White Coat Black Art26:31Hospital at home UK style
Health-care teams in the U.K. are providing hospital-quality care for people in their homes to help ease systems facing a shortage of hospital beds. And while versions of these programs exist in Canada, some experts say we need more of them to help ease our own health-care system’s bottleneck.
Hospital-at-home care is designed to look more like a visit to an actual hospital, rather than other community medicine such as long-term care. It can include ultrasounds, blood tests and IV treatments, sometimes checking off a list of services that might otherwise take several separate hospital stays.
Patients could receive one-time visits to assess their condition, or receive regular visits analogous to staying in a hospital for several days or weeks.
“Why make hospital or home binary? You know, you either come to hospital [and] get everything or stay home [and] get nothing,” Dr. Dan Lasserson, the clinical lead for the Acute Hospital At Home program in the U.K., told White Coat, Black Art’s Dr. Brian Goldman.
In February, Goldman accompanied Lasserson and his team on a visit to a long-term care home in Thame, east of Oxford. They’re there to see a patient, Joan Baxter, who is 88.
Baxter had been admitted to hospital a few weeks earlier after a fall, but was then allowed to return home. She was referred to Lasserson’s team for a check-in after she told her GP she wasn’t feeling well.
Davinia Newell, a team member and nurse working on her master’s degree, applies gel to a miniature ultrasound probe, then presses it onto Baxter’s stomach. Images of her stomach, then heart and lungs show up on Newell’s smartphone.
“My tummy must be the most looked-at tummy,” said Baxter with a chuckle.
After consulting the results and asking some follow-up questions, Lasserson and Newell decide Baxter can continue to stay at home for now.
“We did a very thorough assessment with her. Did a point of care, ultrasound, bloodwork, blood cultures, urine,” said Newell.
“We deliver it all in the home,” she explained, except for some procedures such as X-rays.
‘They’re always given a choice’
Much of the time, Lasserson and his team are on the road. When they’re not, they work out of their home base at John Radcliffe Hospital in Oxford.
There, they regularly review the medical profiles of their patients in painstaking detail: medications, test results, blood pressure, and assessing whether they need continuing treatment or monitoring.
They receive about two or three referrals a day from emergency doctors, GPs, paramedics, concerned relatives and patients who’ve been treated at home and are asking to be seen again.
The average age of the patients they see is about 75, but the range goes anywhere from 16 to 105, said Lasserson. Many, like Baxter, are in long-term care homes, but others are living in their own homes alone or supported by family or caretakers.
“They’re always given a choice, so a hospital at home is never forced on anybody,” said Lasserson.
“I’ve got to say, you know, 999 times out of 1,000 people, the people choose home.”
The program also helps keep costs down, he argues, because staying in one’s home relieves the health-care system of the “hotel costs” of staying in hospital — including food.
A U.K.-based 2021 study found that hospital-at-home care “is a cost-effective alternative to admission to hospital for selected older people,” with little-to-no difference in quality of care between home- or hospital-based patients.
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Growing interest in B.C.
Hospital-at-home programs have launched with successful results in Alberta and B.C., but have seen little-to-no commitments elsewhere in the country, according to a February article in the Canadian Medical Association Journal.
Proponents have said it could help Canada’s health-care system, which has come under immense pressure since the pandemic, including staff and bed shortages and longer wait times for procedures ranging from joint replacements to cancer surgeries.
B.C.’s program launched in late 2020, operating out of the Victoria General Hospital, as a response to COVID-19. It’s since expanded to the Royal Jubilee Hospital, also in Victoria. Sean Spina, regional clinical pharmacy manager at Island Health, says they serve the equivalent of a 20-bed ward through their home visits.
In B.C., patients need to be admitted to hospital first. If their condition doesn’t require a longer hospital stay but they still require regular care, they can complete their treatment at home.
Similar to the U.K. program’s team, the B.C. program’s multidisciplinary team includes an occupational therapist, pharmacist, dietitian, nursing educator and more, said Dr. Nancy Humber, the program’s physician co-lead.
Humber says that as of the end of February, the program has treated 1,391 patients, for an equivalent of nearly 10,000 hospital days. Many, though not all, of the patients are in their senior years, not unlike Lasserson’s patients.
“We’re trying to take the geriatric patients directly from the emergency room, because our program really allows them to have the rest of their care at home,” Humber said.
“We also know that there’s a reduced 30-day readmission rate. And because of that, I think it’s a good fit for that population.”
‘An uphill battle’
The oldest hospital-at-home program might be Australia’s, where it’s been a part of their health-care system for about 30 years, said Dr. Elisabeth Crisci, a physician who advocated for, and co-led B.C.’s first hospital-at-home program when it launched.
But Crisci says “it’s been an uphill battle” in Canada to convince policymakers to invest more in the model.
“There’s still a sense that in Canada, unfortunately, our system is divided in these two silos,” she said. “Acute care belongs in the hospital, [and] community care belongs in the community.”
Crisci worries that as pandemic measures have wound down, the program may also become neglected. She’s also critical that B.C.’s program requires patients to be admitted to hospital first.
“The … program in Island Health has quickly become an enhanced discharge service and not one of hospital-avoidance, which should be the whole point,” she said.
B.C.’s “prototype programs” for hospital-at-home care have brought “significant benefits” to patients and caregivers, the province’s Ministry of Health told White Coat, Black Art in an emailed statement.
It said that over 1,850 patients in the Island Health and Northern Health units have received care at home instead of in a hospital since the program launched. It said it’s “exploring options for potential expansion” of the program, but did not have a timeline for when this might occur.
Lasserson said he’s also heard “a lot of corridor trash talk” from skeptics who don’t think the program is sustainable. He says he invites colleagues to look at their data and talk out potential solutions and improvements instead of writing them off.
“How do we tell people what we do, the way we do it? It’s hard to write papers about this stuff. A lot of it is experiential, seeing it and getting a sense of what’s going on,” he said.
