Stakeholders’ perspectives on the necessary requirements of implementing the Hospital-at-Home program: a qualitative study

Abstract

Background

Hospital at Home (HaH) is an effective solution to address the challenges in healthcare systems; however, the inherent complexities of this program have created obstacles in implementing it. This study was conducted to explore the perspectives of managers and policymakers in the Iranian healthcare system on the necessary requirements for the implementation of the HAH program.

Methods

This qualitative study was conducted from December 2023 to June 2024. The 14 participants consisted of health policymakers, faculty members, and hospital managers from Tehran and Shiraz universities of medical sciences. The participants were selected by purposive sampling. Data were collected through semi-structured individual interviews. Data analysis was conducted using conventional content analysis.

Results

Following data analysis, 652 initial codes were extracted, which were subsequently classified into 7 categories and 2 themes. The themes were “alignment of macro-level mechanisms in supporting the HaH program” and “organizing the HaH program within the healthcare system”.

Conclusions

The study highlights that successful implementation of the HaH program in Iran is influenced by economic, legal, and socio-cultural factors, as well as the policies of the Ministry of Health and Medical Education (MOHME). Addressing the challenges in these areas requires a comprehensive and integrated approach. Additionally, the program’s success depends on development of precise structures within the healthcare system, which involves configuring this program within the healthcare service processes, executive support from managers and beneficiary healthcare centers, and the development of essential infrastructure. The findings provide valuable insights for managers, policymakers, and stakeholders, offering guidance on the design and implementation of the HaH program as a supplement to routine healthcare services.

Background

Development of HaH programs is one of the effective solutions that healthcare systems around the world, have adopted to deal with such problems as aging populations, increase in chronic diseases, complexity and diversity of health needs, increasing burden of caring for patients with multiple diseases, growing demand for health services, rise in medical costs, and shortages of hospital beds and human resources [1,2,3,4].

HaH, an approach to providing acute care, provides healthcare services in the patient’s home as an alternative to the traditional hospital stay. There are two main types of HaH programs: early supported discharge (ESD), which aims to expedite the discharge of hospitalized patients who still require inpatient care, and admission avoidance (AA), which is a partial replacement for hospital care, whereby patients are transferred directly to the HaH, either through a referral from a general practitioner or through direct admission from the emergency department, thus avoiding physical contact with the hospital [5, 6].

The terminology for this approach is not consistent in the existing literature, and different studies use different terms for this type of care, including “hospital-based home” “hospital at home,” “hospital in the home,” and “home hospitalization.” In some cases, these terms are used in a way that does not imply a substitute for inpatient hospital care [7, 8]. In the present study, the HaH program refers to a set of hospital-level services and care provided to patients with complex clinical conditions who, require hospitalization in traditional hospital settings. These patients require 24/7 monitoring and follow-up, which is typically available only within a hospital [8].

The HaH program functions as a distinct but integrated part of the hospital [8]. The development of this program could play an important role in decentralizing care from traditional centers, allowing for the provision of systematic care, facilitating rapid expansion of bed capacity, and controlling hospital infections [4]. Evidence suggests that this program can help improve clinical outcomes, reduce patients’ length of stay, provide high-quality and safe care in the home environment, and reduce hospital costs. It also provides a positive experience for patients and increases their satisfaction. These benefits make HaH an effective solution to address the challenges of healthcare systems [5, 9,10,11,12,13,14,15,16,17]. This program has long been in the focus of attention in many countries, including the United States [18], Spain [19], Australia [20], Canada [21], the United Kingdom [22], and France [23], reflecting its significant potential to complement and enhance healthcare systems on a global level.

Despite the numerous benefits of HaH, the inherent complexities of this program have created obstacles in implementing it. In general, inconsistencies in the structure and definition of HaH services have resulted in lack of clarity in many studies regarding the necessary arrangements for implementing this program. This lack of information has limited the transfer of knowledge about the arrangements required for the acceptance and adaptation of this program, even in countries with similar healthcare systems [7].

