Module 1 - Understanding and establishing Hospital at Home
In this module, you will be introduced to Hospital at Home as a model of care and what it means to provide hospital-level treatment in the patient’s own home. You will explore how Hospital at Home can be organised and implemented, and what needs to be considered when assessing who can receive care at home. The module also presents key frameworks and prerequisites that support safe and sustainable care delivery. Finally, you will consider collaboration as a fundamental prerequisite, both within the healthcare team and across organisational boundaries.
This chapter introduces Hospital at Home as an organised model of care in which patients receive hospital-level treatment in their own homes. It outlines key components and highlights how HaH differs from other forms of home-based care.
What is Hospital at Home
What is Hospital at Home?
In this model, patients receive hospital-level treatment in their own homes, delivered by healthcare professionals and supported by technologies, equipment, and medications that would traditionally be provided in an inpatient setting.
Through digital solutions and interdisciplinary collaboration, acute care can be safely delivered in the patient’s home environment. This approach may reduce pressure on hospital capacity, enhance patients’ sense of safety and comfort, and offer greater flexibility for both staff and relatives.
An international definition of Hospital at Home was developed by the World Hospital at Home Community (WHAHC) in 2023 and presented at the WHAHC Congress in Barcelona.
“...An acute clinical service that takes staff, equipment, technologies, medication and skills usually provided in hospitals and delivers that care to selected people in their homes.”
What is Hospital at Home? In this video, you will be introduced to the fundamental principles of Hospital at Home and how it differs from other forms of home-based care.
Hospital at Home – an organised care environment
HaH involves more than simply delivering care in a patient’s home. It represents an integrated and organised care environment in which technology, clinical expertise, and medical support interact closely. As illustrated below, the various components of HaH together form a structured system of care—fundamentally comparable to a traditional hospital setting in terms of clinical standards, monitoring, and coordination.
A central component of the model is the digitalisation of healthcare. Many patients already have experience of video consultations and home-based follow-up, and telemedicine solutions provide an essential foundation for the development and scaling of HaH services.
An overview of the typical elements of a HaH model, such as nursing care, medications, diagnostics, remote monitoring, and self-care.
Level of care
To further clarify the concept of HaH, it is helpful to distinguish between different levels of home-based treatment (see image below). Terms such as home treatment, home monitoring, and hospital admission at home are sometimes used interchangeably, which can lead to conceptual ambiguity.
To provide greater clarity, we apply a taxonomy which categorises home-based hospital care into three levels:
Level I: Simple treatments provided to clinically stable patients
Level II: Structured monitoring of patients at moderate risk of clinical deterioration
Level III: Full hospital admission at home—a genuine alternative to inpatient hospital care
Level III represents the core of HaH. At this level, patients receive acute, hospital-level treatment in their own homes, supported by continuous (24/7) monitoring, direct access to healthcare professionals, and the necessary hospital equipment and medications.
This distinction is important, as not all forms of home-based care meet the criteria for HaH in its strictest sense.
Fischer et al. (2024) taxonomy.
Level I: Simple treatments for clinically stable patients
Example: Intravenous antibiotics for a stable skin infection
A patient with cellulitis is clinically stable after assessment in hospital. They have normal vital signs, no signs of sepsis, and can manage safely at home. The patient receives intravenous antibiotics once daily at home, combined with basic monitoring of temperature, pain, skin redness, and general condition.
The main focus is to ensure that the treatment is completed safely, that the infection improves, and that the patient knows when and how to contact the healthcare team if symptoms worsen.
Level II: Structured monitoring for patients at moderate risk of deterioration
Example: Monitoring of a patient with worsening heart failure
A patient with known heart failure has increasing shortness of breath, weight gain, and mild leg oedema, but does not currently require acute inpatient care. The patient is treated at home with adjusted diuretics and daily structured monitoring.
Monitoring may include weight, blood pressure, pulse, oxygen saturation, symptoms of breathlessness, fluid balance, and digital or telephone follow-up. The patient may also receive home visits from nurses. The aim is to detect deterioration early and adjust treatment before hospital admission becomes necessary.
