Guideline

Ministry of Health, NSW73 Miller Street North Sydney NSW 2060

Locked Mail Bag 961 North Sydney NSW 2059Telephone (02) 9391 9000 Fax (02) 9391 9101

http://www.health.nsw.gov.au/policies/

spacespace

NSW Hospital in the Home (HITH) Guidelinespace

Document Number GL2013_006

Publication date 20-Aug-2013

Functional Sub group Corporate Administration - GovernanceCorporate Administration - Information and dataClinical/ Patient Services - Medical TreatmentClinical/ Patient Services - Nursing and MidwiferyPersonnel/Workforce - Occupational Health & Safety

Summary Hospital in the Home (HITH) services deliver selected types ofpatient-centred multidisciplinary acute care to suitable, consentingpatients at their home or clinic setting as an alternative to inpatient(hospital) care. This guideline has been developed by clinicians toprovide clear, standardised guidance to Local Health Districts andSpecialty Networks regarding terminology, key elements and principles ofHITH in NSW. They will also support Local Health Districts and SpecialtyHealth Networks to develop, evaluate and monitor HITH services to meetlocal needs.

Author Branch System Relationships and Frameworks

Branch contact Rachel Nash 9391 9632

Applies to Local Health Districts, Board Governed Statutory Health Corporations,Chief Executive Governed Statutory Health Corporations, SpecialtyNetwork Governed Statutory Health Corporations, Public Health SystemSupport Division, Public Health Units, Public Hospitals

Audience Nursing, Medical & Allied Health, Local Health Districts, Speciality HealthNetworks,Medicare Locals

Distributed to Public Health System, Divisions of General Practice, NSW AmbulanceService, Ministry of Health, Private Hospitals and Day Procedure Centres

Review date 20-Aug-2014

Policy Manual Patient Matters

File No.

Status Active

Director-General

GUIDELINE SUMMARY

GL2013_006 Issue date: August 2013 Page 1 of 2

NSW HOSPITAL IN THE HOME (HITH) GUIDELINE

PURPOSE

In NSW, Hospital in the Home (HITH) is defined as the range of service delivery models providing (acute and post-acute) care that is delivered in home (including Residential Aged Care Facilities), clinic or other settings as a substitution or avoidance of hospital.

The HITH Guidelines have been developed by clinicians to provide clear, standardised guidance to Local Health Districts and Specialty Health Networks (LHD/SHN) regarding terminology, key elements and principles of HITH in NSW.

The need for the delivery of acute care in the home as an alternative to care in a hospital setting is being driven by advances in medicine, increased pressure on the healthcare system and evidence of improved health outcomes for patients who spend less time in hospital.

The guidelines reflect evidence based best clinical practice, expert consensus and opinion and although the guidelines are not mandatory, they have been endorsed by clinicians and NSW Ministry of Health with an expectation that the key principles will be utilised in standardising practice across NSW.

KEY PRINCIPLES

The guidelines underlying principles will support LHDs/SHNs to develop evaluate and monitor HITH services to meet local needs.

Underpinning these guidelines are the following key principles: o keeping people healthy and out of hospital o local and system level strategic planning for growth of HITH to meet acute bed

demand o mandatory reporting and data collection framework o consistency of evaluation o leveraging of funding streams including Activity Based Funding

USE OF THE GUIDELINE

Hospital in the Home (HITH) services have been developed to deliver selected types of patient-centred, multidisciplinary acute care to suitable, consenting patients at their home or clinic setting as an alternative to inpatient (hospital) care.

Where suitable, HITH services are made available to both children and adults with certain types of conditions, able to be treated outside of a hospital setting. HITH is proven to be as clinically effective as hospital care and delivers as good, if not better, health outcomes for patients in a familiar setting.

GUIDELINE SUMMARY

GL2013_006 Issue date: August 2013 Page 2 of 2

The HITH Guidelines will assist in guiding LHDs/SHNs in developing and establishing HITH services and details the requirements for the consistent implementation of data reporting for HITH services by Local Health Districts.

REVISION HISTORY

Version Approved by Amendment notes

1.0 Director General

ATTACHMENTS

1. NSW Hospital in the Home Guideline (HITH)

Hospital in the Home

Guideline

NSW MINISTRY OF HEALTH

73 Miller Street

NORTH SYDNEY NSW 2060

Tel. (02) 9391 9000

Fax. (02) 9391 9101

TTY. (02) 9391 9900

www.health.nsw.gov.au

Produced by:

System Relationships and Frameworks Branch

This work is copyright. It may be reproduced in whole or in part for study or

training purposes subject to the inclusion of an acknowledgement of the source.

It may not be reproduced for commercial usage or sale. Reproduction for

purposes other than those indicated above requires written permission from

the NSW Ministry of Health.

© NSW Ministry of Health 2013

GL2013_006

SHPN (SR) 130248

ISBN 978 1 74187 809 7

Further copies of this document can be downloaded from the

NSW Health website www.health.nsw.gov.au

August 2013

Hospital in the Home Guideline NSW HealtH PaGe 1

Contents

1 ACKNOWLEDGEMENTS ............................ 2

2 ABOUT THIS DOCUMENT ......................... 3 2.1.1 Responsibilities of local Health Districts

and Specialty Health Networks ............................3

2.1.2 Responsibilities of the Ministry of Health ...........4

2.1.3 Responsibilities of the agency for Clinical

Innovation .................................................................4

3 KEY POINTS – FOR LOCAL IMPLEMENTATION ................................... 5

4 BACKGROUND ........................................... 6 4.1 What is Hospital in the Home? .............................8

4.1.1 Definition .................................................. 8

4.1.2 PatientEligibilityCriteria ............................ 8

4.2 Hospital in the Home Principles ............................8

4.2.1 General ..................................................... 8

5 HITH SERVICE DELIVERY MODELS ......... 9 5.1 Overview ...................................................................9

5.2 Patient care need...................................................10

5.2.1 Description .............................................. 10

5.2.2 Context ................................................... 10

5.2.3 Categories ............................................... 10

5.3 Care Setting ............................................................11

5.3.1 Description ...............................................11

5.3.2 Context ....................................................11

5.3.3 Categories ................................................11

5.4 Clinical Management ............................................11

5.4.1 Description ...............................................11

5.4.2 Context ....................................................11

5.4.3 Categories ................................................12

5.5 Integration of HItH Service Delivery .................13

5.5.1 IntegrationwithAcuteFacilities ................13

5.5.2 IntegrationwithGeneralPractice .............13

5.5.3 IntegrationwithMedicareLocals ............. 16

5.5.4 IntegrationwithChronicCareprograms .... 16

5.5.5 IntegrationwithCommunityNursing ...... 16

6 OPERATIONS .............................................17 6.1 Referral process ......................................................17

6.2 Service entry – developing an initial

care plan ..................................................................17

6.3 Care plan review processes ..................................18

6.4 Capacity and Workload Management..............18

6.5 transfer of care ......................................................18

6.6 eligibility for Community Packages

(ComPacks) ..............................................................18

6.7 eligibility for Commonwealth transition

Care Program .........................................................19

6.8 Information Management and

technology (IM&t) ................................................19

6.9 Continuous Quality Improvement .....................19

6.10 Health Reform, Costing and Funding ................20

6.10.1ActivityBasedFunding ............................ 20

6.10.2ChargeablePatients ................................ 21

6.10.3Fundingpharmaceuticals ......................... 21

7 HITH DATA GUIDELINES .......................... 22 7.1 Patient selection ....................................................22

7.2 Patient registration ...............................................22

7.3 Hospital in the Home Data Collection ...............23

7.3.1 DailyHITH ............................................... 23

7.3.2 IntermittentHITH .................................... 24

7.3.3 HITHdatacollectionsummary ................. 24

7.4 Hospital in the Home Data Reporting ..............24

7.4.1 HospitalintheHomeActivity–

MANDATORY .......................................... 24

7.4.2 AvoidableAdmissionsfortargeted

conditions–MANDATORY ...................... 24

7.4.3 HITHOutcomes–RECOMMENDED ......... 24

8 KEY DEFINITIONS .................................... 26

9 REFERENCES ........................................... 28

10 APPENDIX A ............................................. 30 10.1 HItH Integration with NSW Chronic

Disease Management Program ..........................30

11 APPENDIX B ............................................. 31 11.1 HItH Data Collection and

Reporting process..................................................31

PaGe 2 NSW HealtH Hospital in the Home Guideline

NSWMinistryofHealthwouldliketoacknowledgethe

dedicationandcontributionofthefollowingprograms

andpeopleinthedevelopmentofthisGuideline:

n PreviousworkbyNSWHospitalintheHomeleaders

andHealthServicesPerformanceImprovement

Branch,includingthesuperseded2006 NSW Health

Community Acute Post Acute Care (CAPAC) and

APAC/GP Shared Care Models of Care byA/Prof

Dr.GideonCaplan,Mr.NicholasMarlow,Professor

StephenWilsonandstaffoftheNorthernSydney

CentralCoastAreaHealthServiceAcutePostAcute

Careservice

n NSWHealthHospitalintheHomeProgram

WorkingGroup

Ms Claire Blackburn,SydneyChildren’s

HospitalsNetwork

A/Prof Gideon Caplan,SouthEasternSydney

LocalHealthDistrict

Mr Grahame Colditz,NorthernSydneyLocal

HealthDistrict

Ms Anne Collings,StVincent’sHealthNetwork

Dr Nicholas Collins,SouthWesternSydneyLocal

HealthDistrict

Dr Ann-Marie Crozier,SydneyLocalHealthDistrict

Ms Pauline Dobson,HunterNewEnglandLocal

HealthDistrict

Dr Chris Geraghty,HunterNewEnglandLocal

HealthDistrict

Mr Jairo Herrera,NorthernSydneyLocalHealth

District

Dr Carolyn Hullick,HunterNewEnglandLocal

HealthDistrict

Mr Drew Kear,StVincent’sHealthNetwork

Ms Kate Lloyd,AgencyforClinicalInnovation

Mr Nigel Lyons,AgencyforClinicalInnovation

Mr Nicholas Marlow,SydneyLocalHealthDistrict

Ms Jennifer Miller,IllawarraShoalhaven

LocalHealthDistrict

Dr Michael Moore,InnerWestSydney

MedicareLocal

Prof Di O’Halloran,NSWGeneralPracticeCouncil

Dr Bin Ong,SouthWesternSydneyLocal

HealthDistrict

Ms Wendy Pietras,WesternSydneyLocal

HealthDistrict

Dr Susie Piper,IllawarraShoalhavenLocal

HealthDistrict

Dr Damian Ryan,IllawarraShoalhavenLocal

HealthDistrict

Ms Sue Saunders,MidNorthCoastLocal

HealthDistrict

Dr Penny Westmore,SydneyLocalHealthDistrict

Ms Julie Lieknins,MinistryofHealth

Ms Annette Marley,MinistryofHealth

Ms Jane Montgomery,MinistryofHealth

Ms Rachel Nash,MinistryofHealth

Mr Ian Richards,MinistryofHealth

Mr Allan Went,MinistryofHealth

Ms Nicole Whittaker,MinistryofHealth

n LocalHealthDistrictandSpecialtyHealth

Networkstaff

– HospitalintheHomeservicemanagers

andclinicians

– Datamanagers

– Executivesandmanagers.

