Lots of people ask me about Hospital at Home in general and about our own service in Midlothian in particular. This is one of my favourite pictures: one of the ward where I work!
In this post I’m going to share some of the contents of a talk I gave recently on Hospital at Home for the Royal College of Physicians of Edinburgh. I’m hoping that it’s of interest not just to a medical audience, but to other professionals too, and people in general.
It’s a nice environment to work in, and the wallpaper is certainly better than some of the other wards where I’ve worked.
Hospital at Home has been running in Scotland since around 2011, initially started up by my colleague Graham Ellis in Lanarkshire. It is not an entirely new concept however – these are quotes from 1878 – when Florence Nightingale acknowledged the perils of an inpatient stay in hospital.
So, what IS hospital at home?
Starting with a definition, the Scottish Government have been keen to set in place a definition for what hospital at home actually is and does. The key phrase is that it provides acute hospital level care for a patient who would otherwise need to be an inpatient.
There are lots of other great initiatives centred on managing patients in the community, but they are NOT “Hospital at Home”.
All of these services are intuitively good things to do however and form part of a bigger picture where we are trying to shift the balance of care from the hospital to community based settings.
Specifically, what is different from other models?
Medical care is led by hospital specialists with a responsible medical officer, sometimes delivered with the help of other grades of medical staff and with highly trained specialist nurses, often from a mixture of backgrounds.
There should be urgent access to hospital level diagnostics such as endoscopy, radiology or cardiology etc.
The nature of the interventions such as access to intravenous fluids, oxygen etc and the acuity of the conditions managed are similar to that which would normally be provided in a secondary care setting.
Hospital at Home provides short time-limited acute episodes of care and is not intended to prevent admission per se.
Patients are treated as though they were admitted to hospital but maintained within their own home. Any existing care arrangements remain in place – and no one needs to organise care of the much loved cat or dog!
Care should comply with current acute standards of care that are delivered in a hospital setting.
It complements rather than replaces other community-based health and care initiatives which support patients to remain in their own home
So why are we doing this?
Hospital at home has been in existence in a number of countries across the world for longer than it has been established in the United Kingdom and evidence points to various drivers for developing a Hospital at Home service for older adults.
Key amongst all these aspects is the drive to provide a better person centred care experience for the patient .
With added benefits of avoiding the risks of healthcare acquired infection, and/or institutionalisation.
Hospital at Home services in Scotland are largely focused and designed for frail older people.
But why focus on frailty?
To be honest – mostly because that’s where we’ll get most value for money.
Here, the numbers are Extrapolated costs over 12 months for people 65 and over with Frailty taken from data from Midlothian Health and Social Care Partnership and projected to the whole of Scotland .
The slide came from Graham Ellis – thank you!
Older adults with frailty are the single biggest users of hospital beds and the fastest growing demographic.
Older people presenting at an Emergency Department in Scotland are more likely to breach the 4-hour target. Older people in the acute setting present greater levels of complexity, have greater numbers of conditions, more medications, greater numbers of agencies involved in their care and more caregiving issues than any other group. They are the highest users of bed days and an increase in the over 85 population will impact on bed day rates significantly in the next decade.
Older adults with frailty are at particular risk of being affected by institutionalisation and delirium.
Some 30 to 56% have been shown to experience a reduction in their functional ability between admission to hospital and discharge.
Such acquired disability adds to the pressure on social care provision and must be minimised if such services are going to be sustainable in the future. To manage the demographic pressures and provide a better experience for individuals, safe effective alternatives to hospital bed based acute care are needed.
A lot of people ask us “but who should we refer”?
It actually comes down to some fairly simple questions!
Starting out with “would your patient prefer to be at home?”.
Many people would much rather be at home, especially if they have a pet that they are missing!
Pet therapy is not to be sniffed at… On the other hand, if someone doesn’t want to be at home, or doesn’t feel safe, they (or their family) will just call an ambulance after we’ve left the house – so we’re best to get everyone’s “buy in” from the outset.
I’m going to try and keep things simple tonight and give you a simple take away message for the kinds of patients that you might send us.
