interview Transcript

I'm Michael Montalto. I'm the doctor in charge of hospital in the Home and Equip Healthcare here in Melbourne in Australia. I run the hospital in the home department here and have done for a couple of decades.

What is the most accepted definition for Hospital at Home (HaH) in your country/ region/ society? What words do you use to refer to HaH in your country?

We refer to hospital home as an acute hospital substitution service. It's a model of care that provides staff, technology that normally you would only find in hospital and delivers them to patients at home. And the patients would be the kind of patients that would otherwise be in hospital were it not the hospital home. That's the most generally accepted definition of hospital in the home.

How did you get involved with Hospital at Home (HaH) care/model/ecosystem? What is your HaH story?

I was very young when I was exposed to a theoretical model of hospital in the home and was interested in it academically. And then I was lucky enough to be in a position where the state government in Victoria, Australia decided to fund hospital in the home services within Australian or Victorian public hospitals. I volunteered to establish a service in 1994.

Alongside that service, I've grown both my academic interest and my clinical interest and my policy interest and my advocacy in hospital and home. It's been a very long but very unpredictable journey because there wasn't a pathway when I started. In that sense, it's been kind of exciting to be involved in something from a very early stage and watch it grow over the years into something that's now not just understood, but it's actually starting to grow and gain momentum, not just in Australia, but internationally. And that's been really fantastic. And it's also been great to see patients, general patients, who years ago would not have had any idea about what we were talking about in hospital at home who now do come to the service already having some idea of what it is that hospital at home provides for them.

What does a day in your life look like?

The first thing in the morning, I have a teleconference with my doctors, and we discuss the patients from the previous night, and we decide which of our patients need to be seen and who will see them. Then I head out and see patients in the morning in their homes and make sure that things are going well, check their blood test results, check them, discuss their problems and fears, get a clinical assessment, make a plan for their treatment.

In the afternoon, I return to the hospital, and I see patients who have been referred to the hospital home service and assess them. I deal with paperwork, test results, test ordering, liaising with my nursing staff who always have jobs for me to do. Some of them that I want to do and some of them I have to do. I spend the afternoon, generally speaking, dealing with hospital issues.

Then, of course, the day doesn't end because I'm often on call. We have an onco roster for our patients and I'm a significant contributor to that onco roster. I spend many of my evenings on call, accepting new patients from the emergency department or dealing with problems that my nurses run into when they're seeing patients in the afternoon or the evenings at home, or occasionally a patient who rings up with a concern and we address those. That keeps me occupied in the evenings as well.

What motivates you in your work?

It’s a great clinical experience because we have both the intensive and acute nature of hospital work and hospital technologies which are great to use, and which are challenging. But we also have the experience of delivering that care to people in their homes and they're usually incredibly appreciative of that.

It's a unique mixture of acute hospital medicine and home practice and it's also about doing things for people in ways that really address their personal needs. Rather than being in hospital, they would prefer to be at home, and we work out the issues and the difficulties. For many people, that's routine but for some patients there are challenges that we have to overcome to deliver their particular care at home. And it's always really gratifying to be able to put together a solution to some difficult problems, be they technical problems from our end in terms of delivering the care, or sometimes difficult social problems or homebased problems at the other end for the patient to receive that care.

It's also gratifying, as I referred to earlier, to be within a movement that's growing and expanding. And that gives you a good feeling, it's a validating feeling. It makes you feel like you're at the pointy end of something. And I think we are at the pointy end of something and so that's also very good feeling. In terms of contributing to the area as a whole, either as a presenter or as a researcher or as a reviewer, all of those things are also very gratifying. So that keeps me going. I've been doing this a long time, I haven't got sick of it in all of that time. There's always something to keep me engaged.

What are the greatest obstacles for the HaH ecosystem and how can we overcome them?

The obstacles are different for different countries, different systems and different clinicians, I think.

I still think one of the greatest obstacles is for us within Hospital in the Home to establish who we are and to more clearly establish the standards and criteria for what we do. And I think that's a challenge for us to do that internally, not just for our sake, but so that people who pay for our service and people who refer into our service have a clearer understanding of what it is that we do and so that the relationship is firmer. The challenge is still around definition of our service, definition of who we are as doctors and hospital in the home nurses, so that we have a firmer place in that spectrum of care that's out there where everyone otherwise knows their place. I think we need to find our place.

