Hospital in the Home version 5

GENERAL COMMENTS

Dr Daryl Kroschel National Medical Director Silver Chain Group Vice President Hospital in the Home Society of Australasia

In the context of the COVID-19 global pandemic, there has been renewed interest in the Hospital in the Home model of care. An international webinar was held in 2020 enabling select attendees of the inaugural World Hospital at Home Congress to share their experience of managing patients at home within COVID-19 hotspots. This demonstrates the global nature of this emerging field and that it is agile, enabling a rapid expansion of the capacity of the health system. This apparent global renaissance in Hospital in the Home is built on a strong foundation, and in the Australian context demonstrates two decades of experience and safe care as monitored by ACHS Clinical Indicators (CIs).

The 2019 data set is compiled from version 5 of the Hospital in the Home Indicators, permitting four years of data on which to draw comparison and trends for a number of clinical indicators. In 2019 there were 117 submissions from 20 Health Care Organisations (HCOs) for nine CIs, reflecting a good split of both metropolitan (55%) and non-metro (45%) representation.

In relation to the domain of patient safety, selection, communication and care co-ordination, the most notable change in trend was in relation to CI 1.5 Unscheduled clinical assessment - adult/paediatric patient with a rate of 0.09 per 100 bed days, most probably due to the significant reduction in the HCO outlier rate relative to previous two years, with a comparable number of HCOs contributing data for this CI. As a marker of quality, centred on service interruption, CI 2.1 – Unplanned return to hospital – adult/paediatric remains one of the most consistently reported measures of outcome with 31 records from 19 HCOs. The annual rate of 0.50 per 100 bed days is significantly reduced on previous years and results in a significant reduction in trend even after allowing for the changing composition of HCOs contributing to the data set over the period. Whilst associated with a lower number of reporting HCOs, indicator 2.3 – unplanned return to hospital within 24 hours – adult/paediatric patient, also showed a significant reduction in rate of 0.057 per 100 bed days resulting in a significant diminution of the trend rate.

Due to the relatively small value of the numerator associated with CI 3.1 unexpected deaths during HITH admission – adult/ paediatric patient, it is not possible to make any specific inferences on the outcome measure of 0.011 unexpected deaths per 100 bed days. The reduction in the rate of unscheduled clinical assessments and unplanned return to hospital rates does not imply an inverse correlation with the increased rate of unexpected deaths, merely that the trends are largely dependent on the case mix and age of patients.

HOSPITAL IN THE HOME

It is worth noting that only ten HCOs have contributed data for this CI over the past three years; other contributing HCOs are encouraged to contribute data to CI 3.1 so that it may be observed closely across a broader patient population. Historically it has been shown that mortality outcomes are not significantly different between HITH and hospital-based care1 and that mortality rates within HITH services is low2,3. Clearly in the event of patient death within a HITH program, the service is required to comply with the broader organisational process for reviewing the case. Forced by global events and enabled by technology, the model of Hospital in the Home will be reinforced as an important component of the health eco-system. International collaboration and consistent definitions of patient complexity and acuity will in time allow international benchmarking; for now the ACHS Clinical Indicators set the standard for measures of safe and effective care in the Australian context.

REFERENCES 1. Aimonino Ricauda N, Tibaldi V, Leff B et al. Substitutive “Hospital at Home” Versus Inpatient Care for Elderly Patients with Exacerbations of Chronic Obstructive Pulmonary Disease: A Prospective Randomized, Controlled Trial. Journal of the

American Geriatrics Society 2008; 56(3): 493-500. 2. Tran A and Taylor DM. Medical model for hospital in the home: effects on patient management. Australian Health Review 2009; 33(3): 494-501. 3. Liu AL and Taylor DM. Adverse events and complications among patients admitted to hospital in the home directly from the emergency department. Emergency Medicine 2002; 14(4): 400-405.

HOSPITAL IN THE HOME

SUMMARY OF RESULTS

In 2019 there were 117 submissions from 20 HCOs for 9 CIs. None were analysed for trend. In 2019, significant stratum variation was observed in 4 CIs. Seven CIs showed greater systematic variation, with centile gains in excess of 50% of all events. Outlier gains in excess of 25% of all events were observed in 3 CIs. See Table of Indicator Results below.

Table of Indicator Results

Indicator Aggregate rate %

Best Stratum Outlier HCOS (%)* Outlier Gains (%)+ Centile Gains (%)+ Events# Trend

Patient safety, selection, communication and care co-ordination 1.1 Unexpected clinical telephone calls - adult/ paediatric patient (N) 0.71 1.2 Unexpected clinical telephone calls - neonatal patient (N) 1.3 Unexpected administrative telephone calls - adult/paediatric patient (L) 0.12 No data since 2017

3 (43%) 21 (81%) 25 (96%) 26

1.4 Unexpected administrative telephone calls - neonatal patient (L) 1.5 Unscheduled clinical assessment - adult/ paediatric patient (L) No data since 2017

0.090 VIC 2 (18%) 8 (22%) 11 (31%) 36

Service interruption 2.1 Unplanned return to hospital - adult/ paediatric patient (L) 2.2 Unplanned return to hospital - neonatal patient (L) 0.50 Metropolitan 9 (47%) 131 (31%) 304 (71%) 428

0.77 2 (67%) 4 (18%) 21 (95%) 22

2.3 Unplanned return to hospital within 24 hours - adult/paediatric patient (L) 2.4 Unplanned return to hospital within 24 hours - neonatal patient (L) Unexpected deaths 3.1 Unexpected deaths during HITH admission - adult/paediatric patient (L) 3.2 Unexpected deaths during HITH admission - neonatal patient (L) 0.057 Metropolitan 1 (7%) 8 (20%) 22 (55%) 40

0.21 5 (83%) 6

0.011

0 1 (20%) 5

# Number of undesirable or non-compliant events + % of events accounted for by outlier/centile gains * % of HCOs that are outliers