Just like in the Mini Mental State Examination, I’ll give you three things to remember at the end of the talk. We’ll then share some stories on the sorts of people we can help.
And finally, I’ll give you some ways of finding out more information….
Instead of the three items in the MMSE of Apple, Table, Penny, I’m going to ask you to remember three new items.
Number one is DRINK Can your patient get themselves a drink? Or do they have carers who can do it for them?
Number 2 is “can they get to the toilet?” Or do they have carers who can help with the bodily functions side of things?
And number 3:
Can the patient be safely left between visits? We usually see the patient ONCE daily – though this can be increased to twice if needed, and we will always go back for a second visit if there are clinical concerns or a high NEWS score on the first visit.
So, to remind you the key criteria for referral:
I couldn’t think of a snazzy acronym but we can use DOT for the time being.
Plus of course – the patient does need to be UNWELL, and have a condition for which they would otherwise normally need to be (or stay) in hospital. If all they need is a blood test in a few days time, then there are other services that can do that – not least the patient’s General Practitioner!
So – what do we actually do?
We can offer daily monitoring of blood tests and management of acute kidney injury. With or without the use of IV or SC fluids.
We can give IV therapy – most commonly antibiotics or diuretics – though it’s amazing what you can achieve with industrial doses of oral treatment! We have our own antimicrobial formulary and a hotline to microbiology. We work closely with colleagues in Cardiology and Renal Medicine too, to discuss treatment, plus of course close links to the Community Respiratory Team who help us with patients with COPD.
We use the same TRAK computer system as all the Lothian Hospitals – which some of you will be familiar with! So we have access to all the patient’s hospital records and all previous results and correspondence. Our ward is actually a little sharper in focus than this normally – but I’ve softened it to protect confidentiality! The ward has also grown since this original picture, now having 15 beds in it.
The other Hospital at Home services in Lothian are larger, but the same principles apply.
Of course, in reality, the patient isn’t in a little box on a screen – he or she remains in the comfort of their own home! These are some old miners cottages near to the Scottish Mining Museum in Newtongrange.
We have access to all the usual hospital based investigations, including CT scans within 2-3 days, depending on urgency.
For echocardiography studies the patient must travel to the hospital, but for routine 12 lead ECGs or for 24 hour Holter monitoring, we can offer them in the house. The results are visible both on our desktop computers at our office base, and also on our laptops.
We usually have a Pharmacist on the team, though she’s now moved to work with another service.
She was great at keeping us right to stay within the rules when we start “tampering” with the prefilled dosette blister packs! A small pair of nail scissors and some sticky labels to reseal the pack are essential pieces of Hospital at Home equipment!
We always sign and date any changes we make, and make sure everyone knows what’s going on.
Sam, whose pack this was – now feels MUCH better that he’s taking fewer medicines every day! We have prescription pads that we can use to prescribe medication and a Pharmacy nearby who can order pretty much anything in the BNF for us, with 12 hours notice! We also keep a stock of fluids, common antibiotics, steroids and diuretics in our cupboard in the office.
It might be easier to give you some stories as examples of the sorts of people that we see…
Mr Acorn is an 83 year old retired carpenter who is known to have cardiac failure on large doses of diuretic and an ACE inhibitor. He lives with his wife in a bungalow. He had become increasingly unwell over the last week or so with deteriorating mobility after an episode of diarrhoea.
He’d been feeling nauseated and off his food. His GP checked bloods and found a Urea of 47.3 and a creatinine of 342 with K+ of 4.8. He was referred to Hospital at Home for ongoing management and was seen at home and assessed that afternoon.
BP was 110 systolic and although a little light headed and off his food, he was drinking well. As Mr Acorn was also on digoxin and as his pulse was 46, a decision was made to give him a complete “medication holiday” for a few days. This made sense as his medication was in a dosette blister pack. Digoxin level was unsurprisingly raised.
We monitored his kidney function which took several days to return to normal. He made good progress with Physiotherapy and was soon able to get back to his garden shed and attend to the seedlings there. Diuretic medication was slowly reintroduced.
