Module 3 – Delivering care in the home
In this module, you will focus on what it means to deliver Hospital at Home care in everyday practice. You will explore how daily care is planned, coordinated, and adapted to the patient’s condition, home environment, and changing needs. The module highlights the importance of teamwork, communication, and relationships when care is provided across professional, organisational, and personal boundaries. You will also consider cultural competence and the role of patients and family members, including both the opportunities and challenges that arise when care takes place in the home. Finally, the module addresses discharge from a Hospital at Home unit and how to support a safe transition after the acute episode of care.
Daily care
This chapter introduces how treatment, monitoring, and daily contact are organised in Hospital at Home. It highlights how clinical procedures, sampling, medication, investigations, and vital signs monitoring can be adapted to the home setting.
The majority of treatment time is spent in the patient’s home
HaH is based on the principle of delivering care in the patient’s own home rather than in a hospital setting. As a result, most treatment and care take place in the home, with a focus on ensuring patient safety and providing appropriate support.
The extent to which care can be delivered at home depends on the patient’s clinical condition and monitoring needs. For example, some patients with cancer may need to attend hospital for specific treatments such as chemotherapy, while other aspects of care—such as sample collection, observation, or management of a central venous catheter (CVC)—can be carried out in the home.
A successful HaH pathway therefore requires careful planning, coordination, and appropriate resources—both human and technological—to ensure that care delivered at home is safe, effective, and of high quality.
The patient has daily contact with healthcare professionals—either in person or digitally
The frequency and type of daily contact are adapted to the patient’s needs, capacity for self-care, and level of digital competence. Some patients may have more digital interactions, for example if they are able to monitor vital signs and report symptoms independently. Others, such as patients with limited digital confidence or more complex care needs, may require more frequent in-person visits or less digital communications forms such as telephone.
Decisions about the most appropriate form of contact are made in collaboration with the patient and are adjusted on an ongoing basis. The key consideration is not the quantity or mode of contact, but whether care is experienced as safe, accessible, and meaningful.
Sampling, investigations, and treatment in the home
In HaH pathways, the aim is to carry out as many clinical procedures as possible in the patient’s own home, in order to support everyday life and promote continuity of care.
Blood samples can often be taken in the home using mobile equipment, and in some cases analysed on site. Alternatively, samples may be transported to the hospital laboratory. Some HaH units also use portable diagnostic equipment, such as X-ray and ultrasound.
Medication is typically administered as oral treatments, injections, or infusions. In some settings, more advanced therapies—such as parenteral nutrition or blood transfusions—may also be provided, depending on the patient’s needs and local organisation.
Vital signs and other parameters may be monitored by healthcare professionals during home visits or by patients themselves using equipment introduced at admission. In many settings, this is supported by remote monitoring systems, where data are automatically recorded and transmitted, for example via ECG devices or fall-detection sensors.
The flexibility of these technological solutions makes it possible to tailor care to the individual patient’s needs and preferences, supporting a safe and person-centred care pathway in the home.
Tasks performed in the home vary in complexity and place high demands on equipment, clinical judgement, and organisational support. The home must be able to accommodate both basic and highly specialised care—maintaining the same standards of quality and safety as in the hospital.
The patient as a co-creator of care
As in traditional hospital care, the treatment plan is a central tool for guiding care in a HaH pathway. A key distinction is the greater involvement of the patient in both decision-making and the day-to-day management of care.
The plan is developed through dialogue between the healthcare team and the patient, taking into account clinical assessments, care needs, and the patient’s life situation, resources, and preferences.
If the patient wishes, relatives may also be involved in planning and delivering care. In this context, healthcare professionals play an important role in ensuring that both patients and relatives are well informed, feel confident, and are equipped to contribute—for example through guidance in the use of technology and support for self-management.
Hamid
Hamid receives HaH care for worsening heart failure symptoms. He lives alone and finds it difficult to remember everything that is discussed during contacts with the HaH team.