Growing knowledge about the influential factors in the implementation of innovative models of care delivery, which can serve as an efficient strategy in coping with current and future challenges in healthcare systems [24] and promising evidence about the HaH program indicate that the development of HaH can provide an opportunity for developing countries to more effectively cope with the existing and future problems of their healthcare systems.

Today, the Iranian healthcare system faces numerous challenges, including a sharp rise in the elderly population, the increasing burden of noncommunicable diseases, changes in lifestyles, the growth of medical expenses, maintaining the quality of care, managing hospitals’ bed capacity, the place of patients’ demise, and protecting human dignity [25]. These issues highlight the need to develop innovative approaches.

On the other hand, in Iran, the primary healthcare network, with its extensive capacity to reach out to a significant portion of the country’s population, has a good potential for providing a wide range of community-based interventions. Also, the changes registered in the future outlook of the country’s health services, including the implementation of the family physician program as the guardian of the healthcare system and the development of home care programs, indicate the efforts of policymakers to promote equity and efficiency in the health sector [26].

In a review of literature, no study was found that showed what measures should be taken by policymakers and managers to make HaH operational. In a systematic review that aimed to summarize the indicators of HaH and strategies for its implementation, it was found that previous studies had mainly focused on factors within the organizations which provided these services [7].

Currently, HaH has no place in the structure of Iran’s healthcare system, while the health system transformation plan of the Islamic Republic of Iran, based on the Iranian-Islamic model, emphasizes the decentralization of hospital services and the development of a comprehensive system of home care, making it essential to explore this program in a national context.

Since the successful implementation of any new program in a country requires understanding its various dimensions from the perspective of its key stakeholders, this qualitative study was conducted to explore the perspectives of managers and policymakers of the Iranian healthcare system on the necessary requirements for the implementation of the HaH program in the Iranian society.

Methods

Research design

The present study employed a qualitative descriptive design to explore stakeholders’ perspectives on the requirements for implementing the HaH program in the Iranian society. Data analysis was conducted using thematic analysis. This design was chosen for its methodological flexibility and its suitability for providing rich, in-depth insights into participants’ views and experiences [27]. Thus, it allowed for a comprehensive exploration of the primary requirements for implementation of HaH.

Research settings and participants

The study was conducted from December 2023 to June 2024. A total of 14 participants were recruited, consisting of health policymakers, faculty members, and hospital managers from Tehran and Shiraz University of Medical Sciences. The participants were selected through purposive sampling. The inclusion criteria were having a management position in one of the fields of medicine, nursing, home care, health economics, medical technology, healthcare management, or insurance management, having at least two years’ experience of management, and willingness to participate in the study. The participants who withdrew from the study during or after the interviews or failed to provide the required information were excluded.

Data collection

After being selected based on the inclusion criteria, the participants were informed about the study’s objectives, the interview process, and the time and place of the interviews. Next, the participants were asked to complete an informed consent form. Data were collected through individual, in-depth, semi-structured interviews and focus group session with the participants. Both the individual interviews and focus group session were conducted using an interview guide developed specifically for this study. The complete individual interview and focus group session guides are provided in Supplementary file 1.

Before each interview, the researcher contacted the participants to arrange a suitable time, date, and location for the interview. At the beginning of the interviews, the researcher explained the study objectives to the participants and assured them of the confidentiality of the collected data. The participants were then asked for permission for recording the interviews using an audio recorder. Sample size was determined based on data saturation [28]: sampling continued until no new information, categories, or themes emerged. Data saturation was confirmed after the fourteenth interview through a thorough re-examination of the codes and categories by the research team. For greater certainty, two additional interviews were conducted, bringing the total to sixteen. As these last two interviews did not yield any new insights, they were not included in the final analysis. A focus group session was also held to further enrich the findings. Seven individuals participated in the focus group, six of whom had participated in the individual interviews and one was a new participant.

