Facilitators and barriers to provision of hospital in the home: does geographical location matter? A scoping review

Abstract

Background

There is an increasing imperative for hospital services delivered in the home due to overburdened hospital systems, ageing populations and rising prevalence of chronic disease. Hospital in the home services have numerous advantages including reduced mortality, reduced hospital readmission and emergency department presentations and improved patient quality of life. Despite anticipated benefits for rural communities, which typically experience high prevalence of chronic disease and high rates of potentially avoidable hospitalisation, there appears to be limited research that focusses specifically on the provision of hospital in the home care in rural areas.

Methods

The aim of this scoping review was to identify facilitators and barriers to the provision of hospital in the home services in rural areas. A scoping review of literature published in English between 1990 and 2023 was conducted using Medline and EMBASE. A key term search strategy was employed using ‘hospital in the home’ and ‘rural’ plus equivalent search terms. Inclusion criteria primarily focused on articles that described acute, in-patient bed substitution for adult patients.

Results

Thirty-five articles met the inclusion criteria. These articles were diverse in terms of methodology, models of care, patient populations and country of origin. Many facilitators and barriers to the provision of hospital in the home were not necessarily specific to rural contexts, for example, workflows and patient selection. Rural specific facilitators included rurally tailored models of care, and rural community strengths such as resourcefulness, social capital and reciprocity. Conversely, rural specific barriers included travel distances and associated costs, complicated by challenging weather conditions or terrain.

Conclusion

Whilst the evidence base for provision of hospital in the home care in rural areas was limited, consideration of the facilitators and barriers identified in this review should assist with the provision of hospital in the home services in rural areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-12935-y.

Background

Overburdened hospital systems, ageing populations and the rising prevalence of chronic disease are contributing to policy imperatives for the provision of acute hospital services in the home [1, 2]. At present, fewer than 4% of acute admissions are provided in the home [3, 4] in Australia. In contrast, a recent report estimated that up to 30% of hospital admissions in the United States would be suitable to be provided in the home [5, 6]. Another recent report by Klynveld Peat Marwick Goerdeler (KPMG) estimated economic benefits to the health system of up to AUD$1 billion would accrue by 2030 through shifting to home-based hospital care, particularly if the current scope of care was expanded [7]. Indeed, Hospital in the Home in Australia has already yielded economic benefits by reducing the need to build new hospitals [3, 8]. Hospital in the Home services can be suitable for patients with a diverse range of health conditions and for the delivery of a broad range of therapies, but older patients with chronic health conditions tend to be the highest users of these services, and may be the group who stand to benefit the most [9]. Research suggests that there are numerous advantages to provision of Hospital in the Home services including reduced mortality, reduced hospital readmission, increased caregiver satisfaction, reduced or earlier presentation to emergency departments, improved patient quality of life and enhanced continuity of care [10]. However, hospital services provided in the home can face challenges including difficult working conditions for staff, difficulty during transitions of care, sustainability issues, unclear access pathways and risk of patient and carer isolation. In rural areas, where communities tend to have older age structures and higher prevalence of chronic disease, hospital in the home services may offer advantages. Provision of home-based services could also assist small rural health services to reduce expenses, reduce transfers to larger institutions and improve clinical outcomes, all whilst enabling patients to remain in their home communities [11]. However, provision of hospital in the home services in rural areas may be hampered by workforce shortages, extended travel distances and connectivity issues [12], although research about these barriers appears limited at present [13, 14]. The aim of this review was to identify facilitators and barriers to the provision of hospital in the home services in rural areas.

Methods

A systematic scoping review was conducted following the five-stages recommended by Arksey and O’Malley [15], that is (i) identify the research question, (ii) identify relevant studies, (iii) select studies for inclusion, (iv) chart the data, and (v) summarise and collate the results. Prior to identifying relevant studies, the protocol for this review was registered with Open Science Framework [16]. The results of this review are reported here as per the PRISMA Extension for Scoping Review checklist (see Appendix 1) [17].

