The Case for HITH and the
Cultural Change Required
Health Innovation Exchange – Hospital in the
Home 13-09-2012
Dr Colin Kennett
Staff Specialist
Primary and Community Health Services
Overview
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Why HITH?
Some terminology
HITH – What is it?
What does the literature say?
Governance models
What cultural change is required?
The future
Why HITH?
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Ageing population
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Chronic disease
Complexity
Rising costs of health care
Ageing ‘baby boomers’
Pyjama paralysis!
Clinical, costs, patient flow, flexible
bedstock
Some Terminology
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HITH:
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Substitution:
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Hospital in the Home
Patient is an in-patient in a ‘virtual’ ward.
Medical governance by hospital team.
Avoidance:
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Patient is not an in-patient. Medical
governance by GP.
What is it?
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Many models:
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Acute, subacute
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Nursing
Nursing + allied health
Nursing + allied health + medical
General, medical, surgical, rehabilitation
Disease/condition specific eg COPD, stroke
Population specific eg elderly
‘inpatient’, discharged
What is it?
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“Hospital in the Home (HITH) provides
care in the community setting for acute
conditions requiring clinical governance
and monitoring/input that would
otherwise require treatment in a
traditional inpatient hospital bed.”
Queensland Health (2012) “Hospital in the Home Guidelines” in
prep.
What does the literature say?
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Cochrane reviews note:
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at least equivalent medical outcomes
reduced mortality at 6/12
higher patient satisfaction
insufficient evidence to support reduced
readmission rates
insufficient evidence to support reduced cost
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Shepperd and Iliffe. Cochrane Database Syst Rev., 2005 (3) CD000356
Shepperd et al. Cochrane Database Syst Rev., 2008 (4) CD007491
Shepperd et al. Cochrane Database Syst Rev., 2009 (1) CD000356
What does the literature say?
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Successful model:
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Acute condition
Hospital substitution
Medical input and ownership
Direct nursing care
24 hour coverage
Cheng, Montalto, Leffe (2009) “Hospital at Home” Clin Ger Med,
25, 79-91
What does the literature say?
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“HITH is an efficient and effective
model of care….strongly encourage
health services to offer HITH care to
appropriate patients.”
DLA Phillips Fox (2010) “Report on evaluation of Hospital in the
Home Programs” Victorian Dept of Health
What does the literature say?
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Cost effective
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Cellulitis,VTE, PE, respiratory infection,
COPD, knee replacement
Average saving of 32% per separation
Deloitte Access Economics (2011) “Economic analysis of
Hospital in the Home (HITH)”
What does the literature say?
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Hospital in the Home is associated with:
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Reduced mortality
Reduced readmission rates
Reduced cost
Increased patient and carer satisfaction
No change to carer burden
Caplan et al. (2012) “A meta-analysis of substitution of care at
home in Hospital in the Home, for hospitalisation” Med J Aust
(in press)
Governance models
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(1) Inpatient team
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(2) HITH consultant
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For: reduced medical FTE, expandable,
wider casemix, organic, drives change
Against: not traditional
For: traditional
Against: more medical FTE, restricted
casemix, does not drive change
(3) Combined – for/against closer to (2)
What cultural change is
required?
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Patients
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Doctors
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“What do you mean, I’m not going to
hospital?”
Ambulatory care principles
Management at a distance
Service providers
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Sufficient funding for ‘spare’ capacity
The Future
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Expansion of HITH
Discharged service
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medical governance by GPs
direct referral from GPs (with medical
management plan)
physician oversight (LOS, specialist input,
registrar supervision)
Combined service with only difference
being where the governance lies.
Summary
HITH
the way of the future!
but remember…
Not all Homes are ideal