Hospital-in-the-Home

The Past and the Future Dr Krispin Hajkowicz Staff Specialist in Infectious Diseases and Internal Medicine, Royal Brisbane and Women’s Hospital

Senior Lecturer, University of Queensland School of Medicine

HITH – The Past and The Future

Our implementation journey

Referrals

The decline of traditional HITH indications

New indications

Challenges and Opportunities

“Hospital in the Home (HITH) involves the provision of

acute, sub-acute and post-acute treatments by

health care professionals at patients’ usual place of

residence, as a substitute for inpatient care received

at a hospital”

Caplan, G. Med J Aust 2006; 184:599.

Our Implementation Journey

HITH Services

Previously hospitals managing

the case finding and

admission and subacute and

ambulatory services providing

home-based care

One-team approach

FTE for Staff Specialist,

Registrar and CNC

Private-Public Partnership

commenced 2014

RBWH – TEMPO PROJECT CLOSURE DOCUMENT

What we did

What We Learned Project Closure Checklist

Key Results (Benefits & Return On

Investment)

Overview Transition / Sustainability Plan

Project Name:

Final Metrics

Background:

Target

Problem:

TEMPO Project Closure V0.4 May 2013 Location:. PMO NEW\10. Templates

Replication Standardisation Opportunities

PROJECT REVIEW CLOSURE DOCUMENT

DC4 HOSPITAL SUBSTITUTION / HITH

Item Completed Verified

Communication

Phase 2 Report Out Yes

Case Study written in rough format News @ the Royal

Project team recognised for work completed Yes

Documentation

Documents filed in TEMPO PMO

Operating Procedure (s) documented Yes

HITH Operational

Document

Standard/ Policy documented Yes RBWH

.

Process Flows documented Yes

HITH Operational

Document.

Quality and Performance Check Sheets verified Yes HITH audit

completed monthly.

Escalation process / plan documented

Training plan written into on boarding of staff Yes

KPIs and escalation process documented Yes

PMO MNHHS /

RBWH HITH

Error Proofing documented

Next Steps documented Yes

Audit Mechanism & Owner documented Yes

Countermeasure Baseline Outcome

Increase in HITH referrals 0.17% 0.31% (26 patients) with a

target of 0.51% (40

patients)

Replication Standardisation

Location Spoken to Next steps

Metro North Dr Cameron Bennett (ED, Subacute

and Ambulatory Service)

Monthly meeting of involved clinicans

and administration

Metro North Ms Mary Slattery Steering Committee meeting

Metro North All other HITH providers MNHHS RBWH Operation Manual to be

deployed HHS-wide

QH HITH State Committee Laureen Hines, Project Manager Streamlining of RBWH HITH with

statewide guidelines

0.15% of RBWH admissions transferred into Hospital-in-the-Home compared with

purchasing framework 1.5%

Hospital-in-the-Home (HITH) delivers safe, efficient care

at a discounted rate compared with traditional

ward care for selected Diagnostic Related Groups (DRG’s).

•Established a safe, embedded, proactive RBWH HITH team

•Developed a governance and risk management structure in liaison with key

stakeholders

•Engaged key referrers in new HITH-amenable diagnoses

•Integrated the program with Metro-North HITH services – pioneering a “one team”

approach

•There were significant numbers of patients in RBWH

that can safely be transferred to HITH.

•Medical governance and antimicrobial stewardship are

critical components of a HITH team.

•Integration with community care providers is essential.

•Other members of the hospital have creative and

innovative ideas about HITH.

•The service has substantial potential to grow further.

•The screening and transfer of patients to HITH is a

complex process to ensure the right patients are safely

transferred.

•The project lead and executive sponsor will meet with the Executive Director RBWH to finalise

a permanent, funded HITH team in the first week of July 2013.

•Recruitment to permanent staff positions HITH will be required.

•The RBWH HITH team is now closely linked with the Metro North HITH service, and is moving

towards full integration.

•MNHHS will be adopting the RBWH Operating Manual as their on-going procedural

documents.

RBWH performance has been trending

favourably for the last 2 months ending

March at 0.31%, the highest admission

rate at RBWH this financial year to

date. Monthly performance however

was still below required target of

0.51%. YTD performance is currently

0.18%, which is below the YTD target

of 0.30%.

11.2 Count of HITH admissions - (weekly)

-4

-2

0

2

4

6

8

10

12

Sun

, 1

Jan

12

Sun

, 19

Feb

12

Sun

, 8

Apr

12

Sun

, 27

May

12

Sun

, 15

Jul

12

Sun

, 2

Sep

12

Sun

, 21

Oct

12

Sun

, 9

Dec

12

Sun

, 27

Jan

13

Sun

, 17

Mar

13

Sun

, 5

May

13

Week Ending

Indiv

idual V

alu

e

Source data: HBCIS

Increased HITH referrals, reaching 0.7% of all discharges by

June 2013 in accordance with purchasing framework.