Acknowledgements

ONE

Hospital in the Home Guideline NSW HealtH PaGe 3

Hospital in the Home services in NSW provide

acute, subacute and post-acute care to children

and adults residing outside hospital, as a

substitution or prevention of in-hospital care.

Thisdocumenthasbeendevelopedtoprovideclear,

standardisedguidancetoLocalHealthDistrictsandSpecialty

HealthNetworkmanagersandcliniciansonthedefinition

ofservicemodelsofHospitalintheHomeinNSW.

ThisguidelinewillprovidedefinitionsrelatingtoHospital

intheHome(HITH)andoutlineskeyelementsand

principlesofservicedeliverymodelsinadditiontothe

datacollectionandreportingrulestoensurethatHITH

activityiscapturedforperformancemonitoringand

ActivityBasedFunding.

ThisguidancewillalsosupportLocalHealthDistricts(LHDs)

andSpecialtyHealthNetworks(SHNs)todevelop,evaluate,

andmonitorHITHservicesthatmeetlocalneeds.

SuccessfulimplementationofthisGuideline

willassistwith:

n Assessmentofexistingservicemodels

n Localandsystemlevelstrategicplanningfor

growthofHITHtomeetacutebeddemand

n Consistencyofevaluation

n Leveragingoffundingstreamsincluding

ActivityBasedFunding(ABF)

n NegotiationwithPrivateHealthFunds

n EstablishingNSWHITHatthenationallevel

tocontributetorelevantnationalnegotiations.

Itisproposedthatasstatewideimplementation

andevaluationoftheservicemodeloccurs,aprocess

ofcontinuousimprovementwillbeusedtomaintain

thecurrencyofthisdocument.

TWO

AboutthisDocument

2.1.1 Responsibilities of Local Health Districts and Specialty Health Networks

LHDsandSHNscancontributetotheNSWHITHstrategy

forimprovedconsistency,outcomes,performance,

efficiencyandcapacityby:

n Assessingcurrentcapabilities,opportunities

andbarriersinrelationtoHITHservicestomeet

localpopulationneeds

n DevelopingDistrict/Networklevelgovernance

forHITHthat:

– IntegratesHITHaspartofoverallacutedemand

managementstrategy

– Establishesappropriateclinical,non-clinical

andcommunityengagement

– Definesandimplementsastrategicplantoincrease

HITHcapacityatbothserviceandDistrict/Network

levelsthatalignwiththeNSWHITHGuideline

– Isincludedinstrategicplanningcollaborative

initiativeswithMedicareLocalstofacilitatelocal

HITHdevelopment

– IsincludedinlocalClinicalServicePlandevelopment

– Seeksopportunitytoengageinservicerelationships

withGeneralPractice,otherLHDs/SHNsprivate

serviceproviders,whereappropriate

– Evaluatesandactslocallytocontinuouslyensure

HITHconsistency,bestoutcomes,performance

andefficiency.

PaGe 4 NSW HealtH Hospital in the Home Guideline

2.1.2 Responsibilities of the Ministry of Health

TheMinistryofHealthcancontributetotheNSWHITH

strategyforimprovedclinicaloutcomes,financial

performanceandhumanresourceefficiencyby:

n SettingclearstandardsthroughtheNSWHITH

Guideline

n Establishingpolicyandprocessesthatfacilitates

implementationofLHDHITHstrategicplans,

including:

– Aligningsystemstrategywithresourceallocation

andpurchasingandperformanceframeworks

– Dataguidelinesandrules

– FundingmodelforActivityBasedFundingforHITH

includingincentives

– Chargingmodelforprivate,compensableand

ineligiblepatients

– ServiceAgreementstoreflectthepurchasing

andperformancerequirementsforlocalprovision

ofHITH

– ServiceCompactswiththepillaragenciesto

supportservicemodelimplementation,clinical

engagement,qualityandsafetyadvice,reporting,

evaluatingandaccesstoinformation

– Developingrelationshipswithstatelevelgeneral

practiceorganisationsonstrategiestofacilitate

generalpractitionerinvolvementinHITHprograms.

2.1.3 Responsibilities of the Agency for Clinical Innovation

TheAgencyforClinicalInnovationcancontributetothe

NSWHITHstrategyforimprovedconsistency,outcomes,

performanceandefficiencyby:

n Establishingstrongclinicalengagement,innovation,

implementationandevaluationnetworkswithand

betweenLHDs/SHNsatmultipleorganisationallevels

n EstablishingstrongrelationshipswiththeMinistryof

Healththatfacilitatealigningstrategic,resource,

purchasingandperformanceopportunitieswith

demonstratedsystempriorities

n SeekingopportunitytointegratetheNSWHITH

Guidelineservicemodelstrategicallyintothebroader

outofhospitallandscape.

Hospital in the Home Guideline NSW HealtH PaGe 5

KEY POINTS PAGE

Patient care need for HItH is categorised as Daily or Intermittent 10

a variety of care settings are available to align with patient & local needs 11

For each entry to HItH, medical management is agreed and documented 13

Where a GP management model is used, local processes for funding a GPs activity are established 13

Development of locally appropriate referral processes that facilitate equity and ease of access 17

Risk screening should occur at the time of referral 17

HItH services will have systems in place, including an after-hours procedure, to recognise and manage deteriorating patients

17

a Collaborative care plan review should occur between patient, carer, GP and HItH to tailor the treatment plan to patient needs

18

HItH services will have systems in place, where clinically appropriate, to avoid a patient representing through emergency Department

18

HItH services will have systems in place for effective clinical handover at the transfer of care 18

Information management systems must support coding, record management, data collection and reporting for HItH

19

Development of quality, safety and professional improvement processes to share innovation and implement local solutions for local problems

19

each patient entering HItH care will be registered according to PD2007_094 Client Registration Policy 22

Daily HItH data will be collected in the Patient administration System/admitted patient data collection and coded as Bed type 25

23

Data processes must capture the transition of a patient’s care need between Daily and Intermittent HItH 23

Intermittent HItH Data will be collected in the Non-admitted Patient data collection as Service type 225 23

Daily HItH patients presenting to the emergency Department as planned or unplanned will be coded in the eD data collection as ‘type of visit 13 Current admitted Patient Presentation’ for intermittent HItH code as ‘visit type 04 outpatient presentation’

23

HItH activity is reported monthly in the NSW Health System Performance reports 24

KeyPoints–ForLocalImplementation

THREE

PaGe 6 NSW HealtH Hospital in the Home Guideline

Background

Hospital in the Home delivers equivalent or better outcomes, at better value compared with inpatient care for specific patient groups1

NSWHealthaimstoprovidethepeopleofNSWwiththe

bestpossiblehealthcare.HospitalintheHomeisakey

strategyforachievingbestpatientoutcomesaswellas

meetingcriticalgoalsandtargets,including:

n NSW20212Goal11–Keepingpeoplehealthyand

outofhospital

n ServiceAgreementsbetweentheDirectorGeneral,

NSWMinistryofHealthandLocalHealthDistricts/

SpecialtyHealthNetworks

n NationalEmergencyAccessTargets

n ActivityBasedFunding.

TheNSWMinistryofHealthiscommittedtoastrategic

andevidencebasedapproachtomanagingtheincreasing

demand3onhospitalbeds.

Evidenceshowsthatbothpeopleandthehealthsystem

benefitfromaccesstoacutecareinalternatesettingsto

inpatientcare.Thesebenefitsincludeimprovedoutcomes

inclinicalmarkerssuchasreducedlevelsofconfusionand

deliriuminpeoplewhoarecaredforathome4,highlevels

ofacceptanceofthesemodelsbyGeneralPractice5with

noincreaseincarerburden6.UsingHospitalintheHome

whenappropriateenableshealthteamsandhospitalbeds

tobemanagedmoreefficientlyandeffectively7,8.

Inarecentextensivemeta-analysisofrandomisedcontrolled

trialscomparingHITHandin-hospitalcare,Caplanetal9

showedunequivocallythatHITHissaferandmore

efficient.Thestudyanalysedhealthoutcomes,costsand

patientandcarersatisfaction,showing:

n A19%reductioninmortality

n Forevery50patientstreatedinHITH,

onelifewillbesaved

n A23%reductioninreadmissiontohospital

n HITHcosts26.5%lessthanin-hospitalcare

n Highpatientandcarersatisfaction.

Patients and Carers

✔ Preferredbypatients

✔ Abletorecoverinthecomfortofownhome

✔ Reducedriskofadverseeventsinhospital

suchasfallsandinfections

✔ Individualisedcare

✔ Patientsandcarersreporthighsatisfaction

withservice

✔ Childrenfeellessthreatenedinownenvironment/

greaterparentalroleincarepromotesfamily

centredcareprinciples.

Hospital

✔ Moreefficientuseofhospitalbeds

foracutelyillpatients

✔ ImprovedEmergencyAccessPerformance

✔ Reducedlengthofstayinhospital

✔ Reducedadverseeventsfromhospitaladmission

✔ Increasedstaffsatisfaction

✔ Bettervalue

✔ OpportunitytoleverageActivityBasedFunding.

General Practice (GP)

✔ Improved,co-ordinatedinteractionwith

aspecialisedhospitalservice

✔ Appropriatecareforpatientsinthecomfort

oftheirownhome

✔ GPsmanagepatientsintheirownenvironment.

Thereare67servicesinNSWprovidingHospitalin

theHomecare.Theseoperateunderavarietyofnames

andhavedevelopedheterogeneously,inresponseto

identifiedlocalneedsandasaconsequencehavea

varietyofoperationalsystems.

FOUR

Hospital in the Home Guideline NSW HealtH PaGe 7

HospitalintheHomeservicesinNSW–August2013

In2011/12therewereover18,000admissionstoHITHin

NSW10whichrepresents2.0%ofovernightseparations

inpublichospitals10.ByincreasingadmissionstoHospital

intheHometothepublishedVictorianrateof5.4%11,

NSWcouldreleaseapotentialannualefficiencyof$33M.