Level III: Full hospital admission at home
Example: Hospital-level treatment for pneumonia at home
A patient with pneumonia would normally be admitted to hospital but is instead admitted to a Hospital at Home service. The patient requires hospital-level care, such as intravenous antibiotics, oxygen therapy, regular clinical assessment, blood tests, and close monitoring of vital signs.
The care team provides daily medical review, nursing visits, access to escalation pathways, and coordination with diagnostics or specialist input if needed. This level represents a genuine substitute for inpatient hospital care, not just follow-up or community-based support.
Hospital at Home models
There is no single, standardised HaH model that can be applied uniformly across all settings. There is considerable variation in how HaH models are implemented, which patient groups are included, and the overall strength and consistency of the evidence base.
For home-based hospital care to function effectively, it must be adapted to local conditions—including the hospital’s organisational structure, available regional resources, and the wider national healthcare system.
Despite these contextual differences, most HaH services follow one of two overarching strategies:
Early Supported Discharge (ESD)
The patient is discharged earlier than usual from hospital and continues to receive hospital-level treatment at home. Ongoing treatment and monitoring are provided at a level equivalent to that which would otherwise have been delivered in hospital.
Admission Avoidance (AA)
A strategy aimed at preventing unnecessary hospital admissions. The patient avoids hospital admission entirely and receives hospital-level treatment directly at home.
The patient has access to care around the clock
In HaH pathways, it is essential that patients can contact healthcare professionals at any time—24 hours a day, seven days a week. Contact may be made directly with the HaH unit or via other hospital-based services that operate around the clock.
The healthcare professional responding to the patient should have access to relevant medical records and the competence required to make an initial assessment. They must also be able to initiate appropriate actions, either independently or in collaboration with other professionals.
This access to timely and qualified support enhances patient safety and contributes to a sense of security throughout the care pathway.
How much care is delivered in person—and how much digitally?
The balance between physical and digital care in HaH varies and should be guided by the patient’s needs and preferences. Some units carry out frequent home visits, while others rely more on digital solutions and use in-person contact when specific needs arise.
Mobile teams have the equipment and competencies to deliver a wide range of interventions in the home, many of which correspond to tasks normally performed in hospital settings. These may include initial assessment and clinical examination, medical history taking, sample collection, and monitoring of vital signs—procedures traditionally carried out in emergency departments.
In practice, many units offer at least one daily visit, although the frequency of contact may vary depending on the patient’s condition, diagnosis, and treatment pathway.
Care is typically delivered through a combination of physical and digital interventions, with the intensity and mode of contact adjusted over time and planned in close dialogue with the patient and, where appropriate, their relatives.
Alex
Alex is a 30-year-old patient with Crohn’s disease who lives with his partner and works from home. He is used to digital tools, tracks symptoms in an app, and is comfortable communicating with healthcare professionals by video or chat. If admitted to HaH during a moderate disease flare, much of his follow-up could be supported digitally, for example through symptom reporting, remote monitoring of vital signs, and scheduled video consultations. Physical visits would still be needed for clinical examination, blood sampling, intravenous treatment, and reassessment if his condition deteriorates.
Stina
Stina, in contrast, is 85 years old with heart failure, hypertension, type 2 diabetes, reduced mobility, and an acute illness involving suspected pyelonephritis, worsening heart failure, and a possible pelvic fracture after a fall. She has limited digital capacity and depends more on her husband, home care services, and direct professional assessment. In her case, HaH would require more frequent in-person visits, careful clinical observation, support with medication and mobility, and close collaboration with relatives and other care providers. Digital tools may still be useful, but mainly as a supplement rather than the primary mode of care.
Alice
Alice is a six-month-old infant receiving HaH care for bacterial meningitis with intravenous antibiotics through a central venous access. Both parents are at home and are confident using digital tools, which means that communication, symptom updates, and some observations can be supported digitally. At the same time, Alice’s young age, clinical vulnerability, and treatment complexity mean that care must remain highly person-centred and partly hands-on. Regular in-person visits are needed to assess her condition, monitor feeding, responsiveness, temperature, and the central venous access, and to support her parents in recognising subtle signs of deterioration. Digital contact can strengthen continuity between visits, but it cannot replace direct clinical assessment.
