Your place or ours?—the case for mainstreaming Hospital at Home programmes is persuasive (2025)

Older patients may benefit most from Hospital at Home care

Older patients cared for at home are less likely to develop delirium as their carers and surroundings are familiar. So is the food and this, together with more freedom to “mobilise” at will, reduces rates of nutritional and functional decline. Fall rates are no lower than they are in hospitals, speakers noted, and uneven floors and pets got much of the blame for this.

Carers are often as old or older than those they care for and shoulder high disease burdens. In Barcelona one of the Hospital at Home programmes has linked up with a community based enterprise. Volunteers who want to help others are trained to become substitute carers when the main carer needs respite. This training subsequently helps them find formal employment.

Around 1 - 2% of acute hospital level care is currently provided via Hospital at Home programmes, which are patchily distributed between and within countries, and even within the same city. Views on how much acute care could be provided in home settings ranged from 15% to a possible 45%. Encouraging evidence presented from US Medicaid and rural programmes suggests that this model of care is not only for urban dwelling, middle class patients, and it seems that some providers are “betting big on it.”8

The seductive potential of new technologies and an invitation to vote on the top 10 innovations in Hospital at Home care, in a session led by David Levine, had participants gripped. Levine is an internal and primary care physician from Harvard Medical School, and the driving force behind a newly launched journal, The Journal of Advanced Home Care, dedicated to publishing research and comment on Hospital at Home care.⁹

His list included augmented reality headsets to help guide staff, carers, and patients to carry out relatively complex tasks safely, drones to ensure just in time supply of essential materials, and new implantable sensors. AI fuelled data analysis to rapidly identify patients who fit the criteria for admission to Hospital at Home care, and to detect any deterioration in their condition while undergoing this form of care, got many votes.

Hospital at Home programmes have largely been driven by individual consultants who often run them alongside their “day” jobs. Their passion stems from their belief, and the evidence, that Hospital at Home care is more patient centred, and outcomes are better. It’s also clear that they, and their teams, find it very rewarding to have to really engage with how people live (as well as their pathologies) and to work in partnership with them.

Might high staff burnout rates, which are prevalent in hospitals, along with patients' preference to steer clear of hospitals, support the spread of Hospital at Home programmes? Realistically, speakers underlined, it will depend on bolstering the economic case for them, and putting the necessary financial, organisational, and policy levers in place.

Cultural and educational changes are needed too. Few junior medical staff know much about Hospital at Home models of care and fewer get the opportunity to train to work in them. Jim Pollard, an infectious disease consultant with 30 years experience of leading Hospital at Home programmes in Australasia predicts that Hospital at Home care will eventually emerge as a clinical specialty with a distinct career pathway.

Hearing that “the biggest demand for Hospital at Home care is from those who have experienced it” and that “patients and carers can do more than you think” came as no surprise to me. What did surprise me was scant mention of where, and how, patients are being involved in co-designing services and working as allies to help advance the Hospital at Home movement.

But change is in the air. And as I contemplate my next round of cancer treatment, I am thinking about the poster Pollard told me about in the chemotherapy ward of the unit he runs in Melbourne. It reads “Your place or ours?” Patient choice? Bring it on.