Hospitals are moving into private homes – are homes and patients ready?

• Healthcare, including hospital care, is rapidly moving into the home as a response to rising costs of hospital care, the shortage of healthcare workers and patient preferences
• The Hospitals in the Home (HiTH) model requires a new mindset and more holistic approach to health and healthcare
• Providing a viable HiTH experience requires paying attention to the non-medical, intangible challenges of moving hospital care into the home

The Hospitals in the Home (HiTH) care model is gaining traction in the Global North, largely in response to rising costs of hospital care, the shortage of healthcare workers, and advances in digital health solutions.¹ Operational HiTH services are already available in several countries, including the United States, United Kingdom, Canada, Australia, Switzerland, and Denmark.

Until now, the primary emphasis in shaping this model has been on the provision of healthcare services, specifically digital solutions. As we seek to lay the foundations for this new arena of healthcare delivery, it is important that we carefully evaluate all the building blocks that must be put in place for this new construct to succeed over the longer term.

For many people, HiTH represents an enhanced iteration of the conventional concept of home healthcare. But HiTH goes much further than this. This framework incorporates tasks that demand diagnostic, clinical, and monitoring skills. Essentially, HiTH entails the transition of clinical and technical responsibilities into the domestic setting.

The shortage of skilled health professionals and tighter operative margins are major incentives for shifting hospital care into the home. It may, in some cases, also lead to better patient care.

According to the CEO of DispatchHealth, the implementation of hospital-in-the-home services results in a 25% reduction in costs, a 25% decrease in readmission rates, and a 20% decline in mortality rates.²

Another essential factor is convenience. Proponents of HiTH assert that the logistics involved in visiting a doctor’s office are often burdensome for patients, especially those facing mobility challenges. The comfort of remaining at home, free from the need to arrange external appointments and travel, plays a significant role in this regard.

Another reason is the surge in affordable digital healthcare innovations designed for diagnosing, treating, and monitoring patients remotely from their homes. Telemedicine facilitates various interventions, whether self-administered or overseen by a caregiver or within the home environment. This means that it could effectively address a broad spectrum of patients’ physical and healthcare requirements.

We believe three critical aspects must be considered when transitioning hospital-level care to private dwellings, specifically:

• How to address social factors impacting health
• How to safeguard the privacy and sanctity of the home
• How to address physical and design challenges within existing living spaces

Access to digital tools and a good internet connection are prerequisites for the HiTH model. Digital health solutions are meant to promote access, but the emergence of the “digital divide” could exacerbate existing differences in access to healthcare. People from different social and geographical backgrounds may struggle to use digital equipment and services, especially personal computers and smartphones. Physical connection and affordability issues may put the internet out of reach for many others.

A UK international evidence review has shown that moving primary health care online creates inequalities in access to health care, making it more difficult for some patients – often those already in poorer health and materially disadvantaged – to access the care they need. However, the results are complex. The review describes a “digital inverse care law” that makes seeing a doctor easier for those who are most likely not to need one – i.e., younger, white, highly-educated people living in well-to-do areas.³

As we move forward with this shift in location of healthcare delivery, it is important to remember the original purpose of our homes so that this may be preserved even as new dimensions are added to them.

A home is much more than just the material structure, the décor and the location. Having a home is a prerequisite for well-functioning individuals. The home provides stability, tranquility, and privacy from the public and society. The body is more relaxed when it is at home. We breathe more freely and often feel more carefree at home than outside of it. The sounds and smells of one’s home are unique and recognizable, and usually the result of careful planning by residents. As a result, it may seem that a home would be an entirely appropriate place to locate the delivery of healthcare. But there is a risk that in making this shift, our dwellings could lose the very characteristics that make them our places of refuge and protection.

In most countries around the world, the home is protected by law. The sanctity of the home is a part of the fabric of the Fourth Amendment to the US Constitution, which protects people, their homes, and their property against unreasonable searches and seizures by the government. In the UK they say, “A Man’s Home is His Castle”. Several religions have laws that deal with the importance of the home for a balanced life and for the soul.

While many patients may favor their own homes over hospitals, it is essential to consider the impact on the family.  The introduction of medical procedures and equipment into the domestic environment can disrupt patients’ and caregivers’ autonomy and privacy. The situation can cause stress among caretakers and family members, underscoring the importance of consulting all parties involved and ensuring they have a say in the matter.

The providers of HiTH must also consider privacy issues as well as the architectural and design challenges that may accompany a shift to the HiTH model. Introducing hospital healthcare into the home is a disruption to the comfort and aesthetics of the existing physical living space. The link between housing and health has been described for over a century in scientific literature, for example, how poor housing conditions contribute to respiratory illness.

Moving diagnostic, rehabilitation and monitoring devices and equipment into the home will challenge the existing space and may quickly result in clutter.  The transition to and the feasibility of HiTH requires cooperation with experts outside the medical community. In recent years, psychologist research has shown that living and working in cluttered spaces causes stress and anxiety and can harm both our mental health and our productivity.⁴ Factors such as limited space, lack of appropriate facilities, and inadequate technology infrastructure could hinder the successful implementation of HiTH. Incorporating designers and architects into the HiTH model is essential and will encourage collaboration with healthcare professionals, patients, and their families to enhance spatial optimization and to maintain the dignity of the home.

The establishment of secure home-based hospital services requires guidelines and ultimately an action plan to safeguard the welfare of both patients and healthcare workers. To effectively carry out a viable plan for HiTH, it is crucial to engage in cooperative endeavors with stakeholders from the healthcare ecosystem and beyond. This collaboration will enable the smooth implementation of suitable organizational frameworks and cutting-edge technologies that ensure security and a sustainable plan.

Healthcare providers will need to make informed decisions regarding patient eligibility and tailor the HiTH program to the unique needs of the patient and their illness and condition.

Healthcare institutions will have to ensure a smooth and compliant integration of hardware and digital solutions into their electronic health systems, enhancing the efficiency and quality of patient care while maintaining data security and regulatory compliance.

Healthcare organizations will need to prepare their staff to successfully transition hospital-based care into the homes of patients, ensuring high-quality and patient-centered care.

Healthcare providers will need to develop informative and accessible educational materials that empower patients to actively participate in their HiTH care, leading to better patient outcomes and experiences.

Healthcare providers and decision-makers should seek to preserve the sanctity of the home while delivering essential medical services in a respectful manner.

Decision-makers can ensure that the transition to the HiTH model is well-planned and accommodates the diverse needs of patients by making necessary adjustments to the patients’ home environment that support positive patient outcomes.

The HiTH model is currently gaining momentum and is swiftly expanding across the Global North. Implementing HiTH services offers several benefits, such as addressing the shortage of healthcare professionals, reducing costs, and increasing convenience for patients. However, as we make this shift, it is essential we take steps to ensure equal access to digital healthcare services, preserve the privacy and sanctity of the home, and overcome architectural and design obstacles.

Factors such as differences in education, income, and digital literacy contribute to unequal access. The home is a place of privacy and freedom, and medical procedures can disrupt that. The integration of hospital equipment can also disrupt living spaces, especially for underprivileged patients.

We have presented preliminary guidelines that offer general principles and advice. We look forward to seeing the detailed action plan that healthcare workers and decision-makers will draw up as they map out the clear, time-bound, and task-specific instructions that will be required to develop a sustainable HiTH model.