A future for the hospital‐in‐the‐home (HITH) deteriorating patient: shifting the paradigm

To the Editor:

We read with great interest the article by Cubitt and Lim.1 The authors provide valuable insights into the evolving role of hospital‐in‐the‐home (HITH) services in managing deteriorating patients, emphasising the need for enhanced clinical pathways and emergency treatment plans. However, we believe the article’s flowcharts could be strengthened, particularly regarding in‐home escalation options, to ensure equitable access to care.

HITH is designed to deliver hospital‐level care in the home environment,2 and as such, the expectation should be to provide as much care at home as possible. Although patient needs, safety and resource availability must be balanced, an escalation pathway that includes in‐home nursing and medical reviews should be fundamental practice within HITH services. The ability to deliver timely in‐home medical or nursing reviews when deemed clinically appropriate following a telehealth consultation should be considered an essential option to support patient care. The article’s flowcharts, however, solely describe hospitals or designated care locations rather than patients’ residences. This omission in the flowcharts may result in unnecessary hospital transfers, limiting the full potential of HITH.3 This perspective aligns with the most recent published Australian state‐based guidelines, the Queensland Health Hospital in the home guidelines, which emphasises that HITH should deliver comprehensive, patient‐centred care in the home, ensuring escalation pathways prioritise in‐home responses wherever clinically appropriate.4

Several HITH services in Australia provide 24‐hour face‐to‐face escalation capabilities.5,6 The Cubitt and Lim article, however, dichotomises in‐hours and out‐of‐hours services, raising concerns about continuity of care. Highlighting variability in service provisions could create the perception that HITH is a secondary option rather than a viable alternative to inpatient care. This variability, particularly around weekends and public holidays, might discourage hospital‐based teams from referring patients to HITH,7 for fear of inconsistent escalation pathways. Ensuring equitable access to escalation pathways across all hours could improve confidence in HITH and encourage timely referrals.

To support the success and sustainability of HITH, discussions should prioritise consistent, high quality care that is accessible at all times. Strengthening the capacity to provide in‐home escalation when appropriate will reinforce HITH’s role as a trusted and effective alternative to inpatient care.