Evaluating Hospital at Home: Acuity, Complexity, and Health Inequalities in Community Care for People Living with Frailty

Introduction

Hampshire and Isle of Wight Healthcare NHS Foundation Trust (HIOW) delivers a Hospital at Home (H@H) service providing acute care to patients with complex needs within the community. While physiological acuity is routinely assessed using tools such as NEWS2, these measures do not fully capture the objective complexity, dependency, and resource requirements of the H@H population.

Robust assessment of acuity and complexity—and their translation into workforce planning—is essential to ensure safe, effective, and equitable care. This evaluation aimed to explore how acuity and complexity are currently measured and how these inform staffing models for patients with variable degrees of complexity.

Methods

A mixed-methods service evaluation was undertaken using an anonymous Qualtrics survey distributed to staff across HIOW H@H services. Quantitative data were analysed descriptively, and qualitative free-text responses were analysed thematically to identify key patterns and examples of best practice.

Results

Ninety-nine responses were received, including 25 managers. Only 44% (n=11) of managers reported routinely adjusting staffing based on caseload complexity. Acuity was most commonly assessed using tools such as NEWS2, while complexity was primarily determined through clinical judgement.

Key determinants of complexity included multimorbidity, falls risk, welfare concerns, and unmet care needs. Three themes were identified: (1) assessment of acuity and complexity, (2) patient and caregiver communication, and (3) coordination across services.

Conclusion

There is marked variation in how complexity is defined and used operationally, with limited translation into workforce planning. Developing standardised approaches that integrate clinical and social determinants could support more responsive workforce models and improve equity, enabling H@H services to safely manage increasingly complex caseloads and reduce reliance on hospital care.