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Gen Cooper, Dept Health Victoria delivered the presentation at the 2014 Discharge Planning Conference. The 2014 Discharge Planning Conference - Assisting health services to adopt an integrated and consumer directed approach to discharge planning. For more information about the event, please visit: http://bit.ly/dischargeplan14
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“Hurrying Home to Hospital”
Utilising Hospital in the Home (HITH)
as early as possible.
Gen Cooper : HITH Senior Project Officer
03 9096 61332
Hospital in the Home (HITH)
The Opportunity
HITH & Discharge
Planning
The Evidence
Potential Barriers
Making a Difference
The Opportunity
The Opportunity
Hospital in the Home
• Provision of acute admitted care in the home or suitable environment
• Direct substitution - criteria as per Victorian Hospital Admission Policy
• Casemix funded
• Reported through VAED (Victorian Admitted Episode Dataset)
2012-13 Victorian HITH
• 27,647 separations
• 196,868 HITH bed days
• 2.1% all Victorian separations involve HITH
• 6.0% of Victorian multi day separations
2013-14 Q1-3 Victorian HITH (indicative data)
• 6.4% of Victorian multi day separations
The Opportunity
Most common diagnostic related groups (DRGs)
• J64B (cellulitis),
• F63B (DVT) and
• E61B (pulmonary embolus)
The most common HITH therapy
• intravenous antibiotic therapy for cellulitis, genitourinary, respiratory or
postoperative/post-traumatic infections, and
• anticoagulant therapy for deep vein thrombosis or pulmonary
embolism
• chemotherapy at home
HITH provides equivalent care that is direct substitution and can be
safely delivered at home. This allows scope for a range of care types.
HITH provides a safe and viable
alternative to hospital treatment in
an environment familiar to the
patient and with far less disruption.
HITH supports the health system by
providing an efficient and flexible
resource for hospitals
Aim is for patient to receive the
most appropriate treatment in the
most appropriate setting.
HITH & Discharge Planning
HITH & Discharge Planning
Consider direct admission to
HITH for appropriate clients
Consider HITH at the earliest
appropriate time
NEAT
A whole of system approach
Primary care Emergency department
Acute admission
Sub-acute admission
Community services
Home
Additional capacity
OPTIMISE PATIENT FLOW •Redesign •Clinical pathways •Criteria-based discharge •Weekend rounds •Rigorous bed management
ALTERNATIVES TO ED ADMISSION •Chronic disease management/ HARP •Resi-care inreach •Direct admissions •Call referral •Expanding primary care
SYSTEM COORDINATION •HITH/ PAC/ Transition Care •Health Independence Programs
EARLIEST DEFINITIVE CARE •Fast track/streaming •Short Stay Units •Senior consultants ‘up front’ •Access to diagnostic testing •Direct admitting rights •Acute medical units •Acute surgery units •Direct Access (inc Aged Care)
1
SYSTEM COORDINATION •Ambulance arrivals boards •Ambulance distribution
•NHS 111
•ED role delineation
2 3 5 6
ADDITIONAL CAPACITY •Fast-track / streaming •Short-stay units •Senior consultants •Diagnostic testing •HARP/resi-care inreach
REDUCE VARIATION IN CARE •Clinical guidelines •Clinical pathways
4
HITH Evidence
Report on evaluation of Hospital in the Home Programs
DLA Phillips Fox 2009
Commissioned by Department of Health Victoria 2009
1. Clearly safe and effective for a range of conditions
2. Cost efficient
3. Patient preference. Highly valued by consumers & carers
Report on evaluation of HITH Programs
“It is clear that there is considerable
opportunity to increase the utilisation of
HITH for a broad range of conditions.
Failure to do so represents a lost
opportunity in light of the very positive
evaluations HITH receives from patients
and carers and the literature confirming
its utility and efficiency.”
HITH Evidence
Deloitte Report: Economic analysis of HITH
Commissioned by the HITH Society 2011
Examined 6 HITH care types: cellulitis, venous thrombosis, pulmonary
embolus, respiratory infection, chronic obstructive pulmonary disease.
