospital in the home units (HHUs).

Intravenous therapy
Intravenous therapy mainly involves antibiotics, but also corticosteroids, chemotherapeutic agents, blood and blood products, crystalloids and inotropes.

Anticoagulation
Subcutaneous low molecular weight heparins can be given at home to patients with uncomplicated deep venous thrombosis.

Dressings
Complex wounds including postoperative wounds, wound breakdown and burns can be managed using expensive dressings that generally require hospitalisation.

Patient selection
Patients are referred from inpatient wards or the emergency department, and are assessed by a HHU nurse. Choosing appropriate patients is a challenge. Selection criteria need to be applied with experience and flexibility, but should include:

– a patient who would normally require hospital care for a stable condition who is unlikely to need emergency interventions. Fever and moderate pain (not requiring opioid analgesia) are not contraindications

– the availability of a carer

– the patient's ability to move to and from an accessible toilet

– an appropriate standard of housing with telephone access

– patient consent

– the absence of an active drug or alcohol habit

While these criteria select the preferred clientele, in reality some patients who do not wish to be hospitalised are referred to a HHU. Patients who are, strictly speaking, inappropriate for home care, but who would otherwise receive suboptimal care, can be given a 'trial of hospital in the home'.

Methods
After intravenous access is established, patients go home with a lockable kit containing drugs, dressing tray, replacement intravenous equipment, anaphylaxis pack (intravenous adrenaline, hydrocortisone and promethazine) and the original hospital medical record. Patients are visited, intravenous drugs are given by the HHU nursing team and the record maintained. Every patient receives a written emergency plan which explains the 24-hour telephone back-up medical and nursing service. Some general practitioners may be able to undertake medical supervision while the patient is at home. The medical director visits the patient regularly. At the conclusion of treatment, the patient, who has retained their status as a hospital inpatient, is formally discharged from the HHU.

Problems
Anaphylaxis is an obvious concern; therefore, the first dose of intravenous medication should be given in hospital. However, this does not guarantee against a subsequent life-threatening anaphylactic reaction, so the anaphylaxis pack is included in every patient's kit. Only one case of anaphylaxis has been experienced at Frankston Hospital in the Home in over 2500 doses of intravenous therapy and transfer to hospital was not required in that case.

Well-trained nursing staff can detect complications, as can regular attendance by a doctor. The availability of all-hours telephone support by medical and nursing staff who know the patients and the HHU is essential, as is the ability to attend the patient's home after hours. This will reduce anxiety and ensure that only appropriate returns to hospital are made.

Quality indicators
Three indicators are useful for quality assurance. The prompt and correct response to these events are as important as the causes. These events are:

– the rate of return to hospital during a HHU admission. Returns are mainly because of non-response of the patient to treatment, unexpected complications or carer/patient withdrawal.

– the need for unscheduled staff visits to the patient, usually to manage nausea, vomiting, anxiety or fever

– unexpected patient or carer telephone calls to the HHU. These are mostly enquiries about a problem such a fever, pain or anxiety.

Self-administration
Patients or carers may administer intravenous therapy especially when patients require therapy for a long period (or frequently recurring episodes) or when the administration occurs several times each day. Patients and their carers must be educated in the early detection of anaphylaxis and its treatment.

Evaluation and research
Descriptive and quasi-experimental studies have shown good outcomes, excellent patient satisfaction and cost-efficient care.^3-8 Central to patient acceptability are all-hours cover and an on-going link with the hospital.³ Recent work has shown the effectiveness of home anticoagulation for deep venous thrombosis in randomised trials.⁹ Studies in infections and cystic fibrosis have demonstrated equivalent outcomes for home treatment compared with hospital treatment.^10,11 However, there are few randomised trials or large-scale evaluations of hospital in the home, mainly because randomised examination of health service interventions raises serious methodological and practical problems.^12,13,14 Despite these problems, recent randomised trials have been Australian-based, in cystic fibrosis patients and the elderly, and demonstrate equivalent or superior outcomes for acute treatment at home.^15,16 However, the models of care used as interventions were different, so the results of such trials are not cumulative. This lack of uniformity is common to many health service interventions which are translated according to local expertise, but this interferes with the establishment or interpretation of trials.

The estimation of cost savings in HHU care is complex, mostly because the extraction of accurate cost data on individual patients treated in hospital is poor. Costs are generally more accurately available for HHU care. With this caveat, HHU has shown significant savings in direct costs, particularly in the areas of nursing and overheads including catering and laundry.

Calculating the indirect costs to families is also difficult. Although the presence of a carer is generally required for HHU, it is possible that such carers would have taken time from their usual duties if the patient had stayed in hospital. Carers usually also need to travel to visit the patient in hospital, and these costs are removed for HHU patients. Households continue to function, so that any increase in supportive costs for HHU patients would be marginal. Thus, the lack of knowledge of the impact of traditional hospitalisation on family costs is important and needs to be addressed. HHU may allow patients to return to some level of work, and the intangible benefits (such as familiarity of food, companionship, comfort) are difficult to cost. In a study in the U.S.A., patients with pneumonia were willing to trade the equivalent of one week's salary to be treated at home.¹⁷

Finally, the cost-benefit of any beds released by the HHU is influenced by the funding of the hospital and its unmet demand. The 1300 bed days released by the Frankston HHU next year may be used either to address its elective surgery waiting list, or to reduce waiting times for a ward bed for non-HHU patients in the emergency department. In a casemix-funded system, both situations result in economic and social gains for the health system. The situation may be different for hospitals funded by block grants, or for small rural hospitals, where closure of beds may be the only way to realise efficiency through HHU bed days.

Conclusion
Hospital in the home is new to Australia, and although it has much support, it has also drawn some opposition based on a perception that it is part of a wider anti-hospital movement. Ironically, some community-based health providers see hospital in the home as an encroachment on community health by hospitals. The temptation to rename routine post-discharge care or ambulatory care as hospital in the home in order to maximise billings should be resisted. While hospital in the home has called into question the definition of hospitalisation, more evaluation is needed. In the meantime, patients have shown a willingness to accept well-organised alternatives to hospitalisation. Even if hospitals were not being constrained in their ability to deliver services, hospital in the home should be addressed as a positive part of the future of acute health-care delivery. It facilitates the structured transfer of appropriate technologies out into community practice, without absolving the hospital of its responsibilities as some early discharge programs have been accused of doing.