Eligibility criteria

The Population/Concept/Context Framework was used to inform the development of the inclusion and exclusion criteria [18]. For this review, ‘hospital in the home’ was the concept of interest, while the context and population of interest were services delivered in rural areas (herein used to encompass regional, rural and remote areas) to appropriate patient populations. There is no single, universally accepted definition of hospital in the home. The terminology related to ‘Hospital In The Home’ (HITH) varies internationally and includes ‘Hospital at Home’ (HAH) and ‘Home Hospital’ [19]. These variances likely reflect the complexity and diversity of the delivery of home based services across different health systems. For the purpose of this review, the term ‘hospital in the home (HITH)’ was used, and followed the World Hospital at Home Congress consensus statement definition [20]:

“[HITH/HAH] is an acute clinical service that takes staff, equipment, technologies, medication and skills usually provided in hospitals and delivers that hospital care to selected people in their homes or in nursing homes. It substitutes for acute inpatient hospital care. Its goal is to improve the lives of sick people who need hospitals, by changing the culture of hospitals to deliver hospital-level care at home” [20]

The above definition was selected to include all services internationally that provide acute, in-patient bed substitution care within the home environment.

Based on the population/concept/context for the review, the inclusion criteria were articles published between 1990 and June 2023, human studies, adult population, English language, acute health service, in-patient bed substitution, rural context, or rural specific data able to be identified. Exclusion criteria: maternity, pediatric, district nursing, residential aged care, home care and other non-health services provided at home (meals, gardening etc.), transitional care, primary care home visits. Maternity, paediatric, residential aged care and district nursing services were excluded due to distinct differences in modes of delivery and predominance of older patients with complex, chronic disease in hospital in the home services. Home care services were excluded, if they were not provided by health professionals and were not acute, in-patient bed substitutions. We did not exclude articles based on country of origin because, prior to embarking on the search, we formed the consensus that there were important learnings despite differences in health systems and their locations. In accordance with scoping review requirements, and to avoid favoring certain types of studies, a quality appraisal was not conducted.

Search strategy

The literature search was conducted in June 2023 in Medline (OVID) and Embase, using the search terms outlined in Appendix 2. A simplified title and abstract search was repeated in Medline in April 2025 (“rural” AND “hospital in the home” OR “hospital at home”, limited to English language and adult populations to identify relevant articles published since June 2023. Five articles were identified by this search; one did not relate to home-based hospital services, three did not include rural data and one article was a review that briefly discussed that ‘HaH programs could [also] play a pivotal role in bridging healthcare disparities observed in rural areas’ [21].

Screening, selection, and data extraction

Results for the literature searches were uploaded to Covidence (https://www.covidence.org/). Prior to screening the abstracts, a validation exercise involving the same, randomly selected twenty abstracts and multiple inclusion/exclusion criteria was undertaken by independent reviewers. Before the full text screening, a second validation exercise involving five randomly selected full text articles and multiple inclusion/exclusion criteria was also undertaken by independent reviewers. Each abstract and full text article was screened by two reviewers, with six reviewers undertaking abstract screening and seven reviewers undertaking full text screening. Two reviewers extracted data from each of the included articles, namely authors, study methodology, sample size, country, rurality information, context, aims, objectives, patient population, outcome metrics and source of data (patient, carer, health professional, clinical file data etc.). Reviewers extracted data related to facilitators/barriers regarding hospital in the home. These barriers and facilitators were then discussed and refined into groups by the reviewer team. In total, six reviewers undertook the data extraction. A quality assessment was not conducted due to the mix of literature types included in this scoping review.

Results

The abstract screening validation exercise resulted in 84% agreement (8 reviewers). The full text validation exercise resulted in 100% agreement (3 reviewers). Thirty-five (35) papers met inclusion criteria after the title, abstract and full text review (see Fig. 1).

Fig. 1.

Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) diagram of scoping review

The articles included in the review originated in Australia (n = 5), Canada (n = 6), the United States of America (n = 12), Japan (n = 3), South Africa (n = 1), Spain (n = 3), New Zealand (n = 1), Sub-Saharan Africa (n = 1), France (n = 1) and Sweden (n = 1) (Fig. 2). They were diverse in terms of methodology and included quantitative studies (n = 9), qualitative studies (n = 11), mixed methods studies (n = 6), commentary or opinion pieces (n = 6), reviews (n = 2) and case studies(n = 1). Patient populations were also diverse, and included hospice/palliative care (n = 14), perioperative care (n = 1), general patient populations (adults (n = 10), acute care (n = 1), chronic disease (n = 1), elderly patients (n = 3)), patients with specific health conditions (cancer (n = 4), including multiple myeloma, heart failure (n = 3)) or requiring specific therapies (peripheral intravenous catheters (n = 1)) (Table 1). The range of data reflected the perspectives of patients, carers, health professionals, policy advisors/health system representatives or was extracted from clinical files (Table 1).

Fig. 2.

Map of included studies

Table 1.

Data extraction

Title	First author	Year	Country	Methodology	Sample size	Patient population	Data source (Patient, carer or health professional perspective, clinical file etc.)
Perioperative services reach into community.	Anonymous [22]	1996	USA	Commentary/opinion	NA	Perioperative	Patient, health professional
Triangulation analysis of tele-palliative care implementation in a rural community area in Japan.	Aoki [23]	2006	Japan	Mixed methods	2	Palliative, cancer	Patient, policy advisor/health system
The five A’s of rural home care.	Bosch [24]	1997	USA	Commentary/opinion	NA	Rural home care patients	Patient, health professional, community, policy advisor/health system
“Making it”: qualities needed for rural home care nursing.	Boucher [25]	2005	USA	Qualitative	12	Rural home care patients	Health professional
A world apart. The challenges and rewards of rural hospice.	Braveman [26]	2004	USA	Commentary/opinion	NA	Hospice	Health professional
Experiences of nurses practising home-based palliative care in a rural South African setting.	Campbell [27]	2011	South Africa	Qualitative	4	Palliative	Health professional
Implementing a home telemonitoring program.	Canady [28]	2008	USA	Commentary/opinion	NA	Rural home care patients	Patient, health professional, policy advisor/health system
“It’s not necessarily the distance on the map…”: using place as an analytic tool to elucidate geographic issues central to rural palliative care.	Castleden [29]	2010	Canada	Qualitative	31	Palliative	Patient, health professional, community, policy advisor/health system, carer
An application of the Hospital-in-the-Home unlearning context.	Cegarra-Navarro [30]	2010	Spain	Qualitative	9	Regional home care patients	Health professional
Improving quality of service of home healthcare units with health information technologies.	Cegarra-Navarro [31]	2011	Spain	Mixed methods	252	Regional home care patients	Patient
Overcoming counter-knowledge through telemedicine communication technologies.	Cegarra-Sanchez [32]	2017	Spain	Mixed methods	252	Regional home care patients	Patient
Hospital-Level Care at Home for Acutely Ill Adults in Rural Settings: Proof of Concept	Desai [33]	2024	USA	Qualitative	3	Acute care patients	Patient
Palliative care costs in Canadian rural areas, a descriptive comparison of studies of urban and rural patients near end of life.	Dumont [34]	2015	Canada	Quantitative	416 (80 rural patients, 84 rural informal caregivers, 125 urban patients, 127 urban informal caregivers)	Palliative	Patient, carer
Is there a doctor in the house? Integrating medical education and home health care.	Engelke [35]	1998	USA	Commentary/opinion	NA	Rural home care patients	Patient, health professional, curriculum developers
The challenge of providing palliative care to a rural population with cardiovascular disease.	Fernando [36]	2014	New Zealand	Review (literature, scoping, systematic etc.)	NA	Palliative patients with cardiovascular disease (heart failure).	Patient, health professional, policy advisor/health system
Current state of palliative and end-of-life care in home versus inpatient facilities and urban versus rural settings in Africa.	Jang [37]	2013	Sub-Saharan Africa (mainly Uganda, South Africa)	Review (literature, scoping, systematic etc.)	NA	Palliative care	Health professional, policy advisor/health system
Resource utilization and cost analyses of home-based palliative care service provision: the Niagara West End-of-Life Shared-Care Project.	Klinger [38]	2013	Canada	Quantitative	95	Palliative	Policy advisor/health system
Scoping and testing rural acute care at home: a simulation analysis.	Levine [39]	2021	USA	Quantitative	2 simulated patients, feedback from patients, clinicians and carers.	Chronic illness with acute exacerbation	Patient, health professional, carer