SignificantinequityintheuptakeofHITHfortargeted

diagnosticrelatedgroups(DRG)alsoexistsacrossNSW.

Forexample,deepveinthrombosis(F63B)hasthehighest

admissionratetoHITH,withanaverageof61%across

thestate.

Howeveradmissionratesrangegreatlyfrom25-93%

acrossdifferentfacilities.Cellulitis(J64B)admissionrates

rangefrom1-34%.

Thereisaclearopportunitytoreduceunwarranted

variationandincreasetheoveralluptakethroughaligning

HITHcapacitytomeettheneedsofthepeopleofNSW.

Hospital in the Home Program

AHospitalintheHomeProgramWorkingGroupofLocal

HealthDistrict,SpecialtyHealthNetworksandGeneral

PracticeexpertswasestablishedinJune2011tobuild

capacityinHospitalintheHomeforthesustainable

provisionofsafe,effectiveandperson-centredacutecare

insettingsotherthananinpatientbed.

TheNSWHITHProgramWorkingGroups’objectivesare:

1 NSWHITHserviceshaveconsistent,measurableand

clearlydefinedservicedeliverymodels

2 NSWLocalHealthDistrictshaveaclearlydefined

strategytoincreasetheirHITHcapacitytomeetthe

needsofspecifictargetpatientgroupsandtheir

broadercommunity.

HITHcapacitywillnotbeincreasedinisolationofother

programsandsectors,butwillseekcoordinationand

integrationofoutofhospitalcarethatrespondsto

patientsneeds,changingtechnology,bestpracticeand

theevolvingcollaborationwithMedicareLocals.

ThesuccessofHITHdependsonsponsorship*and

strategicsystemplanningfromseniorlevelsofLHDand

SHNmanagement,particularlyintheearlystagesof

programdevelopment.AstrategicapproachtoHITHwill

reduceduplicationorinequityofserviceswithinadistrict.

*  See Key Definitions on page 26.

PaGe 8 NSW HealtH Hospital in the Home Guideline

4.1 What is Hospital in the Home?

InNSW,HospitalintheHomereferstoclinicalservices

thathavebeenestablishedbyLHDs/SHNs,ideallyin

collaborationwithMedicareLocalsandGeneralPractice

servicestobothsubstituteimmediateandpreventfuture

admissiontoinpatienthospitalbeds.

4.1.1 Definition

HospitalintheHome(HITH)servicesprovideacute†,

subacute‡andpost-acute§caretochildrenandadults

residingoutsidehospital,asasubstitutionor

preventionofin-hospitalcare.Theplaceofresidence

maybepermanentortemporary.

Substitution–Thedefiningfeatureisthatifthepatient

isnotreceivingtheHITHservice,thepatientwould

requirehospitalisationoralongerstayinhospital.

Prevention–Carethatdoesnotimmediatelysubstitute

forahospitalstay,howeveritisprovidedasa

preventativeoptiontoavoidanimminenthospital

admissionorreadmission.

Apersonmayreceivetheircareathome(including

ResidentialAgedCareFacilities)orinanambulatory

settingthatmayincludeahospital,communityclinic

setting,schoolorworkplace.

HITHcareisshort-termandpreferablyinterdisciplinary,

includingdoctors,nursesandalliedhealthpractitioners.

Hospital in the Home services must provide acute /

subacute care substitution (Daily HITH – p.10). These

services may provide additional preventative care

(Intermittent HITH – p. 11) as an adjunct to maintain

the short term continuum of care.

†  See Key Definitions on page 26.

‡  See Key Definitions on page 26.

§  See Key Definitions on page 26.

4.1.2 Patient Eligibility Criteria

ThesecriteriamustbesatisfiedtobeeligibleforHospital

intheHome:

n Presenceofanacute,subacuteorpost-acute

condition

n HITHservicecansafelyprovidetherequiredpatient

carewhichmeetsevidencebasedguidelines

n Patientsmustbemedicallystableandnotrequirehigh

clinicalsupport(multi-morbidpatientswithcomplex

needsareeligible)

n Medicalresponsibilityestablishedandagreedbased

onHITHPrinciples

n Patientresidespermanentlyortemporarilyin

catchmentarea

n Agreementofthepatientorsubstitutedecision

maker¶toreceiveHITH

n Adequacyofthehomeenvironmenttoprovidethe

needsofdailyliving

n Safetyofstaffinthehomeisassured

n Accesstoareliablemobileorlandlinetelephone.

4.2 Hospital in the Home Principles

4.2.1 General

ThefollowingprinciplesunderpinthedeliveryofHITH

careinNSW:

n Person-centred,continuing,comprehensiveand

interdisciplinarycare

n Easeofaccesstotheservicebythosewhoneedit

n Voluntarypatientparticipation

n Cost neutral to patientandcarers-asaresultof

receivingHITHcare,aMedicareeligiblepersonshould

notincurcostsinadditiontothosetheywouldhaveif

receivingcareinhospital

n Full involvement of patientsandcarersthrough

takinganactiveroleincareplanningandtreatment,

sharingresponsibilityfortheirowncarewiththe

HITHteam

n Time-limitedcarewithrapidresponseandtransfer

ofcare

n 24/7 Emergency Response–processesfor24hour,

7dayperweek,emergencyresponse

n Highquality,safecareadministeredbyappropriately

skilledworkforce.

¶  See Key Definitions on page 26.

Hospital in the Home Guideline NSW HealtH PaGe 9

InNSWarangeofHITHservicesarerequiredtomeetthe

needsofindividualsandsystems.

MappingexistinglocalHITHservicemodelsagainstthe

definingelementswillassistLHDs/SHNstounderstand

anddevelopHITHservicestomeetbothlocalpatientand

healthservicedemandneeds.

5.1 Overview

TheapproachtodescribingHITHservicedeliverymodels

inNSWhasbeentofirstlyidentifydefiningelementsthat

differentiateonemodelfromtheothers:

n Patientcareneed

n Clinicalmanagement

n Caresetting.

Secondly,elementssupportingoperationanddata

processeshavebeenidentifiedthatareconsistenttoall

HITHmodels–operations,safetyandquality,outcome

measurementandintegration.

HITHServiceDeliveryModels

FIVE

Patient Care Need

Care setting

Clinical Management

SAFETY & QUALITYOPERATIONS

OUTCOME MEASUREMENTINTEGRATION

· Medical management

· Funding / Credentialling

· Provider – Hospital, Community Health, GP

· After hours / Leave cover

· Setting – home, ambulatory (clinic, RACF, community)

· Geography & Transport

· Care type – acute / subacute / post-acute (admitted / non-admitted)

· Service intensity

· Service accessibility

PaGe 10 NSW HealtH Hospital in the Home Guideline

ThekeyelementsdefinethedecisionpointsindeliveringindividualisedHITHcare.

NOT HITH· Admit to hospital· Refer to GP· Refer to other service

Does the patient meet

eligibility criteria for HITH?

Do they require DAILY review of

treatment?

Daily HITH

Intermittent HITH

CARE DELIVERY AND REVIEW

Yes

No

No

Yes

Who will be primarily

responsible for medical care?

GP

Specialist

Shared

Where is care predominantly

delivered?

Home

Ambulatory

See 5.4

See 5.3

See 5.2

Theparticularmodel(s)establishedacrossthestatewill

dependonlocalneedandresources.However,any

chosenservicedeliverymodelwillbeconsistentwith

theseguidelines.

By clearly defining and classifying Hospital in

the Home patients, LHDs/SHNs will be able to

benchmark their HITH services with similar services

and understand their HITH activity in relation to

national and state activity targets.

5.2 Patient care need

The patient care need is the defining factor as

to whether a person’s entry to HITH is clinically

equivalent to an admission or not.

5.2.1 Description

Patientcareneedistheacuityandintensityofcare

requiredbyanindividual.

5.2.2 Context

Careneedisdeterminedthroughcomprehensiveclinical

assessment,agreedbythemedicalofficerresponsible

andreviewedregularly.Carewillbedeliveredaccording

toindividualneedwithrespecttotheirsafetyandthatof

thecaredeliveryteam.TheNSWAdmissionPolicy12

definesthecriteriaforanadmittedpatientbasedon

definitionsofintendedmedicalcareandintended

procedure.Intensityandacuityofneedwillchange,and

servicedeliveryshouldreflectthis.

5.2.3 Categories

Daily HITH

Anindividualrequiringatleastdailyclinicalcareand

assessmentoftheirtreatmentneedswillbeclassified

asclinicallyequivalenttoanadmitted**patient.

DailyHITHsubstitutesforinpatientcareandmay

includeacuteandrehabilitationcaretypes.Access

tomedicalcaremustbeavailable24hoursperday,

inthehomeorothersetting.

**  See Key Definitions on page 26.

Hospital in the Home Guideline NSW HealtH PaGe 11

Assessmentoftreatmentneedsisperformedbyan

experiencedclinicianandmaybedoneface-to-faceoras

acombinationofface-to-faceandtelephoneassessment.

Telephoneassessmentmustbedocumentedinthe

medicalrecordandadocumentedescalationprocess

mustbeestablishedforeachindividual.

Intermittent HITH

Anindividualwithpredominantlypost-acutecareneeds

whorequireslessthandailyclinicalassessmentoftheir

treatmentneedstopreventadmissionorreturnto

hospitalwillbeclassifiedasnon-admitted.Intermittent

HITHisdeliveredinordertopreventanimminent

hospitalisationorareadmission.Itisclinicallyequivalent

tonon-admittedcare.

Key points to remember

n PatientcareneedforHITHiscategorisedasDaily

orIntermittent

n DailyHITHdatawillbecollectedinthePatient

AdministrationSystem/Admittedpatientdata

collection

n IntermittentHITHDatawillbecollectedinthe

Non-AdmittedPatientdatacollection

n Dataprocessesmustcapturethetransition

ofapatient’scareneedbetweenDailyand

IntermittentHITH.

5.3 Care Setting

Differentiatingthevariouscaresettingsrecognisesthat

thebestlocationtodeliveroptimalcaremaydependon

thepatientneedandlocalserviceoptions.

HospitalintheHomeservicesandLHDs/SHNswillnote

thattherearedifferentcostsrequiredtodelivercarein

differentlocations.

5.3.1 Description

Caresettingisthepredominantplacewherethecareis

delivered.

5.3.2 Context

ForallservicedeliverymodelsofHITH,thepatientresides

outsideofthehospital.

Anindividualmayreceivecareinanumberofsettings

duringthesameepisodeofcare.Thepredominant

settingisusedforcategorisationpurposestoimprove

outcomemeasurementandbenchmarkingandto

facilitateActivityBasedFunding.

