key: cord-0921276-px5rap0h
authors: Dickson, Hugh G
title: Hospital in the home: needed now more than ever: Changes in models of care elicited by COVID‐19 may improve the quality of at‐home care for patients
date: 2020-06-11
journal: Med J Aust
DOI: 10.5694/mja2.50662
sha: f2029c4addaddcd998c0b5042d27cac16d087eac
doc_id: 921276
cord_uid: px5rap0h

nan

A s the coronavirus disease 2019 (COVID-19) epidemic continues, attention in Australian hospitals has rapidly become more focused on methods for safely caring for patients while avoiding, when possible, admitting them to hospital or having them visit a hospital outpatient clinic. Diversion from hospitals reduces the risks for both patients and staff of cross-infection or new infection with the COVID-19 virus (SARS-CoV-2). Telehealth 1 and hospital in the home 2 (HITH) are two approaches for removing or reducing the need to attend a hospital while maintaining access to its clinical services. Neither system of care is novel, but each is experiencing a predictable surge in activity as the epidemic advances, and the two methods can be combined.

Patients with COVID-19 who are well enough to remain in home quarantine can receive telehealth monitoring. Daily or higher frequency contact with a health professional, either in person or via a virtual care system, can be classified as HITH care, and the patient occupies a virtual rather than a physical bed; this bed occupancy can be counted as part of a hospital's activity. 3 The limiting factor for care is then staffing and equipment rather than hospital floor space for patient accommodation.

For patients with COVID-19 managed in a HITH service, the degree of remote physiological monitoring depends on the resource base of the treating service. Information exchange by group email within NSW Health indicates that the availability of take home monitoring equipment differs markedly between Local Health Districts; only some services can supply patients with pulse oximeters and thermometers. The superiority of a combination of remote monitoring and telehealth over telehealth alone for people with COVID-19 has not yet been shown.

Different models of HITH are employed in Australia, ranging from unitary systems of care in which all medical and nursing care is delivered by a single service to matrix models in which different components of care are delivered by separate services in a coordinated manner. Each HITH service has a different mix of patients, depending on the referral characteristics and admission policies of the service. The Liverpool Hospital HITH service, for example, has a matrix model that includes both generalist and specialist medical and nursing care. Patients with COVID-19 admitted to the Liverpool HITH service are contacted by telephone twice a day by community nurses using a standard protocol linked to the patient's electronic medical record. Any problems can be referred to an on-call respiratory physician. The Liverpool HITH service does not currently supply home monitoring equipment to patients, but this may change in future. Not all NSW patients with COVID-19 managed in the community are registered as HITH inpatients. The lack of rigour in the classification of HITH services has improved since Montalto and Leff commented in 2012 that the definition of HITH needed to be settled, 4 but the situation is still not ideal.

In this issue of the Journal, Montalto and colleagues report their retrospective, secondary database analysis of HITH activity in a group of Australian hospitals during 2011-2017. 5 In a sample of 2 185 421 admissions to 19 principal referrer hospital members of the Health Roundtable, 80 167 (3.7%) included a HITH component. Growth in the number of HITH admissions was more rapid than that of inpatient admissions (mean rise per quarter: 3.1% v 1.6%). The difference, although not statistically significant, probably reflects expansion of HITH over the past ten years as the growing population of aged people in Australia increases the pressure on bed availability in public hospitals. 6 There is still room for growth in HITH services in Australia as clinicians gain confidence in its use. Although the safety of HITH depends on careful patient selection and education, patients consistently perceive their experience of HITH care as positive; 7 they are typically relieved that they do not need to be admitted to hospital. Incorporating virtual care into HITH models would probably further improve the quality of the experience for patients and increase the demand for this form of care. In this respect, the COVID-19 epidemic has been highly effective as a catalyst for change in models of HITH care.

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