Dr Amy Heskett  -  3 February 2021

Hospital at Home team members have a strange and magical mix of skills; they must focus on attention to detail and think creatively; lead confidently and share decision-making; use clinical skills accurately and act pragmatically to maximise a person’s function at home. 

A Hospital at Home kit bag must have essential items to hand to allow quick initiation of hospital-level treatments and the visits are intense as they amalgamate the traditional triage, clerking and post-take ward round formula into one session.  The team must have an in-depth knowledge of clinical guidelines, access to a person’s medical records and investigation results, but also an ability to adapt those to a given situation.  The team’s senses are heightened as they appraise both the physical, social and environmental setting for the given clinical scenario and candid conversations to clarify expectations may be needed within minutes to ensure decision-making incorporates risks of a situation.  The creation of a management plan is not complete until it fits the context in which it will flourish; hooks to allow drips to hang may need to be fashioned, temporary adjustment of a room may be needed to maximise mobility or access to a telephone and temporary care arranged 

I work in a setting of extremes; I need to know basics such as how to access a property, I use coat hangers as drip stands and I proudly carry a venous blood gas machine.  Laptops allow access to acute trust and primary care records, pathology and radiology results are invaluable.  Bedside-testing of renal function, CRP levels and ECG readings allow real-time decision-making for an unwell person and the honest sharing of risks.  I can start hospital-level treatments within minutes (IV fluids, IV antibiotics, oxygen), or maximise the control of a long-term condition causing symptoms; there are no delays if a palliative approach is required as we carry a huge variety of medications to focus on symptom control.  We are often the first team to look at the variety of specialist opinions sought for multiple co-morbidities and to rationalise and adapt these to maximise their impact in the context of a person’s everyday life.  De-prescribing to minimise side-effects or altering drug timings can be life-changing and allow a person to optimise their well-being and ability to adhere to complex regimes. 

Communication is key; you enter someone’s home and a quick rapport is essential.  There is a wonderful instant flattening of the hierarchy and this feels like the true patient-centered dialogue aspired to in a hospital-setting.  In their own home environment people are emboldened to debate and become actively involved.   Working with an extremely unwell person has a heady mix of a need to work quickly and confidently, but being open to adapt these steps in line with a person’s wishes.

It is a great privilege to work in someone’s home; they are trusting you to work with them in their chosen setting and there are often reasons behind the desire to avoid a hospital admission.  There is a high level of satisfaction as you are responsible for assessing, initiating and reviewing the treatments alongside your multi-disciplinary team; feedback is instant.  The treatment you initiate is adapted to a person’s long term goals; there is a sense of realism as you incorporate the medical and social aspects of the disease, there is hope that the changes you make are sustainable because they are made within the context that the person will continue to function within.

The Hospital at Home model is particularly suited to those working alongside people with frailty.  This group has many characteristics in common; unintentional weight loss, loss of muscle strength, slow walking speed and low energy levels.  When unwell this group of people will often present in non-specific ways and teams used to working with them are aware of the importance of spending time to elicit the underlying cause of even a small change.   An assessment in a community setting allows the exploration of multiple underlying factors and those with frailty have often walked a long path alongside a variety of medical teams and have reached a point where they are keen to prioritise their own goals.

Hospital is often the right setting for people when acutely unwell; however for those with frailty there are increased risks including falls and delirium.  For many in this group repeated admissions cannot resolve all their medical problems and a hospital stay results in deconditioning and a need for increased support.  Hospital at Home teams appreciate the importance of initiating quick treatments as those with frailty can deteriorate quickly due to reduced physiological reserve, but are mindful that this needs to be done alongside the person’s wishes and with a balanced view of the risks and benefits from every action.

Our treatments may not be perfect, but they realistic.  Working in a Hospital at Home challenges the training you have been provided and invites you to think differently.