Duetothecomplexitiesofpeople’slivesavarietyof

settingsshouldbeavailable.Thispermitspatientchoice

andallowsforadegreeofpatientempowerment.

5.3.3 Categories

Home

Careisdeliveredintheindividual’splaceofresidence.

ThismayincludeaResidentialAgedCareFacilityor

supportedaccommodationinthecommunity.

Ambulatory Setting

Careisdeliveredinahospitalclinic,communityhealthor

primarycarecentreorothercommunitysettingsuchasa

schoolorworkplace.

Wherecareisdeliveredinaschoolorworkplace,the

organisationmustalsoconsenttotheindividualreceiving

careinthatlocation.

Key point to remember

n Avarietyofcaresettingsareavailabletoalign

withlocalneedandresources.

5.4 Clinical Management

Thevariousmodelsofclinicalmanagementhaveevolved

toprovidegreateraccesstoHITH.Thisvarietydoesnot

changethecarereceivedbythepatientbutresultsindifferent

costing,fundinganddataimplicationsforLHDs/SHNs.

Opportunitiestointegrateclinicalmanagementbetween

LHDs/SHNsandGeneralPracticewillbedependenton

localcircumstances,particularlywiththeevolutionof

MedicareLocals.

5.4.1 Description

Clinicalmanagementisprimarilydefinedbythemedical

officerwhoismanagingtheepisodeofHITHcare.

5.4.2 Context

HITHservicesrequireorganisationalandclinical

governancesystemsthattakeintoaccountpatientacuity,

clinicalaccountabilityanddeliveryofqualityoutcomes.

PaGe 12 NSW HealtH Hospital in the Home Guideline

Whileclinicalmanagementisultimatelyaboutpatient

care,itisimportanttonotethatindevelopingHITH

services,differentclinicalmanagementmodelswillhave

varyingimplicationsforfundingoptions.

5.4.3 Categories

Medical Management

Itmustbecleartothepatient,theircarerandthe

patient’steamwhoisresponsibleformedicalsupervision

duringtheHITHepisodeofcare.

Processesfor24/7emergencymedicalresponseshould

beestablishedlocally,includingcoverforleaveandafter

hours.

Specialist care

Astaffspecialist,VMO,locummedicalofficerorprivate

specialistacceptsmedicalmanagementofthepatient.

Ajuniormedicalofficercannottakeonthisrole.

General Practice (GP) care

AGeneralPractitioneracceptsmedicalmanagementof

thepatient.

GPswithoutadmittingrightscannotprovidethemedical

supervisionforDailyHITHpatientswheretheyare

remuneratedthroughMedicare.(Seepage15forfurther

discussion)

Shared care

Amedicalmanagementarrangementofacombination

ofSpecialistandGPcareisagreed.

Sharedcarecanbedefinedasjointparticipationinthe

planneddeliveryofcareofdifferentspecialistmedical

officersoraGPandaspecialistmedicalofficer13.This

modeliscommoninchronicdiseasemanagement,

mentalhealthandantenatalcare.

Essentialelementsareagreed:

n Clearpractitionerresponsibilities

n Proceduresandprotocols

n Resourceallocations.

Interdisciplinary Care Delivery

Regardlessofthemedicalmanagementmodelinplace,

theHITHcaredeliveryteamcanvary,withconsequent

implicationsforlocalresourcing.Thereisnotstrong

evidenceforapreferredstructure.

Stand alone HITH team

Theteamisformedspecificallyforthepurposeof

deliveringHITHcare.Inthismodel,theHITHservicehas

itsownmedical,nursing,alliedhealthanddomiciliary

careandsupportstaffthatareemployedandresourced

directlyastheHITHteam.

SuchamodelallowsforanoptionwhereaHITHteam

mayberesourcedseparatelyfromanacutehospital,and

servicesareentirelydeliveredbyaprimary/community

careteam.

HITH integrated team

Theteamisdevolvedwithmedical,nursing,alliedhealth

anddomiciliarycareandsupportstaffemployedbya

mixtureofhospital,communityandprimarycare

providers.ThisHITHteamiscoordinatedandfunctions

accordingtotheindividualneedsofpatients,withoutthe

needfordedicatedHITHresourcing.

Suchamodelallowsforflexibilitytomeetthedemand

needsofthesystem,sothatmoreclinicianscanbe

integratedintotheteamtomeethighdemand,or

releasedbacktotheirprimary,acuteandcommunity

teamsasrequired.

Inthismodelitisessentialtoensurethatthereisno

ambiguityastothemedicalmanagementofthepatient.

Supervised Self-Administration

Supervisedself-administrationhasbeendemonstratedto

haveequivalentoutcomestohealthcareworker

administrationinselectedpatientsreceivingintravenous

treatments14,15.Thepatientortheircarerchoosesthe

optionofcliniciansupervisedself-administrationandis

educatedtoadministertherapybytheHITHteame.g.

administrationofhomeIVantibiotics.

Thecareisdirectedbyamedicalofficer.TheHITHteam

reviewsthepatientcaredaily(non-face-to-face),andhas

aminimumweeklyface-to-faceassessmentofprogress

bythetreatingmedicalofficerandHITHteam.The

patientandtheircareraresupportedby24houroncall

nursingandmedicalstaff.

Paediatric Hospital in the Home

Currently,dedicatedpaediatricHITHservicesaresituated

intertiarypaediatrichospitals.Otherpaediatricservices

mayalsoprovideHITHcarewithinthesuiteofcare

delivered.

Hospital in the Home Guideline NSW HealtH PaGe 13

ThegeneralprinciplesofHITHrelatingtopatientcare

need,caresettingandmedicalmanagementapplyto

servicestargetingchildrenandyoungpeople.

AdditionalobjectivesfromNSWKidsandFamilies16 can

beappliedtothedeliveryofHITHservicestochildrenand

youngpeople:

n Equitableuniversalaccesstochildren’shealthservices

acrossthespectrumofcare

n Childrenachievingtheiroptimalhealthand

developmentaloutcomes

n Adherencetotheprinciplesofpatientcentredcare

n Theabilityofachildtoenterthehealthsystematany

placeandbegiventherightlevelofcareinthemost

appropriateenvironment

n Thesystemwillrespondtothechild

n Safeservicesareprovidedasclosetohomeas

possible

n Parentshaveresponsibilityasprimarycarersfortheir

children’shealthandneedtobeactivelyengagedin

buildingthechildandfamily’shealthandwellbeing.

Principles for Paediatric HITH

n ThemajorityofpaediatricpatientseligibleforHITH

requireshorttermacutetreatment(theseacute

episodesmayormaynotbeassociatedwithlonger-

termconditions)

n Childrenwithpalliativecareneedsrequiringepisodes

ofacutecaremayalsobeeligible

n Specialistacutepaediatricskills(medical,nursing&

alliedhealth)arerequiredforthebestoutcomesfor

childrenandfamiliesreceivingHospitalintheHome

n ClinicalmanagementofpaediatricHITHwill

predominantlybethroughspecialistcare,i.e.General

orSub-SpecialistPaediatricians(including

neonatologists)whoareappointedtohospitalbased

acuteservice’s

n Sharedcaremodelsofcareareoftenprovided

betweenlocalpaediatricservicesandtertiary

paediatriccentres.

Key points to remember

n ForeachentrytoHITH,medicalmanagementis

agreedanddocumented

n WhereaGPmanagementmodelisused,local

processesforfundingaGPsactivityareestablished

n It isnotessentialthataHITHteamhasitsown

dedicatedclinicianresources.Itispossibletousean

integratedmodeltoflexcapacitytomeettheneeds

ofpatientsasrequired.

5.5 Integration of HITH Service Delivery

Alocallyappropriate,district-wideapproachtoHITH

serviceplanninganddeliveryisrecommended.This

approachshouldclarifytheservicerolesofrelated

programsandseekintegrationofprogramswithprimary

andcommunitycarewherepossible.

Integrationisconcernedwiththeprocessesofbringing

organisationsandprofessionalstogether,withtheaim

ofimprovingoutcomesforpatientsandserviceusers

throughthedeliveryofintegratedcare17.

Integrationensurescontinuity,whichisfundamentalto

high-qualitycare.Withoutit,careisunlikelytobeclinically

effective,safe,personalised,efficientorcost-effective18.

HospitalintheHomemostsignificantlyinterfaceswith

hospitals,GeneralPractice,PrimaryandCommunityCare

andChronicDiseaseManagementprograms.Defining

clearroles,responsibilitiesandopportunitiestowork

collaborativelyisessentialtoreducingclinicalriskwithin

siloedservicesandunnecessaryduplication.

5.5.1 Integration with Acute Facilities

HITHprovidesacutecaredeliverythroughhospital

substitution.Inmanagingdemand,HITHdevelopment

shouldintersectwithEmergencyDepartmentmodels

ofcare,plannedadmissionstrategiesandshortstay

(EDbypass/3rddoor)options.

Inaddition,paediatricHITHteamsmayconsiderfacilitating

linkswithNeonatalIntensiveCareUnits,Specialist

Children’sHospitals,Paediatricinpatientandspecialist

teams,AmbulatoryCare,MedicalAssessmentUnitsand

theirPalliativeCare,SocialworkandPsychologyservices.

5.5.2 Integration with General Practice

GeneralPracticeisthepredominantproviderofprimary

careinAustraliadeliveringover118millionpatient

consultationseachyear19.IntegrationwithGeneral

Practice(GP)isessentialforsuccessfuloutcomesand

capacitybuildingforHITHservices.

PaGe 14 NSW HealtH Hospital in the Home Guideline

Inanenvironmentofnationalandstatehealthreformthe

relationshipbetweenLHDs,SHNsandGPsischanging,

collaborationbetweenDistricts,NetworksandMedicare

LocalswillbecriticalinthesuccessofHITHdevelopment

acrossNSW.

General Practice and HITH

HITHisdeliveredthrougharangeofclinicalmanagement

modelsthatincludeGeneralPractice.Withdiffering

practicesize,workforceandcapacitythereisnosingle

approachtointegratinglocalHITHdevelopmentwithin

GeneralPractice,howevertherearedifferentlocal

implicationsforeachmodel.