Together with Hamid, the team agrees that his children can access the care plan from a distance. The plan includes information about his medication, daily monitoring, use of compression stockings, mobility support, and when the team should be contacted.
This makes it easier for Hamid’s children to stay informed and support him when they visit, without Hamid having to explain or remember every detail himself. For Hamid, the shared plan creates reassurance, while still keeping him involved in decisions about his care.
Teamwork
This chapter introduces interdisciplinary teamwork as a core principle of Hospital at Home. It highlights how physicians, nurses, physiotherapists, occupational therapists, pharmacists, and other professionals contribute according to the patient’s clinical needs, functional ability, and home situation.
Care is delivered by an interdisciplinary team
HaH is an interdisciplinary approach in which healthcare professionals from different disciplines collaborate to deliver coordinated and holistic care. While nurses and physicians form the core of many HaH teams, input from other professional groups is often required to meet the patient’s needs.
For example, older patients and those with orthopaedic conditions may benefit from input from physiotherapists and occupational therapists. These interventions may be delivered in the home, digitally, or, when necessary, in a hospital setting.
In more complex care pathways, pharmacists may contribute by supporting medication management, advising on treatment plans, and providing guidance to both healthcare professionals and patients. Dietitians may also play an important role, for example by analysing digital food diaries and providing follow-up through home visits or video consultations.
Interdisciplinary collaboration is tailored to the individual patient and may vary in scope and format depending on diagnosis, functional level, and personal preferences.
Hamid
Hamid receives HaH care for worsening heart failure symptoms, increasing leg swelling, and reduced mobility. Although the nurse and physician are central to his care, his situation also requires input from other professionals.
The physiotherapist assesses his mobility and risk of falls, while the occupational therapist considers whether he needs additional assistive devices or changes in the home environment. The nurse coordinates daily monitoring and supports Hamid with his treatment plan, including medication, compression stockings, and contact with home care.
This shows how HaH care is delivered by an interdisciplinary team, where different professionals contribute according to the patient’s clinical condition, functional ability, and home situation.
Who collaborates in Hospital at Home—and when?
The professional team surrounding the patient often includes physicians and nurses, as well as physiotherapists, occupational therapists, and pharmacists. Depending on the patient’s needs, the team may also be supplemented with additional expertise, such as a dietitian, speech and language therapist, or social worker.
In some HaH models, the hospital unit retains overall clinical responsibility throughout the care episode, while municipal services contribute with practical care. In other models, the hospital takes on a more coordinating role, with responsibilities distributed flexibly between providers. These organisational differences mean that collaboration must be actively shaped and adapted to both the patient’s needs and local conditions.
Coordination between professions and organisations is essential—at the initiation of care, during treatment, and particularly during transitions, when responsibility shifts. Lack of clarity regarding roles, responsibilities, and documentation can lead to errors that affect patient safety. Clear communication and a shared direction are therefore critical components of a safe and coherent HaH care pathway.
Collaboration takes place not only between individuals, but also between systems and organisational cultures. Regional and municipal services often have different working practices and documentation systems. This can create barriers—but also opportunities for innovation and learning across boundaries.
Care within a Hospital at Home unit may be initiated by several different healthcare professionals, making effective interprofessional collaboration particularly important.
Collaboration in practice – who does what?
In practice, HaH requires close coordination of tasks, responsibilities, and roles. Collaboration should ensure that the patient experiences continuity and a sense of safety—regardless of who visits the home and which profession they represent.
Specific tasks depend on the patient’s condition and the local organisation of services. The physician usually holds overall clinical responsibility, while the nurse often has day-to-day oversight and coordinates care activities.
Although roles are often clearly defined on paper, experience shows that collaboration requires flexibility. Situations may arise where roles overlap—or where there is uncertainty about responsibilities. This is particularly evident during the initial days of a HaH episode, when new routines are being established and both the patient and their family are becoming familiar with the technology and the professionals involved.
