The potential and pitfalls of hospital-at-home programs

“Could bringing the hospital home expand acute care capacity?” That question was asked in the headline of a February CMAJ article, which explored this model of hospital care in Canada. The article discussed hospital-at-home programs as an approach to expand acute-care capacity in Canada by offering hospital-level therapies, tests and monitoring for patients who are sick enough to require acute care but stable enough to receive it at home. It cited some studies that showed this is a cost-effective and beneficial model, while acknowledging uptake had been slow in Canada, especially compared to the U.K. and other countries. A subsequent letter published in May in the CMAJ expanded on the downside of hospital-at-home in Canada. Headlined “Hospital-at-home programs in Canada: challenges and pitfalls,” the letter was written by Elisabeth Crisci, a lobbyist and expert in the hospital-at-home model in Canada and former medical lead for the hospital-at-home program in Victoria, B.C. She wrote that despite its numerous advantages and benefits, “developing and executing a hospital-at-home service that offers a true alternative to a standard hospital admission remains elusive in Canada.” B.C. and Alberta experience In 2020 when the pandemic hit, British Columbia’s Island Health Authority launched a hospital-at-home program that was already in the works as health systems were scrambling to accommodate the rising number of COVID-19 cases. The goal of the B.C. program is to reduce readmissions among marginalized populations, older people and those with chronic conditions, like COPD or congestive heart failure—essentially, patients who tend to visit emergency departments frequently. Community paramedics provide a wide range of services for these patients, like bloodwork, IVs and wound care, and also check if they have enough food and a safe home. Patients also typically receive a remote monitoring kit that includes an oximeter, blood pressure cuff, thermometer, scale and digital tablet for tracking their vital signs and communicating with care providers. Alberta Health Services launched a similar “Complex Care Hub” program in Calgary before the pandemic, offering patients the option to receive acute care at home from a team of healthcare providers. Read: How to manage patients with heart failure according to heart failure phenotype The future of hospital-at-home For at least two decades, Spain, Australia and France have had hospital-at-home programs that offer similar care to what is available in traditional hospitals. The U.K. has also had successful programs. According to various studies, including Cochrane reviews, patients who use these programs often experience shorter lengths of treatment, fewer readmissions, and a reduced risk of entering residential care within six months. The February article said that most economic analyses of Canada’s hospital-at-home programs show the model reduces the cost of care, while acknowledging that a recent review had cautioned that these studies likely overestimate the potential savings. Experts also note that hospitalization can inadvertently make patients sicker as they spend most of their time in bed and can be exposed to infections. Hospital-at-home can also be a good alternative for patients who have experienced institutional abuse or discrimination. Read: Involuntary psychiatric hospitalizations trending upwards The article also noted that uptake in Canada outside of Alberta and B.C. is slow, likely because other provincial health systems, like Ontario’s, are more fragmented. In her letter, Crisci wrote that running such programs is expensive and requires high staff-to-patient ratios. Staff transportation and remote monitoring technologies add to the costs. Crisci also noted that hospital-at-home programs are often used well past the acute phase and can become too similar to already-in-place discharge-to-home programs. “Despite the high operating costs of what should be an acute care service, hospital-at-home programs tend to operate as a post-acute service. . . . By not intervening early enough in the care continuum, in the acute or pre-acute phase, hospital-at-home does not prevent a hospital admission, which is its very raison d’être.” Crisci recommends that Canada take inspiration from successful “hospital-avoidance” examples, such as the U.K.’s Somerset Ambulance Doctor Service, which has been delivering acute pre-hospital care since 2014.

The potential and pitfalls of hospital-at-home programs

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