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The virtual Home Hospital in Borgholm

Sweden Distance treatment
The work procedure known as the Borgholm model and the (virtual) Home Hospital in Borgholm are a forerunner and prototype before a necessary shift in Swedish healthcare, towards close care and less hospitalization. The virtual Home Hospital in Borgholm is a health facility where up to 300 severely ill get good and close care in their own homes. The base is enough staff and a seamless collaboration between Healthcare Centre, Ambulance Care, Home Healthcare and Home Care. To patient this means more safety, availability, participation and continuity. Sixteen of the heart failure patients cared for at the Home Hospital in Borgholm used a digital tool for home monitoring which, during project time, brought about less hospitalization, more confident patients, content staff and economic benefits.
Some effects for the patients are less hospitalization with the possibility to stay at home, higher safety and confidence. The patients experience seamless care and better contact with healthcare, increased perception of disease, participation and independence. For the care units, some effects are better interaction with patient, more confident and enjoyable work situation, more easy to recruit and safety in having support and time to assess. Furthermore, there are better collaboration between care givers and better use of competence in patients and staff.
The virtual Home Hospital in Borgholm care for up to 300 patients in their own homes. Work procedure is performed by 50 employees from two healthcare centres, 20 district nurses, 180 employees at home care and ambulance staff. Work procedure also affect staff at the County Hospital in Kalmar. Sixteen heart failure patients, age 70 or older, participated in the home monitoring project.
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The virtual Home Hospital in Borgholm care for up to 300 patients in their own homes.

Quotes/testimonials

”Biggest hospital in Sweden is neither Sahlgrenska nor Karolinska; but the Home Hospital.” “Home care staff are very important actors at the Home Hospital and the only ones that see patients every day”

- Doctor, Borgholm

Elaboration

Needs and challenges

Vacancies, fluid communication, trust and agreements between care givers and home care patients calling ambulance to get to a doctor – Borgholm had some challenges, connected to and consolidating one another. Borgholm is one of the municipalities in Sweden with the eldest population. The demand for a shift, towards new work procedures, focusing patients needs of good and close care, was prominent in 2016, when employees at Borgholm health centre took initiatives towards the Home Hospital.

Some years later, in spite of the fact that the home hospital worked well, was a challenge in that some patients nevertheless had to go to the emergency at the county hospital. Home hospital therefore wanted to find a way to accurately follow patient status, to be able to institute proceedings and prevent hospitalization. 

Solution and function

The virtual Home Hospital in Borgholm is a health facility, where up to 300 severely ill get good and close care in their own homes. The base is enough staff and a seamless collaboration between Healthcare Centre, Ambulance Care, Home Healthcare and Home Care. Aim is seamless care and to cut the number of days in hospital unit by half.

As a part of the Home Hospital´s quality improvement strategies, a digitalizing project took place. Point of departure was patient needs for continuous pursue of health status. Project aim was to evaluate home monitoring. Sixteen heart failure patients participated in the home monitoring project during 4 months. 

Through a digital tool, Cuviva, patients daily reported selected measurements as saturation, body weight and body  temperature. They also answered questions about current health status. Patient reported measurements and answers are, by Cuviva, put together in one digital oversight per patient and transferred by internet so that the Home Hospital staff can take part of it. Oversight point out changes and the Home Hospital can take actions in an early stage. During project time none of the project participators needed emergency care at the County Hospital. 

Economy

The Home Hospital in Borgholm aim to cut the number of days in hospital unit by half for their Home Healthcare patients, a target that should save huge amounts to the region. The Healthcare Centre´s economy is by now balanced but there is a need for an adding of 10%  in the long run.

Project home monitoring had 16 participants and savings were 350 000 sek during  a project period of 4 months. 

Process

It all began in 2015, with a work environment improvement at the Borgholm healthcare centre. All employees could agree on that major impact on work environment should be stable doctor staffing, with enough of doctors. Several improvements were done. Retired doctors were hired as Senior Advisors, and new doctors were recruited by guarantee on a ceiling of no more than 1000 patients on each doctors list.

