Welcome to Hospital At Home.

A Prof Michael Montalto PhD MBBS

Epworth Hospital in the Home
Co-Convener, World HAH Congress
Director, Mobile Radiology Australia
Conflicts

• Director, Mobile Radiology Australia

• Convener, World Hospital in the Home Congress
• Why HAH?
• Definitions: What is HAH? What isn’t HAH?
• What makes HAH possible?
• Introduction of HAH – Australia
• Covid
• Clinical applications of HAH
• Challenges
• A rising tide
• A new clinical paradigm
 Expertise

Severity/
Differentiation
Admission Patient

Technology
HAH is a direct substitute for traditional inpatient
care.

Hospital At Home (HaH) is an acute clinical

service that takes staff, technologies,
medication and skills usually only found in
hospitals, and then delivers those
interventions to selected sick people at
home or in nursing homes.

12
HAH is
Subject to the same obligations as hospitals
Specialist/hospital directed
Technology and skills otherwise found only in hospital
Delivered at home/nursing home
Starts and ends - episodic
Comprehensive, responsible
24 hours, 7 days
All medical and nursing and allied care
All pathology, radiology, pharmacy
HAH is not
Outpatient (thus not OPAT)
Admission prevention
Co-ordinated Care or Chronic Care
Virtual Care
Day Facility based
Primary Care
Basic community nursing
Self-administered care
 Pharmaceutical PICC lines

Pump design Portable diagnostics

 Imaging Technologies
Mobile (plain) Xray

Portable Head Scanning

Portable Ultrasound
Patient suitability

• A diagnosis
• Stable
• Treatment that HIH can deliver
• Adequate home/carer support

• Patient remains inpatient and subject to some rules

• Task of HIH to watch and respond to changes

Results

80 167 of 2 185 421 admissions to the 19 hospitals

included HIH care, or 3.7% (95% CI, 3.6–3.7%) of all
admissions across 96 DRGs.

The 50 DRGs with greatest HIH activity encompassed

65 811 HIH admissions (82.1%), or 8.4% (95% CI, 8.4–
8.5%) of all admissions in these DRGs.

Median length of stay for admissions including HIH (7.3

days; IQR, 3.1–14 days) was longer than that for those
that did not (2.7 days; IQR, 1.6–5.1 days).HIH patients
were more complex.

For HIH admissions, the proportion of patients who

died was lower (0.3% v 1.4%), and re‐admission within
28 days was less frequent (2.3% v 3.6%).
How to build capacity in a crisis
 How to build hospital capacity in Covid – The HIH Way

• Direct Covid care

• Increased non-Covid scope and activity

Fig. 1 Number of patients with COVID-19 infection admitted to
the Hospital del Mar Barcelona between March 13 and May 13,
2020.
1. Urgent care: Direct GP referral or Emergency Department

Skin and soft tissue: Cellulitis/abscesses/wounds

Pyelonephritis/complex UTI
LRTI/Pneumonia/Bronchiectasis
DVT or submassive PE where DOAC not indicated
Nursing Home acquired infections
MDR infections
Heart failure exacerbation
Dehydration
2. Infectious Disease: viral, bacterial, fungal

Community or NH acquired: SSTI, pneumonia, urosepsis, ENT, other

Hospital acquired
Immunocompromised: cancer; BMT; renal transplant; infl arthritis; etc
Diabetes related/complicated
Post-operative surgical
Prosthesis related
MDR
TB
Serious: end organ, spine, brain, etc
Chronic recurrent: urosepsis, bronchiectasis
Renal impairment: PD peritonitis; infections in HD pts
3. Haematology Clinical
Iron infusion
DVT/PE
Peri-operative anticoagulation

4. Cardiology
CCF - Intravenous inotropes
CCF - Intravenous diuretics
AF
Endocardiac infections
5. Haematology/Oncology
Pre-SCT conditioning with IV fludarabine
Intravenous antiviral: post-BMT CMV for IV gancyclovir
Palliative blood/platelet transfusion
Post-auto SCT monitoring
Febrile neutropenia: low risk
Intravenous antifungal for invasive/disseminated disease
Intravenous fluid – supportive
Day Chemotherapy: over 20 drugs, immunotherapy
Sepsis: bacterial, viral, fungal
6. Peri-Operative Medicine/Surgery
Diverticulitis
Cholecystitis: +/- cholecystostomy
Biliary sepsis
Appendicitis
Diabetic foot: PVD+Infection+Amputation
VAC dressings
Complex acute post operative wounds and drains: breast; GI inc
cholecystostomy, nephrostomy, post-Whipples etc; flaps
Wound infections; abscesses
Short gut – high output stoma. dehydration
7. Respiratory
Pneumonia: community/NH/hospital acquired
Bronchiectasis/Inf COPD/CF
Empyema/Abscess
Cystic fibrosis

8. Obstetrics

Mastitis
Venous thromboembolism
Hyperemesis of pregnancy
CTG monitoring
9. Immunology: ulcerative colitis, MS
IV corticosteroid
IVIG

10. Palliative Care - acute

IV fluids/antibiotics/steroid/diuretic/blood product
Drainage of pleural effusion/ascites

11. Geriatrics
Combination with all of above
Complicated by delirium, swallowing problems/renal
impairment/CCF/dehydration/hyperNa
12. Paediatrics: all of the above

13. Rehabilitation
Research and evaluation

Define the intervention

HIH specific quality outcomes:

• %unplanned return to hospital during HIH
• %unplanned mortality

Disease/condition specific outcomes

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Patient acceptability

PGenerally extremely high

• Prior, repeated experience of system
• Hospital linked and supported

• Reviewed prior
• Physical visits i.e show up
• All hours care and support
• Expert care, similar care
• Ease of return if necessary
Costs
This is neither a cheap nor easy option

Reimbursement needs to be appropriate and commensurate with

hospital care rather than community care

The major cost benefit of HIH is in the capital efficiency in

building new acute hospital capacity in constrained systems

Major risk is in mission/definition slippage

Challenges – a selected few

1. Hospital executive support

2. Measuring quality/outcomes
3. Logistics
4. Hospital specific or district specific
5. Dedicated HIH Unit v Not
6. Medical ownership/leadership/culture
7. Legal issues
8. Hospital executive support
9. Telehealth: a tool for HAH, not HAH
Establishing Global Network

• Total number of
registrations:
402
• Number of
countries: 33

45
250 abstracts submitted