Hospital Substitution (Hospital in the Home)

Hospital in the Home

· Daily or Intermittent

· Home or ambulatory

ComPacks

· Non-clinical services to support early discharge

Community Nursing

Primary & Community Care

Chronic Care

Palliative Care

Aged Health

Out of HospitalCare

General Practice

3rd Door OptionsInpatient

Short Stay UnitsEg. Medical Assessment Units,

Urgent Care Centres

Planned Admission InpatientWards

ED StreamingQuick TriageEmergency

Department (ED) Models and Units

General Practice

GP ONLYGP only(clinicalmanagementandcare)

GP(medicalmanagement)andPractice Nurse / Residential Aged Care Facility (RACF) nurse(clinicalcare)

GP AND LHD GP(medicalmanagement)andLHD Specialist/ nursing / allied health(clinicalcare)

LHD ONLY Specialist(medicalmanagement)andLHD nursing / allied health(clinicalcare)

HITH Patient Streaming

Hospital in the Home Guideline NSW HealtH PaGe 15

InconsideringoptionsforGPintegrationwithHITHprograms,therearebarriersandincentivesfordevelopingHITH

servicesinpartnershipwithGeneralPracticetheseinclude:

INCENTIVES BARRIERS

n Preferredbypatients n Maintainscontinuumofcare n Broadenedscopeofpractice n PotentialfinancialincentiveforGP n Directaccesstomedicalspecialistreviewasrequired n OpportunitiesforGPsandpracticeteamtoaccesseducationrelatedtokeyconditions

n Accesstocommonclinicalguidelinesandotherdecision supportresources

n Accesstostatefundedadditionalteammembers

n LackofGPcapacitytotakeonadditionalworkloadandresponsibility

n UnclearprocessesforremuneratingGPstomanageadmittedpatients

n HistoryofdifficultGP–LHDrelationships n Practicenurseavailability n Requiresongoingeducationandevidencebase n Fundingofconsumables n RealtimeaccessbyGPtosecuremessagingmedicalrecords, testresults

n IntegrationandconnectivitybetweenGPandLHDITsystems n AdequatelevelsofsupportandaccessforGPs

Remuneration of GPs in HITH

InclusionofGPsinclinicalgovernancemodelsforHITHrequiresclearinterdisciplinaryandorganisationalagreements,

transparentremunerationstrategiesandshareddecisionsupporttools.Theappropriatemodelshouldbedecidedlocally,

consideringtheimplicationsforeachoption.

GPmanagementofnon-admittedpatientsisfundedbyMedicare.Withoutadmittingrights,aGPcannotclaimthe

MedicarerebateforreviewingMedicareeligibleHITHpatients.

OptionsforremuneratingGPmanagementofadmittedpatientsare:

GP OPTION IMPLICATIONS

1. Provide GP with admission rights to HITH services

n EnablesdirectadmissiontoHITH,bypassingEDwithclinicalmanagementremainingwithGP n Medications/disposablesfundedbyLHD n Credentialingissues –RequireslocalMedicalandDentalAdvisoryCommitteeapproval –MayneedtoconsiderVirtualFacility –AddedresourcesrequiredforaGPs‘admittingrights’arrangements –Consideraccreditationoptions

n Requiresdevelopmentofpartnershipswithcommunitybasedpharmaciststostockparticipating doctorssurgerieswiththerequiredmedications

2. Brokerage with Medicare Locals / GPs

n LHDpurchasesGPservices –BrokeragethroughMedicareLocals –ContractfordirectpaymenttoGP

n AvoidsGPclaimingMedicareforinpatientcare n Medications/disposablesfundedbyLHD

PaGe 16 NSW HealtH Hospital in the Home Guideline

5.5.3 Integration with Medicare Locals

MedicareLocalsareprimaryhealthcareorganisations

establishedtocoordinateprimaryhealthcaredeliveryand

tacklelocalhealthcareneedsandservicegaps.Theywill

driveimprovementsinprimaryhealthcareandensure

thatservicesarebettertailoredtomeettheneedsof

localcommunities,includingimprovingintegrationand

accountabilityacrossthehealthsystem.

MedicareLocalswillbeaccountableformeeting5

strategicobjectives20

n Improvingthepatientjourneythroughdeveloping

integratedandcoordinatedservices

n Providesupporttocliniciansandserviceprovidersto

improvepatientcare

n Identificationofthehealthneedsoflocalareasand

developmentoflocallyfocusedandresponsive

services

n Facilitationoftheimplementationandsuccessful

performanceofprimaryhealthcareinitiativesand

programs

n Beefficientandaccountablewithstronggovernance

andeffectivemanagement.

AsMedicareLocalscommenceanddevelop,LHDs/SHNs

willneedtoexploreopportunitiesforreorientingand

reconfiguringthewayhealthcareandservicesare

providedacrossthehospital-communityinterface.

Thiswillinevitablyincludeexploringwaystoreduce

unnecessarypreventablehospitaladmissions,which

includeHITHstrategies.

Somesuggestedstrategies21are:

n Establishaformalcollaborativeagreementwhich

identifiessharedpriorities,agreedwaysforwardand

specificresponsibilitiesforeachinitiative

n Establishclinicalgovernanceprocesseswhichinclude

feedbackofclinicalinformationtolocallevelsto

supportlocalclinicalqualityimprovementprocesses

n Establishopenandeffectivecommunication

mechanismstoroutinelyshareinformationonlocal

needsandavailabilityofservices

n Developinformationresourcesthatmeettheneedsof

GeneralPracticeandthecommunity

n Shareknowledgeandexpertisewhendeveloping

services

n IdentifyandmitigatebarrierstoGeneralPractice

participationinservicedelivery

n Jointworkforcedevelopmentstrategies.

5.5.4 Integration with Chronic Care programs

Morethanhalfofallpotentiallypreventable

hospitalisations††arefromselectedchronicconditions22.

EffectivecollaborationbetweenHITHservicesandchronic

careprogramsisessentialforeffectiveexacerbation

managementthroughthedeliveryofacutecareinthe

homeasasubstituteforhospitalcare.Sharedcare

planningcouldincludeanexacerbationactionplan

specifyingthispreferenceforcare.

SeeAppendixAforamodelofChronicDisease

ManagementshowingrelationshiptoHITH.

5.5.5 Integration with Community Nursing

Communitynursingincludesbothgeneralcommunity

nursesundertakinghome(domiciliary)visitingand

specialistsconductingservicessuchasnurse-ledclinics

focusingonchronicdisease,childhealth,women’s

health,palliativecareandotherspecialties.Community

nursesworkwithapopulationhealthfocusinavarietyof

settings.Theyareinvolvedincoordinatingcarein

multidisciplinaryenvironments23.

CoordinateddeliveryofHITHwithintheCommunity

Nursingserviceensuresthecontinuumofcareis

maintained,reducesduplicationofserviceandtakes

advantageofexistingskillandrelationshipswithin

primaryhealthcare.

††  See Key Definitions on page 26.

Hospital in the Home Guideline NSW HealtH PaGe 17

ThekeyoperationalelementsofHospitalintheHomeare

commontoallservicedeliverymodels.

6.1 Referral process

n Localreferralprocessesshouldbemadeassimpleas

possibletopromoteHITHaccessandequity.

n ReferraltoHITHmustbemadeasaresultofaclinical

decision.

n Localprocessesshouldbedevelopedtoaccept

referralsfrom:

– EmergencyDepartment

– Outpatientclinics

– Hospitalwardsandclinics,pre-admission

andmedicalstaff

– GeneralPractice

– Specialists-private,communitybased,rooms

– MedicalAssessmentUnitsorsimilarshortstayunits

– Directreferralfromexternalreferrers

toavoidinpatientadmission

– Privatehospitals

– Nursinghomes,hostelsandagedcarefacilities

n Case findingwillfacilitateacoordinatedreferral

toHITH.

6.2 Service entry – developing an initial care plan

n Followingreferral,theHITHserviceshouldensure

patientagreementandregistrationprocessesare

complete

n Alocalriskassessmentprocessshouldoccurattime

ofreferral:

– Clinicalriskincludingamedicationriskassessment

– Physicalenvironmentofthehome,associated

accessarrangements,parkingandanimals

– Aggressionriskfrompatientand/orothers

– Manualhandlingrisks

– Utilisation/effectivenessofcommunicationdevices

inthehomeandsurroundingareas(egmobile

phonecoverage)

– Drugandalcoholconcerns,includingsmokingin

thehome

– Non-clinicalsupportrequired

n Thepatientand/orcarershouldbefullyinformed

abouttheoperationaldetailsoftheHITHservice,

andprovidedwithcontactinformation

– 24/7emergencycontactinformationandresponse

processesareessentialforthepatientandcarerto

understand

n Atwo-wayrelationshipshouldbeestablishedwith

thepatient’sGP,whethertheyaremanagingthe

HITHcareornot,andothercareprovidersasrelevant

– IfthepatientdoesnothaveaGP,theHITHteam

willworkwiththepatienttoidentifyone

n Acomprehensiveassessmentofthepatient,carerand

theirenvironmentisnecessaryforanindividualised

careplantobedeveloped(see6.3). Theplanismade

inconjunctionwiththepatient,theircarerandother

serviceproviders.Thepatientshouldbeprovidedwith

acopyofthecareplan,including:

– Instructionsonwhatmeasurestotakeshould

anycomplicationsariseandhowtocontact

theon-callservice

– Medicationmanagementplan

– Informationontransportarrangements/options

– Informationregardingtheservice,pharmaceutical

use,rightsandresponsibilitiesofpatient,carer

andstaff

– Itmaybenecessarytotranslatethisinformation

forculturallyandlinguisticallydiversepatientsand

gainconfirmationthatthepatientfullyunderstands

theinformation

n Thepatientand/orcarerhavetherighttowithdraw

fromtheHITHserviceatanytime,oriftheHITHstaff

findthathomebasedcareisunsafeorineffective.

IntermittentHITHpatientscanbereferredto

alternativeservices.

DailyHITHpatientscanbeadmitted/readmittedto

theinpatientfacilityfortheremainderoftheirepisode

ofcare.Themedicalofficer,thepatient’sGPand

othercommunity-basedservicesmustbenotified

ofthepatient’schangeincarearrangementsassoon

aspossible.

Operations

SIX

PaGe 18 NSW HealtH Hospital in the Home Guideline

6.3 Care plan review processes

n Acollaborativecareplanisdevelopedforeach

individualandreviewedregularly.Thecareplan

shouldconsidernotjustthemedicalandnursingcare

requiredbutalsotheindividual’ssocial,functional,

environmentstatus,needsandadvancecareplanning

choices

n Patientsandcarersarepartnersinthecareprocess

andareencouragedtoactivelyparticipate

n Plannedmedicalreviewisrequiredtoensuretailoring

ofthetreatmentplantothepatient’sneed

n HITHserviceswillestablishprocessestoensurethe

recognition,responsetoandmanagementofpatients

whoareclinicallydeteriorating

Patientsandcarersaresupportedthrougheducation

andwritteninformationofthesymptomsof

deteriorationandunderstandtheactionsrequired.

RefertoPD2011_077Recognition and Management

of Patients Who Are Clinically Deteriorating.

