In 2018, it was identified that the acute Maidstone and Tunbridge Wells NHS Trust (MTW) needed to create extra capacity because of patient demand, without the financial or staffing implications associated with increasing inpatient beds. A pilot project was run for 6 months over the winter of 2018 to 2019 to set up a hospital-at-home service as a model of care that would allow patients to leave the acute hospital once they were clinically stable, and complete the remainder of their care pathway at their normal place of residence.
The project was in line with the NHS Long Term Plan (NHS England/NHS Improvement, 2019), which sets out the need to redesign community services to improve care outside of hospitals and the need to integrate care to meet the needs of the ageing population.
For the pilot, appropriate patients would be discharged from an acute bed, but would remain the responsibility of the hospital consultant and any concerns or changes in the patient's condition would be discussed, and a medical review in the hospital arranged if necessary.
The hospital-at-home service allows more patients to be cared for in the right clinical environment, both by having clinically stable patients finish their treatment in their usual place of residence, as well as the hospital having improved patient flow for acutely unwell patients who need to be cared for in hospital. In addition to the impact on length of stay, it was expected that there would be benefits in reducing the risk of hospital-acquired complications, such as the risks associated with reduced mobility and infection. It has been noted that:
‘If a patient does not need acute care, being in an acute hospital can be harmful. Acute hospitals expose patients to potential avoidable harm.’
It was also expected that the change would bring increased patient satisfaction.
It was agreed that the local community trust, Kent Community Health NHS Foundation Trust, would deliver the service to an agreed cohort of patients. This was an exciting opportunity for collaboration between the two local organisations.
Patients were referred to the service by clinicians from MTW and assessed during the hours of 9am to 5pm, Monday to Friday, by the community employed hospital-at-home clinical co-ordinators, who were registered nurses based within the acute hospital. Once deemed fit for delivery for care by the community hospital-at-home team, the patient would be transferred. Exclusion criteria for patients not eligible for transfer were individuals requiring intravenous fluids and those requiring medication or feed via a nasogastric tube.
Initially, the community team comprised two band 6 registered nurses (this later increased to six) and one band 2 healthcare assistant, providing care during the hours of 7am to 10pm 7 days a week and up to four visits per patient per day.
Escalation process
Once the project had been running for a few months, it was felt that there was not enough appropriate work for the healthcare assistant owing to the fact that such a large proportion of the care required could be provided only by registered nurses, such as the administration of intravenous medication and drain care. The healthcare assistant was therefore redeployed and the team then consisted solely of registered nurses. If a patient remained within the parameters set out in the plan of care then the hospital-at-home nurses would implement a criteria-led discharge at the end of treatment. If a patient became unwell once he or she had been transferred on to the hospital-at-home caseload, there were escalation processes in place via the acute hospital or, if a problem occurred out of hours, the community medical team would be contacted.
A data collection set was agreed to measure the success of the pilot scheme and to provide data to inform improvements to the efficiency and quality of the service.
In November 2019 the model was changed so that patients were discharged to the care of the community Trust, and the consultant at the acute Trust did not remain medically responsible. This was mainly due to clinician concerns about liability associated with being responsible for patients they were not able to regularly review and assess in person. Since this change, referral numbers from most specialties have increased (this can be seen in Figure 1).
Figure 1. Referrals by specialty, March 2019 to February 2020 (n=461 patients)
In the period from March 2019 to February 2020, a total of 461 patients were transferred to the hospital-at-home service (Figure 1). This saved a total of 4840 acute bed days, which is equivalent to 13.3 hospital beds not being required over a 1-year period (assuming that patients stayed on the hospital-at-home service for the same amount of time that they would have stayed in hospital). Initially, the service provided care for medical, surgical and orthopaedic patients but, as it developed, other specialties were able to be accommodated, such as haematology and gynaecology (Figure 1).
The length of stay in the hospital-at-home service improved as the service became more established and remained on a downward trend (Figure 2).
Figure 2. Average length of stay in the hospital-at-home service between 1 March 2019 and 28 February 2020. Average length of stay over the 12-month period was 10.81 days
The most common conditions treated by the hospital-at-home service are shown in Table 1. There is a long treatment period associated with some patients, for example those with osteomyelitis, which means that they have been able to receive a significant amount of their care at home and reduce length of stay in hospital.
Table 1. Referrals to the service by diagnosis, March 2019–February 2020
| Patients' main diagnosis | Total number referred |
|---|---|
| Infection | 82 (17.7%) |
| Cellulitis | 82 (17.7%) |
| Breast surgery | 62 (13.4%) |
| Osteomyelitis | 44 (9.5%) |
| Chest infection/pneumonia | 32 (6.9%) |
| Bronchiectasis | 24 (5.2%) |
| Other medical conditions | 39 (8.4%) |
| Other surgical conditions | 25 (5.4%) |
| All other conditions | 71 (15.4%) |
| Total number of patients | 461 |
By far the most common intervention provided by the hospital-at-home team was administration of IV antibiotics, required by 294 (64%) of the patients.
To address concerns raised early in the project about the early discharge of acute patients causing deterioration in their condition, a review was undertaken of all patients readmitted to hospital while still under the hospital-at-home service. Of the 50 readmissions over this period, 25 patients experienced a worsening of their current condition; 23 patients were readmitted with a new condition and 2 patients were unable to be investigated because of readmission to a different hospital.
There were no omissions or substandard levels of care identified as a cause for readmission, with the exception of one case where there was a delay by the medical team in acting on abnormal blood results provided by the hospital-at-home service. The readmission rate for hospital at home was 10.8%, which is below the MTW ‘readmission in 30 days rate’ of 14.7%, showing the service did not increase the likelihood of patients' conditions deteriorating and requiring readmission to hospital. Two patients died (0.4%) over the period being reported. These cases were referred to the coroner and, although the deaths were unexpected, both were attributed to natural causes.
Patient satisfaction
A patient experience satisfaction survey questionnaire was given to patients on discharge from the service. The score for hospital-at-home service was consistently at 98%, indicating very high satisfaction. Almost exclusively the patients were pleased at being referred to the service because they were keen to be treated at home and not remain within the acute hospital.
The hospital-at-home service has been one of a range of measures at MTW that have contributed to improving the flow of patients through the hospital and helping to achieve the accident and emergency access targets. It has also reflected a shift in the balance of health care from hospital to the community, particularly delivering interventions in the patient's own home. The service has encouraged both organisations to think along less traditional means of care and its success has been reliant on effective collaborative working between the two Trusts.
The hospital-at-home service continues to run today and remains a success for both organisations with regard to collaborative working, increased patient flow and patient satisfaction.