A recent CMAJ news article discussed hospital-at-home programs as an approach to expand acute care capacity in Canada.1 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.2–4
Running such a program is not cheap; staff-to-patient ratios can be double those of the hospital, and staff transportation and remote monitoring technologies add to the operating costs. These operating costs are certainly justified when hospitalat-home functions as an acute care service, offering an alternative to a standard hospital admission. Unfortunately, hospital-athome programs have a tendency to be used well past the acute phase and can become little more than a glorified, expensive discharge-to-home program. This is a common pitfall for the few hospital-athome programs in Canada. These programs have not met their objective, as patients are identified and taken charge of past their acute phase, while in hospital.3 These programs simply allow them to complete the therapies already started in hospital. Although patients may return home a few days early, this type of program is unlikely to be cost-effective or even qualify as a true hospital-at-home program. 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. Canadian health care systems already have many efficient post-acute care programs and services, some of which have been operating for decades, such as home intravenous programs, community care or home-based rehabilitation programs. Any other post-acute program risks duplicating these services. By not intervening early enough in the care continuum, in the acute or pre-acute phase, hospital-athome does not prevent a hospital admission, which is its very raison d’être.
Various jurisdictions in Canada may fail to see the true value of hospital-athome programs if they offer little more than a duplication of existing post-acute services, albeit with more substantial operating costs and without the ability to avert a hospital presentation or admission in the first place. To avoid this, it is essential for any hospital-at-home program in Canada to provide services in the acute phase of the care continuum, which would translate into taking charge of a patient much sooner, while they are still in the emergency department or, ideally, while still in the community (pre-acute phase). Taking inspiration from some successful examples of hospital avoidance — such as the Somerset Ambulance Doctor Service in the United Kingdom, which has been able to deliver acute prehospital care since 2014 — would ensure hospitalat-home programs offer a true substitute to a standard hospital admission (rather than an enhanced discharge service) and fill a gap in the care continuum.5,6
Footnotes
Competing interests: None declared.
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