Consensus and collaboration was supported by developing teams and groups. The Healthcare Centre in Borgholm is ever since fully staffed.

At this state, with staffing situation under control, during the autumn of 2016, the Borgholm healthcare centre was able to address the issue of accessability and continuity for Home Healthcare patients. The municipality district nurses and ambulance care staff were invited for dialogue and catching needs. Better ways of communication and the opportunity to get home visits by doctors at short notice were some of the needs that emerged. The Home Hospital in Borgholm was under construction.    

In addition to good enough staffing and well-functioning collaboration between care givers, there are other important components: a common and accessible  patient journal, team work, opportunity for consultation and procurement, and to take charge of and develop skills. 

At the home hospital in Borgholm, a digitalization has begun. As part of this developement, the Home Hospital ran project home monitoring for four months. The project focused on heart failure patients. Participants were 70 years or older and some of them had no habit of digital technology. These patients often interact with manyu actors; Home Care, Home Healthcare, Primary Care, Ambulance Care and Emergency Care. An app in a smart phone does neither meet the needs of the elderly nor the health care professionals. Therefore, it was important to choose a system adapted to this target group, where the design and interface are made to fit fragile elderly people , and also connects several different principals. The tecnical solution provider was Cuviva. 

Organisation and politics

County Council Management, subsequently Political Leadership in Region Kalmar County agree that the Home Hospital model is good and should be implemented all over the region.

Therefore region´s client unit, since January 1, 2019, formulated an assignment so that the working methods according to Home Hospital will be introduced at all Healthcare centres in the Region and that all patients in Municipal Home Healthcare shall have a named doctor. 

Follow-up/monitoring

The introduction of the working methods of the (virtual) Home Hospital has, among other things, resulted in increased security for patients, less hospital admissions and better collaboration between care givers.  Employees thrive and it is easier to recruit.

The project where 16 Home Healthcare patients used the digital tool Cuviva shows: 

  • 100% less hospital admissions during project time 
  • 100% of patients experience greater safety and better contact with care 
  • 56% of patients experience increased disease insight 

More about effects

The work procedure known as the Borgholm model and the (virtual) Home Hospital in Borgholm, are forerunner and prototype before a necessary shift in Swedish healthcare, towards close care and less hospitalization. The model has become a reference and is referred to in the Governments ongoing investigation Samordnad utveckling för god och nära vård (SOU 2017:01).

The home hospital is uncontroversial. The quality of life is higher for individuals who can get care at home, compared to those who live their lives in a hospital environment. The working methods are based on the needs of Home Healthcare patients, and designed by the employees in the involved care units, to create more security and better health with much less financial efforts.  

Home monitoring increases the patient´s ability to be more involved and participating in their own care. The financial outcome of fully implementing home monitoring, has every opportunity to be positive. 

Learnings

In Borgholm, one has collaborated and created a model, implicating that the care has come closer to the citizens. Accessability and continuity are prioritized and the result is an efficient, high quality care. At the same time, the focus is on constant developement and improvement. The Borgholm model might not be possible to copy right away in other municipalities, but hopefully provides knowledge, evidence and inspiration to explore the needs of the one´s health care are for, and thereby customize working methods to fit needs and prerequisites. 

The biggest challenge in this paradigm shift is not the introduction of new working methods or the use of various digital tools. The biggest challenge is to hand over the medical control, follow-up and monitoring of treatment to the residents themselves. 

The virtual Home Hospital in Borgholm is part of the Borgholm model; a model for conducting good and close care. The Borgholm model is based on collaboration and on the fact that there is good enough staffing of all occupational groups. The Borgholm model is in continual developement and currently has the following components: 

Borgholm groups
All employees at the Borgholm Healthcare Centre leads the unit together. Six interdisciplinary ”Borgholm groups” work structured and standardized on issues and improvement ideas. 

Senior Advisor
Experienced retired general practicioners have been hired at the Healthcare Centre. Some of them are always on duty, to give medical advice to all staff. They have no listed patients and do no journal notes.  

