First Nation Integrated Hospital in the Home (i-HITH)

It is believed that culturally appropriate in-patient level care provided within (or closer to) a client’s home will improve clients’ health outcomes, timeliness of their care, and reduce discharge against medical advice of clients who have previously done so. The overarching objective of the program is to provide clinically and culturally safe, high-quality Hospital in the Home services for suitable clients to improve care outcomes and overall health and wellbeing for First Nations clients within the Metro North Health/Brisbane North catchment.

If successful, it is proposed that this integrated HITH model could be replicated for other priority and/or vulnerable patient populations and in partnership with other primary care providers across Brisbane North.

Project Governance

• The study is governed through the Joint Board Committee of the Health Alliance.
• A Project Steering Committee meets monthly and includes senior representatives from the Health Alliance, IUIH and Metro North Health.
• A Project Working Group meets fortnightly-monthly and comprises of operational representatives from the Health Alliance, Metro North Health and IUIH. The Working Group reports directly to the I-HITH Project Steering Committee and liaises closely with the I-HITH Project Community Reference Group.
• Facility specific working groups have / plan to been established to provide clinical and cultural expertise to inform co-design and to monitor delivery.
• An Integrated Cultural Community consultation group has been established to inform co-design and to monitor delivery. Existing consumer networks and groups will be leveraged to ensure broad representation from Aboriginal and Torres Strait Islander communities.
• An Evaluation Working Group is co-chaired by IUIH and Metro North Health and has representation from Brisbane North Primary Health Network and the Health Alliance and provides oversight and direction of the Evaluation project.

Model details

The I-HITH program for Aboriginal and/ or Torres Strait Islander people in Metro North is an integrated model of care wherein clinical governance remains with the credentialed General Practitioner, IUIH or the secondary care consultant, with delivery of care from the current Metro North Health HITH nursing and allied health teams (Community and Oral Health (COH)). IUIH will be commissioned by the Health Alliance and Brisbane North PHN to partner with Metro North Health to provide the HITH medical care and comprehensive holistic and connected support to eligible patients in their home and/or a community environment. In this model, General Practitioners working for IUIH will be credentialed by Metro North Health to deliver clinical care under an agreed clinical governance model.

The initial focus of the project will be on the General Practitioner initiated referral pathways to COH; the Acute HITH Team or a Rapid Access Medical Clinic. Eligible patients can also access the program via traditional patient pathways to HITH including from a physical presentation to an Emergency Department, from a Specialist Outpatient Department clinic or during an inpatient admission in a Metro North facility.

The advantage of this collaborative care partnership program is the streamlined management of an eligible patient who requires acute, inpatient care - from presentation to a GP in the community, to rapid assessment of a patient’s suitability and consent for delivery of clinically, culturally and holistically connected care via HITH. Integrated cultural support is proposed across the patient journey with early intervention by the Mob Link Care Co-ordinator, in consultation with Metro North Health Indigenous Liaison Officers/ Nurse Navigators in acute facilities and COH.