We got to know Mr Acorn quite well over the two weeks he was under our care. He talked a lot about his heart and kidney failure. We discussed what his wishes would be in the event of a future crisis. He felt strongly that he would prefer to stay at home if he deteriorated again and that he would not wish to be revived if his heart stopped. This helped us pass on useful information to his GP team on discharge.
Mrs Willow is 93 years old and has dementia, now, though she used to run the town’s Flower Shop.
She has a four times daily care package which has been working well. Her daughter lives across the road from her.
When she becomes unwell, it is usually attributed to a urinary tract infection and she develops delirium quickly and is at high risk of falls. On this occasion, she was seen by the GP with increasing confusion and her daughter was worried she had an infection. He started her on antibiotics and hoped that she would improve. Unfortunately she did not rally as well as usual and became more drowsy and dehydrated.
The family felt that it wasn’t yet time to move to into an “end of life care” mode as they were hopeful that she might still improve on treatment of the infection.
Interestingly her urine and blood tests were all negative, including fairly normal kidney function and no signs of infection. After discussion with her family, we decided to give some subcutaneous fluids for 2 days to see if it might help – with all in agreement that if it didn’t, then prolonged artificial nutrition wouldn’t be in her best interests.
In fact, after two days, Mrs Willow started to improve. We never found out what had caused her delirium, but her family were delighted she’d been able to stay at home and keep her care package.
Mr Cherry is a retired school teacher with depression with anxiety and possible early dementia. He has not been eating or drinking well in recent weeks. He was referred to the team because of reduced oral intake and a concern that there might be an underlying malignancy.
It wasn’t really an acute crisis, but he had refused to attend the Day Hospital as an outpatient and the GP and family were unsure whether all his problems could be attributed to his psychiatric problems or whether there might be an underlying physical cause for his deterioration.
Routine blood tests were unremarkable, but his albumin was 32 and he had clearly lost a lot of weight.
After discussion with his daughter, who visited regularly from her home in Alloa, we agreed to arrange a CT scan of his chest, abdomen and pelvis. This was fixed for a day when she could accompany him to the Royal Infirmary.
Much to everyone’s relief, there were no signs of malignancy. We discharged him quickly back to the care of his GP and the local Psychiatric team and understand that he’s now making some progress with mirtazepine.
He has also benefitted from input from the Red Cross, who have arranged a befriender service for him – which amazingly he’s accepted.
Mrs Maple gets recurrent urine infections. She became symptomatic recently and her GP sent a urine sample for culture. It did indeed confirm a urinary infection – but unfortunately the only sensitive antibiotic was gentamicin. While we were discussing with her GP the pros and cons of treatment, she became more symptomatic with dysuria and suprapubic pain.
We gave her IV gentamicin. While giving her the therapy, she expressed a strong desire to cut down her polypharmacy. We discussed with her the role of all her different tablets and made suggestions to her and her GP on what might be discontinued. She was delighted that she didn’t have to take so many pills in future.
Although Mr Ash is 94 years old, he still enjoys getting out and playing bowls regularly.
He presented to his GP with an acutely hot, inflamed red leg and was admitted to the Acute Medical Receiving Unit at the Infirmary.
Often we see patients with venous eczema, but on this occasion, a diagnosis of cellulitis was made and he was started on IV antibiotics.
He asked if he could get home, but felt it was too far to travel daily to the Western General to receive outpatient antimicrobial therapy there.
We admitted him to the Hospital at Home and gave him 3 further days of IV antibiotics (over a weekend) and subsequently converted him to oral therapy. He made excellent progress and was discharged.
Mrs Hawthorn has lung cancer.
She became unwell recently and was noted by her GP and the hospice team to have a very high serum calcium.
She has agoraphobia and struggles to leave the house.
She had a previous admission with delirium related to hypercalcaemia and was terrified that this would happen again. We visited and assessed her, before arranging a day of subcutaneous fluid followed by IV therapy with zolendronic acid. She made good progress and only required 3 days of “inpatient” care with us.
As you can see, there are multiple reasons why people might be referred to the Hospital at Home team….
Our “bread and butter” referrals are for patients with acute infections and those requiring management of organ failure such as COPD exacerbations.
Many are struggling with that perennial balancing act of treating a heart and renal failure combination. We use a lot of high doses of oral diuretics, but also spend a lot of time STOPPING medications.
