Hospital in the Home: Lessons from implementing an integrated HITH for Aboriginal and Torres Strait Islander people in South-East Queensland

Abstract

Hospital in the Home (HITH) can deliver acute-level care at home with comparable or improved outcomes and higher satisfaction than inpatient care. For Aboriginal and Torres Strait Islander peoples, Indigenous-led HITH models may offer particular benefits by combining quality care with cultural safety and community control. However, little is known about how such models are implemented in practice. We conducted a qualitative study to evaluate the implementation of an Integrated Hospital in the Home (i-HITH) “proof of concept” service co-developed by an Aboriginal and Torres Strait Islander Community Controlled Health Service (ACCHO), a metropolitan public health service, and a Primary Health Network in South-East Queensland. The service aimed to provide General Practitioner (GP)-led, culturally safe acute care at home for Aboriginal and Torres Strait Islander adults via five referral pathways: Emergency Departments (ED), virtual ED, inpatient hospital wards, specialist outpatients, and ACCHO GPs. Data included key program documents and individual research Yarns with clinical, managerial, policy, and evaluation staff across partner organisations. Yarning, an Indigenous research method grounded in cultural protocols and storytelling, supported culturally safe, relational dialogue. Data were analysed using Normalisation Process Theory (NPT) to examine Coherence (Sense-Making Work), Cognitive Participation (Engagement Work), Collective Action (Operational Work), and Reflexive Monitoring (Appraisal Work). Fourteen Yarns articulated a clear, equity-driven vision for i-HITH and viewed it as a culturally appropriate alternative to standard HITH (high coherence), supported by strong early leadership and partnership commitment (cognitive participation). However, only four admissions occurred over the two-year operating period. Key barriers related to collective action and reflexive monitoring and included fragmented hospital–primary care systems; complex GP credentialling processes; non-interoperable clinical and information systems; pharmacy and logistics constraints; and ambiguity in roles and client governance. These factors made enrolling patients into i-HITH more burdensome than standard hospital admission. Despite these challenges, partners reported strengthened relationships, shared learning, and commitment to future model redesign. The i-HITH model was conceptually coherent, culturally aligned, and strongly valued but was undermined by structural fragmentation across funding, digital, and governance systems. Realising the integrated care potential of i-HITH will require structural reform, including joint funding mechanisms, interoperable systems, community-led governance, and institutional architectures that support integrated care delivery.