It's still important that we have good relationships with the people who fund our service so that they understand that what we're doing is unique and requires a particular way of funding the service so that we can continue to do our work.

Research is a challenge in hospital in the home. There are not many clinicians, there's not that much money available. And it's a difficult scenario in which to do research, but it's very important that we write about what we're doing. It's a challenge to get the resources and it's a challenge to actually conduct that research. Having said that, it's pretty easy now to be published because people are interested in what we're doing. If we meet the challenge of research, then we have a reward at the end in terms of publication.

I think we're still a small group too, so it's important that we come together and support ourselves. And things like the World Hospital at Home Congress are an important part of that, where we can overcome some of the barriers of being small groups spread very far and wide. It's important to come together as a bigger group and that's a challenge for us and we need to take every opportunity that we can find to do that.

What are the most common misconceptions about HaH?

I think the most common misconception about Hospital at Home is that we are just a community nursing service. Nothing against community nursing services, but the misconception is that because we're not in the hospital, that we are by necessity not acute, not highly technical, and not highly skilled, and that's just not the case.

It assumes, for example, that we don't provide our own after-hours care. That's just not the case. So there is a kind of an expectation, a lower expectation among some people that we need to lift and say no, there's many other things that we do other than what you think.

The other misconception is that there aren't doctors directly involved in Hospital at Home care, that it's only a nursing service. And I think that that's a common misconception that we sometimes deal with, that we're not a seven day a week service or 24 hours a day service. There’s a common misconception around the kind of conditions and the severity of patients that we can otherwise accept. So, for example, many people would think that we can't take a patient directly from the emergency department because they feel we're not geared to do that, when in fact we are geared to do that. These things take time to get people to change their understanding. It's around conceptions of what are the limits of what we can do and the expectations of what we can do.

Another misconception that is around is that we're cheap, we're incredibly efficient, and that's in fact not the case. We're providing highly skilled staff, highly high technological input care to people at home, and the travel and the logistics required around that mean that we aren't a cheap form of service, we're an alternative form of service. There are inbuilt inefficiencies in what we do that need to be considered when funding the service. And like anything, if you do something properly, it's not cheap, right? I'm sure that you might be able to do this in a cheap way, but to do it properly, to address the needs of unwell people at home, it actually requires resources to do that.

What is something about HaH you would like everyone to know?

I want everyone to know that over the next generation we will form an integral part of the spectrum of services that a hospital provides. We expect hospitals to provide an emergency department, an intensive care unit, to have theaters, and we're going to expect them to deliver acute care at home. And then we need to work towards that on the assumption that that's what is going to happen. And it's going to happen because the technology is going to let it happen, and because patients want it to happen, and it's because we're capable of doing it and funded to do it.

That's what I want people to know, that we expect to be part of the system in the future, and that we have to work on the basis that we will be part of the hospital system in the future, rather than being a project or a special kind of niche thing. I want people to see us as not mainstream yet but will be mainstream. And to get there, we need to get it right now so that it can slot in as a mainstream service in years to come without hospitals feeling that it's anything unusual or different or special.

What are you looking forward to at the upcoming WHAHC 2023 Congress?

I'm looking forward to meeting people that I don't meet very often. But what comes with that is not just information about what's happening, but a sense of momentum.

I think what I loved about the first meeting was that there was a sense of momentum, there was a sense of growth, and that the conference was bigger than itself in the sense that it wasn't just looking back and reporting on what people have done, but it was looking forward.

And what was great is to see the ideas and the activity that have spun out of the last conference from people getting together, thinking about it, talking about it, being challenged. Maybe all they needed was another little push. And you get that push from the kind of enthusiasm that comes from bringing everyone together, particularly from other countries. We have our meetings in our own countries, but sometimes they can be the same things by the same people. Whereas at a World Congress we have different thoughts, different ideas, different presentations from different people that you've never met before. And when you're talking about the same core principles, that really leads to a sense of encouragement, and enthusiasm that grows from that.

I'm looking forward to going there, to be filled with that sense of encouragement and to be able to come back with new ideas and new enthusiasm to go forward and also to help others who can benefit from the experiences that we've had.