How I helped transform the use of UCLH’s hospital at home service

Dr Lorita Krasniqi, a doctor in internal medicine training, reflects on her role in implementing the hospital at home service within acute care at University College London Hospital (UCLH). The project was highly commended in the RCP’s virtual poster competition 2025.

When I first became involved in the hospital at home project at UCLH, I became increasingly aware of challenges that will be familiar to many working in acute services: sustained bed pressures, poor patient flow and patients who wanted to go home but could not yet be discharged safely.

Although the hospital at home team was already delivering high-quality care across the trust, on the acute medical unit (AMU) the service was significantly underutilised. Despite reviewing approximately 500 patients each month, only around five were being referred to hospital at home.

As a group of resident doctors working regularly on AMU, this felt like a missed opportunity – both to alleviate pressure on inpatient services and to support patients in receiving care in a setting that many would have preferred – the comfort of their own home.

As a team, we discussed these shared observations with the acute medicine quality improvement (QI) lead, who then put us in touch with the hospital at home service. This marked the beginning of a collaborative improvement project.

I helped bring together a multidisciplinary group including resident doctors and the specialist nursing team leading the hospital at home service, ensuring representation from those directly involved in both acute and community-based care. Over time, operational colleagues, managers and consultants also became key contributors, ensuring that the work was grounded in both clinical practice and service delivery.

To better understand the lower referral rate, we conducted structured interviews with seven acute medicine consultants. These conversations highlighted several recurring barriers: uncertainty around eligibility criteria, concerns about continuity of care, limited awareness of the service and limited feedback once patients left AMU.

The insights that we gained formed the foundation for the improvements we went on to make.

Turning ideas into action

Using the plan–do–study–act (PDSA) methodology, I worked with the multidisciplinary team to design, implement and iteratively refine a series of targeted interventions, each aimed at addressing a specific barrier. These included:

introducing a case-finder role at triage meetings
delivering focused teaching sessions for resident doctors
displaying clear, accessible informational posters across AMU
presenting the service at consultant clinical governance meetings
securing dedicated consultant time to support and champion referrals.

We didn’t rely on one big change; instead, we tested multiple small, meaningful changes each aimed at a different barrier.

What went well

The results exceeded expectations. We increased referrals to hospital at home by over 90%, and AMU became one of the highest-referring departments in the hospital. By the end of 2024, UCLH had become the leading hospital at home service in north central London.

I felt incredibly proud of how much had changed because of our project. What was once an underutilised service has now become a deliberate and routine part of day-to-day decision making on AMU. Helping to embed this shift in thinking across the department has been one of the most rewarding aspects of the project.

I found the consultant interviews especially rewarding. Revisiting perceived barriers later in the project and assessing whether our initial assumptions held true was both instructive and motivating. Regular multidisciplinary meetings created space for reflection, shared learning and forward planning, and reinforced the value of collaborative working.

Challenges and lessons learned

Not every intervention delivered the impact that we had anticipated. When some of the ideas I had proposed were less effective, this was initially disappointing. However, these moments became important learning opportunities, highlighting the need for resilience in improvement work and a focus on collective progress rather than individual initiatives.

We also recognised that introducing multiple interventions within the same time period made it harder to determine which changes were driving specific outcomes. If repeating this work, I would stagger interventions more carefully to allow clearer evaluation.

One of the most important lessons for me as a resident doctor was that quality improvement is rarely predictable and what matters is continuously assessing progress with a willingness to adapt. Ultimately, all of this is about improving patient care, and keeping that at the centre makes the work far more meaningful.

Looking ahead

The success of this work has opened fantastic opportunities. We are already expanding pathways with the haematology and heart failure teams. The trust has increased bed capacity and appointed a dedicated consultant and pharmacist for the hospital at home service.

One thing I am particularly keen to do next is formally interview patients and their families. Their experiences should shape how this service continues to grow.

This project reinforced for me the power of multidisciplinary collaboration. By identifying barriers, making iterative changes and embedding patient-centred thinking into everyday practice, we transformed how hospital at home is used within acute medicine and contributed to meaningful, trust-wide improvement.

Most importantly, more patients are now receiving the right care, at the right time, in the place they most want to be – at home.

In April 2025, the RCP published a report setting out a vision for outpatient reform that would bring care out of hospitals and into the community, closer to home. It emphasises the need for timely care for patients, delivered by the right person and in the right setting. Read the full report: Prescription for outpatients: reimagining planned specialist care.

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Dr Lorita Krasniqi

Highly commended - Quality improvement and patient safety/audit