The average duration of the interviews was 70 min (minimum 35 and maximum 180 min), and the focus group session lasted 45 min. Various techniques were employed to enhance the interview process, including probing, providing examples, describing, using exploratory questions, summarizing the interviewees’ responses, active listening, and reflection of the participants’ words [29]. Bracketing was also applied, i.e. the interviewer tried not to interpret the interviewees’ responses. The interviews ended with summarizing the content, announcing the end or continuation of the interview in future meetings, and thanking the participants. The interviews were transcribed on the same day.

Data analysis

In the present study, the qualitative content analysis method developed by Graneheim and Lundman was used [30]. In this approach, interviews and data analysis are conducted simultaneously, with a combination of manifest and latent content analysis in an inductive, conventional manner. According to Graneheim and Lundman, the analysis process is non-linear and involves moving back and forth between the original text and related parts of the text.

Therefore, after each interview, the collected data were transcribed in Persian (the participants’ native language) on the same day. Initially, the transcript was read word by word several times in order for the researcher to get immersed in and acquainted with the text. Subsequently, the unit of analysis was derived by combining the texts obtained from the interviews. Each interview transcript was then divided into meaning units. A meaning unit refers to a set of words or statements that relate to a central meaning and are alternatively referred to as a coding unit, idea unit, or text unit. Ultimately, the meaning units were labeled by codes. Different codes were compared on the basis of their similarities and differences and sorted into sub-subcategories, sub-categories and categories.

Graneheim and Lundman emphasize that in qualitative content analysis, a category often encompasses items, opinions, attitudes, perceptions, and experiences forming a collection of similar data organized in one place for description and analysis [30]. The categories were discussed and revised by the researchers, and contemplation continued until agreement was reached on the final coding. Finally, the underlying meanings, which were the content of the categories, were formulated as themes. All the above-mentioned steps were taken manually and in Persian to preserve the authenticity and contextual meaning of the participants’ responses. For publication purposes, selected quotes were translated into English by two independent bilingual translators familiar with health research. Discrepancies between translations were discussed and resolved in collaboration with the research team to ensure both accuracy and fidelity to the original meaning.

Rigor

To establish rigor in this qualitative study, the researchers used the four criteria proposed by Lincoln and Guba [31], namely credibility, dependability, confirmability, and transferability. Multiple strategies were employed throughout the research process to ensure the trustworthiness of the findings. To enhance credibility, the researchers took various measures, including conducting pilot interviews, allocating sufficient time for data collection, increasing sample diversity, collecting rich and detailed data through both focus group session and in-depth individual interviews (data source triangulation), and conducting interviews until data saturation was reached. The findings were reviewed multiple times by the research team. Immersion in the data through continuous engagement enhanced the quality of the findings. Investigator triangulation was employed to minimize potential bias and incorporate diverse perspectives. All members of the multidisciplinary research team — comprising experts in nursing administration and health policy, management, and economics — independently reviewed the extracted codes, categories, and emerging themes. Discrepancies were discussed collaboratively to reach consensus, ensuring that multiple disciplinary viewpoints informed the analysis. The team also applied member checking (by sharing the findings with several interviewees and incorporating their feedback) and engaged in peer debriefing to enhance the credibility of the results. Immediate analysis following each interview and ongoing comparison of the collected data further strengthened the credibility of the findings.

To improve dependability and confirmability, all the occurrences during the study were documented (field notes) and reviewed. Additionally, an external auditor, a professor of nursing with 29 years of professional experience in qualitative health research and 10 years of experience in management and executive roles, entirely independent of the research team, was involved from the proposal stage to the completion of the study. The auditor monitored the data collection and content analysis processes, reviewed the coding framework and emerging themes, and provided critical feedback to enhance the rigor of the analysis. The researchers provided detailed explanations of the study’s methodology and shared all relevant documents with the auditor throughout the process. The decision to involve a single external auditor was based on the guidelines of the Research Vice-Chancellor of Shiraz University of Medical Sciences and aligns with commonly accepted qualitative research practices, where the involvement of one qualified and independent auditor is considered sufficient to ensure verification, confirmability, and reliability of the findings. Transferability was ensured through comprehensive descriptions of the categories, the participants’ characteristics, and the methods of data collection and analysis.

