Hospital at Home in Scotland evaluation: phase 1 findings report

Appendix A - Hospital at Home Logic Model ^[22]

A logic model for Hospital at Home (H@H) was developed by social researchers within the Scottish Government to demonstrate how H@H is expected to work and outline what the programme is trying to achieve (Figure 6). It was recognised by the research team that to produce the logic model engagement with relevant policy colleagues and external stakeholders was required. To begin the process an example H@H logic model was drafted by the social research team prior to the initial workshops held with Scottish Government colleagues. Feedback from the initial workshops allowed the logic model to be updated for the subsequent workshops with external stakeholders and a small number of Scottish Government colleagues who did not take part in the initial workshops.

Feedback from these workshops allowed the research team to further review and refine the logic model. The opportunity to provide written feedback was also provided. Following this, additional feedback was sought from a Hospital at Home Data and Intelligence Workgroup and the Hospital at Home Programme Board. Comments from these groups and subsequent review by the social researchers overseeing the logic model led to the current version.

The logic model is divided into sections - situation, inputs, activities, outputs and outcomes. Inputs and activities have been organised under the relevant national organisation (e.g. Scottish Government) or at local/service level. The outcomes have been organised under three overarching objectives and split into short and medium/long term respectively^[23]. Links between sections of the model have been proposed (e.g. between specific inputs and activities) based primarily on the social researchers’ local knowledge of the programme. A helpful next step would be to review published evidence to identify which linkages have strong or no empirical support to guide future research and to allow the logic model to be updated accordingly. Assumptions deemed essential for H@H to operate, external factors, examples of unintended consequences and other programmes/policies which may contribute to changes in outcomes are also included within the logic model.

To view the graphic in full, please refer to the PDF document.

Text only description of the Hospital at Home Logic Model at May 2026

Situation

The health system is under significant pressure with high length of stay and occupancy in acute settings. Significant challenges also include delayed discharges and front door pressures (e.g. 4- and 12-hour performance). Hospital over occupancy highlights the need to shift the balance of care to the community avoiding hospital stays, where possible, and improving patient outcomes. This shifting of the balance of care is one of the commitment’s included within NHS reform, and it is recognised that Hospital at Home (H@H) sits within this.

Furthermore, the availability of existing H@H services is poorly understood but is known to be variable regionally and lack standardisation. It is also recognised that some pathways are more established than others. For instance, the Acute/Older adult, OPAT and Respiratory services are reasonably well established in many boards. Heart Failure and Paediatrics and Neonatal are in the early stages. The more established pathways could provide helpful learnings for the expansion of H@H with the commitment made to expand the capacity of H@H to at least 2,000 beds by December 2026. Given the significant expansion planned for H@H, there is an increased need for data and learning on implementation, delivery and the impact of H@H.

Inputs

Inputs from the Scottish Government include:

• Funding and allocation
• National Governance
• Promotion strategy
• National H@H strategic direction
• Commission for HIS to support boards to develop and expand H@H services
• Commission for PHS to develop national level data collection
• SG policy and analytical team(s)

Inputs from Public Health Scotland include:

• National H@H definition for data collection and reporting
• National data collection mechanism

Inputs from Healthcare Improvement Scotland include:

• Training and implementation guidance
• Evidence-based guiding principles
• National learning system

Inputs from local/service level include:

• Workforce
• Equipment and medical supplies
• Clinical space to deliver care, where required
• Dedicated team base
• Working relationships with health and social care services, third sector organisations and private care providers, where appropriate
• Health Board and Integrated Joint Board governance and buy in
• Clinical specialty buy in
• Clear referral criteria and pathways
• Local improvement plans
• Transport arrangements, where required
• Career framework
• Standard operating procedures and policies
• IT and digital infrastructure
• Processes in place to supply H@H teams with equipment and other resources

Activities

Activities undertaken by the Scottish Government include:

• National Promotion
• Ongoing review to utilise new and emerging technology
• National monitoring and evaluation
• Supporting integration and collaboration between [and within] health boards and health and social care partnerships

Activities undertaken by Public Health Scotland include:

• National level data collection and reporting

Activities undertaken by the Healthcare Improvement Scotland include:

• Manage and promote a range of learning system activities
• Provide improvement and implementation support to H@H services
• Support H@H services to enable them to collect local data to evidence impact