Source data: MNHHS HITH Project Report., based on March 2013.

Implementation Successes

Medical governance, audit, safety, quality and

feedback

Training and education

Hospital-post hospital interface

Strong focus on preventing “non-substitution”

services

Particular DRGs including haemophilia and

hyperemesis of pregnancy

Ongoing Challenges

Very simple referral 24 hours a day that still

preserves safety, quality and appropriate

resource utilisation and doesn’t increase

work burden for referrers

Direct GP referrals

Cracking into areas already doing lots of

substitution

Cancer Care

Surgical Services

0

5

10

15

20

25

30

35

40

45

50

Jan

-11

Feb

-11

Mar

-11

Ap

r-1

1

May

-11

Jun

-11

Jul-

11

Au

g-1

1

Sep

-11

Oct

-11

No

v-1

1

Dec

-11

Jan

-12

Feb

-12

Mar

-12

Ap

r-1

2

May

-12

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

Dec

-12

Jan

-13

Feb

-13

Tran

sfe

rs In

(n

)

New HITH program

commences

Impact of New RBWH-HITH Service on Uptake

HITH Referrals Analysis

RBWH HITH Data

Referrals actually seen over 3 months in 2013

Total referrals = 209

Mean referrals per working day = 3.17

Patient resides Outside local HHS district = 10.6%

Medicare ineligible = 1.6%

Referring Division

Referring Service Line

Medicine, 147

Surgery, 29

Emergency, 20

Womens and

Newborns, 0

Cancer Care, 2

Referring Unit Other notables

DEM 12

Orthopaedics 6

Vascular surgery 4

Cardiology 3

Med Onc 2

Referring Medical Unit

Med 1a 17

Med 1b 13

Med 2a 11

med 2b 10

med 3a 17

med 3b 4

med 4a 15

med 4b 5

med 5a 8

med 5b 1

renal 5

respiratory 6

gastroenterology 2

infectious

diseases 6

Person Referring to HITH

Referred By

Nursing, 16

Allied Health, 2

Medical

Consultant, 27

Medical Registrar,

59

Medical RMO, 59

Medical NOS, 8

Other, 1

HITH Team Receiving Referral

Referral Received By

Medical 151

Nursing 26

Other 16

Active Case-Finding

Daily or twice daily round in emergency department and

short-stay unit

Admitting medical team MDT

Specific wards – resp, flex-bed unit

Bed Parliament

PACS review for all admitted pulmonary emboli and DVTs

Source of Referral

Source of Referral

Direct

82%

WR - DEM

3%

WR- SSU

1%

Bed Parliament BP

11%

Multidisc meeting

MDT

3%

What is Being Referred?

Diagnoses Referred

0

5

10

15

20

25

30

35

CELL

ULI

TIS

OTHER PE BJI

BACTER

AEMIA

DVT

UTI

COPD

SSSIOTH

ERCAP

ASPPNEU

CCF

CLD

BRONCH

IECTASIS

PERIT

ONIT

IS OM

DFI

ANTIC

OAG

ULATIONOTH

ER

Nu

mb

er

Medical Reasons for Non-Transfer

33 referrals for cellulitis, 11

changed to orals or no

antibiotics

Medical Reasons for Non-Transfer to HITH

UNSTABLE, 20

ABCHANGE, 27

NOGOAL, 12

REHAB, 1

MOBILITY, 3

BDVISITS, 1

PRIVATE, 1

PATIENTADHEREN

CE, 3

NOPHONE, 1

NODX, 1

Dx for Antibiotic Rationalisation

CELLULITIS, 11

OTHER, 6

UTI, 4

CAP, 2

SSSIOTHER, 2

BJI, 1

BRONCHIECTASIS,

1

0

5

10

15

20

25

30

Internal Medicine Surgical and Periop Critical Care Women's and Newborns

Mental Health Cancer Care

Nu

mb

er

Service Line

Successful Referrals to HITH by Service Line

October 2013

November 2013

December 2013

January 2014

February 2014

Referrals - Summary

Despite active case-finding, most patients still referred by

treating team

Predominant referral pathway is still doctor to doctor

Lots of work reviewing referrals, but not converting to actual

service numbers

Financial class ineligible

Disease not severe enough

Social/other reasons

Still potentials slipping through the net?

