Moving Care Out of the Hospitals in Australia

There are many factors in Australia, such as rising patient needs, an aging population, an aging workforce, demand for care to be delivered in the communities, and the need to reduce unplanned health care use, which are driving change in the health care system. Moving care out of the hospital is one of the ways that the nation is addressing these needs. Since the 1990s, Australia has been moving health care out of the hospital as a strategy to provide patients with greater healthcare choices by incorporating home-based care when acute care is needed. Also, there continues to be more demand for acute hospital care than there are beds so there is need to shift some of the care to communities and people’s homes. This leaves hospitals free to provide more complex, specialised and emergency care only.

Hospital in the Home (HITH) was started in 1994, and launched in every state, with the aim to reduce the length of hospital stay or in some instances to avoid admission altogether. An independent review in 2009 confirmed that HITH is a well-established model of care that is safe and effective and highly valued by all concerned. It is also associated with reduced mortality, readmission rates and cost, and increases in patient satisfaction. However there is no change in carer burden (1).

Health Care Homes was introduced recently and starting from 1 July 2017, more than 200 GP practices will trial the program. Patients suffering from chronic diseases are set to benefit from coordinated care that Health Care Homes provides (2).

The governments of Australia also fund Transition Care, a set of services provided to the elderly after discharge from the hospital which include physiotherapy, occupational therapy, social work and nursing support and personal care. Transition Care is designed to improve the elderly people’s independence and confidence after leaving the hospital, and it helps them to go home earlier.

These initiatives move acute care and primary care from the hospital to the home. Whether they are effective or not is being debated in Australia. Some claim that while moving care out of the hospital might improve health outcomes for patients, it is not going to save the government any money. Yet the concept is successful in other countries. Hospital in the Home has been tested in other countries like UK, Canada, USA and Mexico and found to be successful and effective. In the USA it has been found to reduce costs by 19% while achieving the same or better outcomes for patients compared to those in hospital. Customer satisfaction was found to be high (3). Therefore there is no reason why this initiative should fail in Australia.

The Transition Care Programme is jointly funded by national government and state and territory governments. Health Care Homes will be funded from chronic disease items provided by GPs. In 2017/8 the government will redirect $93 million from the Medicare Benefits Schedule to support flexible and innovative clinical delivery for chronic and complex diseases. The government will also invest an additional $21.3 million over the next 3 years to establish the infrastructure to support the new scheme.

In truth, not all patients who occupy hospital beds need acute care and not all patients in long-term care facilities need to be institutionalized. For some of these patients, care can be provided effectively and efficiently in the home. However, we must not forget to consider the hidden financial and human costs of home care. There are lower wages for caregivers who are not paid for the time (sometimes a whole hour) that they spend travelling between patients. And there is an increased burden on family caregivers, and sometimes there are no family members to give the care. Not to be left out is the issue of on-the-job safety of home caregivers. Instead of debating whether home care should stay or not, we should be asking ourselves how we can make it more effective while saving taxpayer’s money.

Funding is a thorny issue because there is only so much available. But certain changes can be made. People cannot just be shifted from the hospital to their communities and homes for care without any funding and system strategies.

• So far Australia has three homecare initiatives that are separately funded and target different members of the population. Government could combine all these programs into one well-thought-out program that will work for everyone who needs care but does not need hospitalisation. This will make it easier for everyone to understand and to implement.
• At present hospitals operate outpatient departments, providing services that are also offered by GPs. Suppose the government shifts all funding for primary care to GPs and shuts down the outpatient departments in all hospitals? They will save a lot of money which can be used to increase funding for home based care. The funds can strengthen the community nursing workforce to ensure that the healthcare system meets the demands of an ageing population with complex and multiple health/social needs. Priority can be placed on enabling and supporting nurses through education, training and better remuneration. If care at home is improved and better funded, most chronic disease patients will not need hospital care. Only the few people who really need hospitals will be hospitalized.
• One way of improving care out of the hospital is to operate Urgent Care Clinics in the communities to take away the pressure from hospital emergency departments. For this to work there is need for integrated systems and a well-planned and well-funded approach.
• Government can extend the Transition Care to other population groups instead of limiting it to the aged.
• Government needs to focus on integrated and co-ordinated care as a means to improve continuity and to decrease breakdown of the system within the health and social care systems. All this should result in good patient outcomes.
• Medical records for outcome based medical care need to be integrated so that each patient’s needs are known by both the hospital and the community care givers.

It is obvious that change in healthcare is necessary and that the move towards home care is beneficial for the patient, the caregivers and the government. It is also obvious that for Australia to implement better and more efficient change there is need for real whole-some change, not seemingly unrelated changes with separate funding that confuse everyone. Is it time to talk about the National Health Service again? Can each state manage to make changes if the funding models are changed and the home health care model is properly implemented with good integrated health care records?

I must opine that increased levels and quality of care in the communities will drive better person centred care and create a more cost effective and efficient system. Obviously more thinking needs to be done to make sure that there are better outcomes for all concerned while reducing costs for the government.

References

1. Caplan G.A. et al, A Meta-Analysis of “Hospital in the Home”, The Medical Journal of Australia, Aug 2012, https://www.mja.com.au/journal/2012/197/9/meta-analysis-hospital-home

2. Health Care Homes: Reform of the Primary Health Care System, The Department of Health, https://www.health.gov.au/internet/main/publishing.nsf/content/health-care-homes

3. US Model for Hospital Care At Home Reduces Costs and Increases Patient Satisfaction, https://www.thehomecalling.com.au/news/us-model-hospital-care-home-reduces-costs-increases-patient-satisfaction.html