New models of care: making integrated out-of-hospital care a reality
Dr Ayman Shenouda
As the cost and need for care rise – with an ageing population and increasing disease burden - we will need new models of care to meet the healthcare needs of our communities.
Improving the ability of healthcare systems to respond to the demands of patients in acute care and particularly for older patients presents a significant system and funding challenge.
We need to define and fund new ways of working to better support our patients through a preventive strategy to reduce hospital admissions.
We also need to ensure those receiving acute care actually require hospitalisation and for those who don’t we need new ways to transition from hospital to less costly, more appropriate settings.
For our system to be sustainable we need to ensure our patients receive care in the most appropriate, least expensive setting.
But an admission avoidance – hospital avoidance strategy requires integration of acute care with preventive and primary care something our funders resist despite the obvious efficiencies. It requires better integration of acute care within local and nationally funded health systems.
This represents a paradigm shift that provides an acute service but that can be referred to across primary, secondary and tertiary care.
It is about bringing teams together consolidating different points of access to care and providing that care in the home.
This is already being by providing short home-based acute care to public hospital patients through a Hospital in the Home (HITH) model. A model tested and proven to be a viable alternative to hospital admission providing same or better patient outcomes and service delivery.
Hospital in the Home
Recently I met a doctor who is working hard to realise this vision for his community in Townsville.
Dr Michael Young is a rural GP with advanced skills in ED and currently working as a Senior Medical Officer with the Hospital in the Home Service (HIHS) in the Townsville Hospital.
For the last 4.5 years, he has been developing a team to run the acute HITH service in Townsville.
Funded by the Queensland Government since 2014, Dr Young says it is an exceptionally efficient service which has equal or better length of stay and readmission criteria than that of an inpatient stay across a number of different diagnosis-related groups.
These models are often state-led and funded and have been around for some time. An early investment in Victoria more than 25 years ago means we now have good evidence validating the model.
Recent studies have shown significant benefits from an active HITH program affiliated with an acute tertiary hospital.
What makes the model work?
Firstly, the Townsville HITH Service runs as an acute facilitation service with a state-based tertiary hospital. The nature of the services places it as an extension to an acute care setting.
Clearly, the model can be adapted to function from other funded tiers - including primary care and residential aged care – and applying to these models is expanded on later in the discussion.
Secondly, team structure and success in part is reliant on having a doctor-facilitated referral service. This helps to build the required trust between referrers.
It is also well recognised that having a medical officer improves the scope of what you can reasonably treat in the home.
The Townsville experience sees 80 percent of patients come directly from ED while the other 20 percent are step down referred by surgeons, physicians, oncologist.
These patients are usually referred to the HITH service for ongoing care for three or four days to complete their course of antibiotics or other treatment.
The Townsville model operates leveraging three disciplines –infectious diseases physicians; general physicians and gerontologists; and general practitioners.
The GPs involved are usually rural generalists with skills in acute inpatient management and some hospitalist skills.
This brings a solid skillset to the team with GPs having familiarity with community medicine, acute medicine and with good knowledge on what can reasonably be treated in the community setting.
Thirdly, for the model to work, it needs to focus on select conditions and an agreed patient cohort that are HITH amendable services.
Hospital in the Nursing Home (HINH)
I believe a step-up approach within nursing homes is another way to apply this model.
The HITH model is currently predominantly step downs taking patients straight out of the ED and off the ward and back to the RACF to complete their treatment course or for additional care.
However, the model can flex and pilots should be encouraged particularly for HINH and in primary care as an expanded healthcare home model.
We need to focus on different models of nursing home care that can support general practitioner decisions. A step-up approach to support interventions and reduce acute hospitalisations from nursing homes.
Reducing unplanned admissions means we have to start dealing with those issues in the nursing home setting and with that requires appropriately funded infrastructure including adequate nurse support.
It would also work as a model to deliver end-of-life care. This could direct state investment in better quality end of life care facilitated by the GP out-of-hospital.
It would certainly save the $2000 on average per night for a stay in ICU for what is often considered futile treatments.
Tech platforms and monitoring through biometric devices also offer hope particularly in monitoring chronic disease in the home.
Placing the technology into healthcare homes model would help to recognise acute deterioration early. GP can step in early to prevent deterioration and avoid hospital admission.
But technology is only an enabler and we need to focus on investing in the model that underpins that technology.
In summary some key enablers for getting the model to work.
Firstly, the communication framework is really important and a lack of engagement with the referring doctor is where these models have tended to fail in the past.
Whether referral is directly from private rooms or RACF the primary GP has been involved in the diagnosis and finding ways for those lines of communication to stay open is key.
It is important when transferring that care back that a thorough yet succinct discharge summary is transmitted to the GP (and provided to the patient). A shared medical platform would be the ideal to ensure GPs have that window into the acute treatment base.
Another key point, expanding on the discussion earlier, is getting the patient selection correct. That is to clearly design the scope of what you do - clinical or disease pathways – and how you do it based on need.
Finally, in bringing together the required team – doctors, nurses and allied health professionals - to enable treatment to be administered safely and effectively in the home or RACF.
The current funding model is a key barrier in shifting resources to the community - primary care which is federally funded against state-funded tertiary care model makes this difficult.
This is the lingering elephant in the room which sees a state-funded system that cannot always see the value of investing in primary care. This is then often set against a federal funder hesitant to top up what it already sees as a large investment in tertiary care.
It’s a discussion we’ve had before and it comes down to valuing primary care and preventative work. But this investment is surely better than building larger hospitals and funding costly stays for patients that just don’t need to be there.
Whole care continuum
The ideal model is one that supports the whole care continuum so that a patient can achieve acute care whether referred from hospital or GP.
Facilitating direct admissions from the GP is where the funding discussion now needs to occur as an extension of this model. But also looking beyond acute care to enable us to broaden the services we offer such as treating chemotherapy in the home.
As we’ve discussed throughout, this model needs the right clinical and corporate governance framework around it. The right service parameters –patient selection and disease selection. It also needs volume to realise cost benefits and feeding that data back.
We already have enough evidence around the HITH model but we need to do more measuring to ensure our funders start to tangibly realise those benefits. This is the only way we can make integrated out-of-hospital care a reality.
Dr Ayman Shenouda