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Hospital in the Home

Guideline number: QH-GDL-379:2022

Effective date: 5 October 2022

Review date: 5 October 2025

Supersedes: Version 3

The Hospital in the Home guideline can be read in conjunction with the following guidelines:

  1. Purpose
  2. Scope
  3. Context
  4. HITH model of care
  5. HITH principles
  6. Related documents
  7. HITH service delivery: Key components
  8. Definitions
  9. Abbreviations
  10. References
  11. Approval
  12. Review
  13. Version control
  14. Appendix A

1. Purpose

This guideline provides best practice for Hospital in the Home (HITH) models of care in Queensland by:

  • outlining key principles that underpin the HITH program in Queensland
  • assisting and giving guidance to Hospital and Health Services (HHSs) to develop local structures, models, policies, procedures and clinical pathways
  • supporting the standardisation of effective and safe delivery of public HITH services across metropolitan, regional and remote areas of Queensland.

HITH in Queensland is defined as the provision of care in a patient’s permanent or temporary residence for conditions requiring clinical governance, monitoring and/or input that would otherwise require treatment in a traditional hospital bed. The HITH program is focused exclusively on substituting admitted patient care within a hospital setting to the ‘home’ setting of the patient governed by the authorised officer.

The key feature of the Queensland HITH program is that if the patient (child/adult) is not receiving HITH, the patient would be admitted to hospital for treatment and accommodated in a hospital bed. Hospital admission criteria types include acute and sub-acute and specific HITH specialised models of care such as Geriatric Evaluation and Management in the home (GEMITH), Geriatric Evaluation and Management and Rehabilitation HITH (GEMRHITH), Maternity HITH, Palliative HITH and Mental Health HITH.

2. Scope

This guideline applies to all Queensland Health staff (administrative and clinical), and all organisations and individuals acting as agents for Queensland Health, who are providing or planning to provide a HITH service.

Compliance with this document is not mandatory, but sound patient-centric clinical reasoning consistent with high value, ethical and professional care, must exist for departing from this guideline.

3. Context

HITH is a priority commitment for Queensland Government. Benefits of HITH include, but are not limited to:

  • provision of safe, high quality hospital comparable care in patient’s homes including access to allied health and care for paediatric, elderly, and mental health patients with appropriate models of care
  • recognition at a statewide and national level, as hospital comparable care
  • patients receive safe, high-quality care, delivered by a highly skilled workforce
  • patients develop greater autonomy and health literacy with their health care through partnering with the HITH provider in deciding how and where their health care is to be delivered
  • patients have decreased direct and incidental costs associated with their treatment
  • cost effective, flexible and sustainable solution to manage increased demand on acute services by matching resource needs of patients with their clinical requirements, thus reserving highly resourced acute hospital beds for patients of appropriate complexity
  • reduced risk of adverse events from hospital admission and re-presentation to emergency departments
  • culturally appropriate and environmentally safe delivery of care for Aboriginal and Torres Strait Islander (ATSI) peoples and English as a second language patients.

4. HITH model of care (MoC)

HITH in Queensland is defined as providing care in a patient’s permanent or temporary residence for conditions requiring clinical governance, monitoring and/or input that would otherwise require treatment in a traditional hospital bed. The HITH program is focused exclusively on substituting admitted patient care within a hospital setting to the ‘home’ setting of the patient governed by the authorised officer.

Key features of HITH in Queensland are:

  • Hospital substitution—home care replaces a full hospital admission or a component of a hospital admission (without a HITH service, the patient would be admitted to hospital for treatment and accommodated in a hospital bed)
  • Hospital comparable care—a comparable level of care to that provided in the inpatient setting is provided by the HITH services to meet the patients’ needs for their acute admission taking into account the different service deliveries required in the home environment
  • Daily intervention—all patients require a minimum daily clinical intervention or assessment by the HITH service which can be delivered by various and flexible modes depending on the model of care
  • Clinical governance, active treatment and/or monitoring—each patient is identified as requiring clinical governance, active treatment and/or monitoring during the HITH episode of care
  • Person-centred care—provision of care is of value to the patient, their family and carers, and is respectful and responsive to their preferences, needs, values, and is culturally appropriate. The patient’s access to HITH should be informed, consented, voluntary and in the form of a partnership.
    Provision of person-centred care is supported by:
  • Safe, high value care—the care provided must be safe, of benefit to the patient and be of high value (Queensland Clinical Senate 2016 (PDF 714 kB)).
  • Flexible—HHSs can design specific HITH models of care and related clinical pathways for their specific communities and patient cohorts, in compliance with these principles and the HITH: Standards of care.

5. HITH principles

  1. High value quality care
    Provision of high value care, comparable to the level of care provided in the inpatient (hospital) setting, requiring a minimum daily intervention or assessment, that enhances care delivery and positively impacts the patient journey.
  2. Person-centred care
    Provision of care is of value to the patient, their families, and carers, and is cognisant, respectful of, and responsive to, their diverse preferences, needs and culturally appropriate requirements.
  3. Safe
    Safety is a primary function of a HITH service and is applicable to patients, their families and carers and staff involved in providing the service.
  4. Flexible
    Provision of care is flexible to allow for the design of specific HITH models of care and related clinical pathways for specific communities/patient cohorts, and sensitively balances clinical needs with patient needs through partnerships.
  5. Accessible
    All Queenslanders eligible to access HITH, should have the option to receive safe, high value care under a HITH service without being financially disadvantaged. The service should be accessible 7 days a week with 24-hour/7 day a week governance and escalation.
  6. Clear transparent eligibility criteria
    No patient should be excluded from accessing HITH if they can be treated safely in their home environment. Eligibility criteria are to be clearly communicated, documented and supported by a holistic patient-centric method for determining safe selection.
  7. Robust corporate and clinical governance
    Provision of safe care is supported by a comprehensive corporate and clinical governance structure. Corporate governance is backed by strong corporate leadership of HITH that is integrated into HHS planning, demand management and flow strategies. Clinical governance is aided by an integrated service delivery approach with single point accountability, clinical responsibility, and clear escalation protocols.
  8. Skilled, coordinated and adequately resourced HITH teams
    Provision of care is delivered by appropriately skilled, trained and, resourced multi-disciplinary HITH team. Credentialing and training should reflect the specialised skill set required for HITH service delivery.

Documents to be read in conjunction with these guidelines (inclusive of HITH suggested key performance indicators/minimum data set – refer to Appendix A):

7. HITH service delivery: Key components

7.1 Corporate and clinical governance

7.1.1 Corporate governance

Comprehensive corporate governance is a key essential for safe quality patient care and the viability of the HITH service. Comprehensive corporate governance provides transparent monitoring /reporting systems, strong clinical leadership, advocacy, and clinical risk management. Key considerations include:

  • establishment of a corporate governance structure which includes representation from all clinical levels and professionals within the HHS and external providers if relevant
  • incorporation of HITH services into HHS planning, demand management and flow strategies
  • monitoring, analysis and reporting of data and key performance indicators (refer to Appendix A) via local HHS processes and committee structure.

7.1.2 Clinical governance

Clear lines of responsibility for the clinical management of patients are essential to ensure care is coordinated, and a medical management and treatment plan established, implemented and monitored. A multidisciplinary team approach is recommended, with sufficient access to multidisciplinary services. A variety of models of care can be implemented by the HHS to meet local needs and should be reflected in the HHS admission policy and procedures. Key considerations include:

  • patient must be admitted by an authorised practitioner working within their recognised scope of practice
  • independent HITH authorised practitioners are to be appropriately credentialled as per HHS policy
  • patient is transferred to a virtual ward (i.e. HOMEXX) with the treating authorised practitioner recognised in HBCIS as per the Queensland Hospital Admitted Patient Data Collection (QHAPDC) Manual
  • the admitting authorised practitioner holds clinical governance of the patient
  • timely two-way communication between HITH team and the admitting authorised practitioner holding clinical governance is essential to ensure care is coordinated for the patient
  • communication of all changes in the patient’s condition to be notified to the admitted authorised practitioner in a manner that ensures patient safety and allows prompt appropriate clinical decision making
  • HITH team to notify authorising practitioner of changes to the patient’s condition
  • patient review is clinically determined by the governing team and is dependent on patient’s requirements
  • HHS, in collaboration with direct referral source, is responsible for identifying pathway for direct referral to HITH service
  • public private partnerships can be considered to meet local requirements. Clinical care can be contracted either totally or partially to an external provider, however governance remains with the HHS.

7.2 Eligibility criteria

7.2.1 Inclusion criteria

No eligible public patient should be excluded from accessing HITH if they can be treated safely outside the traditional inpatient hospital environment.

Key considerations include:

  • public eligible patients are inclusive of public acute and sub-acute patients, and acute compensable patients, including:
    • Department of Veterans’ Affairs (DVA) funded patients
    • Third party compensable funded patients
    • Motor vehicle accident insurance funded patients
    • Workers compensation funded patients
  • HITH replaces full hospital admission or a component of a hospital admission. Without a HITH service, the patient would be admitted to a bed within the hospital setting for treatment as an inpatient
  • patient requires clinical governance, active treatment and/or monitoring during the HITH episode of care to provide hospital substitution care
  • patient requires minimum daily intervention or assessment by a HITH service to perform a clinical action or enable a clinical decision
  • this clinical interaction can be delivered by various and flexible modes depending on the model of care and is not required to be face to face
  • provision of HITH service is a patient’s choice and should be documented by obtaining consent from the patient or approved guardian
  • the treating authorised practitioner determines that care for the patient can be safely provided and managed in the patient’s permanent or temporary residence, balancing risk, benefit and patient desire
  • there is an appropriate and clinically safe method of communication between the patient and the HITH team
  • clinical supplies/medication can be appropriately stored at care location, including refrigeration if necessary
  • for paediatric patients, the approved guardian must nominate an adult to be present during the treatment of minors.

7.2.2 Exclusion criteria

Patient whose care cannot be managed safely in a HITH environment.

Key considerations include:

  • patients with complex care needs not amendable to HITH (inclusive of physical, cognitive and/or social care needs)
  • non-compensable patients e.g. overseas visitors, including, but not limited to international students and persons holding working visas
  • private patients including public hospital Medicare eligible private patients, are ineligible for HITH services, unless they change their election to public from when the HITH service commences
  • patients in hospital for a continuous period exceeding 35 days and considered maintenance patients
  • non-admitted patient service events that do not fulfil the HITH requirements of hospital comparable care, that are able to be managed by a primary care provider who is available
  • routine follow-up telephone calls post discharge do not constitute HITH activity.

7.2.3 Specialty areas requiring further consideration for inclusion/exclusion

Depending on the models of care, these specialty areas may be in scope:

Sub-acute: Can only be provided where it substitutes a traditional hospital bed admission. The HHS is to have clear guidelines in relation to the difference between substitution and post-acute care. Sub-acute HITH (GEMITH, GEMRHITH) can enhance, but cannot replace existing community-based services. Patients should be able to transfer between acute inpatient care, HITH and sub-acute care depending on their changing clinical needs.
Mental health: Mental health conditions are not traditionally managed through HITH. For patients with mental health conditions that are admitted to general HITH services for the treatment of an acute or sub-acute medical/surgical condition, care is to be coordinated with the mental health case manager for the patient or a mental health plan is to be formulated by the appropriate mental health team before admission to HITH, to ensure all the patient’s needs are met. Alternatively, the HHS can develop a mental health model of care, with suitably safe criteria and appropriate resourcing.
Paediatrics: The HHS is to design services to meet the needs of paediatric patients. Patient safety and family acceptance is primary. Patient appropriateness is to be governed by the HHS and is dependent on the skill mix and experience of the HITH service. All services providing care to paediatric patients are to adhere to the User Guide for Acute and Community Health Service Organisations that Provide Care for Children.
Women and newborn HITH: Women and newborn HITH are services that require specialised input and usually a bespoke model of care. All women and newborn HITH models of care need to provide hospital substitution, fulfil women and newborn admission guidelines and should not duplicate care that is already otherwise provided in the community setting.

7.3 Patient care

7.3.1 Screening of eligible patients

Patient and staff safety is essential to delivering a HITH service. Good governance requires an assessment of the patient and environment before acceptance of the patient onto the service and after initiating service. The assessment needs to identify any potential treatment and environmental risks e.g. environment hazards, infection control or personal threat.

A complete assessment should include: home visiting safety screen and assessment of the competence of patients and carers to provide necessary self-care health interventions.

The assessment of patients in residential aged care facilities (RACFs) is a partnership and should include: the ability of the facility to manage the patient’s acuity, the agreement to the provision of a HITH service, the capability of complying with treatment within the care setting and the interaction with the patient’s normal treating clinician.

7.3.2 Admission/transfer of care

The patient journey through the HITH service should be seamless. Tools such as clinical pathways and Criteria Led Discharge (CLD) support patient flow and are frequently adopted by HITH services. Formal clinical pathways are not mandatory for HITH services.

It is essential that care of the HITH patient is planned and coordinated from admission to separation and transfer of care. Key considerations include:

  • patients need to meet the admission requirement as stated in the relevant HHS admission policy
  • receiving authorised practitioner must accept responsibility and governance
  • clinical handover is to be consistent with National Safety and Quality Health Service Standards – refer Australian Commission on Safety and Quality in Health Care
  • patients are to be admitted by an authorised practitioner working within their recognised scope of practice
  • patient/carer consents to the transfer of care (this is to be documented and evidenced in the patient medical record)
  • ensure the receiving service has capacity, can meet the patient’s needs and agrees to the transfer of clinical care
  • document estimated date of discharge (EDD) informed by clinical criteria and the management and treatment plan
  • patient pathways to facilitate the transfer of the HITH patient to post-acute care occur in a timely manner
  • appropriate documentation must accompany the transfer of care, including discharge summaries where appropriate
  • direct referral pathways are recommended to be developed in partnership with the appropriate stakeholders, including consumers
  • development and adoption of electronic referrals to enhance the referral process
  • electronic medical records with visibility to other health care providers are preferred
  • local processes that facilitate access ease and equity to be developed to accept HITH referrals from:
    • General practitioner (GP) to Inpatient team
    • Nurse practitioner (NP)
    • Outpatient clinic setting
    • Emergency Department (ED)
    • Inpatient team, including another HHS
    • Medical specialists in the community
    • Queensland Ambulance Service (QAS)
    • Residential aged care facilities (RACF).

7.3.3 Clinical assessment, treatment, monitoring and documentation

Clinical assessment

Comprehensive assessment of the patient’s care needs is required during patient selection and while the patient is receiving care from the HITH service. Assessment of the patient is to be documented and updated throughout the episode of care. Duplication should be minimised by utilisation of inpatient medical records and information gathered by the hospital. Consider the following:

  • comprehensive assessment should include the clinical, physical, social, environmental, and cultural needs of the patient
  • care plan to be developed collaboratively with the patient and in alignment with the assessment, and should include: consumer driven goals, clinical risk, environmental risk, behavioural risk, communication obstacles, drug/alcohol or smoking assessment, clear transfer of care and case management, and non-clinical support required
  • reason for admission and care location are to be clearly documented in the progress notes
  • care to be reviewed and documented in a multidisciplinary handover (daily, at minimum)
  • handovers to have a holistic multidisciplinary approach and focus on patient safety, quality and discharge requirements
  • HHS shall develop local processes for the patient to return to hospital efficiently as clinically required.

Treatment

Consider the following:

  • telephone consultation by itself does not constitute HITH activity. When utilised it must be part of hospital substitution care for the patient. Telephone consultation would normally be partnered with one or more of the following: face to face care, remote patient monitoring, virtual care or telemedicine, to provide hospital comparable care with daily clinical intervention or daily decision making.
  • telemedicine, a broad term that encompasses a range of technology-enabled healthcare services inclusive of all aspects of virtual care and may constitute the equivalent of a home visit.

Monitoring and documentation

Consider the following:

  • clinical handover to be consistent with National Safety and Quality Health Service Standards
  • all record keeping to be consistent with relevant (Statewide/local) patient record management procedures, and is timely, secure and confidential
  • all documentation to be integrated into the inpatient medical record either while the care is delivered or for services with separate documentation on discharge from HITH
  • HITH services to have daily access to the hospital inpatient medical record during the episode of care
  • 24-hour telephone support to be provided to patients while on HITH
  • 24-hour escalation pathway must be available for a patient requiring physical review
  • patient’s length of stay to be monitored with the use of discharge criteria to ensure timely discharge against accepted benchmarks
  • home visits and all relevant clinical interaction whatever the modality are to be clearly documented in progress notes
  • all relevant clinical information is to form part of the clinical documentation
  • advanced health care directives and acute resuscitation plans to be recorded in the inpatient medical record (if applicable)
  • discharge summary, preferably electronic, to be sent to the GP, referring authorised practitioner and relevant clinicians involved in the provision of ongoing safe patient care within the timeframes set by the HHS following local process
  • acute care certificates to be provided for acute care patients if the patient’s admission is longer than 35 days (refer QHAPDC Manual).

7.3.4 Patient education and health literacy

An empowered and informed patient is a strong partner in the delivery of a safe HITH service. Patients must be provided with multi-modal education/information inclusive, but not limited to:

  • their rights and responsibilities - refer to The Australian Charter of Healthcare Rights
  • how to contact the HITH service, within and outside business hours
  • early recognition and management of deterioration
  • what to do in an emergency
  • how to provide feedback (compliment/complaint)
  • their presenting condition
  • their treatment plan and expected date of discharge
  • chronic disease self-management (where applicable)
  • self-care measures
  • medication management (including safe use/storage)
  • Consumer Medicines Information (CMI)

It is the HITH services responsibility to ensure the patient and /or their carers understand the information provided and are actively engaged in their treatment.

7.4 Quality and safety

7.4.1 Patient safety and quality

Patient safety and quality is a primary aim of HITH. Key elements should be considered to:

  • meet the National Safety and Quality Health Service Standards
  • meet the Medication Safety Standards
  • meet the requirements for pressure injury surveillance, malnutrition screening and falls risk - refer National Safety and Health Quality Standards (2021)
  • meet the infection control requirements in the Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019)
  • clearly specify processes and procedures to ensure safe selection and entry of patients into HITH—where the community setting is not safe for care provision, care may be provided in a clinic environment (clear documentation stating the reason for clinic-based care must be provided in the patient’s clinical notes)
  • clearly specify processes and procedures to monitor and govern patients including to manage emergencies, adverse events and other patient complications
  • clearly specify processes and procedures to identify deteriorating patients
  • support 24 hour on call with clearly specified processes and procedures to identify the deteriorating patient with a robust escalation pathway
  • clearly specify processes, procedures and criteria for returning patients to hospital
  • provide a 7-day service with single point accountability, daily patient review and transparent clinical governance
  • liaise and communicate with service providers and/or referring teams, at exit from HITH service as required
  • manage clinical and non-clinical incidents/near misses in accordance with related HHS health and safety processes, to ensure all incidents/near misses are reported, recorded, reviewed and acted on
  • ensure the HITH service is provided by skilled and experienced staff to provide the care required, who are appropriately credentialled and supported to work within their scope of practice
  • ensure the HITH service has adequately resourced staff and equipment to provide the required number of visits to support the timing of the visits required
  • ensure at risk behaviours are documented, monitored, risk assessed and reported by the HITH service, as per HHS health and safety processes
  • ensure open disclosure and quality improvement is embedded in the function of the HITH service.

7.4.2 Medication management

HITH patients require a transfer of care from one environment to another which increases the risk of medication error. HITH services require diligence and appropriate specific protocols to minimise patient risk. Key considerations include:

  • HITH services shall meet the National Safety and Quality Standards for medication safety
  • medication management (e.g. ordering, supply, administration) must comply with legislative requirements as documented in the Health (Drugs and Poisons) Regulation 1996
  • medication policies, guidelines and practices need to be adapted for the home environment:
    • medications are only to be administered by staff with relevant competencies and clinical privileges
    • medication documentation meets Queensland Health standards
    • intervention medications are to be provided by HITH from the inpatient funding allocation
    • a patient’s own medications can be used for conditions other than the admission condition - refer Patients Own Medicines Guideline
    • S8 medication management protocols, to be developed by the HHS to meet local and regulatory requirements
    • medications are dispensed, stored and transported according to the national standards
    • coordination and communication of care is to occur with the patient and all service providers who are administering medications to maximise patient safety (e.g. RACF staff)
    • HITH service providers to develop workplace instructions for telephone orders and documentation
    • HITH service should have procedures and processes in place to ensure ongoing medication requirements on discharge
  • appropriate and responsible selection of antibiotics as per the Australian Commission on Safety and Quality in Health Care, Antimicrobial Stewardship Clinical Care Standard, Therapeutic Guidelines, and the Queensland Health List of Approved Medicines (LAM), taking into consideration the special safety issues of the individual HITH patient
  • there are appropriate policies or guidelines (including patient and carer education) in place to minimise the risk of anaphylaxis and to manage anaphylaxis appropriately
  • medication incidents and near misses are to be recorded, monitored and reported through the appropriate HHS process and reporting instrument
  • pharmacist is to reconcile medications on admission and discharge from HITH highlighting any medications that require specific monitoring or present increased risk to the patient (pharmacist should consult, as appropriate, with clinicians, GPs, community pharmacy and patients, ensuring an accurate timely medication list is provided and safety for the patient maximised).

7.4.3 Death during or following a HITH admission

It is essential the morbidity and mortality of patients is monitored, and appropriate processes (regular multidisciplinary morbidity, mortality and quality audits and reviews) followed. Key considerations include:

  • meet local procedures that outline the care and management of deceased patients refer (as applicable) to Coroner’s Court of Queensland resources
  • HHSs to develop local workplace instructions for death during a HITH admission
  • clinical incident analysis of Severity Assessment Code 1 (SAC 1) due to unexpected deaths of patients that have had a component of care in HITH, to be conducted with HITH service involvement
  • special processes may need to be developed for the inclusion of palliative care patients on HITH.

7.5 Integrated service delivery model

HITH provides tertiary level hospital substitution care in the community and therefore interfaces with hospitals, intermediate care services, community nursing and allied health services, chronic disease management programs and general practice. Integration of HITH service delivery is essential to provide seamless continuum of care for the patient from the acute to the community setting. Key considerations include:

  • service coordination is essential to transition the patient from acute/subacute HITH episode to post-acute services reducing clinical risk and duplication
  • HITH services should plan appropriate and timely referral to, and engagement with, other programs
  • HITH services whilst holding governance, must take a lead in coordinating care until clinical handover occurs
  • patients that receive services from the below providers can continue to receive these services while on HITH, however HITH must take a lead in coordinating care (if the patient’s needs during the HITH admission are greater than preadmission, HITH is to fund the increased services):
    • Commonwealth Home Support Programme (CHSP)
    • Commonwealth Home Care Packages (HCP)
    • Queensland Community Care Services (QCCS)
    • National Disability Insurance Scheme (NDIS)
    • palliative care prior to admission.
  • if service providers decline to continue providing the service during the HITH admission, the HITH service must ensure coordination of appropriate care
  • whilst on HITH, CHSP, HCP, QCCS, NDIS and palliative care, service providers may review the client to ensure that their care plan is updated and that the service provider has adequate resources to provide and maintain a basic level of support for the client
  • patients in RACFs are permitted to receive HITH care substitution, however the HITH service needs to work closely with the RACF to ensure clear communication
  • post-acute care and transition care programs cannot run concurrently with HITH as this breaches funding agreements
  • if no other services are involved and HITH identifies the patient requires assistance to safely meet their activities of daily living (ADL), it is the responsibility of the HITH service to arrange and fund services for the duration of the HITH episode of care
  • primary care provider should be notified of the HITH admission within 24 – 48 hours of transfer of care as per HHS guidelines.

7.6 Corporate functions

7.6.1 Staffing models/requirements

There are three main models of staffing HITH services:

    • Dedicated HITH team—team recruited to provide HITH only
    • Dual model of care—team recruited to provide both HITH and post-acute care
    • Inpatient shared model—staff work in a hospital and provide HITH care within their scope of practice

Key staffing considerations include:

  • HITH staffing to be sufficient in number, appropriate classification level and skills, to provide high quality safe care for patients in respect to the model of care adopted
  • HITH staffing supports different disciplines within an integrated service delivery/interdisciplinary model (e.g. nurse practitioner, pharmacist)
  • roles and responsibilities are understood and there are clear lines of communication/accountability between HITH team and other relevant stakeholders
  • HITH staff will be required to comply with the HHS human resource requirements, which may include:
    • criminal history check
    • blue card
    • aged care police check.

7.6.2 Staffing workforce profile, training and competencies

Provision of care in the community setting requires both acute and sub-acute specialist skills. Professional development is required to maintain patient and staff safety and enable the provision of specialised HITH services. The development of HITH training pathways underlies the specialist skill competencies needed to provide HITH care. Key considerations include:

  • staffing workforce profiles should be sufficient in number, appropriate classification level and skills, to provide high quality safe care for patients in respect to the model of care adopted
  • staffing workforce profile should be benchmarked against best practice for the model of care adopted, through cross jurisdictional operating models and contemporary available benchmarks and/or published model of care staffing
  • all clinical staff hold appropriate registration and credentialing for the care they provide:
    • clinical staff in positions requiring registration must meet standards set by National Health Boards
    • all staff to be appropriately credentialled according to local HHS requirements
  • all staff are required to meet Code of Conduct for the Queensland Public Service
  • staff supported to work within their scope of practice/professional frameworks and delegate according to their professional standards:
    • all staff have appropriate training (mandatory and ancillary) and equipment to provide safe care
    • staff compliant with HHS mandatory training requirements
    • HITH services to provide training specific for the provision of HITH specialised services and support the development of HITH training pathways
    • staff have the appropriate competence and expertise, with training/competencies tailored to the community setting.