Dandelion group
Reference group consisting of people who work extra at the Healthcare Centre, among others the Senior Advisors. Dandelion group examines procedures and effects from both outside and inside angle and comes with improvement suggestions.  

Acute team
Medical assisted nursing for fast assessment. In about half of the cases a nurse/district nurse can handle a case without the patient being presented to a doctor. In some cases it quickly becomes apparent that patient needs a doctor immediately.   

Referral group
All non-acute referrals are reviewed and commented by all doctors at the Healtcare Centre in a joint session once a week. When reviewed and approved, referral is sent to the hospital with the supplement ”through the Borgholm referral group”. This procedure has led to fewer forwarded referrals, and that the hospital handle referrals quickly, and also less reject of referrals. In addition, consensus and cohesion are strengthened.   

Integration Team 
The competence, developed at the Borgholm Healthcare Centre during a period of many asylum seekers, is now taken advantage of to integrate doctors with foreign descent. In order to acquire Swedish healthcare system and approach, each of these doctors now has a Senior Supervisor and a very experienced District Nurse at side in everything  they do. In parallell, they recieve education in the Swedish language.   

Team with Specialist Nurses
Single-handed work rarely works in the long run and therefore there are always at least two Specialist Nurses in each special area for asthma / COPD, diabetes, heart failure and dementia. The Specialist Nurses limit the specialist efforts to three days per week and therefore change tasks regularly. Dementia and Diabetes Nurses do home visits. Specialist Nurses in heart failure and lifestyle do in collaboration with doctor follow-up after heart attack.  

Kex Borgholm (”Kex” is a wordplay, from ”Lex”)
An action plan for how to handle different approaches. Daily reflection time gives all staff the opportunity to sort things out directly and a checklist exists in cases where the dialogue needs support. If the situation cannot be resolved with the help of the checklist, peer support is contacted. For organizational issues, contact should be taken with the Head of Clinic. The purpose is to have a climate where the staff feel secure in always being directly informed.  

Continous improvement  One of the major challenges is the continued individualisation of the healthcare supply. Of course, the aim is to have a fully digitized Healthcare Centre as soon as possible.  

Home hospital
The virtual Home Hospital is a seamless collaboration between Healthcare Centre, Ambulance Care, Home Care and Home Healthcare. In order for the Home Hospital to function, in addition to good staffing, important factors are: access to patient journal, well-functioning contact paths for collegial consultation, and the opportunity to quickly get home visit by a doctor. In Borgholm, all specialist doctors reserve the time at 11:00 to 12:00 for emergency home visits. The time can be booked by the Municipality's nurses, ambulance nurses or by district physicians (after telephone contact with the patient). District doctors follow up the patients, the Municipality's district nurse is no longer alone in their responsibility. Ambulance nurses do not need to drive patient to hospital for safety reasons. The Home Care staff's expertise is better utilized, among other things through increased knowledge of seeing signs of deterioration. 

Journal access
Common journal is one of the basic prerequisites for the working method. Since the turn of the year 2016–17, the journal system provides information every morning, about which of the Health centre's patients have been admitted to the County Hospital since yesterday. The doctor can, via the journal, receive information about the situation and, if necessary, call the department for reconciliation; reverse care planning. 
 

About project home monitoring
The heart failure patients who used the digital monitoring tool Cuviva were 70 years or older and they usually had little or no experience of new technology. 


There is the possibility to introduce working methods reminiscent of the Borgholm model and the Home Hospital in other parts of Sweden and the Nordic countries. The monitoring tool Cuviva could probably be used and create value for both more heart failure patients and other needs groups. 

Head of Clinic at the Borgholm Healthcare Centre, Åke Åkesson.

E-mail: ake.akesson@ltkalmar.se 

The virtual Home Hospital in Borgholm. 

The virtual Home Hospital in Borgholm is provided by the Borgholm Healthcare Centre in collaboration with Home Healthcare, Home Care and Ambulance Care in Borgholm,  

Provider of the digital tool used in project home monitoring was Cuviva. 

https://cuviva.com