We’re always open to discussion and have taken a variety of patients that didn’t quite fit the usual picture, but were determined to stay at home whatever befell them.
It is very difficult to know how many have definitely avoided a hospital admission – as some of them are adamant that they will stay at home, come what may….
For patients requiring end of life care, we usually hand them back to the GP and District Nursing Services – they are available 24 hours a day, whereas our service runs from 8am to 6pm – though admittedly 365 days a year. It’s unusual for patients to need attention out of hours – but when they do, the notes we’ve left in the patient’s home are usually very helpful.
Patient satisfaction is very high in the Hospital at Home service.
Not many weeks go by without gifts of biscuits, flowers, chocolates, and even the occasional lettuce arriving in the office.
Even in COVID times, we’ve accepted gifts – at the end of August we received a gigantic bag of potatoes!
Many of you will have a number of questions about Hospital at Home as a way of delivering care.
Although an appealing notion, it may not be quite as cost saving an initiative as you might think – after all, I can see many more patients in a hospital ward in an afternoon than I can trundling around the countryside.
On the other hand, there are no “delayed transfers of care”….. When our involvement is finished, we simply say goodbye and go back to the office to write the discharge letter…
Potential reasons to be optimistic though include that patients are much less likely to become deconditioned at home as they potter around the house, and there may well be a reduction in the prevalence and severity of delirium.
My colleagues in Fife tell me that there are several inpatients every week who fracture a bone while in usual hospital care – whereas they have yet to see anyone suffer a fracture while under their Hospital at Home service….
More formally, a Cochrane systematic review, including a meta analysis of randomised controlled trials found that admission avoidance Hospital at home had similar rates of mortality and readmission when compared with inpatient care.
A UK Randomised Controlled Trial published subsequently, reported similar findings.
For those who would like to read more on Hospital at Home, I would very much recommend this document from Healthcare Improvement Scotland. You can find it on their iHub webpage.
The principles are exactly the same for any location in the UK – this might be the sort of thing that local commissioners would be interested in wherever you are based, and the advice is completely transferable to other settings, both in the UK and further afield.
This document looks in some detail at the questions of value for money, and the evidence for this form of service delivery.
Although the Cochrane Review looked at the healthcare related costs, the evidence on the impact of Hospital at Home on informal carers is under developed.
For some families, it’s much easier if their relative is at home, for others, the increased burden is problematic. This has become more of an issue than ever before in the context of the COVID19 pandemic.
It’s about getting the right answer for each individual.
Perhaps more importantly, in these days of patient choice and trying to get people more involved in decisions regarding their health, patients are very much empowered by being in their own environment.
In hospital, sometimes the first thing you know about having an echocardiogram is that a nice person with a wheelchair appears.
The advantage of seeing people at home is that they feel better able to take part in the decisions being made about them – which has to be a good thing.
Interestingly although we are able to do lots of fancy scans for people, they very often choose not to have them….
Everything changes when you are on the patient’s territory and not the other way around!
This is Realistic Medicine in real life – or, if you are from outside Scotland, you might think of it instead under the banner of “Choosing Wisely”
Before I finish, I’m going to remind you again of how you might decide whether the patient you are seeing on your ward round tomorrow might be suitable for our care.
Think of DOT!
Even before sending the patient through to the acute receiving unit – think! Could this be done at home?
A final word, with some thoughts about the future…
We already have point of care blood testing for simple biochemistry and haematology that we use in our day to day work. We’re also interested in learning a bit more about Point of Care Ultrasound.
We’re trying to link in more with the ambulance service – we’re pretty sure there are some people who don’t need taken to hospital at all…
Who knows what the technology will throw up in terms of remote monitoring? It might be useful – but ultimately this is about human contact, not about robots…. Though the idea of piloting drones to drop things off to patients is rather attractive!
(The drones were also Graham Ellis’ idea… but it’s a good one!)
Think about what you would want, if you were the patient….
Most of us would agree this is definitely a nicer view than the Royal Infirmary car park!
Thank you for reading this!
And if the email address isn’t clear there: it’s here: