Hospital in the Home: Standards of care

Guideline number: QH-GDL-379-3

Effective date: 22 December 2023

Review date: 22 December 2023

Supersedes: Version 1

1. Purpose
2. Background
3. Related documents
4. HITH model of care
5. Patient safety and quality
6. Communication and coordination
7. Governance
8. Approval
9. Version control
10. References

1. Purpose

This guideline outlines standards that define the type and quality of care to be provided by Queensland public Hospital in the Home (HITH) services. It is intended to provide a foundation for clinicians to provide high quality care in their professional capacity, fulfilling their duty of care to the patient. These standards guide practice and monitor improvement in Queensland Hospital and Health Services (HHSs), and ultimately give clinicians the necessary information regarding the quality of care that is required to be provided to patients.

2. Background

Statewide consultation was undertaken by Clinical Excellence Queensland (CEQ) with key stakeholder groups to examine HITH service delivery statewide. Consultation identified the value of developing overarching HITH Standards of Care to guide public HITH service provision and provide reassurance to clinicians, patients and the greater public of uniform standards of care, despite varying models.

3. Related documents

• Hospital in the Home guideline (inclusive of HITH suggested key performance indicators (KPIs)/ minimum data set)
• Clinic-based Hospital in the Home: Block funded facilities and Clinical Services Capability Framework Medical Services 3 and below
• Hospital in the Home: During a pandemic
• Queensland Hospital Admitted Patient Data Collection (QHAPDC) Manual

4. HITH model of care

HITH in Queensland is defined as providing care in a patient’s permanent or temporary residence for conditions that require ongoing clinical governance, monitoring and/or treatment, as a substitution for in–hospital admitted care.

• An alternative patient preferred location can be requested by the patient, ensuring the rationale is appropriately documented in the patient record (where appropriate).

  AND/OR

• An alternative safe location can be nominated by the HITH service, ensuring the rationale is appropriately documented in the patient record (where appropriate).

• 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 service to meet the patient’s 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—the 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.
• Safe, high value care—the care provided must be safe, of benefit to the patient and be of high value (Queensland Clinical Senate 2016) – refer Section 10.
• Flexible—HHSs can design specific HITH models of care and related clinical pathways for their specific communities and patient cohorts in compliance with these standards and HITH guideline.

4.1 Patient eligibility

HITH service should have processes and procedures to support safe patient selection from a holistic point of view. No eligible public patient should be excluded from accessing HITH if they can be treated safely outside the traditional inpatient hospital environment.

Public eligible patients are inclusive of public acute and sub-acute patients, and acute compensable patients, such as:

• Department of Veterans’ Affairs (DVA) funded patients
• Third party compensable funded patients
• Motor vehicle accident insurance funded patients
• Workers’ compensation funded patients.

Patients are eligible if all of the following criteria are met:

• HITH replaces full hospital admission or a component of a hospital admission. Without a HITH service, patients would be admitted to hospital for treatment and accommodated in a hospital bed
• 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 consent from patient or approved guardian.

Public hospital patients who elect to receive admitted patient care as private and who are subsequently treated by a HITH service, will be required to change their election to public, from the point at which the HITH service commences.

5. Patient safety and quality

Patient safety and quality is a primary aim of HITH. In addition to the Australian Commission on Safety and Quality in Health Care National Safety and Quality Health Service Standards and National Health and Medical Research Council infection control requirements, essential patient safety and quality requirements:

• 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:
  • an alternative patient preferred location requested by the patient, ensuring the rationale is appropriately documented in the patient record (where appropriate)

    AND/OR

  • an alternative safe location nominated by the HITH service, ensuring the rationale is appropriately documented in the patient record (where appropriate)
• clearly specify processes and procedures to monitor and govern patients, inclusive of to managing emergencies, adverse events, and other patient complications
• clearly specify processes and procedures to identify deteriorating patients
• 24-hour on-call support 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
• provision of a 7-day service with single point accountability, daily patient review and transparent clinical governance
• liaison and communication with service providers and/or referring teams, at exit from HITH service as required
• all clinical and non-clinical incidents/near misses managed in accordance with related HHS health and safety processes, to ensure all incidents/near misses are reported, recorded, reviewed and acted on
• HITH service is provided by skilled and experienced staff to deliver the care required, who are appropriately credentialled and supported to work within their scope of practice
• HITH service has adequately resourced staff and equipment to provide the required number of visits and support the timing of visits required
• at-risk behaviours are documented, monitored, risk assessed and reported by the HITH service, as per HHS health and safety processes
• open disclosure and quality improvement is embedded in the function of the HITH service.

5.1 Staffing workforce profiles, 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 to provide HITH care.

Essential requirements would be:

• staffing workforce profiles 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
• staffing workforce profile to 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 to 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 requirements
• all staff are required to meet the Code of Conduct for the Queensland Public Service
• staff are 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 are 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.

6. Communication and coordination

Timely and accurate communication is essential to ensuring care is coordinated for patients and that they are appropriately informed and understand what their care will entail. Essential requirements would be:

• clear, concise, complete, and timely communication between HITH service, referring service, primary care provider, patient, and other relevant stakeholders to enhance care delivery and positively impact the patient journey
• clinical handover to be consistent with Australian Commission on Safety and Quality in Health Care 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
• HITH service to have processes and procedures to collect data needed to monitor, analyse, and benchmark the HITH service, to allow appropriate governance and safety management. At a minimum, this should be inclusive of the HITH suggested KPIs/ minimum data set
• patients are under the care of the HITH service, with the service responsible for care coordination and management, including services being supplied external to HITH
• HITH service to undertake discharge planning to ensure appropriate referrals are made if patients require additional support following discharge
• HITH service to have processes and procedures to communicate and clearly articulate to referring teams the nature, scope, and clinical governance of the service
• HITH service to have a clear, concise, and well communicated and documented referral process.

7. Governance

7.1 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. Essential elements would be:

• 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, including HITH suggested KPIs/ minimum data set via local HHS processes and committee structure.

7.2 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. Essential elements would be:

• patients 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
• patients are 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 retains clinical governance of patients
• timely two-way communication between HITH service and the admitting authorised practitioner holding clinical governance to ensure coordination of care
• communication of all changes in the patient’s condition to be notified to the admitted authorised practitioner to ensure patient safety and enable prompt appropriate clinical decision making
• HITH service to notify authorised 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).

8. Approval

Document custodian
Director, Healthcare Improvement Unit, Clinical Excellence Queensland (CEQ)
Approval officer
Executive Director, Healthcare Improvement Unit, CEQ
Approval date: 22 December 2023

9. Version control

10. References

1. Queensland Clinical Senate. (2016). Queensland Clinical Senate, Meeting Report: Value-based healthcare – shifting from volume to volume. 1st ed. [pdf] Brisbane: Queensland Health. Available at:
   https://www.health.qld.gov.au/__data/assets/pdf_file/0028/442693/qcs-meeting-report-201603.pdf