What are the best guidelines for hospital‑at‑home onboarding and condition selection?

Hospital-at-Home Onboarding and Condition Selection Guidelines

Use early supported discharge (ESD) as the preferred model for hospital-at-home programs, with patient selection based on clear exclusion criteria rather than attempting to predict ideal candidates. 1

Core Patient Selection Framework

Absolute Exclusion Criteria

Exclude patients with any of the following 1:

• Impaired consciousness
• Confusion or altered mental status
• Acidosis (respiratory or metabolic)
• Serious co-morbidity requiring intensive monitoring
• Inadequate social support at home

Essential Assessment Components

When evaluating patients for HaH, systematically address four key questions 1:

1. Confirm the diagnosis - Verify the patient has the condition your HaH program treats
2. Confirm acute exacerbation/need - Document that hospital-level care is required
3. Determine home safety - Assess if treatment can be safely delivered at home
4. Tailor the treatment package - Ensure medications and equipment can be managed at home

Critical Home Environment Assessment

Before discharge, verify 1:

• Patient/family can manage nebulizers or oxygen equipment unsupervised
• Adequate social or nursing support for activities of daily living
• Patient can rapidly access help if deteriorating
• Medication compliance is feasible
• If oxygen required, assess current smoking status (safety concern)

Onboarding Infrastructure Requirements

Standardized Documentation

Implement an assessment proforma, protocol, or integrated care pathway (ICP) to ensure uniform care delivery and facilitate audit. 1 This is critical despite lack of RCT evidence, as it provides consistency across providers and enables quality monitoring.

Multidisciplinary Team Composition

Your HaH team should include 1:

• Specialist respiratory nurses/physiotherapists (preferred for condition-specific programs)
• OR Generic teams with district nurses (acceptable alternative)
• Allied health professionals with disease-specific experience
• May include occupational therapists and generic health workers

Preferred Care Model

Prioritize early supported discharge (ESD) over admission avoidance for most hospital settings 1. This means:

• Brief initial hospital assessment (reducing stay from ~6 days to ~3 days)
• Confirmation of stability before home transfer
• Structured home follow-up with specialist team

This approach is safer than pure admission avoidance, as it allows initial stabilization and treatment package confirmation before home discharge.

Condition-Specific Guidance

COPD Exacerbations (Best-Established Evidence)

Hospital-at-home for COPD exacerbations is safe and effective (Grade A evidence) 1, with approximately 1 in 4 emergency presentations suitable for home treatment 1.

Treatment package includes 1:

• Nebulized bronchodilators
• Oral corticosteroids
• Antibiotics
• Supplemental oxygen if needed
• Home nebulizer equipment

Follow-up structure 1:

• Visit day after discharge
• Continue visits until near-full recovery
• Provide 24-hour mobile contact number
• Monitor for deterioration requiring hospital readmission

Emerging Conditions

Recent evidence suggests expanding to 2, 3:

• Medical conditions requiring acute care (consensus reached)
• Oncologic patients with treatment complications 4
• Perioperative care (early development stage) 5

However, strict eligibility criteria significantly limit enrollment - one study found only 12.3% of screened ED patients eligible, with just 0.4% ultimately enrolled 6. This highlights the importance of realistic program planning.

Quality Monitoring Framework

Mandatory Audit Criteria

Track these metrics for all HaH programs 1:

• Proportion of eligible patients accepted for HaH
• Inappropriate admissions (patients meeting exclusion criteria)
• Readmission/admission rate from HaH
• Mortality during HaH and within 3 months
• Readmission rate within 3 months
• Duration of hospital stay reduction
• Patient and carer satisfaction

Expected Outcomes

Evidence shows 1:

• No difference in mortality compared to hospital care (Level 1a evidence)
• No difference in FEV1 or functional measures
• Possible reduction in unscheduled ED visits at 1-2 years (conflicting evidence)
• Equal or better health status outcomes
• High patient satisfaction

Common Pitfalls to Avoid

1. Don't attempt pure admission avoidance initially - ESD is safer and more feasible 1

2. Don't rely on predictive criteria for "ideal" candidates - insufficient data exists 1. Instead, use clear exclusion criteria and accept all others who meet basic safety requirements.

3. Don't implement without standardized protocols - this leads to inconsistent care and prevents meaningful audit 1

4. Don't underestimate social support requirements - inadequate home support is an absolute contraindication 1

5. Expect low enrollment rates initially - real-world data shows only 9.6% of referred patients may ultimately transfer to HaH after clinical team review 7

Patient Communication

Provide clear written information including 1:

• Diagnosis and treatment plan
• Expected recovery timeline (typically 1-2 weeks)
• Visit schedule and 24-hour contact number
• Equipment management instructions
• Criteria for hospital readmission
• Long-term equipment provision if needed

The evidence strongly supports HaH as safe and effective when proper selection criteria and infrastructure are in place, with outcomes equal to or better than traditional hospitalization. 1