6.4 Capacity and Workload Management

n HITHispartofwholeofsystemplanningtodeliver

patientsthebestcareandmanageacutedemand.

It isessentialthatDailyHITHservicesarefacilitatedto

flow,byensuringthatsubstitutionpatientsonly

occupytheserviceforaslongastheyclinicallyrequire

n ThesystemrequiresHITHserviceplanningstrategies

thatcansupportafluctuatingworkloadincluding:

– Earlypatientreferral

– Inclusioninpatientflowmanagemente.g.inclusion

inPatientFlowPortal

– Earlynotificationofsignificantclinicaleventseg

operatingtheatreclosure,potentialworkforce

shortagessuchasmedicalconferences.

6.5 Transfer of care

n ThedecisiontoceaseHITHtreatmentismadebythe

teamwhenthepatientnolongerrequiresacuteor

post-acutecareasasubstitutionorpreventionof

in-hospitalcare

n HITHpatientshavetheoptionofself-discharge,under

thesameprocessasfromhospital

n HITHpatientsarereferredtomainstreamcommunity-

basedservicesassoonasitisclinicallyand

operationallyfeasibletodoso

n TheHITHpatient’smaintenancecareand/orongoing

monitoringandreviewareidentified,andaplanis

developedpriortotransferofcareincludingthe

clinicianresponsible

n Ondischargepatientsandcarersshouldbeprovided

with:

– Dischargereferralinformation,medication

managementplanandfollowupappointmentsfor

Specialists,GPsandotheragencies

– Communitysupportcontactinformationand

referralmade,whereappropriate

n HITHpatientsshouldnotbedischargedfromthe

serviceuntilclearprocessesareinplaceforongoing

care,ifrequired

n WhenapatientcompletesaHITHepisode,the

treatingGeneralPractitionerreceivesadischarge

summaryfromtheHITHservice

n Aclearlydefinedpathwayforpatientstoaccessa

higheracuityserviceshouldbeavailableforthose

patientswhorequireaccesstohospitalbasedcare

– Whereitisnecessaryforapatienttoreturnto

hospitalandfinishtheircareasahospitalin

patient,considerationshouldbemadetoaccess

careviaalternativeroutesratherthanthroughthe

EmergencyDepartment

n ClinicalHandoveroccursaccordingtoNSWHealth

policydirectivePD2009_060Clinical Handover –

Standardised Key Principles.

Key point to remember

n HITHserviceswillhavesystemsinplace,where

clinicallyappropriate,toavoidapatientrepresenting

throughEmergencyDepartment

6.6 Eligibility for Community Packages (ComPacks)

n AComPackspackageisanon clinicalcasemanaged

packageofcommunity careavailableforpeople

beingtransferredhomefromaparticipatingNew

SouthWalesPublicHospital

n Eachpackageisavailableforupto6weeksfromthe

timeofthetransferhome. Thereisnoagelimit

n DailyHITH(hospitalsubstitution)patientsmaymeet

otherreferralcriteriaareeligibleforComPacksupon

transferofcaretohome. Theydonothavepriorityto

ComPacksaccess

Hospital in the Home Guideline NSW HealtH PaGe 19

n Forinformationregardingeligibilityandreferral

processes,pleasecontactyourlocalLHDs/SHNs,

ComPacksrepresentative

n ForgeneralinformationpleasevisittheComPacks

websiteat http://www.health.nsw.gov.au/compacks/

Pages/default.aspx.

6.7 Eligibility for Commonwealth Transition Care Program

n TransitionCareprovidesshort-termcarethatseeksto

optimisethefunctioningandindependenceofolder

peopleafterahospitalstay.TransitionCareisgoal-

oriented,time-limitedandtherapy-focussed.It

providesolderpeoplewithapackageofservicesthat

includeslowintensitytherapysuchasphysiotherapy

andoccupationaltherapy,aswellassocialwork,

nursingsupportorpersonalcare. Itseekstoenable

olderpeopletoreturnhomeafterahospitalstay

ratherthanenterresidentialcareprematurely24

n Potentialrecipientsmustundergoanassessmentby

anAgedCareAssessmentTeam(ACAT)andeach

packageisupto12weeks

n Becauserecipientscanonlyentertheprogramdirectly

ondischargefromhospital,IntermittentHITHpatients

maybeeligibleforTransitionCare. Sincestillclassified

asaninpatient,adailyHITHpatientisnoteligiblefor

thisservice. Forinformationoneligibility,please

contactyourlocalACAT.

6.8 Information Management and Technology (IM&T)

n Seesection7.3fordetailonHITHdatacollection

andreporting

n DevelopmentandmanagementoflocalIM&Tsystems

mustallowtimelyandaccurateHITHdocumentation,

datacollectionandreporting

– Thehospitalmedicalrecordismaintainedforthe

DailyHITHpatient

– Medicalrecorddocumentationmustcomplywith

PD2005_004Medical Records in Hospitals and

Community Care Centres

n Opportunitiesformobiletechnologyandtelehealth

areencouraged.

6.9 Continuous Quality Improvement

n AsignificantfeatureofsuccessfulHITHservices’is

‘localsolutionsforlocalproblems,’thereforeany

state-levelqualityevaluationandimprovementshould

leverageofflocallytailoredcontinuousimprovement

processes

n It isrecommendedHITHservicesemployabroad

rangeofstrategiestoassessserviceoutcomes,and

qualitymeasures,whichsupportevidencebased

practiceapproaches,suchas:

– Patientfeedbacksurveys,andconsumer

participationinserviceplanning

– Peerreviewofservicesandclinicalstandards

– Consistentperformanceandoutcomedatato

informplanningandevaluation

– Documentedqualityimprovementplan

– Bestpracticedevelopmentandinnovationand

informationsharingprocesses(literaturereviews,

guidelinedevelopment,journalclub)

– Partnershipsbetweenmetropolitanandrural

servicesformentorshipandskillsharing,

– Benchmarking,collaborativeormulti-centred

researchintotheefficiencyandeffectivenessof

HITHinNSWisencouraged

n Clinicaloutcomesthatshouldbemonitoredlocally

include:

– Clinicalstandards

– Readmissionrate

– Lengthofstay

– Adverseevents

– Waitingtimes

– Patientexperienceofcare,andfunctionalstatus

n In additiontotheabovequalityimprovement

processesmandatoryreportingshouldbemonitored

andevaluated

n AdverseeventmonitoringwithIncidentInformation

ManagementSystemsandSeverityAssessmentCode

(SAC)rating.

Morbidityandmortality/qualityreviewmeasurement

andanalysisPD2005_608Patient Safety and Clinical

Quality.

PaGe 20 NSW HealtH Hospital in the Home Guideline

6.10 Health Reform, Costing and Funding

AspartofHealthreforminNSW,forthefirsttime,Local

HealthDistrictsandclinicianshavebudgetsthatare

transparent.Localmanagers,communitiesandclinicians

nowworktogethertoensurethatthefundingallocated

ismoredirectlylinkedtopatientcare.

SinceJuly12012aspartoffundingreform,allLocal

HealthDistrictshavebeengivenbudgetsthatsetout

clearlyhowtheirservicesarefundedaccordingtothe

levelsofactivitytheyneedtoundertakeintheir

community(ActivityBasedFunding).

WiththeadventofNationalActivityBasedFunding

(ABF),thereisanimperativetocount,categoriseand

costthesignificantadmittedandnon-admittedactivity

thatoccursinNSWHospitalintheHome,tobeable

tocapturethatactivity.

6.10.1 Activity Based Funding

TheIndependentHospitalPricingAuthority(IHPA)has

determinedthat,from1July2013,thescopeofpublic

hospitalserviceseligibleforCommonwealthfunding

willbe:

n Alladmittedprograms,includingHospitalinthe

Homeprograms.Forensicmentalhealthinpatient

servicesareincludedasrecordedinthe2010Public

HospitalsEstablishmentCollection

n AllEmergencyDepartmentservices

n Non-admittedservices.

Non-admitted Services

Thelistingofin-scopenon-admittedservicesis

independentoftheservicesettinginwhichtheyare

provided(e.g.atahospital,inthecommunity,ina

person’shome).Thismeansthatinscopeservicescan

beprovidedonanoutreachbasis.

Tobeincludedasaninscopenon-admittedservice,

theservicemustmeetthedefinitionofa‘serviceevent’

whichis:

n Aninteractionbetweenoneormorehealthcare

provider(s)withonenon-admittedpatient,which

mustcontaintherapeutic/clinicalcontentandresult

inadatedentryinthepatient’smedicalrecord26.

TheintroductionofABFisakeycomponentwhichaims

toimprovethestandardsofcare,strengthen

accountabilityandperformancereportingandenhance

efficiencyandcapacityofthepublichealthsystem.In

developingthefundingpolicytheministryhasthe

followingoverarchingpolicyobjectives:

n PersonCentredCare-promotionofsystemsand

processesthatfocusonimprovingpatientcareand

outcomeindependentlyofthesettinganddelivering

servicesinacosteffectiveway

n Equity–fairnessoffundingacrossLHDs/SHNsand

achievementofcomparableaccesstohealthservice

bylocalpopulation

n Coherency–consistencyinobjectivesandoutcomes

acrossallfundingpolicyapproaches

n Balance–encourageafocusonandencouragean

appropriatebalancewithinoutputs,outcomeand

quality

n Efficiency–useofresourcesinawaythatmaximises

theproductionofservices

n ClinicalEngagement-encouragecliniciansand

managerstoidentifyvariationsincostandpractices

sothattheycanbemanagedtoimproveefficiency

andeffectiveness

n Createexplicitrelationshipbetweenbudgetand

serviceprovisions

n Consistencywiththenationalfundingdevelopments

suchastheNationalABFframework.

Theobjectivesaremeasurableandwillprovidean

importantstepinevaluatingtheeffectivenessofthe

fundingmodelattheendofeachfundingcycle.

Inachievingthefundingpolicyobjectivesincludedfor

HITHservices,developmentofABFinNSWisguided

bythefollowingcriteria:

n Minimisingperverseincentives–themodelshould

minimiseunintendedincentivesthatconflictwiththe

policygoals

n Stability-themodelresultsshouldnotwildly

fluctuatefromyeartoyearandthemodelshould

remainflexibletoevolveovertime

n Simplicityandcomprehensibility–themodelstructure

shouldbeassimpleaspossibleandbeabletobe

understoodbystakeholders

Hospital in the Home Guideline NSW HealtH PaGe 21

n Validity–themodelcanwithstandcriticalreview

andincludesuptodatedata

n Transparency,objectiveandevidencebased–any

changestothemodelshouldbeclearly

communicatedandjustifiedwithsoundrationale

andevidence

n Administrativeease–themodelshouldbesimple

toadministerlocally.