Implementation of in-home telemedicine in rural Kansas: answering an elderly patient’s needs.	Lindberg [40]	1997	USA	Qualitative	38	Elderly or disabled patients	Patient
‘I don’t want to be in that big city; this is my country here’: research findings on Aboriginal peoples’ preference to die at home.	McGrath [41]	2007	Australia	Qualitative	72	Palliative care	Patient, health professional, carer, interpreter
Oncology hospital at home in rural communities: The Huntsman at Home rural experience	Mooney [42]	2022	USA	Qualitative	47	Cancer patients	Patient, health professional, policy advisor/health system
Palliative home care in a rural setting: reflections on selective interactions	Morgan [43]	1997	Australia	Qualitative	Not stated	Palliative	Patient, health professional, carer
Wiisokotaatiwin: development and evaluation of a community-based palliative care program in Naotkamegwanning First Nation.	Nadin [44]	2018	Canada	Mixed methods	2 client/family, 22 healthcare providers plus focus group of leadership.	Palliative	Patient, health professional, carer
Challenges and solutions in the continuity of home care for rural older people: A thematic analysis.	Ohta [45]	2020	Japan	Qualitative	4 focus groups (109 participants), 12 individual interviews	People aged 50 + years	Potential home care patients and their families
Implementation of a virtual and in-person hybrid hospital-at-home model in two geographically separate regions utilizing a single command center: a descriptive cohort study.	Paulson [5]	2023	USA	Quantitative	686 (408 urban patients and 278 rural patients)	Adult patients	Health professional, policy advisor/health system
Feasibility of using an in-home video conferencing system in geriatric rehabilitation.	Peel [46]	2011	Australia	Mixed methods	44 listed in logs, 10 eligible	Aged clients	Patient, health professional, carer
Implementing the first regional hospice palliative care program in Ontario: the Champlain region as a case study.	Pereira [47]	2016	Canada	Case study	320 individuals involved in community consultation.	Palliative care	Patient, health professional, carer, community, policy advisor/health system
Satisfaction With Access To Health Services In West Virginia Despite Covid-19	Petitte [48]	2022	USA	Quantitative	13	Palliative patients with heart failure	Patient, carer
Rural palliative care to support dying at home can be realised; experiences of family members and nurses with a new model of care.	Spelten [49]	2019	Australia	Mixed methods	10 family members and 4 nurses.	Palliative patients with cancer	Health professional, carer
Clinical pathways can improve the quality of pain management in home palliative care in remote locations: retrospective study on Kozu Island, Japan.	Tateno [50]	2012	Japan	Quantitative	24	Palliative	Patient, health professional
Health cost modelisation of home versus hospital administration of bortezomib. Experience of a French hematologic care network	Touati [51]	2012	France	Quantitative	54	Multiple myeloma	Cost
Routine replacement versus clinical monitoring of peripheral intravenous catheters in a regional hospital in the home program: A randomized controlled trial.	VanDonk [52]	2009	Australia	Quantitative	316	Patients requiring peripheral intravenous catheter	Patient
Rural home care: social work intervention in social isolation and safety concerns.	White [53]	1997	USA	Commentary/opinion	NA	Rural home care patients	Patient, health professional
Reducing risks in complex care transitions in rural areas: a grounded theory.	Winqvist [54]	2023	Sweden	Qualitative	21	Rural patients in transition from hospital to home care	Health professional
Occupational hazards for home care nurses across the rural-to-urban gradient in Ontario, Canada.	Wong [55]	2017	Canada	Quantitative	823	Nurses	Health professional

Facilitators and barriers to the provision of HITH were extracted from the included articles. These were grouped into home environment and patient factors, health system factors (either associated with information and communication technology or otherwise), health professional factors and rural context factors (Table 2). Patient selection was an important consideration for the successful provision of HITH services [25, 28, 29, 31, 35, 39, 42, 45, 46, 49, 53]. Patients were reported to need adequate health literacy, physical ability and cognitive capacity to be suitable for HITH services. A capable carer was another important factor in the provision of home-based care [23, 37, 46, 49]. Unsafe home environments [46, 53, 55], poverty or food insecurity [25, 42] were less conducive to effective home-based care. In contrast, appropriate home environments enabled care to be provided in familiar, comforting spaces [23, 27, 29, 33, 41] and by informal support networks.

