‘Hospital at home’: How to safely keep vulnerable older people out of emergency departments this winter

Doctors hope that enhanced community care programmes around the country are beginning to have a positive impact

As an already over-stretched health service braces itself for winter, virtual home monitoring and other health innovations may be part of the solution to keeping vulnerable older people out of emergency departments and acute hospitals.

Dr Emer Ahern is national clinical advisor for older persons and, as a geriatrician at Cork University Hospital, is all too aware of the potential risks our current hospital system can hold. “Older adults used to make up 10 per cent of people presenting to hospital every day, now it’s around 30-35 per cent,” she says. “In lots of ways, Covid exposed the needs of older adults not being met. What we need to do now is reset and redesign the system so that it is actually meeting those needs. We need to have age-attuned environments.

“Traditionally, the only way for older adults to access urgent care was through emergency departments, with all the associated issues, including prolonged waiting times, and being on trollies, and all the associated harms from that. So we’re developing an integrated kind of system between the community and the hospital that gives them the urgent response and care they need in the community.”

This winter will see an increase in designated emergency teams going out to assess older people in their homes, and linking them to the care they need. She also believes the new enhanced community care programmes around the country are beginning to have a positive impact for older people. 21 hubs are up and running, including one at Cork University Hospital: “Their objective is to achieve reductions in waiting lists and waiting times, emergency-department attendances, and hospital admissions.”


Traditional hospital systems, says Ahern, were designed to deal with a person coming in with one thing wrong with them and to treat only that need. The enhanced-community-care hubs will address the multiple needs of older people, regardless of what they actually present with. “For example, if a person falls they might have to come into hospital to make sure their hip isn’t broken, but their care will be in the community. And they will have access to physiotherapy, specialist nursing, occupational therapy, speech and language therapy, social work – any service they need to recover. For a lot of people the care is even delivered in their own home.”

The ultimate aim, says Ahern, is a national integrated system of co-ordinated care, “with the patient at its centre. Things should just happen. You don’t have to know someone. You don’t have to ring someone. Family members don’t have to try and access a service for you. And this system needs to be replicated no matter where you are, or where you actually enter into it – through your public health nurse, GP, or a physio. It’s about equity of access”.

Rehabilitation and recovery are key in keeping older people healthier and independent, says Ahern. “Some older people will need acute hospital care for a period of time, maybe for a stroke or fracture. But for a proportion of those people, prolonged hospital care is also harmful. Recent studies show that approximately 30 per cent of older adults who go into hospital will have more functional decline coming out of hospital than they did coming in – that’s a huge issue. We need to intervene to ensure that we’re giving a better kind of recovery and rehabilitation care.”

Dr Rory Nee is consultant physician in geriatric medicine for St James’s Hospital and Cherry Orchard Hospital, and is already discharging patients early for rehab. “If you have a hip fracture, and you have your whole journey in St James’s, it’s 54 days, but we get people home on average at 17 days. With rehab in hospital you learn how to manage in the hospital toilet and shower and the hospital kitchen. In the community we can do it in your own kitchen and bathroom, or if you have always got the bus to Mass or town that will be part of the rehab goal.

“And the patients love it. Everyone is so used to delays that it’s great to say to them, ‘You go home today and someone will check in later, and your physio will be there tomorrow.’ Care can be so responsive, and so seamless when it’s designed right.”

A “hospital at home” service is now being planned in partnership with the local community intervention team, who can provide intravenous antibiotics and other treatments. “We’re hoping to start bringing people who are a little sicker home,” says Nee. “A study has demonstrated that getting your treatments at home, six months later you’re much more likely to still be at home, rather than a nursing home. "

Ahern says another shift is needed in how we care for older adults because many people no longer have the informal support of families nearby. “So, instead of just simply supporting older adults in their home, we need to send in teams to actually rehabilitate them - not only doctors and nurses and therapy staff, but care staff. That recovery shouldn’t be just about doing things for older adults., it should be about how we can facilitate them continuing to do things for themselves. Because, ultimately that will reduce the need for dependency services, like home supports and nursing homes.”

Nee is currently seeking funding to introduce this kind of re-enablement service. “A traditional homecare package is task orientated. The assessment is done, and a person needs help washing and dressing, so the carers come in and complete that task. With re-enablement, trained rehabilitation carers work with that person’s ability until they can manage those tasks themselves. You give people a lot more independence and improve quality of life that way. In a UK study, 35 per cent of people didn’t actually need a homecare package after re-enablement.”

Nee saw the success of integrated and community-based care for older people while working in Australia, and he envisages building a Community Virtual Ward, that will include geriatric assessment, rehab beds, an expansion of dementia homecare, and step-up beds for older people who need inpatient care that can be managed outside of hospital. He wants more funding, but the biggest challenge at the moment is staffing. They currently need dieticians, speech therapists, and social workers.