HITH was 32% cheaper relative to hospital care across all six AR-DRGs by
separation on average.
“Health services should be investigating
opportunities for HITH growth as a flexible way
to manage demand for appropriate patients and
care types.”
HITH Evidence- Clinical
• HITH provides a safe and viable alternative to hospital
treatment in an environment familiar to the patient and with
far less disruption.
• Comparable mortality, and adverse event rates to inpatient
care. (Montalto et al, 2010, Australian Health Review; Tran & Taylor 2009 Australian Health Review, 33 ,3; MacIntyre,
2002, International Journal for Quality in Health Car,14,4; Caplan et al, 1999, Medical Journal of Australia, 170)
• As effective as inpatient care (Deloitte Access Economics, 2011, Economic Analysis of
Hospital in the Home; Richards et al, 2005, Medical Journal of Australia, 183,5; Caplan ,2006, Medical Journal of Australia,
184,12)
• Reduction in complications frequently related to hospital
inpatient care such as falls and infections (Richards et al, 2005, Medical Journal
of Australia, 183, 5)
• For older patients – decrease in delirium, and deterioration in
continence and mobility. (Frick et al, 2009, American Journal of managed Care, 15,1; Mendoza et
al, 2009, European Journal of Heart Failure; Inouye et al,1999, New England Journal of Medicine,340,9)
HITH Evidence- Health System
HITH supports the health system by providing an
efficient and flexible resource for hospitals
• Cost Effective (Sheppard et al, 2008 ,Cochrane Library of Systematic Reviews; Wilson et al, 2005, Australian Health Review,
29,3; Richards et al, 2005, Medical Journal of Australia, 183,5)
• Impact on Health System (including capacity) (Sheppard 2009, Cochrane Library of
Systematic Reviews; Cameron et al, 2009, Medical Journal of Australia, 190, 7; O’Neill,2008, Home Healthcare –an Economic Choice for
the Health Service; Cameron et al, 2009, Medical Journal of Australia,190,7; Scott, 2010, Australian Health Review, 34,3; Ram et al,
2004,British Medical Journal,329,7461)
• Readmission rates- positive
preliminary data (DH Victoria)
HITH Evidence- Patient Preference
For appropriate patients, HTH offers the best
care in the right place.
Leff et al, 2005, Annals of Internal Medicine, 143 (11) Wilson et al, 2002, British Journal of General practice, 52
Potential Barriers- ED & Wards
• Lack of understanding of HITH and eligibility
• Difficulty making referrals after hours and weekends
• Difficulty arranging visit more than once a day
• Response and responsiveness to referrals “Long Memories”
• Completion of referral documentation
• Patients that do not meet the HITH admission criteria
• Lack of medical lead
• Process and timing of PICC line insertions
• Review process- time, place, person
• Lack of organisational protocols, clinical pathways for HITH
Potential Barriers- HITH
• Capped services ‘HITH beds’
• HITH service area, geography, subcontracting
• Limited hours, typically evening, overnight,
weekend services limited
• Time of referral (late decision)
• Lack of nursing EFT to support demand, case
finding in hospital, recruitment issues
• Lack of cars, phones, computers, clinical
equipment
• Lack of dedicated medical EFT
• Lack of space – office, review clinic, treatment
room
Making a difference
• Executive Support
• Medical governance and leadership
• Direct substitution- at start or end of
episode
• Safeguards are in place to ensure
equivalent care and quality outcomes
• Flexing resources to meet demand-
flexible workforce, cars, no capped
beds
• Staff education/ marketing
• Physical space
• Patient choice
Can I make a HITH referral please?
Making a difference
• Emergency & HITH interface
• Medical oversight & HITH bed card
• Case finding – not waiting for referrals
• Residential Aged Care In-reach
• HARP
• Clinical pathways for HITH suitable
conditions
• Streamline processes and paperwork