Cultural differences in working practices, pace, and perceptions of responsibility may influence collaboration—both between healthcare professionals from different sectors and in interactions with patients and their families. For example, there may be differing interpretations of “close follow-up” or “shared decision-making”. It is therefore important for healthcare professionals to be aware of both their own and others’ professional and cultural perspectives.
Effective collaboration is built on three key elements:
Clear allocation of roles and responsibilities—both in writing and in practice
A shared understanding of the patient’s situation and needs—even as these evolve
Communication that is two-way and respectful of professional differences
Digital tools can support this—for example, by enabling shared access to up-to-date information and clear care planning. However, this requires that all parties have the necessary digital health literacy and that systems are interoperable.
In HaH, care is often delivered in a decentralised manner, with both physical and digital points of contact. This places particular demands on communication within the team. Differences in professional background, responsibilities, and terminology may lead to misunderstandings, while a lack of trust can make it difficult to ask questions, take responsibility, and act collaboratively. Interprofessional collaboration therefore requires more than coordination—it requires relationships, mutual understanding, and intentional communication.
This also applies to collaboration with patients and their families. The team needs to present itself as a coherent unit and communicate clearly and consistently—especially at the start of a HaH episode, when much is new. This is particularly important when family members are involved in care or when patients are introduced to new technologies. Cultural differences in views on illness, responsibility, and communication may also influence collaboration, requiring the team to demonstrate cultural humility and situational awareness.
Collaboration around admission to Hospital at Home.
Collaboration requires maintenance and continuity
Effective collaboration does not occur automatically. It requires ongoing attention, relational awareness, and space for reflection in everyday practice. This is particularly important in HaH, where teams work more independently and are more geographically dispersed than in a traditional hospital ward.
In practice, this means that teams:
Agree on how and when to communicate
Take shared responsibility for decisions
Regularly review how the team is functioning—even when care episodes are short
Psychological safety, and a culture in which it is acceptable to raise concerns and ask questions, are essential for both quality of care and staff well-being. Awareness of each other’s professional roles and digital health literacy is also important. If even one team member feels uncertain about the technology, this may affect coordination as well as patient safety.
Interprofessional collaboration in HaH is not only desirable—it is essential to ensure continuity, patient safety, and integrated care pathways. When care is delivered in the patient’s home, coordination across sectors, professions, and physical distances is often required. It is therefore important that the team has space for shared dialogue, where collaboration
Communication and relationships
This chapter introduces communication as a clinical tool in Hospital at Home. It highlights how clear, person-centred communication supports safety, trust, participation, and shared decision-making. It also explores how healthcare professionals need to adapt communication to the patient’s needs, digital literacy, and home context, while ensuring that instructions, care plans, and actions in case of deterioration are clearly understood.
Communication as a clinical tool
Communication with patients and relatives is critical. Instructions must be clear to avoid misunderstandings, and it is important to ensure that patients and relatives understand communication pathways, monitoring, treatment, and actions to take in case of deterioration or unexpected events. Digital encounters introduce additional uncertainty due to technical limitations and reduced opportunity for direct observation. Clarify the purpose and plan, confirm what has been understood, and summarize agreements. This reduces the risk of misinterpretation.
Sender-Message-Channel-Receiver Model of Communication, David Berlo (1960).
Person-centred care
In HaH, healthcare professionals work in closer proximity to the patient’s everyday life—both physically and relationally. This creates opportunities for more person-centred care, where the patient’s life, routines, and preferences are directly reflected in clinical decision-making. It can strengthen both relationships and quality of care, but it also requires a different professional approach when entering someone else’s home.
Person-centred care involves recognising the patient as an active participant—not merely a recipient of care. As a healthcare professional, this means listening to the patient’s narrative, documenting respectfully, and planning care in collaboration with the patient. It is also important to recognise that the home is not simply a backdrop—it actively shapes the care process. The physical layout of the home, its atmosphere, and the dynamics between family members all influence how care is planned and delivered.
