Long queues in emergency departments is something that never seems to go away, regardless of healthcare management strategies to fast-track certain patients and free up hospital beds for those who need further monitoring and treatment.
But, what if patients – even those with complex medical needs – could be seen by hospital consultants in their own homes instead?
Dr Daniel Lasserson, professor of acute ambulatory care at the University of Warwick and geriatrician at John Radcliffe Hospital in Oxford, is an expert in the “hospital at home” model of care. And he presented strong evidence on the benefits of this innovative approach to treating sick people at a talk in Maynooth University (MU) recently. “We provide a multidisciplinary assessment and diagnosis. We deliver treatment at home and supportive care and monitoring at the same level as that provided in hospital,” said Dr Lasserson.
The use of hand-held digital devices to carry out ultrasound tests and receive instant results from blood tests – with the data returned via cloud-computing to the electronic patient records at the hospital – can mean faster diagnosis and decisions around treatment than in a busy hospital. Portable heart monitors can also be used and the medics treating a patient at home can speak with cardiologists and other specialists at the hospital to get a second opinion while in the person’s home.
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“We take a whole range of common drugs with us and we do e-prescribing as if the patient was in a hospital bed. It’s the equivalent of hospital care, but more personalised. When you are in people’s home, you see a lot about how they live their lives,” he says. The service also delivers intravenous fluids, medicines and oxygen to patients in their own homes.
He suggests that older people are particularly vulnerable to hospital-based care. “The bed is too high. There is a concrete floor rather than a carpet. They don’t know where the toilet is and they can’t walk around like they can at home.”
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Dr Lasserson cites a Scottish study of hospital-at-home care which found that there was no difference in patient mortality if patients were managed at home. “There were fewer cases of delirium and fewer patients went into care homes afterwards. And, [even considering the costs of delivering care in people’s homes] it was cost-effective,” he explains.
When asked whether there is resistance among doctors to treating patients in their own homes, Dr Lasserson says that GPs don’t have a problem with it. “They just ask us to let them know when we are handing back the patient care to them.
“But hospital consultants take two different views – some are glad that someone is doing it, but not them. And some geriatricians are resistant because they fought hard for older people to get the care they need in hospitals.” Some professional specialist societies are also resistant to developing policy frameworks for such an alternative model of care, he adds.
For hospital-at-home care to scale up – there are currently more than 70 examples of it working to varying degrees in the UK – Dr Lasserson says that more healthcare professionals, particularly advanced nurse practitioners, need to have the autonomy to diagnose and treat patients at home too.
And, he contends that healthcare professionals delivering acute medical care in people’s homes need to be willing to take risks. “You have to have the confidence to manage things in people’s homes. You can often end up giving a drug for the first time at home so it’s case-by-case learning. For some patients, I have brought the hospital pharmacist with me when making these decisions.”
As people are living longer with multiple conditions and treatments, healthcare is undoubtedly becoming more complex. Dr Lasserson argues that to cope with these changing healthcare needs, hospital care should become more targeted. “Understanding what’s wrong with you before you go into hospital is the key. This should be the reason why to go from home to hospital. If you land in hospital with a plan already in place, you can get out quicker.”
We need culture change. There are no training pathways at the moment – you are either a GP or a hospital doctor
— Dr Daniel Lasserson
As a geriatrician, he often treats people in the last year of their life who don’t want to go into hospital. “We actually see people who are sicker on average than those who go into hospital. But we also see people who want to stay at home rather having multiple admissions and then die in hospital.”
Dr Lasserson was visiting Ireland because he is interested in international collaborations to advance the hospital-at-home movement. “We need culture change. There are no training pathways at the moment – you are either a GP or a hospital doctor. We need doctors in the future who have a blend of hospital training and community understanding. And we need to democratise diagnostic and treatment skills so that are spread throughout the medical team.”
Prof Martin Curley, professor of Innovation at MU and former digital health lead with the HSE, invited Dr Lasserson to speak on campus. “Shifting more care from hospital to home is one of the key shifts needed to drive change in our healthcare system,” says Prof Curley. As a strong advocate of digital healthcare, he argues that the use of hand-held diagnostic devices and digital technologies that measure patients’ vital signs are key to such a transformation. “It is positive to see the HSE looking to introduce virtual ward solutions but we need to go faster to help solve Ireland’s acute hospital bed occupancy problems and more importantly to bring better care and a better patient experience to all.”
Ireland currently has the highest levels of acute hospital occupancy in Europe. Implementing such a transformative change to treat more patients in their own homes rather than in hospitals would also require parallel levels of support for carers – either family members or professional carers – to meet the needs of patients in between visits from their hospital-at-home medical teams.
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