Hospital In The Home Care

1.   Purpose

2.   Definition

Hospital in the Home care is defined as:

the provision of care to hospital admitted patients in their place of residence as a substitute for hospital accommodation. The place of residence may be permanent or temporary.

-National Health Data Dictionary, Version 12

HITH care may be for the entire admission or for part of an admission.

HITH is considered a ward within the hospital.  Transfers to and from HITH are ward transfers.

Before a patient is admitted to care in this service a medical officer will have assessed the patient to see if the treatment, the patient and the home environment are suitable for HITH.

Hospitals may accommodate a patient:

• directly and exclusively into a HITH ward on admission; or
• into one of its onsite wards for part of the admission and in a home environment as a HITH patient for another part of the same admission,

before discharge from the hospital system.  The doctor responsible for care has overall management of the patient until discharge from the service but other health professionals may also provide the care.

There are patients who, after discharge, require follow up care, post acute/domiciliary care or who are discharged under an early discharge program.  This type of care is not Hospital in the Home care.  It must be ensured that those patients who have been formally discharged and then receive post-discharge care at home are not counted as HITH patients.  During HITH care the patient is still an admitted patient and the care is a genuine substitution for hospital inpatient ward care.  The change of location is a change in ward.  In contrast, domiciliary care or early discharge programs provide care after the patient has been formally discharged from admitted care.

3.   Criteria for Inclusion in Hospital in the Home Care

3.1  Criteria pertaining to the provision of HITH care:

If Hospital in the Home care was not available, the patient would be accommodated in hospital;

Care provided must be a genuine substitution for inpatient care; it cannot be care normally or exclusively provided after discharge

• The treatment forms all or part of an episode of care for an admitted patient;
• The hospital medical record is maintained for the patient;
• There is adequate provision for emergency care or intervention; and
• The care is provided under the supervision of a medical officer -while the care may be administered by another medical professional for example nursing staff, the medical officer responsible for care directs orders for treatment.

3.2  Criteria pertaining to patient suitability for HITH care:

• The hospital deems that the patient requires health care provided by professionals funded by the hospital to take an active part in the treatment;
• The patient does not require continuous 24 hour assessment, treatment or observation;
• The patient’s condition has a clear diagnosis and prognosis and he/she is at low risk of rapid deterioration;
• The patient’s place of residence is safe and has carer support available, if required;
• The patient has given the appropriate level of consent to this form of treatment;
• The patient’s residence has adequate communication facilities and access to transportation;
• The patient agrees that if the doctor responsible for care decides that patient care is better provided in hospital, rather than at home, the location of the care will be changed
• The patient’s residence is accessible for emergency care.

4.   Diagnoses for Hospital in the Home Care in WA

Within the parameters defined by the criteria above, any episode of care for an admitted patient is potentially eligible for HITH care, at the discretion of the treating clinician and the HITH Service.

In Western Australian hospitals, the scope of the HITH program, at least initially, will be limited to acute care episodes only with some exceptions (see over page). 

HITH care in WA is primarily directed at acute management, of (but not limited to):

• Cellulitis;
• Deep Vein Thrombosis;
• Infectious diseases managed by intravenous antibiotic therapy.

For each diagnosis, hospitals should develop clinical protocols to specify:

• Selection criteria for HITH patients;
• Referral processes;
• Procedures for dealing with adverse events;
• Procedures for dealing with death during HITH care.

In some circumstances, due to the unavailability of other helping agencies, HITH services may provide care that includes some maintenance care episodes.  For instance:

• Example 1:  A patient, who would otherwise be discharged, requires HITH care over the weekend until appropriate post-discharge nursing services are available.
• Example 2:  A non-admitted patient who is receiving nursing care at home, may be admitted to HITH over the weekend while usual care is unavailable.

* Principal diagnosis: unavailability/inaccessibility of other helping agencies (ICD code Z75.4).

Episode of care type:  maintenance care

* See Section 8 – Clinical Coding for Hospital in the Home Programs

5.   Reporting Requirements

For reporting requirements, a HITH event is defined as:

A period of hospitalisation, during which the patient is continuously accommodated in the HITH ward, without a leave period of more than 7 days.

Days on leave do not break the continuity of a HITH event.

Transfers to hospital ward with return to HITH on the same day do not break the continuity of a HITH event

One HITH event begins with admission to the HITH ward and ends with:

• Separation (discharge from the total admitted patient episode of care) or
• Transfer to hospital ward, with subsequent overnight stay in that ward.

A HITH event may be all or part of one admitted patient episode of care.

There may be more than one HITH event in one admitted patient episode of care.

5.1  The HITH Minimum Dataset

The following items comprise the current HITH Minimum Dataset.  They are collected for internal use by the Health Service and for reporting of clinical indicators.  They are not required for HMDS reporting. Please note that the dataset may change over time.