7.6.3 Roles and responsibilities

Good corporate and clinical governance requires that individuals understand their roles and responsibilities. Key responsibilities for the following roles include:

  • Chief Executive Officer (CEO):
    • endorsing and promoting compliance with this HITH guideline
    • nominating an Executive Sponsor to lead HITH guideline implementation
  • Chief Operating Officer (COO):
    • ensuring mechanisms are in place to enable the requirements of this HITH guideline to be applied, achieved, and sustained
    • ensuring local procedures are reflective of this HITH guideline
    • establishing local monitoring and reporting processes to ensure the active management and review of HITH activity and HITH Key Performance Indicators (KPIs)
    • reviewing HITH program performance and the implementation of local improvement strategies
  • HITH program managers/clinical directors:
    • oversight and accountability for HITH program
    • escalating significant HITH program issues within HHS and Department of Health as appropriate
  • HITH clinicians:
    • provision of safe, patient-centric, high value care
  • Administrative staff:
    • administrative tasks performed in a timely manner to facilitate efficient admission and discharge from the HITH program and assist in the collection of accurate coding data

7.6.4 Activity based funding (ABF) and revenue

HITH patients are considered hospital inpatients and are funded through ABF.

  • While patients remain under the HITH model of care, the items/services below are funded within the ABF funding allocation:
    • consumables
    • clinical services
    • clinical investigations
    • intervention medications
    • equipment
  • Alternative models for an external provider option can be developed via separate negotiations. Irrespective of service provider, no treatment cost is to be transferred to the patient.
  • The Queensland Department of Health annually updates a range of purchasing intentions that incentivise the delivery of efficient and effective care, with the HITH Purchasing Incentive available from the Healthcare Purchasing and System Performance Division website (refer Purchasing and non-activity based funding specifications)
  • Further information available in the KPI Attribute sheets:

7.6.5 Service evaluation, reporting (including KPIs) and risk management

HITH services, to monitor, analyse, benchmark and report on HITH activity data (inclusive of clinical incident data) and KPIs in accordance with local HHS processes and procedures, to ensure transparency of HITH service delivery practice, KPIs are met, and allow appropriate governance and safety management.

  • Minimum data set for HITH reporting/HITH suggested KPIs are outlined in Appendix A
  • A risk management approach underpins HITH service delivery and management within Queensland Health. HHSs are responsible for establishing processes and procedures to support risk mitigation.

8. Definitions

Term

Definition / explanation / details

Source

Acute care

This care type is care in which the principal clinical purpose or treatment goal is to:

  • manage labour (obstetric)
  • cure illness or provide definitive treatment of injury
  • perform surgery
  • relieve symptoms of illness or injury (excluding palliative care)
  • reduce severity of an illness or injury
  • protect against exacerbation and/or complication of an illness and/or injury which could threaten life or normal function
  • perform diagnostic or therapeutic procedures.

Acute care excludes care which meets the definition of mental health care.

Queensland Hospital Admitted Patient Data Collection (QHAPDC) Manual 2022-2023

Authorised practitioner

A clinician (for example, a nurse practitioner or Senior Medical Officer - SMO) credentialed to admit patients and retain and provide clinical governance

HITH Guidelines 2013

Care setting

Location in which the HITH service provides care to the patient.

HITH services are designed and funded to deliver care in the home. The decision regarding HITH treatment is to be patient-focused, taking into consideration the psychological, physical and environmental needs of the patient and not influenced by the funding models. Care settings can include, but are not exclusive to, patient’s permanent or temporary residence, Residential Aged Care Facility, hotel, prison and boarding house.

HITH Guidelines 2012

Clinical governance

The mechanism, relationships and responsibilities under which a patient is appointed a healthcare team to assume clinical responsibility for the patient’s treatment plan and oversee the patient’s clinical care to ensure good patient outcomes.

(Adapted from)
HITH Guidelines 2012

Clinical handover

Transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis.

National Safety and Quality Health Service Standards (2021)

Clinical pathways

Clinical pathways are standardised, evidence-based multidisciplinary management plans, which identify an appropriate sequence of clinical interventions, timeframes, milestones and expected outcomes for a homogenous patient group

Queensland Health Clinical Pathways Board (2002)

Consumables

Equipment required by the patient and HITH team to provide care.

HITH Guidelines 2012

Coordination

The structured organisation of the care including communication and role delineation between services.

HITH Guidelines 2012

Dedicated HITH Team

Team recruited to provide HITH care only.

HITH Guidelines 2012

Hospital in the Home (HITH)

HITH in Queensland is defined as providing care in a patient's permanent or temporary residence for conditions requiring clinical governance, monitoring and/or input that would otherwise require treatment in a traditional hospital bed. The HITH program is focused exclusively on substituting admitted patient care within a hospital setting to the ‘home’ setting of the patient governed by the authorised officer.

(Adapted from)  HITH Guidelines 2012

Inpatient shared model

Staff that work in an acute facility and also provide HITH care within their scope of practice.

HITH Guidelines 2012

Interface

Staff that work in an acute facility and also provide HITH care within their scope of practice.

HITH Guidelines 2012

Medication management

Process whereby medication requirements of HITH patients are met.

HITH Guidelines 2012

Patient journey

Flow of the patient through the HITH service from time of admission / transfer to HITH until discharge of care to the primary provider, or transfer to another inpatient team.

HITH Guidelines 2012

Record management

The practice of maintaining patient information while the patient is admitted to the HITH service.

HITH Guidelines 2013

Remote patient monitoring (RPM)

Refers to the use of technology to enable the monitoring of patients’ condition qualitatively or quantitatively through physiological or symptomatic observations outside of conventional clinical settings, such as in the home or in a remote area.