Implications

Asasignificantcontributortohospitalresource

managementandsustainableaccesstohealthcare,HITH

servicesrequirerealisticallocationofresourcestoenable

themtofunctionandgrow.

n ThemajorHITHexpenditureisinhumanresources,

equipmentandwherethepatientsareclassifiedas

inpatients,pharmacy. Considerationoffunding

streamsforlong-termorexpensivedrugsshould

beconsideredonanindividualisedbasis

n Motorvehicles,withon-siteparkingandmobile

phonesare‘toolsoftrade’,andmustbeavailable

tostaffatalltimes

n Equipmentforloantoassistwithactivitiesofdaily

livingmustbeavailableatalltimes,provisionmade

forretrievalandcleaningofthisequipmentand

workplacehealthandsafetyrequirementsaddressed.

AsafirststageincostingHITH,TheNSWMinistryof

HealthengagedHealthPolicyAnalysistoprovidea

costingandfundingmodelforHITH.Thesubsequent

recommendationshavebeenconsideredandaplan

forbaselineandongoingcostingwillbeestablishedto

developABFmethodologyforHITH.

6.10.2 Chargeable Patients

n Currently,theonlyFinancialClassesforHITHarefor

Public,ReciprocalHealthCareAgreementand

DepartmentofVeteransAffairs(DVA)

n ForIntermittentHITHpatients,usenon-admitted

gazettedrates

n TheNSWMinistryofHealthnegotiatesandgazettes

allchargeablerates

n FutureHITHcostingwillinformstateandnational

negotiationswiththeDVAandPrivateHealthFunds

tofacilitateremunerationforchargeablepatientsfrom

thesesources.

6.10.3 Funding pharmaceuticals

n PharmaceuticalsareamajorcostdriverforHITH

services

n ForDailyHITHpatients,asforotheradmitted

patients,theLocalHealthDistrictorSpecialtyHealth

Networkisresponsibleformeetingthecostsof

pharmaceuticals. Forthesepatients,highcostdrugs

andrelatedequipmentincludeintravenoustherapy,

compoundedantibioticsanddruginfusionpumps

n ForIntermittentHITHpatients,whoareclinically

equivalenttonon-admittedpatients,pharmaceuticals

arefundedthroughthePharmaceuticalBenefits

Scheme

n DistrictsandNetworksmusthavesufficient,

dedicateddrugbudgetsforHITHtoensurethereis

noadditionalcosttothepatientforreceivinghospital

substitutioncare

n Processesfortransparentacceptanceofcostsmust

alsobeestablishedforcrossdistrictreferralsandGP

managedpatientssothatthepatientisnot

disadvantagedduetotheirplaceofresidenceor

medicalmanagement.

Key points to remember

n Developlocallyappropriatereferralprocessesthat

facilitateaccesseaseandequity

n Riskscreeningoccursatthetimeofreferral

n Collaborativecareplanningoccursbetweenpatient,

carer,GPandHITH

n HITHserviceswillhavesystemsinplace,including

anafterhoursprocedure,torecogniseandmanage

deterioratingpatients

n HITHserviceswillhavesystemsinplace,where

clinicallyappropriate,toavoidrepresentationthrough

theEmergencyDepartment

n Collaborativecareplanreviewshouldoccurbetween

patient,carer,GPandHITHtotailorthetreatment

plantopatientneeds

n HITHserviceswillhavesystemsinplaceforeffective

clinicalhandoveratthetransferofcare

n Informationmanagementsystemsmustsupport

coding,recordmanagement,datacollectionand

reportingforHITH

n Developquality,safetyandprofessionalimprovement

processestoshareinnovationandimplementlocal

solutionsforlocalproblems

n DailyHITHiseligibleforActivityBasedFunding

atequivalencytoinpatientcare.

PaGe 22 NSW HealtH Hospital in the Home Guideline

Withcleardatacollectionandreportingguidelines

forHITH,NSWwillachievegreatertransparencyand

consistencyinclassification,countingandcostingof

thistypeofcare.

Itwillalsoenablebetterevaluationofthebenefits

andoutcomesofthistypeofcare.

TheprocessforHITHdatacollectionandreportingis

showninAppendix B.Theseguidelinesapplytoall

servicesprovidingHITHcare,whetheroperationallyunder

ahospitalorcommunityhealthlineofmanagement.

7.1 Patient Selection

NOT HITH· Admit to hospital· Refer to GP· Refer to other service

Does thepatient meet

eligibility criteria for HITH?

No

Yes Patient Registration

7.2

ThepatientmustmeettheeligibilitycriteriaforHITH(see

page8).Ifthesecriteriaarenotmet,thepatientwillbe

admittedtoahospitalbedorreferredtootherpost-acute

orprimarycareserviceaccordingtotheirneeds.

7.2 Patient Registration

No

Yes

Data Collection7.3

Adopt unique LHD identifier

Register patient

Do they have a unique LHD identifier?

PD2007_094 Client Registration Policy

Clientregistrationistheprocessofidentifyingand

collectingdataonanindividualandrecordingofthat

datawithinaLocalHealthDistrict-wideclientregistration

databaseforthepurposeofuniquelyidentifyingthat

individual.

TheallocationofaLocalHealthDistrictuniquepatient

identifier,tobeusedasauniquekeyforthatclient/

patient,isaproductofthisprocess.

Theintentofclientregistrationistobeabletolink

informationheldonaclient/patientandthereby,

supportthedeliveryofservicestothatclient/patient

andthemanagementandunderstandingofservices

andserviceneeds.

Patientregistrationinvolvesallofthefollowing:

n Gathering minimum standard informationabout

aclient/patientofahealthservicetoensurethatthe

client/patientisproperlyidentified

n Searching theLHD-wideclientregistrationdatabase

todetermineiftheclient/patienthasalreadybeen

registered

n Recording mandatory informationaboutthe

client/patientorupdating existing information

intheLHD-wideclientregistrationdatabase,and

populatinganyothercopiesofthisinformationwith

theupdatedinformation,ensuringthatinformation

heldbythehealthserviceiscorrectandup-to-date

n Allocating a Local Health District unique patient

identifier tonewclients/patients.

Registrationisforthepurposeofprovidinghealthcare

totheclient/patientorotherrelatedfunctions.

Key point to remember

n EachpatiententeringHITHcarewillberegistered

accordingtoPD2007_094ClientRegistrationPolicy

HITHDataGuidelines

SEVEN

Hospital in the Home Guideline NSW HealtH PaGe 23

7.3 Hospital in the Home Data Collection

15/08/2013 - 22/08/2013Interval Description

Clinical notes in medical record

Intermittent

Daily

Data reporting7.4

Admitted Care

Non-Admitted Care

What is the patient care

need?

NSW Admission Policy

Commence admitted patient

record in PAS

PD2005_210 Inpatient Statistics

Collection

NAP data collection tool /

information system

PD2011_067Non-Admitted Patient Activity

Record service events

Map service events to state data definitions

At discharge, AMO completes

front sheet

RULES – 7.3.1eg. Planned readmission

Review in ED

Recommend - collectoccasions of service

in NAP datacollection

RULES – 7.3.2

7.3.1 Daily HITH

n DailyHITHpatientsareadmittedintotheadmitted

PatientAdministrationSystem(PAS)

n DataiscollectedaccordingtoNSWHealthPolicy

DirectivePD2005_210InpatientStatisticsCollection(ISC)

–PublicFacilitiesSeparationsDatedfrom1July2001]

n DailyHITHpatientsareadmittedtoBedType25–

HospitalintheHome–General.

n CaresettingisnotdefinedorcollectedintheNSW

Admittedpatientdatacollectionsomustbecollected

locally,inaHITH,communityhealthoroutpatientsystem.

– Caresettingincludeshome,RACF,Ambulatorycare

orcombination.

Admitted Patient Data Collection Rules - HITH

n AcuteandRehabilitationasServiceCategoryarevalid

n InpatientwardtoHospitalintheHomeBedType25

–executewardtransfer

n PlannedandUnplannedpresentationofpatientsto

EmergencyDepartments–useTypeofVisit–“13

–CurrentAdmittedPatientPresentation”

n RenalDialysispatients–asforanyotherinpatient

requiringrenaldialysis.

n IntheNon-Admittedpatientdatacollection,Service

type224AdmittedPatientServiceContact-Hospital

intheHome(DailyHITH)maybeusedforstaff

recordingoccasionsofserviceforDailyHITH

(admitted)patients,forexampleAlliedHealthstaff

–theseoccasionsofserviceareexcludedfromnon-

admittedactivityreporting.

Transfer to Non-Admitted care

ThedecisiontoenddailyHITHtreatmentismadebythe

teamwhenthepatientdoesnotrequirefurther

involvementofhospitalsubstitutionservices.Subsequent

postacutecareistransferredtooutpatientclinicsandor

communityhealth/services.Transferinvolvesclear

communicationanddocumentationofthepatientand

theircaretotheappropriatecommunityhealthservices,

GeneralPractitionerorMedicalSpecialist.

Ontransferofcare,activityreportingagainstHospital

intheHomeBedType25willcease.

PaGe 24 NSW HealtH Hospital in the Home Guideline

7.3.2 Intermittent HITH

n IntermittentHITHdatawillbecollectedaccording

toPD2013_010 Non-Admitted Patient Activity

Reporting Requirements

n IfLHDhasacommunityhealthoroutpatient

informationsystemthatallowstherecordingofeach

serviceevent(interactionwithpatient)then:

Non-Admitted Patient Data Collection Rules – HITH

n UseServicetype–225 Hospital in the Home

Intermittent – Non Admitted

n Providertypeisreportedbyindividualprovider.

Acombinedvisittoasinglepatientbymultiple

providerswillbereportedasanon-admittedoccasion

ofservice(NAPOOS)foreachprovider

n PlannedandUnplannedpresentationofpatients

toEmergencyDepartments–useType of Visit–

“04–OutpatientPresentation”

7.3.3 HITH data collection summary

Inpatient Ward

Patient transferred from HITH care

Daily HITH

SeparationWard Transfer

ADMITTED PATIENT BED TYPE ADMITTED BED TYPE 25

Intermittent HITH

NON-ADMITTED SERVICE TYPE 225

· To hospital ward via ED· Direct to hospital ward or

· To HITH via ED· Direct to HITH

Patient Admitted to HITH care

· At resolution of acute care needs or

· Following a period of post-acute care support

7.4 Hospital in the Home Data Reporting

Thedesiredpatientoutcomeisimprovedhealthand

increasedindependenceofpeoplewhocanreceive

clinicalcareintheirhomeandreducingpreventable

hospitalisations,thereforereducingdemandoninpatient

hospitalservices.Thegoalofreportingistodetermine

thenumberofpatientsreceivingHITHcarethatwould

otherwiserequireinpatienttreatment.Thisdatawillalso

informcostingofHITHservicesinthecurrentABF

environment.

