Dr Amy Heskett  -  28 July 2023

I have been fortunate to work as a Specialist SAS Doctor in a Frailty Hospital at Home team for many years and have recently welcomed trainee Doctors into our team.  Integrating them into our team of SAS Doctors, Advance Clinical Practitioners, Therapists, Nurses and Pharmacists allowed me the chance to reflect on the challenges of adapting their current hospital-based training to this new model of care and the challenges and joys observed along the way.  Development of the team has been both challenging and rewarding in equal measure and working in a Frailty Hospital at Home team brings many benefits to the workforce; it offers a chance to work creatively and provide continuity during an episode (and often subsequent episodes) of illness.  Patients choose their place of care and welcome you to join them, balancing the relationship with clinicians to allow management plans that are truly co-developed with the patient.  The constant change of venue brings opportunity for activity and fresh air; while movement out of the hospital opens communication channels across multiple organisations.  However, there are many other Cs that contrast with that list and require thought; there are challenges (physical and emotional) and a great deal of support required to work courageously with curiosity in community settings. 

Members of a Hospital at Home team require a dizzy mix of attention to detail alongside the ability to work flexibly.  Prior to the home visit it is necessary to gather information on recent investigation results, medications and clinic letters as they may not be accessible in the person’s home.  However, this is often balanced by the need to remain curious on arrival as the context discovered may be far from that described at the point of referral.  Detail is needed before going onto complete a holistic assessment and it is important to understand what a patient’s goals for care are so that management plans are developed in this context.  There is a need for clarity and transparent discussion regarding risks and benefits of a Hospital at Home approach and the patient’s ability to weigh this up needs to be evaluated.  The patient and their family are central to their care and therefore details such as checking medications against the repeat medications are key, so that those being started and omitted can be clearly identified.  There has to be a discussion about the next points of communication and consideration of the next incoming clinician or family member/carer.  It is important to pause at the end of a visit and check all parties have the information they require; the equivalent of returning from the ward station to the bedside to clarify queries.  You have to feel at ease with the final plan; you may not be visiting daily, trust passes to the patient and you cannot aim for perfect.

There is a need to adapt to multiple environments within one shift and variety is the norm.  This starts from when a clinician takes on a role within Hospital at Home, as they are often adapting training skills developed in a primary or secondary care setting.  There is a joy in relying on clinical skills and bedside investigations to come to a diagnosis, but a need to balance this by sharing any clinical uncertainty and risks.  Often guidelines are worked with and adapted, sometimes because of environmental constraints but often when working within a patient’s goals.  There are alternating modes of working within community teams; requiring autonomous clinicians who can then come together within a multi-disciplinary team to coordinate a response and review plans from another viewpoint.  The need to work collaboratively extends across many organisations and within one shift links need to be extended to care agencies, care home staff, families, wardens, paramedics, primary and secondary care.

Working in a Hospital at Home model distorts time; there are both pauses and periods of intense activity.  An initial home visit to manage an acute illness may take hours, but this is in contrast to the ED admission, clerking, post take ward round and ward stay you are avoiding.  Conversely, patients that focus their treatment escalation plans on community management often get to know the Hospital at Home team over multiple episodes and even complex situations may be managed quickly.  A prolonged pause in initial home visits and the investment in bedside diagnostics, examination and candid conversations can save time for the whole system at a later date.  Time also has to be invested in new team members and induction periods need to be prioritised.  An induction can require months as many clinicians come from an acute setting with limited exposure to community contexts or an understanding of services available. 

Remote monitoring of vital signs offers another chance to grow Frailty Hospital at Home teams, but is just one example of the technology that already compliments the multidisciplinary team. For it to add to the team’s resources the remote monitoring is only useful if the trend of vital signs for that patient is appreciated, if their escalation plan is clear should vital signs change and if combined with softer signs that may herald a deterioration.  There is a careful balance required between using the clinicians’ resources well and not overwhelming patients, carers and families with yet more tasks.  It should generate the right response at the right time rather than just increase concern.  Importantly, remote monitoring is needed alongside other hands on support with important daily tasks important to promote recovery such as nutrition, hydration and rehabilitation. 

So, in summary the ‘big C’ challenges of developing workforce within a Hospital at Home model are the need to work with courage, creativity, constant change, candid communication and curiosity.  The opportunities for trainees within a Hospital at Home are vast and yet we are only just starting to see this being explored within the new Geriatric medicine curriculum.