Person-centred communication—in the home and via the screen
In Hospital at Home, communication with patients occurs in multiple formats: during face-to-face encounters, via video or telephone, and through written communication such as chat functions, secure messaging platforms, or text messages. Regardless of the medium, communication is a core component of care and essential for patient safety, trust, and participation. The principles of person-centred communication therefore apply across all formats, although they may be expressed differently depending on the mode of communication.
Respect and dignity
Person-centred communication is grounded in respect for the patient’s values, autonomy, and life situation. When care is delivered in the patient’s home, physically or digitally, we are entering a private sphere. This places particular demands on sensitivity, professionalism, and humility.
Empathy and active listening
In digital encounters, empathy needs to be communicated more intentionally. Presence can be conveyed by:
ensure that the patient can see and hear clearly
maintaining eye contact through the camera
using affirming nods and appropriate facial expressions
allowing the patient to speak without interruption and acknowledging what they say
In written communication, empathy and attentiveness must be conveyed solely through words. A respectful and warm tone, clear responses, and explicit acknowledgement (e.g. “I understand” or “Thank you for explaining”) become especially important, as non-verbal cues are absent.
Individualisation
Communication should always be adapted to the individual patient’s needs, abilities, and preferences. This includes:
pace and language
level of detail
consideration of cognitive capacity, language proficiency, and digital literacy
In written communication, individualisation requires particular care. Clear structure, short sentences, and plain language are essential, as patients cannot rely on body language or ask follow-up questions in real time.
Partnership and shared decision-making
Person-centred care is built on partnership. This means:
communicating with the patient rather than to them
encouraging questions, dialogue, and active participation
recognising the patient’s experiences and perspectives as valuable
Written communication should also be dialogical and inviting, for example by using open-ended questions and offering opportunities for follow-up or clarification.
Clear information and support
All communication—especially digital and written—places high demands on clarity. Healthcare professionals should:
avoid unnecessary medical jargon
break information into manageable parts
actively check understanding, for example by asking the patient to confirm or summarise key points
In written communication, the risk of misunderstanding is greater. It is therefore particularly important to choose words carefully, clearly state expectations, and specify when and how the patient should seek help or make contact in case of questions or deterioration.
Important considerations when communicating with patients.
Cultural competence
This chapter examines why cultural competence and cultural humility is essential in Hospital at Home, where patients’ diverse backgrounds shape their experiences of care. It introduces a broad understanding of culture and highlights how it influences communication, relationships, and health outcomes.
Why is cultural competence important?
Healthcare professionals working in HaH encounter patients with diverse backgrounds, experiences, and circumstances. Cultural competence contributes to:
Promoting respect and a sense of safety in interactions with patients and their families
Improving communication and reducing the risk of misunderstandings
Strengthening relationships with both patients and those close to them
Supporting person-centred care and ensuring that treatment is perceived as meaningful
Preventing unequal treatment and clinical errors
Cultural competence also involves the ability to adapt one’s communication and approach to the patient’s individual needs and life situation. It is not about “knowing everything about everyone”, but about maintaining an open, curious, and reflective mindset.
What is culture?
The concept of culture is commonly used in everyday language, but it can be difficult to define precisely. Below are three examples:
Culture as values, norms, and social practices linked to ethnicity, religion, and social groups—often shaped by time and place
Culture as shared attitudes, values, and goals within an institution—for example, in a hospital or organisation
Culture as profession-based values and practices—for example, how physicians, nurses, or other healthcare professionals act within their professional communities
Together, these three perspectives provide a nuanced understanding of how culture influences both individuals and organisations.
A broad understanding of culture
Culture is not limited to ethnicity and religion. A contemporary understanding of the concept includes a range of factors that influence how individuals perceive and manage illness:
Ethnicity
Spirituality and religion
Sexual orientation and gender identity
Age and stage of life
Geography (urban, rural, global contexts)
Socioeconomic status
Level of education
Specific groups (e.g. people in custody or those in socially vulnerable situations)
Language and forms of communication
These aspects shape patients’ expectations, understanding, and experiences of health and illness, and should therefore be taken into account in interactions between patients, their families, and healthcare professionals.