Adapting the balance between digital and physical care
The comparison shows that HaH is not defined by a fixed ratio of physical and digital contact. Instead, the mode and intensity of care should be guided by clinical risk, functional ability, digital health literacy, home circumstances, and patient preferences. Alex may benefit from a more digitally supported pathway because he is clinically more stable, independent, and digitally confident. Stina, however, represents a more complex and fragile situation where physical presence is central to safe assessment and treatment. In both cases, the balance may change over time: digital follow-up may be sufficient when the patient is stable, while deterioration, uncertainty, or increased care needs should trigger more frequent home visits or hospital admission.
Organisation and implementation
In this chapter, we take a closer look at how Hospital at Home is organised in practice, focusing on the four key components of the model: the office, the mobile teams, the hospital, and the patient’s home as the care environment.
Implementation and scaling
To implement a successful HaH-service certain requirements have been identified:
Workforce & Training
Staff require additional training and expanded roles. Advanced and specialist nurses form the clinical core, supported by daily physician oversight (in-person or virtual).
Patient Selection
Selecting appropriate patients is challenging, especially early on. Programs typically start with strict criteria for specific acute conditions (e.g. COPD exacerbations, heart failure, pneumonia, cellulitis, UTI) and expand over time. Training for ED and hospital physicians improves referral accuracy. Common exclusions include clinical instability, need for continuous monitoring or intensive care, and unsafe home environments.
Operational Infrastructure
HaH requires coordination of services such as mobile imaging, lab testing, rapid medication delivery, equipment, transport, and specialist input. Electronic health records often need adaptation, and patient identification is frequently still manual. Fast access to equipment and test results is critical.
Scaling Hospital at Home involves expanding services in a safe, sustainable, and efficient way while maintaining quality of care. Both barriers and strategies for successful scaling have been identified:
Barriers to scaling
Financial challenges - Hospital at Home requires high upfront investment, mainly related to staffing rather than buildings or equipment. This creates financial risk, especially if patient numbers grow slowly. As a result, larger healthcare systems are more likely to implement these programs.
Regulatory and payment issues - Uncertainty around regulations and long-term funding makes planning difficult. Programs must often provide the same level of services as in hospital care, which can be demanding. In addition, reimbursement varies between payers, with some offering lower compensation or not supporting HaH at all.
Workforce and capacity - Smaller or rural hospitals may lack the necessary staff, technology, and infrastructure. Some healthcare professionals may also feel uncertain about managing acutely ill patients at home, which can reduce adoption.
Strategies for successful scaling
Developing sustainable payment models – New funding approaches are needed to support start-up costs and enable more hospitals to participate, including smaller and rural providers.
Using flexible care models – Care delivery can be adapted to patient needs by combining home visits with virtual care, and by starting with less complex patients before expanding to higher acuity levels.
Phased implementation – Starting on a small scale allows teams to test workflows, ensure patient safety, and improve processes before expanding the program.
Engaging stakeholders and building partnerships – Successful programs involve early collaboration with healthcare professionals, leadership, and external partners such as laboratories, pharmacies, and transport services. Continuous education helps build confidence and improve referrals.
The model
The HaH model is based on dynamic interaction between several core components, which together ensure that care is delivered safely, efficiently, and in a well-coordinated manner.
To understand how care is organised and optimised, we focus on four key components of the model:
The office
The mobile teams
The hospital
The home
The image below provides a visual overview of how these components interact in practice. It illustrates how key functions and stakeholders are interconnected and structured.
Surrounding these are activities and functions such as diagnostics, medication management, nursing care, and remote monitoring. The arrows indicate how tasks and responsibilities move between stakeholders, depending on the patient’s condition and available local resources.
The Hospital at home-model.
The office – the central hub of Hospital at Home
The office serves as the organisational centre of HaH, where care is planned, coordinated, and monitored around the clock.
It is typically located within a hospital and equipped with workstations, computers, and communication systems. From here, staff maintain an overview of patients’ clinical status and can respond rapidly to changes—either through digital contact or by deploying a mobile team.
