Hospital at Home - Ministerial Decision No.28804/2023

On 19th May 2023, Ministerial Decision No.28804 (Government Gazette B' no.3396/19.05.2023, hereinafter referred to as the "Hospital at Home MD") on the regulation of specific issues for the organisation and operation of Hospital Homecare (hereinafter referred to as the "Hospital at Home") was issued. The Hospital at Home programmes are expected to have numerous and significant benefits for the patient, the Hospital at Home Reference Centre, as well as the National Health System (ESY, per its Greek initials), as the services are provided to the patient safely and respectfully, at lower costs, decongesting existing structures, improving the quality of hospital health services and reducing the risk of in-hospital infections that often lead to complications, ongoing hospitalisations and ultimately place a significant burden on the health system.

According to reports, eight (8) hospitals in the country will join this programme within 2023. The first to initiate such programme will be the Oncology Hospital "Agios Savvas", which is already implementing the innovative pilot program "OIKOTHEN", designed with the contribution of EY Greece teams.

While the option of organizing and operating such programmes had already been provided for since last May (by article 50 of Law 4931/2022, amending article 28 of Law 2071/1992), the regulation of various more specific issues that would enable the implementation of Hospital at Home programmes was pending. The Hospital at Home MD concerns the definition of the terms and conditions for the establishment of a system of hospital care at home by hospital units - Reference Centres of ESY for children and adults with serious complex health problems and/or chronic diseases, which either require frequent hospitalisation or long-term hospitalisation.

What is defined as “Hospital at Home”?

According to the Hospital at Home MD, "hospital care at home" (the internationally accepted term is “Hospital at Home”) is the provision of health services to the patient at home, in conditions similar to inpatient hospital care, medical support and continuous monitoring, with parallel support from trained caregivers (parents and other family members who have been trained in the needs of their patient) while also providing for medical intervention and care when the patient needs it. At the same time, the possibility of immediate access and admission to the Reference Centre or an interconnected designated facility is ensured
in the event of a deterioration in the patient's condition.

Which institutions can provide Hospital at Home services and how are the related costs covered?

Article 1 of the Hospital at Home MD stipulates that such services are provided by interdisciplinary teams, with a capacity to supervise 100-120 patients per year, linked to One-Day Hospital Clinics and to inpatient beds of the Reference Centre, namely a clinic or department of a public (ESY) hospital, or clinics linked to the Centre.
The designation and coordination of the system comprising the Hospital at Home Reference Centre and the interconnected hospital facilities is the responsibility of the respective Health District (YPE, per its Greek initials). The Hospital at Home costs shall be borne by the budget of the hospital to which the Hospital at Home Reference Centre belongs.

Which patients are able to join Hospital at Home programmes?

Patients hospitalised in departments and clinics that are either designated as Hospital at Home Reference Centres or are linked to them, and who meet certain criteria, can continue their hospitalisation at home, provided that conditions similar to those of hospital care are guaranteed. For the purposes of the provision of services in the context of the Hospital at Home, the patient's home shall be equated with the hospital environment.

In particular, in accordance with Article 2 of the Hospital at Home MD, this Decision concerns:

• patients, children and adults, with a different underlying major disease (chronic obstructive or restrictive respiratory diseases, neurological diseases of rapid or slow progression such as motor neurone disease, myasthenia, cystic fibrosis, chronic heart failure and other chronic diseases) and oncological patients requiring specialised long-term care; and 
• cancer patients for the conditional provision of oncological home treatment.

The criteria for a patient's inclusion in a Hospital at Home programme are based mainly on the complexity and chronicity of the disease, as well as the need for technology-specific support, while said criteria vary according to the patients’ characteristics. The patient's health history, compliance and response to treatment determine the intensity and duration of care according to the assessments of the Hospital at Home team (Article 3(1) of the Hospital at Home MD). As regards specific categories of patients, such as paediatric patients, adult chronically ill patients and oncological patients who require home care or can be treated at home, the MD provides for specific inclusion criteria.

What are the general conditions for the safe operation and implementation of the Hospital at Home programme?

• The Hospital at Home Reference Centre shall ensure the continuous medical support and monitoring of the patient participating in the programme and ensure its capacity for the immediate access and admission of the patient to the hospital at any time this becomes necessary.
• The patient's home environment is suitable for the provision of Hospital at Home services. This suitability is checked and certified by the Hospital at Home team before the final selection of the patient.
• The patient meets the criteria for inclusion in the Hospital at Home programme, which is certified by the attending physician and confirmed by the Hospital at Home team. A consent form for participation in the Hospital at Home programme is then signed by the patient (or his/her legal guardians in the case of a minor patient).
• Specifically for oncology treatment at home, this concerns patients who will have received the first cycles of chemotherapy within the hospital structure (One-Day Clinic), as well as the first three cycles of immunotherapy or biological agent.

How is the safety and quality of medicines and equipment monitored during transport from the Hospital at Home Reference Centre to the patient's home?

According to the provisions of Article 5 of the Hospital at Home MD, the responsibility of compliance with all rules regarding the safety of transport and the quality of medicines and other medical equipment during the course of the Hospital at Home programme falls upon the attending physician in cooperation with the physician and the nurse who offer health services in the patient’s home. In addition, the Hospital at Home nurse is responsible for supervising the collection and management of the waste in accordance with the relevant protocol of the hospital's Infection Department.

How is the ongoing health monitoring of the Hospital at Home patient ensured?

Through successive communications and contacts with the Hospital at Home team as often as is necessary depending on the severity and needs of the patient, and according to the follow-up protocol. The patient is required to follow the treatment and to keep the Hospital at Home team informed of his/her health progress by any appropriate means, such as the use of telemedicine/telehealth technologies and wearable monitoring devices (wearables).

What applies to the transport and supply of drugs and other medicines by Hospital at Home doctors and other health professionals?

Article 52 of Law 4931/2022 already provided for the possibility for doctors and other health professionals working in Hospital at Home programmes to transport and dispose of narcotic drugs in the homes of patients who have been admitted to said programmes. The Hospital at Home MD specifically provides that the Hospital at Home physician is responsible for transporting the drugs, while the pharmacy of the hospital where the Hospital at Home Reference Centre belongs is responsible for delivering the drugs to be transported as well as for receiving the returned drug residues. As mentioned above, given that it is stipulated in the MD that the patient's home is equated with the hospital environment, it is entirely legal and possible to transport and dispense drugs that are licensed and labeled as "FOR HOSPITAL USE ONLY" to the home of a patient participating in a Hospital at Home programme. 

In particular, oncological medicines will be dispensed at the pharmacy of the hospital-Reference Centre, and will each be placed separately in a special refrigerator in the Hospital at Home car, in order to ensure both the safety and quality of the medicine and that, in the event of damage to the refrigerator, it will not be necessary to dispose of all the treatments of the day.