Maria
Now we’ll meet a new patient, Maria 59 years, who receives HaH treatment for a urinary tract infection. Her adult son is present at every visit and answers most questions on her behalf. The team initially assumes this is simply supportive family involvement, but Maria gives short answers and avoids eye contact when medication changes are discussed.
The clinician asks Maria, with an interpreter, how she prefers information to be shared and whether she wants her son involved in all conversations. It becomes clear that she appreciates his help with practical matters but wants some conversations with staff alone. The team documents her preferences and adjusts communication accordingly.
Family involvement can be a resource, but cultural competence requires checking the patient’s own preferences, autonomy, and consent.
Why is cultural competence needed?
When healthcare professionals understand and respect a patient’s background, collaboration becomes more meaningful—and disparities in health outcomes and access to care can be reduced.
However, more recent perspectives emphasise that it is not sufficient to simply acquire knowledge about others. A reflective approach is also required. This is sometimes referred to as cultural humility, and includes, for example:
Recognising one’s own preconceptions and privileges
Being open to the patient as an expert in their own life
Having the confidence to ask questions—and to listen without prejudice
Cultural humility in Hospital at Home: a reflective perspective
Cultural humility is based on an understanding of culture as dynamic, relational, and context-dependent—not as a fixed entity that one can become an “expert” in. This perspective shifts the focus from knowledge about others towards care practices, relationships, and self-reflection.
As a healthcare professional in HaH, this means, for example, that you:
Work in a person-centred manner
Are attentive to both verbal and non-verbal communication
Acknowledge openly what you do not know
Are willing to learn from the patient
Reflect on your own preconceptions, values, and professional practices
Recognise power dynamics within the clinical context
This approach supports collaboration and respect in encounters with diversity, while also requiring courage and ongoing reflection.
Hamid
Hamid is admitted to HaH for treatment of heart failure decompensation. He speaks the local language fluently, but has difficulty understanding written health information and becomes embarrassed when asked to use the tablet for symptom reporting. He nods during instructions but later enters random values because he does not want to “do it wrong.”
The team explores this through open questions rather than assuming non-compliance. They simplify the written instructions, use teach-back, involve a trusted relative with Hamid’s consent, and agree that some reporting will be done by phone instead of only through the app.
Cultural competence also includes recognising health literacy, shame, and communication barriers that are not immediately visible.
Patients and family members – opportunities and challenges
In this chapter, we explore in greater depth how patients and their families can be involved as partners in HaH. You will be introduced to different perspectives on roles, responsibilities, and collaboration, with a particular focus on the importance of communication, support, and cultural understanding.
Opportunities and challenges for patients in Hospital at Home
In HaH, the patient has an active and central role in their own care. Treatment takes place in the home, but still involves close collaboration with healthcare services—both through in-person visits and digital contact. For some patients, this can enhance their sense of safety. At the same time, it may also be experienced as demanding. Receiving care at home often involves greater personal responsibility, which can create uncertainty for some individuals.
Some patients appreciate the opportunity to maintain contact with healthcare professionals remotely, allowing them to remain in their home environment and avoid travelling to hospital. At the same time, a degree of ambivalence is often described. Patients may miss face-to-face interaction with healthcare professionals and feel uncertain about whether their condition is being assessed thoroughly.
The initial days of HaH can be particularly challenging. Patients need to adjust to a new model of care in which responsibility and communication differ from traditional inpatient care. In addition, digital solutions require a certain level of technical competence and access to appropriate equipment, which not all patients have. Healthcare professionals must therefore balance the need for flexible, digitally supported care with the patient’s need for relational continuity, clarity, and understanding.
The role of family members in Hospital at Home
When family members are present, they often become key participants in the day-to-day care process, acting as supporters, observers, and practical helpers.
