Lower Hunter Sector Hospital in the Home Clinical Redesign

Improving service delivery and increase overall staff satisfaction

This project is making meaningful change to the Hospital in the Home (HITH) service in the Lower Hunter Sector to improve service delivery and increase overall staff satisfaction.

View a poster from the Centre for Healthcare Redesign graduation November 2022.

Lower Hunter Sector Hospital in the Home Redesign Project poster


  • Increase eligible referrals from Maitland Hospital to the Lower Hunter HITH service by 5%.
  • Decrease avoidable admissions to Maitland Hospital by 5% within 12 months of completion of the redesign project.


  • Clear expectations from service and referrers
  • Improved monitoring and reporting
  • Improved multidisciplinary team engagement
  • Improved patient experience


The main goal of the HITH service is to not only meet the needs of the patient, by providing person-centred, high quality and safe delivery of service in their home, but to also meet the needs of the medical team, by ensuring increased monitoring and care.

“HITH is an important model of care, with the demand for hospital beds, advances to medical technology and treatments, and a growing and aging population investment in alternative healthcare models is strongly urged”.1

The Lower Hunter Sector HITH service started in Maitland in 2002, as a stand-alone unit with a nurse unit manager, medical governance and a larger nursing team. The service was equipped with virtual beds, which included orthopaedic patients, emergency department patients requiring short term care, and patients discharged from acute and sub-acute wards early to continue their treatment in the outpatient model (with the security of inpatient status).

In 2017, the service relocated to Lower Hunter Sector Community Health, which is not on the same campus as Maitland Hospital. This resulted in:

  • limited medical governance
  • amalgamated management
  • decreased nursing hours
  • poor continuation of links with key stakeholders
  • a steady decline in referrals
  • an unclear model of care.

In 2019 medical governance ceased completely as it was deemed unsafe, and the service became a nurse-led model of care, with several different service names and reduced overall function.

Upon review of the service, from 2015-2020:

  • nursing referrals were down 20%
  • anticoagulant referrals were down 95% (due to limited medical governance).

At the same time, in the financial year 2020-2021, $2.4 million was spent on unfunded surge beds at Maitland Hospital. This demonstrated a need for a HITH service to help reduce length of stay and reduce avoidable admissions. By facilitating early discharge the number of surge bed days would potentially be reduced.

Discussions and surveys conducted in August 2021 indicated that staff felt there was:

  • inconsistent messaging with the service
  • lack of onsite presence at the hospital
  • lack of clinical governance which led to reluctance to refer
  • confusion over what care could be provided by the service to patients.



Initial scoping of the project included Maitland, Cessnock and Kurri Kurri District Hospitals however this was scaled down to focus on Maitland.
Starting in May 2021, primary metrics were obtained on:

  • avoidable admissions
  • key diagnosis related groups entering Maitland Hospital via the emergency department
  • patient and staff experience
  • HITH referral numbers including review of types of referrals.

Key issues

Root cause analysis of the data, in August 2021, indicated the key issues were:

  • lack of clarity regarding the service capability
  • poor awareness of the service among hospital staff
  • lack of medical governance
  • inadequate supporting referral resources.


While medical governance is a key tenet of a HITH service, at the time of the project the Lower Hunter Sector HITH service lacked this resource. This limitation and the unlikelihood of this being resolved during the term of the project had a significant impact on the solutions generated.

The solutions phase, from September 2021 to March 2022, addressed the actionable issues of poor awareness of the service and inadequate supporting referral resources. It is expected that both of these solutions will increase and reinforce hospital staff members’ understanding of the HITH service.

Increasing awareness

The HITH team are increasing awareness of the service by:

  • scheduling daily presence at the emergency department
  • scheduling daily presence at the wards, specifically talking to the team leader or nurse unit manager to pull appropriate referrals, starting with the surgical unit
  • regular attendance to the long stay clinical review meetings.

Referral process

In place of the existing A4 single page referral form, a clinical applications portal (CAP) based electronic form is being developed. This will prompt for required information, depending on the service being requested. It will also pre-fill referrer and patient information and transmit the referral by email (rather than fax) to a service email address.


Implementation – The project is ready for implementation or is currently being implemented, piloted and tested.


  • Start date: March 2021
  • Anticipated completion date: March 2023

Implementation sites

  • Lower Hunter Sector HITH
  • Maitland Hospital – emergency department, inpatient wards, central intake (East Maitland Community Health)


Centre for Healthcare Redesign


The following measures will be taken:

  • Referral numbers – nursing and total numbers
  • Referral method – CAP vs fax
  • Number of call backs – follow up action to obtain and/or clarify referral information
  • Attendance at emergency department and multidisciplinary team meetings
  • Emergency department staff awareness of the HITH (data gathered via online survey and staff rounding)

Lessons learnt

  • Trust the process.
  • Great opportunity to collaborate and expand networks.
  • Change doesn’t happen over night.
  • Follow the diagnostics.
  • You cannot do it alone.
  • Knowing the strengths and weaknesses of your team is crucial.


  1. NSW Ministry of Health. Adult and Paediatric Hospital in the Home Guideline [Internet]. GL2018_020. Sydney: NSW Ministry of Health; 2018 [cited 11 Oct 2022]. Available from: https://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=GL2018_020

Further reading

  • Caplan GA, Sulaiman NS, Mangin DA, et al. A meta-analysis of “hospital in the home”. MJA. 2012 Nov 5;197(9):512-9. DOI: 10.5694/mja12.10480
  • Lasschuit DA, Kuzmich D, Caplan GA. Treatment of cellulitis in Hospital in the Home: a systematic review. OA Dermatology. 2014 Jan 18; 2(1):2.
  • Varney J, Weiland TJ, Jelinek G. Efficacy of hospital in the home services providing care for patients admitted from emergency departments: an integrative review. Int J Evid Based Healthc. 2014 Jun;12(2):128-41. DOI: 10.1097/XEB.0000000000000011


Natasha Parkin
Project lead
Nurse Unit Manager
Hospital in the Home – Lower Hunter Sector
Hunter New England Local Health District
Phone: 02 4931 2000


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