(Adapted from)
Telehealth Support Unit

Separation

The point in which the patient can be discharged from the service into the care of the primary care provider (e.g. General Practitioner).

HITH Guidelines 2012

Service evaluation

The ongoing monitoring and evaluation of service level data to ensure key performance indicators are met.

HITH Guidelines 2012

Sub-acute care

This care type is a collective term for the following care types: geriatric evaluation and management rehabilitation, psychogeriatric, maintenance, rehabilitation and palliative.

QHAPDC Manual 2022-2023

9. Abbreviations

Term

Explanation

ABF

Activity Based Funding

ADL

Activities of Daily Living

ALOS

Average Length of Stay

ATSI

Aboriginal and Torres Strait Islander peoples

CEO

Chief Executive Officer

CEWT

Children’s Early Warning Tool

CHSP

Commonwealth Home Support Programme

CLD

Criteria Led Discharge

CMI

Consumer Medicines Information

COO

Chief Operating Officer

DRG

Diagnosis Related Group

DVA

Department of Veterans’ Affairs

ED

Emergency Department

EDD

Estimated Date of Discharge/Estimated Discharge Date (both used)

GEMITH

Geriatric Evaluation and Management in the Home

GEMRHITH

Geriatric Evaluation and Management and Rehabilitation Hospital in the Home

GP

General Practitioner

HBCIS

Hospital-based corporate information system

HCP

Home Care Packages

HHS

Hospital and Health Service

HITH

Hospital in the Home

HIU

Healthcare Improvement Unit

KPI

Key Performance Indicators

LOS

Length of Stay

MoC

Model of Care

NDIS

National Disability Insurance Scheme

NP

Nurse Practitioner

PBS

Pharmaceutical Benefits Scheme

QAS

Queensland Ambulance Service

QCCS

Queensland Community Care Services

QHAPDC

Queensland Hospital Admitted Patient Data Collection Manual

RACF

Residential Aged Care Facilities

SAC

Severity Assessment Code

SMO

Senior Medical Officer

10. References

11. Approval

Document custodian
Acting Director, Healthcare Improvement Unit, Clinical Excellence Queensland (CEQ)
Approval officer
Executive Director, Healthcare Improvement Unit, Clinical Excellence Queensland (CEQ)
Approval date: 5 October 2022

12. Review

This document will be evaluated and reviewed every 3 years from date of approval to ensure it remains current.

Date of last review: 29 September 2022

13. Version control

VersionDateComments

1.0

20 November 2012

First issue

2.0

31 December 2013

Reviewed in partnership with NMOQ and HITH Advisory Committee

3.0

21 February 2017

Reviewed in partnership with Health Statistics Unit, Revenue Strategy and Support , and HITH guideline review working group

4.0

30 September 2022

Reviewed and updated by Healthcare Improvement Unit, Clinical Excellence Queensland

14. Appendix A

Hospital in the Home (HITH) suggested key performance indicators/minimum data set

# These are suggested KPIs available for HITH services to select from and adapt to suit local HITH service delivery

Indicators Intended outcomeMeasurement Data sources

Total percentage of hospital separations with a component of HITH in the episode of care for ABF reporting hospitals

Increased % of total hospital separations to be managed through the HITH model of care up to or greater than 1.5%

Total number of patients admitted to HITH as a percentage of total hospital separations

HBCIS/ QHAPDC

Total percentage of hospital separations with a component of HITH in the episode of care that utilised Remote Patient Monitoring (RPM)

Increased % of total hospital separations to be managed through the HITH model involving the use of RPM

Total number of patients monitored with RPM admitted to HITH as a percentage of total hospital separations

HBCIS/QHAPDC

Length of stay

HITH service compared to Hospital

DRG Groups - HITH service compared to Hospital
HITH length of stay is comparable to the hospital length of stay for the same DRG group 
DRG Groups – HITH service compared to Hospital
Denominator - Total number of patients with HITH component of care per DRG
Numerator - Total cumulative length of stay per DRG of patients with a HITH component of care

Compared to
Denominator - Total number of patients per HITH DRG without a HITH component in the episode of care

Numerator- Total length of stay per HITH DRG for hospital admissions of patients with no HITH component of care

HBCIS/QHAPDC

Length of stay

HITH service LOS compared with State ALOS

DRG Group – HITH service compared to State HITH Length of Stay
HITH length of stay is comparable to the State average HITH length of stay for the same DRG group
DRG Group – HITH service compared to State HITH Length of Stay
Denominator - State ALOS for the same DRG
Numerator - ALOS of HITH patients per same DRG in the HITH service 
HBCIS/QHAPDC

HITH service readmissions compared to Hospital readmissions within 28 days

Same DRG –HITH service compared to Hospital
Comparable or reduced re-admission rates for the same DRG under HITH care compared to inpatient treatment for the same condition
Same DRG –HITH service compared to Hospital
Denominator - Total number of patients managed in the HITH program (all DRGs)
Numerator - Total number of patients in the HITH program with unplanned readmissions to hospital for the same DRGs within 28 days

Compared to
Denominator - Total acute patients with no HITH component to their episode of care (all DRGs)
Numerator - Total number of patients with unplanned readmissions to hospital for the same DRGs within 28 days of patients with no HITH component