However, this is not a neutral role. Providing care can be meaningful—but also demanding. Research indicates:
An increased risk of stress and caregiver burden among family members
A need for clear information and the opportunity to accept or decline responsibilities
That relationship dynamics may change when a person takes on a caregiving role
As a healthcare professional, it is important to be attentive to how this affects both the individual and the relationship between the patient and their family. Some individuals may require additional support, while others may need clearer boundaries.
What is perceived as natural and reassuring in one family may feel intrusive or inappropriate in another. Cultural understandings of illness, responsibility, and the role of the family significantly influence how collaboration develops.
Healthcare professionals should therefore:
Avoid assumptions about what constitutes a “good” family member
Ask open questions about the family’s preferences and boundaries
Provide support in ways that are tailored to individual backgrounds, resources, and circumstances
As with patients, the initial days of HaH are often experienced as particularly uncertain for family members. At the same time, many describe a sense of meaning in being closely involved in the care process and contributing actively.
These experiences highlight the need for a person-centred and flexible approach, in which healthcare professionals balance support and expectations with sensitivity to both diversity and potential burden.
Communication with family caregivers
While it is not necessarily expected by the hospital staff, family members are often closely involved as partners in the patient’s HaH trajectory. Although the patient is being monitored from the hospital 24/7, the family members are physically the closest to the patient during HaH. This can be an ambivalent experience for family members, combining the joy of having one’s loved one close with insecurity – an insecurity often linked to a strong sense of responsibility for, and awareness of, the patient’s wellbeing.
In addition, family members might support care and treatment in the home. Some assist with monitoring and reporting measurements to the hospital, and many also take on informal tasks such as cleaning, grocery shopping, and ensuring that the patient eats and is able to rest.
Overall, although supporting the patient is often expressed as self-evident by family members, it may lead to strain. Early involvement and close communication with hospital staff are therefore important, as this can help clarify expectations, support the family and thereby reduce the insecurity of family members during HaH.
Discharge from a Hospital at home-unit
This chapter introduces discharge as a planned transition from Hospital at Home to everyday life. It highlights how early planning, clear information, coordinated follow-up, and involvement of relevant services can reduce uncertainty and support safety after discharge.
Discharge and transition to everyday life
The transition from HaH to everyday life is often smoother and less burdensome for patients than discharge from a conventional inpatient ward, as patients are already in their own home with familiar routines and surroundings.
However, the end of a HaH pathway can still be a vulnerable phase:
Patients may feel uncertain about whether their condition has improved sufficiently to manage without close contact with healthcare services
Patients without adequate support at home may have concerns about loneliness, practical tasks, and ongoing treatment
The transition to independently managing medication, meals, and rehabilitation can feel overwhelming
It may be unclear which services or assistive devices are available, and how to access them
For these reasons, discharge should be planned carefully and well in advance:
Early in the pathway, there should be a clear plan outlining remaining goals, ongoing treatment, and the expected timing of discharge
If the patient receives services such as home care or community nursing, these should be informed in good time of the anticipated discharge date
If new services or ongoing support are required after discharge, these needs should be identified and planned in collaboration with relevant stakeholders
By ensuring a clear and well-coordinated conclusion to the HaH pathway, uncertainty can be reduced and a safe transition to everyday life can be supported, including for patients who require continued care and follow-up.
Alice
Alice has received intravenous antibiotics at home after bacterial meningitis. As the end of treatment approaches, the HaH team begins planning discharge together with her parents. Alice is only six months old, so her parents need to feel confident that they know what to observe after the close contact with the care team ends.
The plan includes the final doses of antibiotics, removal or follow-up of the central venous access, remaining blood tests, and information about signs that should prompt renewed contact, such as fever, reduced feeding, unusual tiredness, irritability, or changes in responsiveness.
The team also discusses how the family can return to everyday routines with two older siblings at home, while still ensuring that Alice gets the follow-up she needs. This helps make the transition from HaH to ordinary family life safer and less stressful.
Følg os på linkedin
© 2025. All rights reserved.