Results

The majority of the participants were female, married, and within the age range of 35 to 55 years old. The demographic characteristics of the 14 participants are presented in Table 1.

Table 1 Demographic characteristics of the participants

Following data analysis, 652 initial codes were extracted, which fell into 7 categories and 2 themes. The themes were “alignment of macro-level mechanisms in supporting the HaH program” and “organizing HaH within the healthcare system” (Table 2).

Table 2 Themes, categories and sub categories resulting from data analysis

Theme 1. Alignment of macro-level mechanisms in supporting the HaH program

The participants’ statements emphasized the need for alignment with and support for the HaH program in the economic, legislative, socio-cultural domains and the policies by the MOHME. This finding underlines the role of governmental mechanisms in making the implementation of the HaH program feasible.

Alignment of economic issues in supporting the HaH program

The participants highlighted the existence of economic challenges in implementing HaH and the need for formulating solutions to overcome these challenges. These views indicated the importance of economic alignment and support as a key factor in the successful implementation of the HaH program.

Potential economic challenges

Most of the participants pointed to the adverse impact of the current economic conditions, including inflation, sanctions, and limited financial resources, on patients’ access to and support for the HaH program. One participant stated that:

“…Given the current economic situation, the existing inflation, and the sanctions, how should the cost of home healthcare services be calculated? What percentage of patients can actually afford these services?” (P3).

Another participant also referred to the limited government budget for the development of HaH, stating that:

“… With the lack of financial resources, the government cannot allocate a budget for the development of these programs” (P5).

Strategies to address economic issues

The participants referred to government support policies as a key strategy for the success of the HaH program. These policies included specific budget allocations, attempts to attract financial assistance from such international organizations as the World Health Organization (WHO), providing tax incentives to centers interested in operating in this area, and offering financial incentives to HaH service providers, patients, and their caregivers. One of the participants stated that:

“… The government’s policies should change, and if they want to support this program, they should specify how much financial credit is needed, so that ultimately those institutions and centers that want to implement this program can receive financial help, and perhaps even tax incentives should be considered for these organizations to encourage them to implement this program … I even think that the caregivers who have to be with their patients 24 hours a day should be offered special privileges.” (P2).

Another participant said that:

“… We can cooperate with organizations like WHO and even request financial assistance from them” (P4).

Alignment of legislative issues in supporting the HaH program

The participants highlighted the potential legal challenges in implementing HaH and the need to develop strategies to overcome these barriers. These views emphasized legislative alignment and support as a key factor in the successful implementation of the HaH program.

Potential legal and legislative challenges

Many of the participants mentioned that there was a lack of appropriate laws and regulations to support home-based hospital services. One participant stated that:

“… any service that is transferred to the home, in addition to the specialized aspects, must have legal support. I believe one of the biggest challenges is that we do not have a legal framework that supports home-based services.” (P10).

Another participant stated that:

“… legal matters and legal protection are very important to me. Am I protected by the law for the care I provide in the patient’s home or not? But we currently do not have legal support for that” (P13).

Strategies to address legal and legislative issues

The participants emphasized the need to develop a legal framework to support home-based hospital services. One participant stated that:

“…setting a legal basis is the foundation of this work. Once that legal basis is in place, the ministry will be free to train and hire staff for this program, and then I, as a nurse, will have the authority to act” (P12).

Alignment of socio-cultural issues in supporting the HaH program

The participants also highlighted the potential socio-cultural challenges in implementing HaH and the need for strategies to cope with them.