Digital communication with patients and care teams enables many enquiries and care needs to be managed without a physical presence, providing greater flexibility for both patients and healthcare professionals.
The office – the central hub of Hospital at Home
Mobile teams – care close to the patient
HaH is based on the principle that most care is delivered in the patient’s home by mobile, multiprofessional teams. These teams typically consist of nurses and physicians, but may also include physiotherapists, occupational therapists, and pharmacists, depending on the patient’s needs. In some models, access to specialised teams is available to perform advanced examinations such as X-rays or ultrasound imaging.
In addition, practical support services may be required, such as patient transport and the delivery of medications, food, and equipment to the home.
An important part of the work of the mobile teams is to support patients and their relatives in everyday life. This may include teaching them how to use medical equipment, explaining clinical aspects of care, and helping to create structure and a sense of security in the home environment.
HaH also strengthens patients’ capacity for self-care—for example, by supporting symptom monitoring, adherence to medication plans, and participation in daily rehabilitation. Relatives are often involved as supportive partners, which can enhance both safety and quality of care.
Mobile teams – care close to the patient
How mobile teams use digital tools
Required competencies in the field
The hospital in Hospital at Home
Although care is delivered in the patient’s home, the hospital continues to play a central role in the HaH model. Patients retain access to hospital resources, including specialist expertise, diagnostic investigations, and treatments that cannot be provided at home.
When necessary, patients can be transported to the hospital for specific procedures and then return home. If the patient’s condition deteriorates, clear pathways must be in place for escalation of care and admission to hospital.
The office and the mobile teams are often based within the hospital, where they have access to workspaces, communication systems, and medical technical equipment. This requires the hospital to have adequate IT support and technical expertise, both for systems located within the hospital and for equipment used in patients’ homes.
Alex
Consider the case of Alex, this could mean that most of his care is delivered at home, while the hospital is used for a specific diagnostic procedure that cannot be performed in the home. For example, if his abdominal pain worsens or blood tests suggest increasing inflammation, he may need to come to the hospital for an abdominal CT scan, ultrasound, or endoscopic assessment to rule out complications such as an abscess, bowel obstruction, or severe inflammation. After the procedure, Alex can return home if his condition remains stable and there is no need for inpatient admission. The HaH team can then continue intravenous treatment, symptom monitoring, blood tests, and digital follow-up in his home. In this way, the hospital remains an important resource within the HaH pathway, without the patient necessarily needing to stay on a hospital ward.
The home – a new care environment
In the HaH model, the patient’s home is transformed into an active care environment, where assessments and treatments are carried out with the support of technology and medical expertise—close to the patient’s everyday life and relatives.
Staff must be able to manage acute and complex medical conditions in the patient’s home. This requires flexibility, the ability to work independently, and a holistic perspective. In this setting, access to colleagues or equipment is not always immediate, as it is in hospital environments, making coordination and clinical judgement particularly critical.
In home-based care, patients are expected to take an active role in their treatment. This requires access to clear information, adequate support, and user-friendly technology. Relatives can also play an important role in creating a sense of security and structure, but this requires clear role definitions and shared expectations.
This chapter introduces how to identify patients suitable for Hospital at Home, focusing on clinical stability, patient preferences, home circumstances, and organisational capacity. The chapter also highlights clinical risk and frailty assessment as key parts of safe, person-centred admission decisions.
Who can receive care at home?
Who can be admitted to Hospital at Home?
HaH is not appropriate for all patients. Individuals with highly complex or unstable conditions, or those requiring intensive or highly specialised care, should continue to be managed in hospital. A comprehensive clinical assessment is therefore essential prior to admission.
Successful admission requires:
Active involvement and support from the patient and, where appropriate, their relatives
Appropriate clinical expertise and relevant professional experience
A safe, flexible, and well-coordinated organisational structure
A larger proportion of patients than might be expected can, in fact, be treated safely at home. There are relatively few universal exclusion criteria. The most important considerations are that the patient wishes to receive treatment at home, feels safe in doing so, and that the hospital has the necessary competencies, resources, and governance structures in place.