TherequirementforreportingofHITHactivitytoNSW

MinistryofHealthdoesnotrequireLHDs/SHNstochange

thenameofserviceteams.

SupportingdefinitionsforthecalculationofKPIsand

ServiceMeasuresincludedinScheduleEofthe2013/14

ServiceAgreementshavebeenpublishedintheMinistry’s

“HealthInformationResourcesDirectory“(HIRD),located

ontheMinistry’sIntranet,whichisaccessibletoallLHD/

SHNstaff.

TheHIRDisaccessiblethroughtheMinistry’sIntranetSite

andcanbefoundat:http://internal4.health.nsw.gov.au/

hird/browse_data_resources.cfm?selinit=K

Hospital in the Home Guideline NSW HealtH PaGe 25

7.4.1 Hospital in the Home Activity – MANDATORY

ThisservicemeasureisreportedmonthlyintheHealth

SystemPerformancereport.Targetsforadmittedactivity

aredefinedforeachLHD/SHNinScheduleDofthe

2013/14ServiceAgreement.

Thismeasureaimstomonitorthenumberofpatients

receivingacuteandpost-acutecareinHospitalintheHome

asasubstitutionand/orpreventionofhospitalisation.

Itisexpectedthattherewillbeanincreaseinthenumber

ofpeoplereceivingHITHcareandthereforereducing

demandoninpatientcare.

7.4.2 Avoidable Admissions for targeted conditions – MANDATORY

InNSW,AvoidableAdmissionsareagroupofacute,low

complexityDiagnosticRelatedGroups(DRGs)thatcanbe

safelyandeffectivelymanagedinalternatesettingsto

inpatienthospitalcare27.PeoplewiththeseAvoidable

AdmissionDRGsaretargetpopulationsfordailyHITH,

howeverservice delivery is not limited to just these

diagnoses–otherMedicalandSurgicalDRGsmaybe

appropriateforHITH.

ThisservicemeasureisincludedinScheduleEofthe

2013/14ServiceAgreement.Itaimstoreducehospital

admissionsforselectedconditions.

Itisexpectedthatthiswillresultinimprovedhealth

andincreasedindependenceforpeoplewhocanbekept

wellathome,whilereducingunnecessarydemandon

hospitalservices.

7.4.3 HITH Outcomes - RECOMMENDED

Tosupplementthemandatoryreportingrequirements,

thesemeasuresshouldbecollectedandmonitoredlocally

toevaluateserviceeffectivenessandefficiency.

MEASuRE VALuE

DaIly HItH

LengthofStay–ALOSinHITH–ALOStotal

Days

Separations–BedType25 Count

BedDays–BedType25 Count

Readmissions–PlannedandUnplanned %bytype

WardUtilisation–HITHonly–EDandHITH–WardandHITH–ED/WardandHITH

%bytype

Referralsource %bytype

Age Histogram

Sex %M/F

PreferredLanguage Count

FinancialClass %bytype

Indigenousstatus Count

Diagnosis Count

INteRMItteNt HItH

LengthofStay Days

NAPOOS Countbytype

Referralsource %bytype

Age Histogram

Sex %M/F

PreferredLanguage Count

FinancialGroup %bytype

Indigenousstatus Count

PaGe 26 NSW HealtH Hospital in the Home Guideline

Acute care

Anepisodeofacutecareforanadmittedpatientisone

inwhichtheprincipalclinicalintentistodooneormore

ofthefollowing28:

n managelabour(obstetric)

n cureillnessorprovidedefinitivetreatmentofinjury,

n performsurgery

n relievesymptomsofillnessorinjury(excluding

palliativecare)

n reduceseverityofillnessorinjury

n protectagainstexacerbationand/orcomplicationof

anillnessand/orinjurywhichcouldthreatenlifeor

normalfunctions

n performdiagnosticortherapeuticprocedures.

Acutecareisshort-termandhighintensity.

Admitted

AHITHpatientwouldbeadmittedif,followingaclinical

decisiononthenecessarycareandtreatment,theymeet

oneormoreofthefollowingadmissioncriteria29:

Intended medical care

n Thepatient’sconditionrequiresclinicalmanagement

and/orfacilitiesnotavailableintheirusualresidential

environment

n Thepatientrequiresobservationinordertobe

assessedordiagnosed

n Thepatientrequiresatleastdailyassessmentoftheir

treatment/medicationneeds.

Intended procedure

n Thepatientrequiresaprocedure(s)thatcannotbe

performedinastand-alonefacility,suchasadoctor’s

roomwithoutspecialisedsupportfacilitiesand/or

expertiseavailable.

FeaturesofadmittedHITHcareinclude:

n Presenceofanacuteorsubacuteconditionthat

wouldrequirehospitalisationoralongerhospitalstay

ifHITHwerenotoffered.Intheabsenceofahospital

alternativeprogramthepatientwouldbeadmittedto

anacutehospitalbedorhavealongerlengthofstay

inacutecare.

n Patientsmustbemedicallystableandnotrequirehigh

clinicalsupport,patientswithco-morbiditiesand

complexneedscanbeincluded.Amedicalofficerhas

determinedthatthepatientcansafelyreceivethe

appropriatelevelandtypeofservicesinahospital

alternativeprogram;

n Accesstoacutelevelmedicalcareisavailable24

hoursperday;theprovisionofmedicalcareinvolves

localarrangementsmadebetweenmedicalspecialists

basedintheambulatorycaresettingandtheGeneral

Practitioner.Itwillbecleartothepatient,andtothe

patient’steamwhoisresponsibleforpatient’smedical

careduringtheHITHepisodeofcare.

n Agreementofthepatient/carertoreceiveahospital

alternativeservice.

n Adequacyofthehomeenvironmenttoprovidethe

needsofdailyliving.Theprovisionoftheseservicesis

inthehomeand/oracomponentofthiscaremaybe

providedasanoutpatientordayclinic.

Interdisciplinary care

Interdisciplinaryteamworkdiffersfrommultidisciplinary

teamwork30.

Multidisciplinarycareisdisciplineoriented,withvarious

professionalsworkinginparallel,usingdifferentplansof

care.Roledefinitionsareclearandaremanagedunder

hierarchicallinesofauthority.

Interdisciplinarycareinvolvesregularcollaborative

meetingsofalldisciplinestodiscusspatientstatusand

theevolvingplanofcare.Itischaracterisedbyshared

decision-makingandflexibleleadership.

KeyDefinitions

EIGHT

Hospital in the Home Guideline NSW HealtH PaGe 27

Non-Admitted

AHITHpatientwouldbenon-admittediftheHITH

admissioncriteriaarenotmet.

Person-centred care

Providingcarethatisrespectfulofandresponsiveto

individualpreferences,needsandvaluesandensuring

thataperson’svaluesguideallclinicaldecisions31.

Post-acute care

Anepisodeofpost-acutecareforapersonisonein

whichtheprincipalclinicalintentispreventionof

deteriorationinthefunctionalandcurrenthealthstatus

ofapatientfollowinganacuteillnessorinjury32.

Post-acutecareisshort-termandlowerintensity.Itmay

requirefurthercomplexassessmentorstabilisation,and

requirescareoveratime-limitedperiod.

Potentially Preventable Hospitalisation

Potentiallypreventablehospitalisations(PPHs)arethose

conditionswherehospitalisationisthoughttobe

avoidableiftimelyandadequatenon-hospitalcarehad

beenprovided.

ThethreebroadcategoriesofPPHsthatareusedin

nationalreportingincludeVaccine-preventable, Acute

and Chronic.PPHcategoriescanbesourcedfromthe

Victorian ambulatory care sensitive conditions study33.

Subacute care

Subacutecaremeansrehabilitation,palliativecare,

geriatricevaluationmanagement,andpsychogeriatric

careasdefinedintheNationalHealthDataDictionary32.

Sponsorship

Sponsorshipisthesinglemostimportantfactorin

ensuringfastandsuccessfulimplementation34.

Sponsorsauthorise,legitimiseanddemonstrate

ownershipforachange:possesssufficientorganisational

powerand/orinfluencetoeitherinitiateresource

commitment(Authorising Sponsor)orreinforcethe

changeatthelocallevel(Reinforcing Sponsor).

Substitute Decision Maker

Asubstitutedecision33maker(SDM)isonemadeon

behalfofanindividualwholackscapacitytomaketheir

owndecision.Substitutedecisionmakerisacollective

termforthoseappointedoridentifiedbylawtomake

substitutedecisionsonbehalfofanindividualwhose

decision-makingcapacityisimpaired.

ASDMmaybeappointedbytheindividual(e.g.oneor

moreEnduringGuardiansappointedbytheindividual

understatutoryprovisions),appointedfor(onbehalfof)

theindividual(e.g.aGuardianappointedbya

GuardianshipTribunal),oridentifiedasthedefault

decision-makerbytheNSWGuardianshipAct(suchas

spouse,carer)asthe‘PersonResponsible’.

Person Responsible

TheNSWGuardianshipActestablisheswhocangivevalid

consentformedicaltreatmenttoanincompetentpatient

aged16yearsandover.ConsentofthePerson

Responsibleisrequiredinrelationtoprovisionofminor

andmajormedicaltreatment.TheActestablishesa

hierarchyfordeterminationofwhoisthePerson

Responsibleasfollows:

n Thepatient’slawfullyappointedguardian(including

anenduringguardian)butonlyiftheorderor

instrumentappointingtheguardianextendsto

medicaltreatment

n Ifthereisnoguardian,aspouseincludingadefacto

spouseandsamesexpartnerwithwhomtheperson

hasaclosecontinuingrelationship

n Ifthereisnosuchperson,apersonwhohasthecare

ofthepatient(otherwisethanforfeeandreward)

n Ifthereisnosuchperson,aclosefriendorrelative.

AlsoseeOfficeofthePublicGuardianFactSheethttp://

www.lawlink.nsw.gov.au/lawlink/opg/ll_opg.nsf/vwFiles/

PR.pdf/$file/PR.pdf

PaGe 28 NSW HealtH Hospital in the Home Guideline

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PaGe 30 NSW HealtH Hospital in the Home Guideline

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entOfficeDRAFTEnhancedCDMmodel

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TEN

Hospital in the Home Guideline NSW HealtH PaGe 31

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HealthChronicDiseaseManagem

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2

SHPN (SR) 130248