Effective strategies to implementing and improving HITH services

Dr Krispin Hajkowicz, Infectious Diseases and General Physician and Senior Lecturer for the School of Medicine at the University of Queensland joined us recently to discuss effective strategies to implementing and improving HITH services in remote and metropolitan areas.

He will be presenting at the upcoming Hospital in the Home Conference 2014, which will take place on 26th and 27th May 2014 at the Rydges in Melbourne.

In your experience, what are some of the most effective strategies to implementing HITH services?

Krispin: I think that many of the traditional HITH DRGs are becoming less important in 2014, so looking creatively for new diagnoses requiring enhanced medical governance and daily nursing review is the way to grow a service in the future. It is more important than ever not to “game” the system and make sure that the HITH service is only accepting genuine hospital substitution cases.

There can sometimes be tension between the hospitals and community service providers, so using a “one-team approach” that straddles this divide is critical to the success of a HITH program. This means all members of the team at all stages of the patient journey being responsible for a quality outcome and efficient use of resources.

Your first presentation at the conference looks at running HITH services in the remote tropics of Australia. What are the common barriers associated with this and how did staff overcome the challenges and make positive steps to change?

Krispin: I had an extraordinary experience running the HITH service in Darwin. In the generally younger population, infectious diseases are the bread and butter of HITH up in the “Top End,” dominated by a cruel and savage infection – Melioidosis. Disaster planning for inclement weather, floods and tropical cyclones and running a service in the vast emptiness always kept it interesting! The “can do” attitude of our amazing Darwin HITH nurses was what enabled us to deliver an extremely high quality service in often challenging situations. Fundamentally, most people prefer to get out of hospital as soon as possible and are prepared to work with the team to achieve this goal.

As part of your second presentation at the conference, you mention new options and new barriers in HITH implementation in a large metropolitan centre. Can you give an example of how new approaches have led to an improvement?

Krispin: Traditionally, hyperemesis of pregnancy has not been managed in HITH services in Brisbane. By developing a consensus clinical pathway with input from all the stakeholders built on a solid framework of evidence-based literature, then identifying a suitable group of patients and the large amount of resources that they used as inpatients and finally by giving it a go, we have developed this into a useful option for pregnant women. Our first patient was complex, had multiple co-morbidities and had had four previous terminations for hyperemesis but was successfully managed in our service at an inopportune time (over the Christmas public holidays) and is now about to deliver her first baby.

Referring to both remote and metropolitan areas, what lessons can be learnt from the different settings that you have worked in?

Krispin: In general, the issues confronting services are similar – creating a service with strong accountability for outcomes, screening admissions for appropriateness and then working with patients to minimise the disruption to their lives are common across remote and metropolitan settings. To me, HITH works really well in both settings and can be done safely and efficiently.

In your opinion, what can health services do to facilitate GP involvement in the facilitation of HITH services?

Krispin: Medicare local is a great opportunity for GPs to become involved in different aspects of the hospital and health services care delivery. Collaborating with GPs on referrals, hospital avoidance and a smooth transition back to post-acute care once the HITH admission is finished are vital. GPs have a lot of knowledge and capability in many of the situations where HITH-type care is delivered, nowhere more so than in aged-care facilities, so early dialogue, particularly before the patient is discharged is not only important for safe care, but can substantially enhance the care that is delivered.

How important are relationships and collaboration with allied health services to improving a patient’s journey and thereby reducing admissions to hospital and enabling a better consumer experience?

Krispin: I am fortunate to work with some cracking allied health professionals in the HITH service. I think this is one of the absolute strengths of the HITH model. There is often a disconnect between the information gathered in a traditional hospital-based allied health review and the on-the-ground reality in the patient’s own home. Pharmacy, OT, physiotherapy and social work reviews in a patient’s home are just so much more relevant, comprehensive and holistic that I have developed a mantra – “if an inpatient team is considering an allied health home visit prior to discharge, this is a strong indication for HITH admission.”

Are there any presentations from the 2014 Hospital in the Home Conference that you are particularly looking forward to?

Krispin: It looks to be an excellent program with a lot of breadth and some great speakers. I am particularly looking forward to James Pollard’s presentation on the “SWITCH” clinical trial, addressing the duration of intravenous antibiotics for cellulitis. There is nothing magical about intravenous antibiotics, all they do is achieve higher tissue levels in some situations. I have a suspicion that short-course intravenous treatment followed by rapid transition to oral antibiotics is appropriate across a range of infections managed in HITH and look forward to the presentation of data on this matter.

I am also looking forward to the presentation by Daniel Kesik and Barb Milner on using Skype and other technologies to facilitate HITH review. This sort of approach seems perfect for HITH patients, I don’t understand why we aren’t doing it all the time and moving away from traditional and clumsy concepts like paper notes. I don’t think Skype will ever completely replace face-to-face reviews, but I think it will enhance services greatly. 

This article was prepared by Krispin Hajkowicz in his personal capacity. The opinions expressed in this article are the author’s own.

To find out more about the event program and to register, please visit the 14th Annual Hospital in the Home Conference website.