Table 2.

Facilitators and barriers to provision of hospital in the home in rural areas

	Facilitators	Barriers
Home environment and patient factors	Patient’s health literacy, suitability for home based care [25, 28, 29, 31, 35, 39, 42, 45, 46, 49, 53] Capable and supported carer at home [23, 37, 46, 49] Familiar spaces and informal support* [23, 27, 29, 33, 41]	Patient’s cognitive decline or physical disability [45, 46, 49, 53] Patient’s reduced social interaction* [25, 40, 53] Poverty, food insecurity [25, 42] Unsafe home environments [46, 53, 55] Lack of anonymity or confidentiality for patients [25]
Health system factors (non-ICT)	Effective communication, collaboration between all parties, relationship equity [43], stakeholder buy-in Robust, clear workflows, policies and procedures [28, 30, 33, 36, 39, 50, 54] Care coordination/care plans, holistic & individualised care [36–38, 43, 48, 54] Sustained funding, adequate reimbursement and adequate time [35, 44] Consideration of differences in delivering care in home environment vs. hospital [23, 35, 46]	Concerns re. medical liability [35] Urban centric policies [24, 29] Sub-optimal policy/procedure/protocols [39, 47], time consuming data collection [50] Lack of diagnostic testing [33, 35] Inadequate resourcing or time [24, 37, 43] Medication supply/administration issues [37, 46]
Health system factors (ICT)	Effective technology (e.g. user friendly and reliable technology, technology to monitor patient’s health, technology to connect patients with health professionals) [28, 30, 32–36, 39, 40, 43, 49]	Ineffective technology (e.g. poor integration of technology in workflows, too many different systems or pieces of equipment to learn) [40, 46]
Health professional factors	Flexible, adaptable delivery, creativity, innovation [22, 25, 26, 43, 47, 49, 53], tolerance of uncertainty [25] Health professional competencies [25, 35], humour [22, 27, 28, 43] Ability to unlearn, willingness to learn [30] Feeling of personal reward* [26]	Workforce shortages/staff turnover [37, 39, 46] Staff isolation [27] Cost of education for health professionals/lack of training/knowledge [32, 46] Infectious disease risk [27] Emotional toll [49]
Rural context factors	Rural tailored models of care [29, 31, 34, 43] Social capital & networks, community development [24, 32, 45] Culturally responsive care [27] Rural reciprocity, resourcefulness [43] Volunteerism [26, 29]	Poor internet, telephone or electricity connections [35, 39] Distance, cost of travel [25, 29, 35, 39, 43, 54] Difficult weather conditions, terrain [25, 29, 55] Lack of culturally responsive care [41] Sub-optimal community or family capacity [45]

*Could be considered a consequence or outcome, rather than a factor associated with the provision of HITH

A number of health system factors were reported to be integral to the provision of HITH services. Strong, equitable [43]relationships [43] between stakeholders were important [28, 47], along with effective communication [23, 42, 45, 54] and collaboration [33, 42, 45, 49, 54]. Robust and clear workflows, policies and procedures [28, 30, 33, 36, 39, 50, 54] were crucial to the effective provision of HITH services, along with adequate and sustainable [35, 44] resourcing. Information and Communication Technology that was integrated, user-friendly and reliable [28, 30, 32–36, 39, 40, 43, 49] could be used for patient monitoring, effective communication between health professionals and patients, or to avoid unnecessary travel. Individualised care, care plans and care coordination were reported facilitators for provision of HITH services [36–38, 43, 48, 54]. Concerns about medical liability [35] and the optimal provision of medication [37, 46] and diagnostic testing [33, 35] in home-based environments were raised.