Transitioning to electronic medical records is a key component of making this integrated system work, says Nee. “An electronic patient record can be shared or accessed in the hospital or patient’s home. This keeps everyone informed and prevents test duplications or breakdowns in communication. If a nurse is out seeing the patient, and the patient has questions about their X-rays or tests, the nurse can open the records up on a mobile device. And if a consultant gets called after hours they can see what has been happening with that person. It’s going to be a really valuable tool.”

Nee is also working on a proposal with a technology company to trial home sensors for patients with delerium/dementia, which will trigger alarms to family or carers “if they fall or have unsafe wandering behaviours”.

His long-term vision is for a virtual nursing home run from Cherry Orchard, with day care services for socialisation, cognitive stimulation therapies, and a 24-hour hub of on-call nurses and doctors responding to remotely managed sensors.

That vision may not be too far in the future. A few projects using remote technology are already at the early stages, according to the HSE.

HaloCare, a private company, has received funding to develop a potential hybrid-care pilot project, using technology to support older people who want to live independently. Introduced during the pandemic, the technology is being used by families for individualised clinical and safety monitoring. It is designed to complement home support hours, or community services. The company also works in conjunction with private hospitals and homecare providers. “They put in the physical care, the nurses and the carers who go in to the home,” explains CEO Sarah Jane O’Dwyer. “And then for the other hours we have our care hub in Carlow manage care remotely.”

Smart tech learns the routine of the client, reacting if something happens outside of the usual: if a person is not up by their usual time; if the temperature in the house is too hot or cold. Care co-ordinators phone with reminders to take medication, or just for a chat - “a comfort call”. A voice-to-voice activated alarm allows direct communication in a possible emergency.

There are no cameras. Contactless sensors can detect motion, if taps are left on, when doors are opened and closed, or even when someone has a fall. A mattress sensor records that someone has got out of bed. A tiny microchip on the back of the microwave signals that a meals-on wheels delivery is being re-heated. Another on the kitchen drawer indicates that cutlery is being taken out to eat the meal.

“All devices have protocols and rules built into them, that are developed with the family or the clinician,” says O’Dwyer. “So if wandering is an issue for somebody with dementia, there could be a protocol to call the Circle of Care – that could be a family member, or carer, or neighbour – if the front door is left open for more than a few minutes.”

O’Dwyer, a former nurse, sees hybrid homecare as a bridging solution for families trying to mind someone who is beginning to decline, and to global healthcare challenges “. . . not enough nurses, not enough carers, not enough doctors”.

“We have to really reimagine how healthcare is delivered. It’s about being able to give health care in the security of your own home, and not having to take the day off work to bring mum to hospital for tests. There’s now even a company, Mobile Diagnostics, that can provide radiology services in the home.”

With patient consent, information collected by HaloCare can be shared with homecare providers and clinicians. “For example, we can let them know, ‘Mrs O’Dwyer was up five times during the night, maybe you should check for a UTI’. Or maybe she’s sitting down a bit longer than normal, so might need additional homecare hours. It’s about catching them before they decline. Even something simple like hydration prompts – because older people can forget to drink – means they don’t end up sitting on a trolley in A&E for two nights because they’re dehydrated.”

Kathleen Doyle, from Co Kilkenny, will be 90 next year, and still enjoys her bingo, sing songs, and dancing. Her day doesn’t feel right, she says, if she hasn’t been out for a walk: “You have to keep going!”

Three of her nine children still live in the county, and are in and out to visit and shop for her. But she has still opted to use the HaloCare service. “It’s a great reassurance,” she says, “but the most important part is that I can keep my independence”.

“I wear my ‘chain of office’ – a safety pendant – when I’m in the house and they call my daughter Catherine if they can’t reach me - she usually knows where I’m gone,” says Kathleen.

Catherine and her siblings also appreciate the reassurance. “She has a home help that comes in for a little while in the morning. But it’s great to have the additional back-up. We’re all working, and we can’t get out everyday, though we’re on the phone all the time, and she can text better than I can. But even that extra company is great. I could walk in and she’s on the phone chatting away, and it will be Halo she’s on to. She knows the names of all the girls.

‘She’s very independent, she’s well able to get herself breakfast and lunch. You’ll go into the house and she has the fire lit, and the iPad up to watch my brother, who’s a priest in Knock, saying Mass or the rosary. She doesn’t need to go to a nursing home. What she needs is a bit more company, and for us to know that she’s safe.”

Louise Ní Chríodáin

Louise Ní Chríodáin, a contributor to The Irish Times, writes about health and family