Stina
Consider the case of Stina. She was assessed at home with fever, worsening heart failure symptoms, and pain after a fall. She may be suitable for Hospital at Home if she is clinically stable, wants to remain at home, and the team can provide IV antibiotics, diuretics, pain relief, monitoring, and rapid reassessment. However, if her oxygen levels fall, confusion develops, pain worsens, or a fracture is suspected, she should be transferred to hospital. HaH admission depends on both clinical stability and the ability to provide safe care at home.
Clinical risk assessments
For frail patients, an individual assessment of the risk of complications is important, even when care is provided at home. Risks that should be assessed include pressure ulcers, malnutrition, falls, delirium/confusion, and oral health status, using established assessment tools according to local routines.
If a risk is identified, an individualized care plan should be created with appropriate interventions. This may be implemented either as a complement to the main care plan or as a separate addendum. The care plans must be known to both the patient and all staff involved in the patient’s care, and should be regularly reviewed and updated as needed to evaluate the effectiveness of the interventions.
Frailty
Frailty is considered a more useful concept than chronological age when identifying older individuals at increased risk of adverse outcomes and extensive healthcare needs. Frail older adults often have complex and rapidly changing needs related to medical care, rehabilitation, and daily support. Physical frailty is characterized by reduced physiological reserve and decreased resilience to stressors due to age-related decline across multiple body systems. Common signs include weakness, fatigue, reduced endurance, weight loss, slower performance of daily activities, and low physical activity, all of which increase vulnerability to complications.
Early identification of frailty is important in order to implement preventive interventions and reduce the risk of deterioration and complications. Research indicates that interventions are most effective when initiated before severe frailty and significant dependence in daily activities develop.
Frailty can be assessed using several validated tools. One commonly used method is the Clinical Frailty Scale (CFS), which evaluates overall fitness and frailty based on physical function, comorbidity, and level of independence. Another widely used model is the Fried Frailty Phenotype, which focuses on physical indicators such as weakness, slow walking speed, exhaustion, unintentional weight loss, and low physical activity. The choice of frailty assessment tool may vary between settings and organizations, and local routines and guidelines should be followed.
Video highlighting some of the key advantages and challenges of HaH.
Frameworks and prerequisites
This chapter introduces legal and ethical considerations in Hospital at Home, with a focus on safe care, confidentiality, documentation, professional responsibility, and data protection. It highlights how digital tools and patient-generated health data can support autonomy, coordination, and safety, while also creating risks related to privacy, information overload, and responsibility.
Legal and ethical frameworks
When care and treatment move from the hospital into the patient’s home, a range of legal and ethical considerations arise. New technologies and digital ways of working create opportunities, but also place increased demands on safety, documentation, data protection, and professional responsibility.
Although legislation and administrative practices vary between countries, several core themes are common:
Patients’ right to safe and equitable access to healthcare services
Regulations governing the handling and sharing of patient information
Confidentiality and protection of privacy
Clinical documentation, record-keeping, and data management
Safe use of medical technology and medications
Collaboration across sectors and professional groups
Learning from adverse events and improving patient safety
Regulatory authorities and national health agencies in each country provide guidance and oversee compliance with these requirements.
Health data
Digital ways of working enable patients to contribute valuable health data, often through self-monitoring and reporting from home. This may include measurements using blood pressure monitors, pulse oximeters, or digital questionnaires. Such approaches can increase patient autonomy and help optimise the use of healthcare resources.
Health data include personal information related to a patient’s health status, including data recorded in patient records (e.g. blood tests, diagnoses, medications) as well as information generated by the patient (e.g. via health apps and wearable devices).
Potential benefits of health data include:
Increased patient involvement and opportunities for self-management
Improved coordination between healthcare professionals
Enhanced safety through access to up-to-date information
However, there are also potential risks:
Information overload and health-related stress for patients
Risk of overdiagnosis and unnecessary treatment
Risk of breaches in data security and privacy
Integrated electronic health record systems, where data are shared across sectors, can improve patient safety. However, they also require clear frameworks for responsibility, data governance, and patient consent.
