Hospital-in-the-Home — essential to an integrated model of paediatric care
C C Hensey1,2, B Freyne 3,4,5, PA. Bryant 2,3,5,6
1. Department of General Paediatrics, Children’s University Hospital, Temple Street, Dublin 1
2. Hospital-in-the-Home Program, [email protected] Department* The Royal Children’s Hospital Melbourne, Victoria, Australia
3. Infectious Diseases Unit, Department of General Medicine* The Royal Children’s Hospital Melbourne, Victoria, Australia
4. Infectious Diseases and Microbiology Group, Murdoch Children’s Research Institute* The Royal Children’s Hospital Melbourne, Victoria, Australia
5.Department of Paediatrics, University of Melbourne* The Royal Children’s Hospital Melbourne, Victoria, Australia
6. Clinical Paediatrics, Murdoch Children’s Research Institute* The Royal Children’s Hospital Melbourne, Victoria, Australia
The National Clinical Programme for Paediatrics and Neonatology is proposing a model of care that will determine the future delivery of children’s health services in Ireland1. The focus is on the provision of an integrated service with improved co-ordination between primary, secondary, and tertiary level facilities. A parallel goal is improvements in chronic care and medical care in the home. An expanded role for ambulatory care and hospital at home schemes with a reduced reliance on inpatient care is proposed in line with international best practice. Achieving these goals requires a paradigm shift in delivery of children’s health care, and reconfiguration of current services to deliver multidisciplinary care in hospital and at home. The recently approved planning application for the new children’s hospital provides an opportunity and heralds a change in the structure of paediatric services in Ireland. It will act as the nexus of paediatric care throughout Ireland; supporting paediatric services nationally through outreach programmes, and ensuring children are treated as close to home as possible. A Hospital-in-the-Home (HITH) program would help meet these objectives; and could provide home based acute paediatric care, leading to economic benefits, and the delivery of quality family-centred care.
HITH is a service that provides active treatment by health care professionals in the patient’s home for a condition that otherwise would require acute hospital inpatient care2. It has been well described in adult literature with a reported high level of patient satisfaction, equivalent clinical outcomes and potential economic benefits3. There is increasing literature on paediatric HITH services. Studies have described outpatient parenteral antimicrobial therapy (OPAT) delivered by a paediatric HITH service4, and have evaluated paediatric HITH in specific conditions including childhood cancer, respiratory conditions, gastroenteritis and febrile illnesses, reporting equivalent outcomes5–7. Advantages to HITH for children and their families include increased parental satisfaction7, reduced social disruption and parental financial burdens, and an increased parental ability to cope when their child has a chronic medical condition8.
The Royal Children’s Hospital Melbourne (RCH) was one the reference sites in the Children’s Health First: McKinsey Report used to establish international best practice in the delivery of tertiary paediatric services, and to examine potential models of care. RCH runs several home care programs through the [email protected] Department providing short, medium and long term support. The HITH program provides daily acute medical interventions that would otherwise require hospitalisation, for up to 32 patients at a time, in their own homes. This asset to the hospital, provides family-centred care enabling children to complete their treatment in the familiar surroundings of their own home. Coupled with the clear benefits to the children and their families, HITH facilitates early discharge or diverts patients from inpatient hospital beds, improving patient flow and facilitating bed availability for elective procedures.
Within RCH a large proportion of HITH patients receive OPAT. Their care, however, is tailored to individual needs with medical, nursing and allied health staff providing a broad range of services. For example, patients with cystic fibrosis complete face-to-face and telehealth physiotherapy in conjunction with OPAT. Children are seen by a member of the HITH clinical team once or twice daily and are provided with a 24-hour contact number for the HITH duty nurse. One of the major strengths of the structure of the HITH service at RCH is that it is medically managed by a consultant and full-time fellow; with daily board rounds (discussion between medical and nursing staff of every patient receiving HITH care), home or telehealth reviews by a doctor for complex patients, and an electronic medical record with real-time incorporation of HITH information. This ensures quality outcomes are met, such as appropriate antimicrobial stewardship, and facilitates coordination of care with the primary treating team. HITH staff attend hospital clinical handovers, speciality meetings (e.g. infectious diseases, cystic fibrosis), and liaise frequently with the emergency department (ED). This enables them to act as advocates, identify potential patients, and facilitate early transfer to HITH care. One of the key areas of success in the HITH service at RCH has been the move to the front of the hospital, with direct referrals from ED and the ability to take referrals 24 hours a day. This coupled with a clinical presence to liaise with paediatricians and neonatologists, has helped transform HITH into an integrated, valuable, and flexible hospital-wide service.
Home-based paediatric care is not a novel idea. In Ireland, OPAT has been provided to selected patients for a number of years; initially through programmes in The Children’s University Hospital Temple Street9, and other local initiatives. The HSE has since established a National Clinical Programme for OPAT and should be commended on the progress which has been made in conjunction with the Infectious Diseases Society of Ireland OPAT Working Group10. TCP Homecare and Fannin Health have been providing the National OPAT Service since January 2013, providing a valuable service for those patients requiring medium or long courses of intravenous antibiotics. However, it is not easily accessible for short courses of intravenous antibiotics, and is not integrated within the acute paediatric hospitals which limits its application. We should embrace HITH or a similar acute ambulatory care programme as a key element in the future of paediatric care in Ireland. A paediatric HITH service could provide OPAT in a wide range of conditions beyond the traditional treatments for osteomyelitis and cystic fibrosis. Patients could be accepted for shorter term treatment with appropriate medical supervision for conditions such as bacterial meningitis, pyelonephritis, skin and soft tissue infections, and pneumonia – all conditions that are regularly managed by the RCH HITH program, including direct referrals from the ED4. In addition, HITH programs can offer a wide range of care beyond OPAT including central venous catheter/port care, eczema care, diabetes education, wound management, home physiotherapy, home enteral nutrition, ambulatory blood pressure monitoring, and overnight pulse oximetry monitoring. Co-ordinating acute home care within an integrated HITH program at the new children’s hospital will provide flexibility, cost-benefits, efficient use of hospital beds and family-centred care in patient’s own home. Utilizing the ‘hub and spokes’ model outlined in recent policy documents will facilitate nationwide home-based care that could be centrally managed and co-ordinated.
HITH is aligned with national health policy, and international best practice, but it is a challenge to our firmly structured health universe, where community services and hospital services operate in distinct orbits. However, technology and patient preference are constantly evolving, resulting in the basis for this separation becoming increasingly cultural only. We are entering a period of significant change in children’s health care and must embrace the opportunity this provides, and advocate for improved home care for our patients.
Corresponding author: Conor Hensey, Department of General Paediatrics, Children’s University Hospital, Temple Street, Dublin 1
Email: [email protected]
1 The National Clinical Programme for Paediatrics and Neonatology. A National Model of Care for Paediatric Healthcare Services in Ireland. 2015 (Cited 2016 Sept 28). Available from: http://www.hse.ie/paeds
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