Activities undertaken at local/service level include:

• Provision of acute clinical care face-to-face and with support from technology
• Shared decision making with patient and family/carers
• Provision of patient and family/carer education
• Collaboration and communication across health and social care services, third sector organisations and private care providers, where required
• Emergency OOH management set up for patient, where required
• Arrange ongoing referral and/or discharge
• Receive and review referrals
• H@H services recruit and train appropriate staff and provision of continuous professional development and learning for existing staff
• Local level data collection
• Local level promotion
• Engagement with referral pathway teams
• Development of new H@H service(s)
• Expansion of existing H@H service(s) capacity and availability
• Optimising existing H@H services
• Contribute to national level data collection
• Procurement of additional medical equipment

Outputs

• Increased number of H@H equivalent beds
• Increased number of referrals into H@H
• Increased number of accepted referrals into H@H
• Greater geographical spread of H@H service availability
• General population are more aware of H@H
• Co-ordinated continuity of care upon discharge, as needed
• Improved knowledge about condition and skills for self-care for patients and families/carers
• Staff across the health system have a better understanding and awareness of H@H and the referral process
• Increased number of H@H staff
• H@H teams feel sufficiently staffed to deliver H@H
• H@H teams feel sufficiently equipped (e.g. medical equipment) to deliver H@H
• Increased availability and take up of continuous professional development
• H@H services available for a greater number of hours per week
• Data for measurement and monitoring of H@H

Overarching objectives

• Improved clinical outcomes and care experience for patients [and families/carers]
• Reduced pressure on hospital and the wider system through improved flow for patients
• Improved workforce satisfaction and retention

Short-term outcomes

The short-term outcomes under the improved clinical outcomes and care experience for patients [and families/carers] overarching objective are:

• Positive patient experience with H@H service
• Positive family/carer experience with H@H service
• Patients receive high quality and safe care
• Reduced occurrence of outcomes that can occur in hospital (e.g. deconditioning, delirium, hospital acquired infections, falls, pressure ulcers etc.)
• No increase in H@H unexpected mortality

The short-term outcomes under the reduced pressure on hospital and the wider system through improved flow for patients overarching objective are:

• Contribute to reduced hospital occupancy
• Reduced length of stay in hospital for H@H patients referred via Early Supported Discharge

The short-term outcome under the improved workforce satisfaction and retention objective is:

• Staff knowledge and skills for H@H enhanced

Medium/Long-term outcomes

The medium/long-term outcomes under improved clinical outcomes and care experience for patients [and families/carers] overarching objective are:

• Greater equity of access to H@H
• Increased acceptance in the general population about receiving care at/closer to home

A number of medium/long-term outcomes were viewed to overlap both the improved clinical outcomes and care experience for patients [and families/carers] and reduced pressure on hospital and the wider system through improved flow for patients overarching objectives. These are:

• Contribute to increase in support packages being retained
• Contribute to reduction in provision of support care packages in the long term
• Contribute to fewer new care home admissions in the long term
• Low rate of re-admissions for patients receiving H@H

The medium/long-term outcomes under the reduced pressure on hospital and the wider system through improved flow for patients overarching objective are:

• Contribute to reduction in delayed discharge
• Contribute to improvement in A&E performance

The medium/long-term outcomes under the improved workforce satisfaction and retention objective are:

• Contribute to improved staff satisfaction – acute and H@H
• Reduced use of bank/agency staff in H@H services
• Contribute to improved staff retention – acute and H@H

Assumptions

• Patients are happy to be managed via the H@H service
• That there will be recurrent funding for H@H services
• Service capacity flexible to meet demands
• H@H can be delivered in various settings
• Sufficient resources for continuous delivery of the H@H service

External factors

• Public commitment made via the budget process
• Political elections
• A pandemic
• Local funding decisions
• Demographic change

Examples of unintended consequences

• Inferior patient health or experience outcomes
• Having care provided in the home may have negative consequences on carers (e.g. lack of respite)
• H@H putting more pressure on care services to fill gaps that patients receive in hospitals
• H@H may result in capacity pressures in the acute workforce (e.g. nursing staff from acute sites moving to a H@H role)

Links to other programmes/policies

• Value Based Health and Care Action Plan
• Frailty at the Front Door
• Discharge without Delay