Instead of admitting patients to hospital, some physicians in London, Ont., are taking the "hospital" to their patients. Integrating Physician Services in the Home (IPSITH) is a pilot project to provide home-based treatment for acutely ill patients who would otherwise be in hospital. Under the plan, they will instead receive between 5 and 15 days of in-home care from a multidisciplinary community team that includes a case manager, nurse practitioner, the patient's family physician and health professionals from provider agencies.
The Ministry of Health project is a collaboration between the Community Care Access Centre (CCAC) of London and Middlesex and local family physicians. A research team funded by the Canadian Health Services Research Foundation will evaluate the program.
Since April, 39 family physicians and nearly 40 specialists have agreed to participate in IPSITH, whose managers expect to serve between 100 and 150 patients during the 2-year project. "What we've asked family physicians to do is look at any patient they think they need to admit," says Dr. Irene Cohen, IPSITH's medical coordinator, "and ask themselves if the treatment can take place at home, given today's improved technologies."
Cohen says people with infectious diseases that require the delivery of intravenous antibiotics, as well as those experiencing dehydration, congestive heart failure, uncontrolled diabetes and anticoagulation, are examples of patients who might qualify. In addition to the acutely ill, Cohen thinks IPSITH can handle patients with complex illnesses, but she stresses that the program is not designed for chronically ill patients already being served by CCAC.
Cohen says home treatment offers several benefits, including elimination of the risk of nosocomial disease. In addition, says Cohen, "research has shown over and over that people get better quicker in the home. The acute stage of illness may be 2 to 3 days shorter. If you look at a 5-to-15-day illness pattern, that's a significant reduction in patients' recovery and economic costs."
Cohen notes that all physicians have observed elderly and ill patients who become confused and deteriorate quickly when taken out of their home environment. In addition, ailing spouses unable to visit the hospital may experience increased complications of their own when separated from their partners. IPSITH aims to ease those difficulties.
To date, IPSITH has admitted 7 patients. That number is slightly lower than anticipated, but Cohen thinks it will rise during the fall and winter, when infectious diseases become more prevalent. Cohen says the program is facing normal start-up barriers. She says physicians may not think actively about IPSITH and may experience anxiety about increased workload and the roles of visiting nurses. Joan Mitchell, a nurse practitioner, says she and other staff constantly try to find ways to help physicians provide home-based care and to develop mutual trust and confidence.
Mitchell says she can take pressure off family physicians by arranging diagnostic testing, providing clinical monitoring and communicating these findings, liaising with specialists and prescribing medications within the scope of her role. Involvement of family members, friends and neighbours is critical. Because this type of care can be stressful, Mitchell says IPSITH is "vigilant about caregiver burnout. If the patient sees a family member stressed, that isn't going to be healing for the patient."
Cohen and Mitchell are delighted that almost 40 specialists have agreed to provide consultations within 24 to 48 hours, including 17 who will make house calls.
Cohen finds this significant, given the "pathetic" fees paid for home visits. She also foresees a "beautiful pairing" between IPSITH and speciality urgent care clinics being developed by local hospitals. All local providers of in-hospital and community-based diagnostic services have agreed to provide urgent testing when required. As much as possible, says Cohen, IPSITH was designed to "imitate" in-hospital admissions, right down to chart design.
The London program was the "brainchild" of Dr. Ian McWhinney, while Dr. James McSherry was a driving force behind its development. An IPSITH multidisciplinary Management Committee and a Research Team meet regularly.
Similar initiatives are also under way in Ottawa, Hamilton and Saskatchewan, while a "hospital without walls" model has operated in New Brunswick for 2 decades.
Organizers, recognizing the importance of communications and networking, have produced an IPSITH newsletter and hold ongoing meetings and information sessions with physicians and residents. As well, a Web site has been developed (www.uwo.ca/fammed/tvfpru/ipsith/index.html).
Cohen believes IPSITH is an ideal fit for this southern Ontario city. "It makes sense," she insists. "It makes sense to everyone we talk to, people inside the hospital, people outside the hospital, the public, physicians, nursing staff, everyone."