Health professional factors identified included personal attributes (sense of humour [22, 27, 28, 43], ability to be creative, innovative, flexible and adaptable [22, 25, 26, 43, 47, 49, 53], being able to tolerate a level of uncertainty [25], willingness to learn and unlearn [25, 30]) and professional competencies [25, 35]). HITH services were challenged by health workforce shortages, staff isolation and staff turnover [25, 26, 37, 39, 40, 43, 46, 53].

Consideration of the unique aspects of providing care in the home environment was discussed in several articles [23, 35, 46], for example, needing to balance the need for masks to protect health professionals from infectious disease risk while also with being respectful of the home environment, or incorporating traditional herbs into care [27]. Consideration of the rural context was discussed by several articles. Barriers to the provision of home-based care in rural areas included inadequate internet, telephone or electricity [35, 39], extended travel distances and associated cost [25, 29, 35, 39, 43, 54] and adverse weather conditions or terrain [25, 29, 55]. Models of care that are tailored to the rural context [29, 31, 34, 43] and utilise the strengths of rural communities, such as strong social capital and networks [24, 32, 45], volunteerism [26, 29], reciprocity and resourcefulness [29], were reported to be facilitators of home-based services, along with culturally responsive care [32, 41, 44]. Conversely, rural service delivery was challenged by urban centric hospital at home policies [24, 29].

Discussion

This scoping review identified thirty-five articles which provided evidence for, or discussion about, the provision of hospital in the home services in rural areas. Despite thirty-five articles being identified, the review revealed that the number of articles, particularly empirical studies, exploring the provision of hospital in the home in rural areas was quite limited internationally. Indeed, a study from the United States went as far as stating that delivery of home-based hospital services in rural areas was rare [12], while a recent systematic review of HITH services for older people in Australia reported there were no rural specific studies and few studies that included rural participants [14].

The articles included in this review were diverse in terms of the models of care and patient populations. However, the predominance of palliative care services within the included articles was striking. This could be due to palliative care being particularly well suited to home based delivery [56], patient preference to be at home to receive this care [57] or specific challenges associated with delivery of palliative care services in rural areas [58].

A range of facilitators and barriers to the provision of hospital in the home services were identified. These facilitators and barriers were informed by patients, carers, health professionals, health system representatives and policy advisors/health system representatives. Facilitators and barriers spanned individual factors (patients and carers, health professionals), health system factors, technical factors and contextual factors. Interestingly, despite the diversity of contexts, models of care and methodological approaches, the identified facilitators and barriers were remarkably similar. A previous systematic review of Australian home-based hospital services identified similar facilitators such as effective education, medical support, holistic approaches and tailored plans [14]. Bransgrove’s review of Australian home-based hospital services identified similar barriers such as lack of carer capacity, ineffective care delivery, unsuitable home environments, safety concerns or models that do not accommodate the needs of patients with cognitive decline [14]. Many of these factors may not be specific to rural contexts and may also be relevant to consider in metropolitan contexts, for example, regarding patient selection and health professional characteristics. An international systematic review of reviews [59] reported that Hospital at Home implementation facilitators included multidisciplinary and coordinated teams [60], while implementation barriers included medical condition instability [60, 61] and degree of disability [59].

The factors identified as facilitators of HITH service provision that were either more prominent or specific to rural contexts included models of care that were tailored to the rural context [29, 31, 34, 43], culturally appropriate care [32, 41, 44] and harnessing the qualities of rural communities, such as resourcefulness, increased social capital and acts of reciprocity [24, 26, 29, 32, 45]. In contrast, factors that were either specific to rural areas, or more common in rural areas, which impeded the provision of HITH included poor connectivity [35, 39], extensive travel distance and associated cost [25, 29, 35, 39, 43, 54], difficult weather conditions or terrain [25, 39, 55], lack of culturally appropriate care [41], inadequate community capacity or family capacity due to decreased family networks [45]. Interestingly, state guidelines informing the provision of HITH services in Australia currently have minimal content about consideration of the rural context.