• Number of referrals to HITH
• Source of referral
• Number of patients treated in HITH
• Number of HITH events
• Principal diagnosis for HITH   events
• Transfers from HITH to non-HITH wards

To facilitate internal reporting requirements, hospitals will report individual HITH events as separate admitted patient ‘episodes’ of care.  This would require that transfers between non-HITH and HITH wards be treated as a statistical discharge.  HITH events would become HITH ‘episodes’ on the hospital system.

NB:  The HITH template supplied to relevant hospitals is to be used for data collection from 1 January 2006, until the hospital systems are able to collect the appropriate information.

5.2   Hospital Morbidity Data System (HMDS)-Reporting Requirements

In addition to the existing data items for HMDS reporting (see Hospital Morbidity Data System Reference Manual) one additional variable is collected for HITH patients.  This is Days of Hospital in the Home Care  (see: HMDS Reference Manual page 131).  The counting rules for this data item are described below (see item 6.0).

For patients who have more than one HITH event in one admitted patient episode, the HITH day count is cumulative.

HITH ‘episodes’ – Counting Rules

For hospitals recording HITH events as separate HITH ‘episodes’ the rules for HITH day count (section 6) are not applicable.  The HITH days will be the total length of stay for the HITH episode, excluding leave days (i.e. normal length of stay counting rules).

In the case of ward transfers, the HITH ‘episodes’ are generated by statistical discharge.  Since, there is no change in episode of care type, these are not true statistical discharges.  The resulting HITH ‘episodes’ will be merged on the Hospital Morbidity Data System in order to comply with national reporting requirements and to meet the national definition of HITH.

The HITH days are reported to the HMDS for each HITH ‘episode’ and will be merged into one cumulative count, when the total patient episode comprises both HITH and non-HITH stays.

Note: Using statistical discharges, multiple ward transfers that involve a same-day event will create three (or more) separate ‘episodes’.  That is:

From HITH to non-HITH with return to HITH on same day

• HITH
• Same Day Non-HITH
• HITH

From non-HITH to HITH with return to non-HITH:

• Non-HITH
• Same day HITH
• Non-HITH

Thus, on hospital systems, the transfer day would always be double-counted (eg. in the first scenario above, once as a HITH day and once as a non-HITH same day episode).  This will have to be noted and corrected when reporting hospital performance.

6.      Calculation of Number of Days in Hospital in the Home Care

The counting rules for Number of Days of Hospital in the Home Care are as follows:

• The day the patient is admitted to hospital is counted as a HITH day if the patient was in HITH at the end of the day (overnight);
• The date of change between hospital and home accommodation is counted if the patient was in HITH at the end of the day (overnight);
• The date of separation from hospital is not counted even if the patient was in HITH at the end of the day.

For same day admissions to hospital, one HITH day is counted if the patient was in HITH at the time of separation.

7.   Number of Days of Hospital in the Home Care and Length of Stay

The Number of Days in Hospital in the Home care cannot be greater than the total Length of Stay.

In the event that a leave period occurs, the leave days should be treated and counted in the same way that they would be counted if the patient was accommodated in hospital.

Days on leave are not included in the count of HITH days.

8.   Clinical Coding for Hospital in the Home Programs

The coding of the HITH event is included in the coding for the total admitted patient episode of care.  Diagnoses and procedures relevant to the HITH event are coded as for those of any other patient who transfers between wards during one admitted patient episode.

The principal diagnosis is assigned as per normal coding rules (Australian Coding Standard 0001).

Where hospitals report ward transfers as “statistical discharges” to meet internal reporting requirements, normal coding rules apply to each individual HITH ‘episode’.  The principal HITH diagnosis required for internal reporting will always be the same as the principal diagnosis for the ‘episode’.  Clinical coding will be merged on the HMDS and one DRG will be assigned.

9.   Discharge Summaries

A discharge summary for the total episode of care, covering both the HITH and any non-HITH portions of the stay, is required and should be completed by the medical officer responsible for care.

Hospitals which report HITH ward transfers as separate episodes, may require their doctors to complete discharge summaries for each separate HITH and non-HITH ‘episode’.  This may facilitate internal reporting but is not a mandatory requirement for the wider reporting system.

10. Private Patients in a Hospital in the Home Program

Under amended legislation of the National Health Act 1953 which was passed in 2001, hospitals seeking to provide Hospital in the Home care to private patients are required to gain Commonwealth Ministerial approval before providing the service.  Only approved services will be covered by the hospital table insurance arrangements of funds.

Dr John de Campo
ACTING DIRECTOR GENERAL
DEPARTMENT OF HEALTH