Hospital at Home

What was the issue you were addressing or working on?

The challenges included shifting from institutional based care to care at home or a homely setting, the need for quicker assessment and care plan coordination and formulation in a more homely setting taking into account the person’s conditions and home situation instead of needs and support being assessed in a ward setting.


What you did?

The Change Fund enabled the establishment of the Hospital at Home Service which was developed in partnership with staff, clinicians, GPs, local authority, voluntary and independent sector colleagues and the public via Fife Partnership arrangements.

The service started as a pilot in Dunfermline and West Fife in April 2012 with 3 GP rolling out in a phased approach across Fife since.  It has taken over 700 admissions since its commencement to date (August 2013).

A significant education and training programme has been developed.

Hospital at Home is run as a “virtual ward” whereby the Hospital at Home Team meet every morning to discuss and review each patient on the caseload and agree any changes required to treatments or care plan.


What were the outcomes - benefits or otherwise?

Outcomes and Benefits include:

  • Early comprehensive geriatric assessment in home environment taking into account home circumstances and involving carers and families
  • Speedy response – target of within one hour of referral from a GP
  • Continuity of care tailored to the individual.
  • Rapid access to equipment, investigations, treatment and therapies
  • Seamless transfer between the different levels of the overall ICASS Team.
  • Development of pathways and protocols and a guide for Care Homes.
  • Patient and carer feedback on the service is positive.
  • Positive feedback from patients and carers
  • Shorter lengths of stay when an admission is required and prevents morbidity associated with a hospital stay.

A case study showing the benefits to patients is  here

Lessons Learned:  Underestimated the complexity, size and challenges of the innovation and the time it would take to develop and agree the various elements and solutions e.g. medical model, IT, staff training.


Contacts - to find out more

Val Hatch, val.hatch@nhs.net  01383565455