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Home and community care: reaping rewards for patients

The raison d’etre of a community based Hospital in the Home program is not simply to take the pressure off an overheated hospital system, says Sue Henning, Support Manager for Silver Chain’s Hospital@Home program.

Started in July 2005, Hospital@Home (HATH) provides cycles of care to a range of patients, in many cases avoiding the need for hospital admission altogether.

“The client’s journey can commence, be treated, complete and have follow up care from their local GP,” she says. “Clients are more comfortable in their own home, and can feel secure in their health and secure in the follow up care of their GP.”

Henning and Perth GP, Dr Scott Blackwell gave a presentation at the recent Hospital in the Home conference in Melbourne on ‘Community Based HITH: Increasing Community Capacity to Reduce Hospitalisations’.

A Western Australian not for profit nursing service provider, Silver Chain has been operating for a century. Its mission is to assist people to continue to live in their community and core services are community care, residential care and rural and remote care. It provides these extensively across the Perth metropolitan area, as well as from 20 country and 12 remote service centres. It also researches community needs and how best to meet them.

One factor is simply geography. Perth’s tertiary hospitals cannot provide services beyond a 30 kilometre radius of the hospital. Yet Perth’s population of just over 1.5 million is spread over an area extending 120kms from Bullsbrook in the North to Waroona in the South. Silver Chain aims to minimise the distance and time patients have to travel to hospital for non-acute care, and maximise their actual hours of care.

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Silver Chain’s Sue Henning and Perth GP Dr Scott Blackwell

For the past 25 years, Silver Chain has operated a hospice service in cooperation with local GPs, and Henning says this served as a model for the HATH program. The program was set up during WA’s health reform in 2005, in response to WA Health Director General Neale Fong’s challenge: “We need to change the way we deliver health services to our community, or face a totally unsustainable future – and a bleak one at that.”

HATH is designed to manage episodes of care at the patient’s home for people who would otherwise require hospitalisation. It is an interdisciplinary medical model of medical governance that operates 24×7. Diagnoses suitable for HATH include cellulitis, urinary tract infection, pneumonia and deep vein thrombosis, cases where the patient primarily requires nursing care. A Silver Chain nurse and/or the local GP visits the patient up to twice a day. Visits generally last around 35 minutes and interventions can include IV therapy and anticoagulant therapy.

Patients accepted for HATH must be medically and mentally stable, not be IV drug users, and must give their consent. If their condition deteriorates and is no longer stable, the patient will be advised to visit their GP or return to hospital for medical review. Patients can enter the program in one of two ways – through referral by the GP, or by referral from a public hospital department. In either case, they must have a medical review within 24 hours of entering the program.

Ensuring 24 hour medical governance is an important factor in the provision of HATH care. Henning says it depends on the pathway the patient takes to enter the program. If the patient is referred by their GP, the GP retains medical governance of the case. If from a department of a public hospital, then generally the referring clinician retains medical governance. If however, the referral is from a hospital’s ED, Silver Chain retains medical governance through its staff doctors or participating GPs.

Patient profile

Of the 602 clients of Silver Chain’s HATH between July 2005 and February 2007, almost half were aged between 50 and 79. The largest cohort (17.3%) were aged between 60 and 69. The next biggest group (15.4%) were a decade younger, followed by the 70-79 year olds at 14.8%. Fifty-four per cent of clients were male, and almost all clients were of non-Aboriginal or Torres Strait Islander background.

On average, the service accepted almost 80 referrals a month. The majority came from hospitals (80%), and most of the rest were from local GPs (17.2%). Almost a fifth of the patients lived alone, and would therefore welcome the regular visits as well as the treatment. The rest lived either with family or with other people, for example in a nursing home.

Forty per cent of patients were admitted for cellulitis, and other circulatory disorders affected 32.9 per cent. Average length of stay for these were 9-10 days. Patients with pneumonia, although only a small number (less than 2%), also required nine days of care. Bacterial infection, abcesses, respiratory disorders, pyelonephritis and pulmonary embolism generally required stays of a week or less. The program saved total 5391 bed days over the 18 month period, with an 8.4 bed days saved per episode.

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Home is where the health is…patients respond best to treatment in their own home.

Henning says the benefits to the patients of care in their own home are many, and community consultations showed that patients recognised these benefits. They include familiarity and comfort in their home environment and culture, with family members and pets around them. HATH provided less disruption to the patient’s normal life, and cost savings in terms of travel, parking, and meals.

Medically, there are clear benefits for HATH patients, Henning says: less risk of cross infection, a ‘healthy’ environment rather than a ‘sick’ environment, and the patient’s resultant positive psychological wellbeing aided their physical recovery.

How HATH works

Service Delivery:

– Interdisciplinary model with medical governance

– 7 days per week 24 hours per day

– Client primarily requires a nursing service

– Visits up to twice a day

– Includes provision of medical consumables

– Referrals accepted 24hrs/day

Diagnosis:

Diagnoses that may be suitable for HATH include

– Cellulitis

– Urinary tract infection

– Community acquired pneumonia

– Deep vein thrombosis

Interventions:

– IV therapy

– Anticoagulant therapy

Medical governance:

24 hour/day medical governance is required for all HATH patients , and a medical review is required within 24 hours of admission. Medical governance

– May remain with referring specialist, or

– Can be provided by Silver Chain doctors (staff or participating GPs)

Patients must have given consent and be:

– Medically stable

– Mentally stable

– Not an IV drug user

IV pic.

Interventions suitable for HITH include IV therapy and anticoagulent therapy.

Total bed days saved over 18 months: 5391

Average bed days saved per episode: 8.4

Widespread practice

Several other states operate HITH or similar programs, as the panel discussion at the conference showed. Panellists were Bronwyn Wilkinson, Manager, Non Acute Care, Health Services Performance Improvement Branch, NSW Department of Health; Susan Race, Manager, Health Independence Programs, Metropolitan Health and Aged Care Services, Department of Human Services Vic; Ros Elmes, Executive Sponsor Ambulatory Care, WA Department of Health; Justin English, Program Manager, Demand Management, SA Department of Health; and Mary Montgomery, District Manager, Brisbane North Health Service District, Qld Department of Health.

In Victoria, care in the home is provided for post-acute patients, those needing rehabilitation and patients with chronic conditions, as well as a specific HITH program Race said. These programs are complementary to in-hospital care. They operate on a principle of shared care – in most cases, the GP takes medical governance, although in the actual HITH program, the admitting hospital retains governance.

HITH has been running since its was trialled in 2001; it was formalised in 2005, and provides approximately 30,000 care provisions a year. Post-acute care services have been offered since 1995, with nursing care provided to patients through the RDNS and personal care sub-contracted to other providers. Like HITH, the service averages 33,000 care provisions a year at 22 population centres in the state.

Rehabilitation services are offered either in the patient’s home or in a community rehabilitation centre at 29 centres across the state. Approximately 20 per cent of the 440 occasions of rehab service a year are provided in people’s homes, Race said.

(Photos: courtesy Silver Chain)

©Sue Cartledge

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