The Decline of Traditional HITH

Indications

Infectious Diseases Physician

Review Prior to HITH IV antibiotics

Mandatory at RBWH since 2010

Either face-to-face or over the phone

Antimicrobial stewardship the prinicple

27 HITH admissions avoided over a three month period

Changed to oral antibiotics or no antibiotics

No antibiotics required

Skin and soft tissue abscess <5cm and systemically well

Bilateral red legs

Asymptomatic bacteruria unless pregnant

Exacerbations of COPD with no sign of bacterial infection

Aspiration pneumonitis (vs pneumonia)

Pseudomonas aeruginosa colonisation of a chronic lower limb wound

Uncomplicated iv cannula thrombophlebitis

Surgical prophylaxis >24 hours

Antibiotics “just in case”

Oral Antibiotics

UTIs

Pyelonephritis

Mild cellulitis

Most abscesses

Mild pneumonia

Mild infective exacerbations

of COPD

Dose orals properly

Amoxicillin 1d po tds

Cephalexin 1g po qid

Augmentin DF 1 tab tds or

midday amoxicillin

Trimethoprim-

sulphamethoxazole DS one

to two tablets BD

Clindamycin 450 – 600 mg

tds

Oral Antibiotics

UTIs

Pyelonephritis

Mild cellulitis

Most abscesses

Mild pneumonia

Dose orals properly

Amoxicillin 1d po tds

Cephalexin 1g po qid

Augmentin DF 1 tab tds or

midday amoxicillin

Trimethoprim-

sulphamethoxazole DS one

to two tablets BD

Clindamycin 450 – 600 mg

tds

Antibiotics with Great Oral

Bioavailability

Metronidazole

Trimethoprim-Sulphamethoxazole

Clindamycin

Linezolid

Ciprofloxacin, Moxifloxacin

Azithromycin (intracellular)

Doxycycline

Rifampicin

Indications with need for brief iv

therapy

Moderate cellulitis 1-3 days

Pyelonephritis 24 hours

Multi-drug resistant UTI

3 days

Oral fosfomycin or nitrofurantoin

Pneumonia

Chronic osteomyelitis where treatment intent is not curative

(perhaps short-course iv antibiotic at beginning)

Antimicrobial Stewardship

• Savings of $US3850

per patient avoided

• No change in

infection outcome

Am J Med 1999; 106: 44-49.

Anticoagulation

Dabigatran and Apixaban

PBS listed for

Non-valvular AF

Prevention of VTE

Rivaroxaban PBS listed for

Treatment of acute DVT and

PE

Prevention of VTE

Non-valvular AF

Pros and Cons of Each Strategy

LMWH plus vitamin K antagonist

PROS

Reliable and well tested/understood

Valves

Reversibility

CONS

Hassle and expense of INR monitoring

Difficulty getting INR in range

Drug interactions

Direct factor Xa inhibitor

PROS

Obviates need for HITH admission

Patient preference

Lower intracranial bleed rate

CONS

Less well understood

Reversal?

Lack of monitoring

Contraindicated in severe kidney impairment

Pros and Cons of Each Strategy

LMWH plus vitamin K antagonist

PROS

Reliable and well tested/understood

Valves

Reversibility

CONS

Hassle and expense of INR monitoring

Difficulty getting INR in range

Drug interactions

Direct factor Xa inhibitor

PROS

Obviates need for HITH admission

Patient preference

Lower intracranial bleed rate

CONS

Less well understood

Reversal?

Lack of monitoring

Contraindicated in severe kidney impairment

Reality = Hard to

sell warfarin with

INR monitoring in

the face of the

new agents

“New” indications that we are

working on

Hip and Knee arthroplasty rapid transfer

Hyperemesis of pregnancy – impact of ondansetron

Heart failure

Liver failure

Haemophilia (factor support)

Delirium

PPROM

Post LUSCS care

Rhabdomyolysis

TPN initiation

Chronic fungal infection

Low-risk febrile neutropenia

Chemotherapy-related hydration

Immunotherapy in autoimmune and neurological disease

Palliative care

Hydration in chronic kidney disease peri-procedure

HITH – The Future

HITH – The Future

HITH – it’s time for resource limitation, focus on length of stay,

admission avoidance and disinvestment like everywhere else

Will require further knowledge about why remaining patients are

in hospitals and what value physical hospital services add

Outpatient care still usually more desirable in most situations

OPAT

Patient preference

Greater expertise and investment in

Palliative care

Communication systems

Hospital-wide acceptance of HITH patient status as inpatients

24 hour availability and acceptability

Adjustment of the denominator in targets as well as the

numerator

Enhanced Clinical Governance Large pool of patients remain in hospital for clinical

governance

Pretexts include pending investigations or

consultations, family meetings

Fear of treating specialist/registrar about “missing”

something versus very real concerns about a risky

period in the patient journey

High risk handover

Feedback about readmissions

Mistrust of primary care and post-acute care options

(rightly or wrongly)

“Allowing a patient to declare themselves” = Thinking

time for clinician

Clinical Governance – HITH Can

Help!

HITH team well known to referring team

Normalise feedback, especially of poor outcomes

Don’t need a pretext, medical governance is the indication

Examples

Liver failure

Delirium

Pulmonary embolism treated with oral rivaroxaban

Complex electrolyte management

Ovarian hyperstimulation syndrome

Rhabdomyolysis

Oral antibiotics plus…

Quasi-palliative care and seeming contradictions of expectation

Thank you!

krispin.hajkowicz@health.qld.gov.au