HBCIS/QHAPDC

HITH service readmissions compared with State HITH readmissions within 28 days

Readmissions for same condition – HITH service compared to State HITH
Similar or reduced re-admission rates for HITH care compared to HITH statewide average
Readmissions for same condition HITH service compared to State HITH
Denominator – Total number of patients managed in the HITH service (all DRGs)
Numerator – Total number of unplanned readmissions of patients with a HITH component to hospital for any condition within 28 days

Compared to
Denominator – Average statewide total acute patients with HITH component to their episode of care (all DRGs)
Numerator – Total number of patients with unplanned readmissions to hospital for same condition within 28 days of patients with a HITH component

HBCIS/QHAPDC

Percentage of transfers back to hospital of patients under the care of HITH

Less than 5% of unplanned transfers back to an acute ward during the HITH episode of care

Total number of unplanned* transfers to hospital during HITH episode of care
Denominator - Total number of patients managed in the HITH service
Numerator - Total number of unplanned transfers back to hospital during the episode of HITH care

* Definition: An unplanned transfer is a return of a patient to the hospital from HITH for reasons not foreseen and arranged for as part of the treatment plan. Normal transfers as part of the treatment plan such as transfers for review, investigation or planned hospital treatment of the patient would not be considered unplanned.

HBCIS/QHAPDC

Percentage of deaths during the HITH episode of care

Lower mortality rate compared to peer, aged and morbidity matched controls

Death during HITH care
Denominator - Total number of patients managed in the HITH service
Numerator - Total number of deaths during the episode of HITH care

Compared to
Standardised in-hospital mortality rate

HBCIS/QHAPDC

Adverse events, near misses and incidents

HITH service compared to Hospital

Similar or reduced adverse events, near misses and incidents compared to inpatient treatment.

Key areas include adverse events, near misses and incidents related to the following:

  • medication
  • pressure injury
  • falls (witnessed and unwitnessed)
  • clinical handover from hospital to HITH
  • blood stream Infections
Total Incidents
Denominator - Total number of patients managed in the HITH service
Numerator - Total number of reported adverse events*, near misses and incidents

Compared to
Denominator - Total acute patients with no HITH component to their episode of care
Numerator - Total number of reported adverse events, near misses and incidents
* Definition: (from RiskMan) An adverse event is a clinical incident in which unintended or unnecessary harm resulted.

RiskMan

Adverse events reports

Pressure injuries (stage 3 and 4) - Admitted patient data record and bed side audits

Blood Stream infections - CHRISP

Patient/carer satisfaction levels

Greater than or equal to 80% of patient/carer satisfaction with HITH service

HHS to develop tool to measure patient/carer satisfaction

HITH patient/carer Satisfaction Surveys

Auditing processes

Similar standard of care to that which is provided in the acute hospital facilities is to be provided by HITH services

Audit processes of the same frequency and quality as per HHS schedule

HHS to develop audit schedule

Aboriginal and Torres Strait Islander people’s utilisation of HITH service

Increase Aboriginal and Torres Strait Islander people’s uptake equivalent to or greater than the demographic percentage in the HHS

Denominator - Total number of patients managed in the HITH service
Numerator - Total number of Aboriginal and Torres Strait Islander patients managed in the HITH service

Compared to
The total % of Aboriginal and Torres Strait Islander peoples in the demographic area

HBCIS/ QHAPDC

Clinician and HITH Referrer satisfaction levels

High level of clinician satisfaction with HITH Service

HHS to develop tool to measure clinician and HITH Referrer satisfaction

Clinician Satisfaction Surveys

Clinical Governance

Dedicated robust clinical governance of HITH service

HHS to develop set of governance tools consistent with National Safety and Quality Health Service Standards (Second edition – 2021)

Local HHS policies and processes

Healthcare associated infections

HITH service compared to Hospital

Low level of healthcare associated infections equivalents to or lower than Hospital

Denominator – Number of patients in the HITH service
Numerator– Number of healthcare associated infections for HITH service patients

Compared to
Denominator - Total acute patients with no HITH component to their episode of care
Numerator- Total number of reported healthcare associated infections

RiskMan

Blood Stream infections - CHRISP

Medication safety

HITH service compared to Hospital

Low levels of medication incidents

Denominator - Number of patients in the HITH service
Numerator - Number of medication incidents for HITH service patients

Compared to
Denominator- Total acute patients with no HITH component to their episode of care
Numerator - Total number of reported medication incidents

RiskMan
Audits
Local incident management tool

Comprehensive Care Plan

100% of patients with a Comprehensive Care Plan

HHS develop integrated screening and assessment processes in collaboration with patients, carers, and clinicians, outlined in a goal-directed Comprehensive Care Plan
Denominator - Number of patients admitted to the HITH service
Numerator - Number of patients with a comprehensive care plan.

Local HHS policies and processes

Communication of critical information

HITH service compared to Hospital

Communication of critical information and effective clinical handover comparable to Hospital

Denominator - Number of patients admitted to the HITH service
Numerator - Number of communication incidents

RiskMan
Audits
Local incident management tool

Recognised acute deterioration

100% of patients have an Acute Deterioration Plan with 24/7 access to clinical advice and support

HHS develop systems to support detection and recognition of acute deterioration
Denominator - Number of patients admitted to the HITH service
Numerator - Number of patients with acute deterioration plan with 24/7 access

Local HHS policies and processes

Last updated: 5 October 2022