Hospital at Home: A collaborative approach to care in a patient with complex needs

Abstract

Introduction: The Hospital at Home (H@H) service delivers hospital-level care to patients in their own homes, aiming to provide holistic, person-centred assessment aligned with the NHS's vision of integrated care in the community. We present a case highlighting the effectiveness of collaboration among healthcare services in managing a patient with advanced cholangiocarcinoma. Case discussion: A 58 year old male patient with stage 4 cholangiocarcinoma, gastroesophageal reflux disease, hypertension and high cholesterol experienced recurrent admissions due to ongoing intra-abdominal sepsis. Imaging revealed a fluid filled structure between the duodenum and hilum of the liver and free fluid in the pelvis which was not amenable to surgical intervention. A conservative management plan with intravenous antibiotics was adopted. Admissions were often prolonged and associated with increasing frailty as well as separation from his family, which caused rising psychological distress.Following discontinuation of chemotherapy and referral to community palliative care, he opted for further assessment and treatment with the H@H team to avoid repeated hospitalisations. A multidisciplinary team (MDT) approach was adopted, involving the hospital at home team, palliative care team, consultant microbiologist and second care physicians to create a tailored treatment plan which prioritised improving his quality of life and experience. His care involved daily clinical assessment, administration of intravenous antibiotics and blood monitoring, with results discussed in a weekly MDT meeting alongside the microbiology team.Parallel planning with palliative care allowed us to address both reversibility, symptom control and psychological goals simultaneously, encompassing the physical, emotional, and spiritual aspects of care to create a comprehensive treatment plan. This approach ensured goal concordance, aligning interventions with the evolving needs and values of the patient, while also providing vital emotional support for caregivers.After responding positively to treatment, the patient's history of recurrent infections prompted us to offer proactive management strategies in the form of implementing remote monitoring technology to anticipate early deterioration and enable prompt intervention during subsequent episodes. This approach facilitated ongoing successful community-based treatment, avoided further hospitalisations and alleviated the need for the patient to explain their story to yet another group of clinicians. Conclusion: This alternative model of care embodies a collaborative approach, ensuring seamless transitions for patients with complex needs and fostering a less fragmented care experience. By prioritising patient comfort and addressing reversible causes of deterioration, this person-centred approach has led to improved patient outcomes. The case underscores the value of integrated, community-based care in managing patients with advanced illnesses and highlights the effectiveness of admission avoidance strategies through cohesive, collaborative care models. Notably, this model has been well-received by patients, with this particular patient going on to become an ambassador for the service. Furthermore, it supports the creation of a more sustainable NHS by providing appropriate care within the community, thereby reducing the burden on secondary care services.