Dr. Elisabeth Crisci says when she first saw a man getting a blood transfusion in his living room as part of a home-based hospital-care program in Australia, she felt disoriented, but that quickly turned into a “lightbulb moment.”
Crisci is one of two physicians in charge of a new pilot program that launched with its first patient on Monday at Victoria General Hospital. It will allow eligible patients to receive treatment at home, rather than in hospital, with support from hospital-based doctors, acute-care registered nurses, and special equipment and technology.
The Hospital at Home program is based on similar programs in Australia and the United Kingdom.
“They’re in their own bed, they can eat their own food, and it just makes sense,” said Crisci, who saw the Hospital at Home model while training in Australia, where it is an established form of acute care. “I went into people’s homes and I saw patient after patient receiving the type of care that, here in Canada, we can only get when admitted to the hospital, and it was a true revelation.”
The elderly and frail do better if they’re in an environment they’re familiar with, she said.
Crisci and Shauna Tierney, the other physician lead for the program in Greater Victoria, have a combined 25 years as hospital-based doctors and a decade as community-based family physicians.
Crisci said five to 10 per cent of all admitted patients in hospital right now could meet the eligibility criteria to receive the same care at home. “For Greater Victoria, that’s the equivalent of a couple of hospital wards.”
The $42.3-million provincial program is being piloted in Island Health and Northern Health, and the plan is to roll it out province-wide next year. It will begin with a nine-bed pilot at Victoria General Hospital, which has 329 acute-care beds. If all goes well, it will expand in the spring or summer to Royal Jubilee Hospital and Cowichan District Hospital.
It was introduced Sept. 9 as a highlight of the province’s $1.6-billion preparedness plan to manage the pandemic through the fall and winter.
The voluntary program is targeted at acute-care patients who have been assessed by a doctor as being appropriate for the program, who have a caregiver at home, who require only a brief hospital stay, and who live within a short drive of the hospital. The catchment areas will vary from region to region. Only designated doctors will work in the program, which is billed as providing patients with in-person and virtual around-the-clock care.
The patient remains “admitted” while at home and is under the care of the “most responsible physician.” If the patient’s condition declines or a complication arises, the patient is sent back to the emergency department or ward. Of those who go home as part of the program, about six per cent typically end up going back to hospital, said Crisci.
Tierney said she once worked in a geriatrics-only clinic that saw patients cared for in their own homes.
Many of us thrive on that level of intimacy,” said Tierney. “I love that degree of connection.”
It’s like going back to the “roots of medicine” before hospitals came into existence, she said.
In October 2018, Tierney was in the audience when Island Health’s Marko Peljhan asked South Island Hospitalists — an association of about 75 to 80 hospital-based physicians — how they would meet the demand for an additional 500 beds in Victoria by 2040.
Tierney pitched the hospital at home model, and Crisci was soon on board. In May 2019, they took it to the South Island Hospitalists, then Island Health. In February, they brought their proposal to Deputy Health Minister Stephen Brown. It was as if Brown “had just been waiting for us to come,” said Tierney. The province followed with exhaustive in-house and independent research, said Crisci.
Care at home is no more expensive than in-patient care in a bricks-and-mortar hospital, and it’s “just as good, if not better, particularly from the patient’s point of view,” said Tierney.
The challenge, the physicians say, will be convincing the public of that. In the case of pneumonia, for instance, a person may need hospital-level interventions such as oxygen, or intravenous antibiotics, close monitoring of symptoms and vital signs, but “all of these things are portable,” said Crisci. Pneumonia, respiratory illnesses, urinary tract infection, chronic heart failure, diabetes complications are some of the illnesses more likely to qualify to receive treatment at home.
The program utilizes technology such as video monitoring and conferencing and equipment including blood-pressure cuffs, vital-signs monitors and a nurse call bell that hangs around a patient’s neck or is placed in their pocket.
In August, the Associated Press reported that hospital at home programs were taking off across the United States amid the pandemic, since patients felt safer being treated at home. In New York, the Mount Sinai at Home program grew from 10 patients a month to 30.
Crisci says medical literature shows the program yields equivalent or better clinical outcomes for equivalent patients, and a higher level of patient satisfaction for less money. “Across the board, we haven’t seen a red flag.”
In 2018, the B.C. Care Providers Association recommended the model to improve care for seniors, saying older adults with an acute illness would opt for “safe, high-quality, hospital-level care” in their homes rather than hospital, and similar programs have shown older acute-care patients cared for at home are less likely to experience clinical complications such as delirium and functional decline.
Crisci and Tierney argue the program frees up much-needed hospital beds. “We are creating, out of thin air, hospital beds,” said Tierney. “We’re actually building a virtual hospital.”
In one of many evaluations that will be done on the Victoria program, Dr. Sean Spina, pharmacy co-ordinator and research lead at Royal Jubilee Hospital, will examine the pilot’s effect on acute-care-bed occupancy, patient experience, clinical outcomes — such as recovery rates, readmission rates and mortality rates — and cost.
Island Health’s Peljhan said the nine-bed pilot is projected to be on par with in-hospital costs at first, but could yield up to 20 per cent savings as more patients are enrolled and the program achieves economies of scale. More importantly for the health-care system, it will free up beds, he said.
“This is a proven model that’s utilized in several places internationally — it’s essentially the first of its kind to be implemented in Canada and we’re very excited to provide hospital-level care in patients’ homes that we believe is going to be more comfortable for our patients and will be able to meet their needs more effectively,” said Peljhan.