Legal and ethical perspectives on digitalisation and health data
As patient data are increasingly managed digitally, issues related to confidentiality and data integrity must be considered from both legal and ethical perspectives. A key challenge lies in balancing the need for high-quality, safe care with the protection of patients’ personal information. This requires healthcare professionals to have a sound understanding of information security and data protection, and how these are applied in everyday clinical practice.
Legal and ethical considerations arise particularly when health data:
are collected by multiple actors (e.g. healthcare providers, researchers, or patients themselves via apps and sensors)
are used for treatment, research, and quality improvement
are shared, or have the potential to be shared, across sectors and technologies
Health data are highly sensitive and require robust protection—both technically (who has access?) and legally (what consent has been given?). Trust is a central ethical consideration: patients must feel confident that their data are handled responsibly. If this trust is undermined, it may affect relationships, care delivery, and broader healthcare decisions.
Alex
Alex uses a symptom app and smartwatch to share information about his temperature, heart rate, abdominal pain, and bowel movements with the HaH team. These data can support safe clinical decision-making, but they also contain highly sensitive personal information. It must therefore be clear who can access the data, how they are stored, whether they are shared with other systems, and whether Alex has given informed consent. If Alex is unsure how his data are used, he may stop reporting symptoms honestly or decline digital monitoring altogether. This could reduce both trust and patient safety.
Collaboration as a fundamental prerequisite
This chapter introduces cross-sectoral collaboration as a critical prerequisite for Hospital at Home. It shows how safe care in the home depends on coordination between Hospital at Home-teams, municipal services, primary care, relatives, and supporting functions such as transport, technical support, and medication delivery.
Cross-sectoral collaboration – a critical prerequisite
We have now reviewed the core components of the HaH model—the office, the mobile teams, the hospital, and the home. However, one important dimension remains: cross-sectoral collaboration.
Although not a standalone component of the model, cross-sectoral collaboration is essential for HaH to function effectively in practice. Healthcare professionals must be able to navigate between multiple stakeholders—both within HaH services and in collaboration with, for example, municipal services, general practitioners, and relatives, as care pathways delivered in the home rarely involve only one sector.
This applies not only to direct patient care but also to supporting functions such as transport, technical support, medication delivery, and access to urgent clinical advice.
Cross-sectoral collaboration in practice
For HaH care to function in real-world settings, strong internal teams and clearly defined responsibilities are not sufficient on their own. A key prerequisite is effective collaboration across sectors and functions. Cross-sectoral collaboration is therefore not merely an organisational necessity—it is an active framework that surrounds and supports the entire HaH model.
In practice, cross-sectoral collaboration involves coordinating care across organisational boundaries and ensuring clear communication between all parties involved in the patient’s care pathway.
HaH units often collaborate with municipal home care services and regional primary care providers, particularly when patients already have established contact with these services. This can strengthen continuity of care and enhance patients’ sense of safety, as familiar caregivers remain involved in the care pathway. For example, municipal services may take responsibility for aspects of daily care that do not require hospital-level competencies.
Stina
Stina is admitted to Hospital at Home for intravenous antibiotics and treatment of worsening heart failure. The HaH team is responsible for hospital-level care, including medical assessment, blood tests, IV medication, and adjustment of diuretics. At the same time, municipal home care continues to support Stina with compression stockings, personal care, and meals. Her primary care provider is informed about the treatment plan and expected follow-up after discharge from HaH. Clear communication between the HaH team, municipal services, primary care, Stina, and her husband helps prevent gaps in care and makes it easier to identify early signs of deterioration.
External resources and supporting functions
To deliver HaH care in a safe and reliable manner, a range of supporting functions may be needed. While these tasks do not always require clinical expertise, they play an important role in maintaining care quality and patient safety.
These functions can be carried out either by hospital-based teams or by external providers, depending on local organisation and resources. Although they may not always involve direct patient contact, they contribute to the overall care pathway. Examples include:
Transport of patients, equipment, and medications
Delivery of materials, food, and assistive devices
Technical support, including IT systems, networks, and software
Medical technical services, including the installation and maintenance of equipment
Some HaH units also have agreements with 24-hour services that can provide support outside normal working hours, such as triage, clinical advice, or specific interventions during the night.
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