It is important to consider the challenges that are specifically rural in nature given that policies may be urban centric, and experienced differently in rural areas or indeed unsuited to rural contexts. This point was also raised by Bransgrove and colleagues who state ‘it is essential that research considers their (rural patients’) experience of healthcare, and how that experience may differ’ [14]. It is also important to note that each rural community is unique, with distinct challenges and resources available. Whilst metropolitan and large rural HITH services have been in place for over two decades, specific challenges may exist for smaller rural health services which have had HITH services in place for less time or may be operating under the auspice of larger health services. Although the perspectives of carers were considered in the included articles (n = 10), only three gave explicit attention to carers’ experiences and circumstances specifically in rural settings. Castleden and colleagues [29] noted that as many key care services are not available locally, rural carers felt an increased sense of isolation and distress when sudden changes occur in the health status of care recipients. The same authors also found ethnic minorities providing care in rural settings operate in sites of care that are largely invisible. Dumont and colleagues [34] found informal caregivers in rural households face greater expenses in regard to prescription medications, out-of-pocket costs and transportation, compared to their urban counterparts. Morgan [43], in discussing the delivery of palliative home care in rural settings, notes the importance of encouraging the involvement of informal carers, acknowledging their contribution and recognising them as members of the care team. She argues that ‘This sense of teamwork is crucial to the continuity of care in rural areas where distance and resources may limit the availability of visiting nurses’ [43]. Otherwise, the importance and challenges of carers at home who enable and facilitate the delivery of HITH in less well-resourced rural settings are largely overlooked by the literature reviewed here. This suggests that the crucial role of informal caregivers, currently missing from the Hospital in the Home definitions and model descriptions, needs to be recognised and added as a vital component.

The location and unique characteristics of a patient’s home and community and their proximity to health services can impact the provision of home-based hospital services and the flexibility and adaptability required for successful care delivery. Castleden and colleagues [29] describe these elements as ‘place’ and ‘place-based variables’ which are disregarded in palliative care research and policy. Many of the articles noted the importance of accommodating rural culture into service provision. This included discussion of the beneficial impacts of social networks [24, 30, 45], social capital [29], community capacity, rural resourcefulness [29] and reciprocity [43]. Similarly, the importance of First Nations culture featured in a number of articles, particularly in regard to consideration of culturally appropriate language and priorities such as traditional healing practices [27] and spiritual beliefs and values [41, 44].

Limitations

This scoping review was limited to English language, peer-reviewed academic publications and only two databases, therefore important publications in other languages, articles indexed by other databases and in the grey literature may have been overlooked. The barriers and facilitators reported here are noted for consideration and are not likely to be applicable in all contexts. The inclusion of articles without quality appraisal may have overstated these factors. In addition, developments in technology including telemedicine may mean that barriers identified in older articles are no longer relevant. Definitions of Hospital in the Home are poorly developed in the literature and vary widely according to country and health systems. This issue likely contributes to difficulties in comparing models of care across different jurisdictions and learning from successful models. Similarly, what constitutes ‘rural’ was poorly defined and varied widely in the literature, compounding these challenges.

In conclusion, the number of empirical studies related to the provision of HITH services in rural areas internationally was quite limited. Several facilitators and barriers to the provision of HITH services were identified, and encompassed considerations for patient selection, carer capacity, technology, the health system and healthcare providers. Some of these facilitators and barriers were specific to rural contexts, whilst others are likely to be broadly applicable. Consideration of rurally tailored and culturally responsive models of care that harness the strengths of rural communities to include resourcefulness, social capital and reciprocity, should assist with the provision of HITH services in rural areas.

Abbreviations

HAH

Hospital at home

HITH

Hospital in the home

Authors’ contributions

KG, RM, RO, KCT, JK and LA each contributed to the design, review, data extraction and preparation of the manuscript.

Funding

This project received no dedicated finding. Research within the Department of Rural Health is supported by Australian Government Department of Health and Aged Care through the Rural Health Multidisciplinary Training Program.

Data availability

The data analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.