Covid showed us we could do it successfully. Here’s how (and when) to scale it up.
In the not-so-long-ago time of the covid Omicron wave, a Queensland virtual hospital in the home kept thousands safe and out of hospital beds.
But its successes were not just clinical, and it’s the lessons about implementation, reach, adoption, access and sustainability that can help scale things up and take virtual HITH to the mainstream.
The dedicated covid service, set up in a rural area of Queensland, admitted just over 3000 adult, maternity and child patients during its 11 months of operation from 19 December 2021 to 28 November 2022. It cost $5.4 million and saved 16,651 inpatient bed days during that time.
Its achievements were in no small part due to staff commitment and adaptability in a volatile time, according to an independent analysis published last week in the Journal of Medical Internet Research.
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In 2021, they had to make do, to a large extent. Now we can plan and invest in resources, build a strong multidisciplinary workforce to meet diverse patient needs, a data aggregation system, clear governance pathways to improve patient selection and reduce administrative burdens, and shared decision-making tools.
The research was led by Linh Khahn Vo, from the Australian Centre for Health Services Innovation at the University of Queensland, who ran a fine-toothed comb over the service as part of her doctoral thesis research.
Ms Vo said she was now an advocate for the implementation of virtual HITH services, in the right context.
“A virtual HITH is a really good service. It can improve access for everyone. People have more choice and a more convenient way for receiving care,” said Ms Vo.
“But before you go spending a huge amount of money, try to be really strategic and see if it brings any value to your community.
“The first thing is to see if there is a demand within the organisation, and if people support the idea of having virtual care platforms for delivering health services.”
Building workforce capacity and knowledge to deliver virtual health was expensive, but in Queensland’s West Moreton area, which is largely regional and rural, clinicians already had a lot of experience delivering telehealth and the infrastructure was already there, said Ms Vo.
In another paper using data from West Moreton Health, Ms Vo compared the costs and health outcomes for patients in the virtual HITH model with those in regular hospital care.
“We found that the virtual HITH model saved $201 per patient and resulted in an additional 0.015 quality-adjusted life years (QALYs) per patient,” she said.
None of the patients in the virtual HITH died, compared with a 3% death rate for those in hospital care, with hospital-acquired infections contributing significantly to that number, she said.
“Patients at home also reported higher quality of life: 0.5 out of 1, compared with 0.25 out of 1 for those in hospital, on a scale of 0 to 1 where 0 is death and 1 is perfect. These findings line up with my recent paper, where many patients interviewed described better psychological outcomes when recovering at home.”
But since then, there hasn’t been widespread implementation of the model, with reported reasons including not enough “compelling evidence of safety, the lack of perceived need, digital health equity, and misaligned or a lack of financial incentives for implementing such a complex intervention that may disrupt traditional clinical practices”, according to the research paper.
The problem was that a lot of these questions could not be properly addressed without looking at context, as well as clinical outcomes, so the researchers set about analysing the Queensland virtual HTIH covid service in terms of reach, effectiveness, adoption, implementation and maintenance (succinctly known as the RE-AIM framework).
The patients admitted to the virtual HITH came under the purview of a large 350-bed acute care public hospital serving the rural western region of southeast Queensland, which has the fastest-growing population in the state, projected to almost double in a decade, and “faces unsustainably high demand for hospital services”.
Just over half of residents are classed as being among the most disadvantaged in the state. The covid service was run by the hospital’s existing HITH unit which looked after patients with skin infections, severe chest infections, UTIs and IV antibiotics.
The patients were deemed lower risk, but they still needed to be monitored in case their condition deteriorated. They had moderate symptoms and added health concerns including chronic conditions and pregnancy.
They were admitted under a consultant and their care incorporated paediatricians and midwives. But there was a single point of contact. They were considered inpatients and funded through the same activity-based mechanism.
The findings came from service usage and cost data, patient surveys, and one-on-one conversations with patients and staff.
The staff were very much onboard. But as seen in all parts of the health service during covid, they were still often overwhelmed. They had to set things up extremely quickly and react to frequent changes. Staff had to be brought in from other areas who didn’t have virtual experience, and there wasn’t time for enough preparation. The workspace wasn’t purpose built, there wasn’t enough equipment, and sometimes the equipment didn’t work as expected, so workarounds were needed.
And there were so many patients.
“The amount of administrative resources required to run a service like this were significantly underestimated,” a staff member told researchers.
“There’s a big difference between aiming to avoid hospital presentations for low-acuity covid-positive patients, and substituting hospital care for those who are acutely unwell with covid.
“This distinction is where the administrative workload comes in. We had to quickly create outpatient encounters for all screened patients and then admit only those who required higher-level care.”
An important factor they noted was that having on-site doctors enabled quick clinical decision making and prescribing.
“As a consultant-led care model, it achieved quicker patient turnover compared with nursing-led services in nearby hospitals,” the paper said.
After the service was decommissioned, covid patients were looked after via the hospital’s existing HITH service.
“The choice of virtual, face-to-face, or a hybrid care is now applied universally across all HITH patients, regardless of diagnosis. Virtual platforms are used to monitor clinically stable patients at home more efficiently, while in-person visits remain important for tasks requiring physical presence, such as assessing dietary habits, home setup, or other factors that may impact patient outcomes,” the researchers reported.
The existence of the service has had a long-lasting effect on the people who delivered it and the skills they gained during that time, with the model being implemented to other populations.
They had some recommendations for those looking to implement virtual hospital in the home:
- Strong interdepartmental communication is essential to ensure patients get equitable access, including timely access to medical imaging and specialist consultations, comparable to those on site.
- Address scepticism of staff and patients by providing an introduction in training or initial consultation.
- Give organisational recognition and a voice to those involved in providing virtual HITH. (As one staff member put it: “I think a lot of the work that HITH does generally is really unseen. And because our patients are at home, it’s almost like out of sight, out of mind.”)
Overall, the patients who talked to researchers said they were happy with the care they’d received under the virtual HITH model and that they would recommend it to others in similar circumstances.
The covid HITH service had good reach in areas of high socio-economic disadvantage, but that mainly included people with English as a first language. And generally, people didn’t know the service existed.
One way to address this was better access to interpreting services, said Ms Vo. Another was to reach out to GPs to connect with culturally and linguistically diverse communities and promote the service to them.
You can read the full, detailed paper here and the related paper on costs here.
