Digital Considerations for Designing Hospital in the Home Services

Hospital in the Home (HITH) is an established model of healthcare delivery, providing hospital-level care outside the traditional inpatient setting. Care may be delivered in a patient’s home or another appropriate setting, with clinicians providing face-to-face care alongside virtual care and remote monitoring where appropriate.

Taking hospital care beyond the ward changes the environment in which the service operates.

Within a hospital, patients, clinical teams and many of the activities involved in an episode of care are organised around a defined setting. HITH can extend those activities across different locations, teams and modes of care.

For health services, the digital challenge is how to maintain a coordinated view of the patient journey and the activity around it as care moves across those settings.

Different pathways need different workflows

HITH services can support a range of clinical conditions and care pathways.

The assessments, clinical reviews, scheduled visits, communications and follow-up required can vary between patient cohorts and models of care.

Digital care pathways can help organise these different requirements. A pathway can define the activities that need to occur throughout an episode of care, including assessments, tasks, scheduled interactions, patient questionnaires and communications.

For health services supporting multiple HITH pathways, this provides a way to configure workflows around different models of care while maintaining a consistent approach to how activity is coordinated.

Maintaining a view across the service

Once care is being delivered across different settings, teams need visibility beyond an individual clinical interaction.

Which patients require review today? Which visits are scheduled? What activities are outstanding? Have required assessments been completed? Has new information been received from a patient? What needs follow-up?

The answers may involve different clinicians, locations and systems.

Bringing patient pathways and service activity together can give teams a clearer view of what has happened, what is planned and what still requires attention.

Coordinating care across settings

A HITH episode may include face-to-face clinical care, virtual consultations, patient-reported information and remote monitoring, depending on the model and the needs of the patient.

Each interaction can affect what happens next.

A home visit may result in a new task or change to the care plan. A patient response may require clinical review. A virtual consultation may lead to follow-up from another member of the team. Remote observations may require assessment or escalation.

The challenge is keeping these activities connected around the patient pathway, so teams can understand what has happened, who is responsible for the next action and where the patient is in their care journey.

Digital workflows can provide structure around the activity taking place across different settings and modes of care, rather than treating each interaction as a separate process.

Coordinating a mobile HITH workforce

Delivering care in patients’ homes also changes how clinical teams need to be coordinated.

Home visits need to be scheduled, clinicians allocated and travel between patients considered. Clinician availability, patient requirements, service priorities and changes during the day can all affect how visits are coordinated.

For HITH services, scheduling therefore sits within the wider care workflow. A change in a patient’s needs may affect the timing or priority of a visit, while an assessment or clinical interaction may create additional activities for the team.

CareMonitor supports workforce scheduling and route optimisation as part of the wider HITH workflow, helping services coordinate clinicians, patient visits and care activity across different locations. Clinicians can access their scheduled visits and relevant patient information through the CareMonitor Clinician App while delivering care in the community.

As the number of patients, visits and clinicians being coordinated increases, visibility across both the patient pathway and the activity required to deliver it becomes increasingly important.

Patients also interact with the pathway

Delivering hospital-level care outside the ward can also change how patients receive information and participate in their care.

Depending on the pathway, patients may receive appointment information, care instructions, education or reminders. They may complete questionnaires, report symptoms or provide other information between clinical interactions.

Building appropriate patient interactions into the pathway means information provided by the patient can sit alongside the other activities involved in their care, rather than being managed as a separate process.

Virtual care and remote monitoring are part of the model

Virtual care and remote patient monitoring can support HITH alongside face-to-face clinical care. Their role will differ depending on the patient cohort, clinical pathway and service model.

Where they are used, they need to connect with the wider HITH workflow. A virtual consultation may need scheduling and follow-up. Remote observations need processes for review and response.

Virtual care and remote monitoring will not be relevant to every HITH pathway in the same way. Where they are used, the important consideration is how they connect with the wider service and its workflows.

Connecting HITH with hospital system

HITH remains part of the health service, even when care is delivered in another setting. HITH changes where care is delivered, but the patient remains part of the hospital’s clinical environment.

Existing clinical systems therefore remain an important part of the digital environment. At the same time, HITH can introduce additional workflows involving mobile teams, patient-facing applications, virtual interactions and monitoring technologies. The digital systems supporting HITH therefore need to work alongside existing hospital systems, including the Patient Administration System (PAS) and Electronic Medical Record (EMR), rather than creating a separate environment for care delivered at home.

Integration allows relevant information to move between systems and be available across different parts of the care journey. This becomes particularly important when HITH introduces activities that may extend beyond traditional inpatient workflows, including mobile visits, patient interactions, virtual consultations and remote monitoring.

CareMonitor’s implementation with St Vincent’s Health Network Sydney provides a practical example. Before PAS integration, patient records had to be created manually in CareMonitor, contributing to discrepancies between HITH admission data and records held in the platform. Integration established the PAS as the source of truth for patient information, while CareMonitor supported the workflows required to deliver the HITH service.

Other hospital workflows may also need to extend beyond the ward. CareMonitor supports electronic prescribing through the platform, allowing prescribing to form part of care delivered outside the hospital.

The Australian Digital Health Agency’s work on interoperability similarly emphasises the importance of making relevant health information available when and where it is needed to support connected care.

The digital foundations for HITH therefore need to support the way care is delivered outside the traditional inpatient setting while connecting with the broader clinical environment.

How CareMonitor supports Hospital in the Home

CareMonitor is a health care platform supporting the delivery of Hospital in the Home, from patient admission and clinical care through to workforce coordination, patient engagement, reporting and discharge.

For HITH services, CareMonitor brings together capabilities across the care journey, including:

• HITH episode and pathway management, including onboarding, configurable care pathways, assessments, tasks, clinical handover, care planning, referrals, follow-up and discharge workflows.

• Clinical care and monitoring, including observations, early warning scores, alerts and escalation, medication workflows, electronic prescribing and patient-reported information.

• Workforce and field operations, including rostering, appointment scheduling, clinician allocation, travel-time planning, route optimisation and mobile access for clinicians delivering care in patients' homes.

• Virtual care and remote patient monitoring, connecting virtual consultations, monitoring and the resulting clinical activity with the wider patient pathway.

• Patient engagement, including questionnaires, communications, appointment information, care plans and other interactions with patients at home.

• Hospital integration and interoperability, enabling CareMonitor to work alongside existing hospital systems, including PAS and EMR environments, rather than creating a separate digital environment for HITH.

• Operational and compliance reporting, including dashboards and HITH activity reporting such as VINAH and MDS requirements.

• Embedded AI and automation, supporting activities including documentation, scheduling, task management and care coordination within the wider workflow.

CareMonitor can be configured around different HITH models, patient cohorts and service requirements, allowing health services to bring clinical and operational activity together while continuing to work within their broader hospital environment.

Speak with our team about how CareMonitor can support your Hospital in the Home service.