Potential socio-cultural challenges

Many of the participants referred to the prevalent negative public attitude towards receiving hospital services at home. One participant stated that:

“…Many families think that if their patient receives hospital services at home, they are neglecting their patient; this way of thinking needs to change” (P2).

Another participant referred to the cultural challenges of the society:

“…I think our biggest challenge is the mindset of individuals and the society as a whole: people ask themselves what their neighbors and relatives will think if nurses and doctors come to their homes every day? … The society is not yet mentally prepared for this” (P3).

Strategies to address socio-cultural issues

The participants emphasized the importance of raising public awareness of HaH through various methods. One participant stated that:

“…It might be necessary to create some television programs on this topic; maybe we need to put up some billboards, or even start raising awareness in schools.” (P13).

Another participant pointed out the importance of holding educational events and introducing the HaH program widely and said that:

“It would help to hold such events to introduce this program to people, just like the conferences and conventions that are held on different topics” (P2).

Alignment of the MOHME policies in supporting the HaH program

The participants’ statements highlighted potential challenges for the MOHME in preparing the grounds for successful implementation of the HaH Program.

Potential challenges faced by the MOHME

According to many of the participants, there were shortcomings in the education of nurses and physicians. One participant stated that:

“… Here, we call it hospital-at-home, meaning that nurses and doctors work shifts but at the patients’ home. Currently, there are no specific units for this purpose, nor is there an appropriate understanding of HaH. It is a significant challenge to get these professionals to accept to move away from the dignity of working in hospital settings and provide care and treatment in the patients’ home” (P3).

Strategies to address issues faced by the MOHME

The participants stressed the need for change in the educational policies of the Ministry of Health. One of them stated that:

“…Our educational policies need to change; the students should complete courses at universities that acknowledge the existence of conditions that demand the presence of nurses or doctors in the home.… Special training programs for these initiatives should be provided, for example, in the form of in-service training or continuing education” (P5).

Another participant emphasized the need for change in the research policies of the Ministry of Health:

“Currently, not much research is being conducted on HaH. The Ministry of Health should prioritize research in these areas…” (P4).

Theme 2. Organizing HaH program within the healthcare system

The participants’ statements underlined the importance of designing and configuring an HaH program within healthcare service processes, executive support from managers and beneficiary health centers, as well as the development of essential infrastructure for this program.

Configuring HaH within healthcare service processes

The participants’ statements stressed the importance of clearly defining the coverage of the HaH program and the need to map the patients’ journey in this program. These findings emphasize the need to configure HaH within the health system’s care service processes.

Defining the coverage of HaH

The participants mentioned that the coverage of the HaH program should be defined accurately. They said that the characteristics of the target population, the type of therapeutic interventions that can be provided at home, the duration of patients’ presence in the program, and the geographical area covered should be specified. One participant stated that:

“… It should be determined which groups of patients are included, what diagnoses these patients have been given, what their conditions are, and what types of medical interventions can be provided to them at home…. Also, it should be clarified how long these patients should receive treatment and care within the program …. If this program is to be implemented in hospitals, it should also define how far the patients’ home should be from the healthcare center” (P13).

Mapping the patients’ journey

Mapping the patients’ journey in the HaH program consists of various stages: before the patient enters the program, the point of entry into the program, the pathways to receive services while in the program, and the point of exit from the program.

One participant stated that:

“It should be clear where these patients are referred to the program from: from family physicians, hospitals, or outpatient clinics” (P2).

Another participant noted:

“… The triage of these patients, their initial assessment, and how they should receive medical services should be done just like in the hospital” (P3).

Another participant added:

“… It should be specified when these patients will be discharged, and what their discharge plan and follow-up care will entail. Should they return to the hospital to be discharged, or will they be followed up and discharged through their family physician?” (P13).

Executive support from managers and beneficiary health centers

According to the participants, executive support from managers and beneficiary departments within the healthcare system was one of the key factors in the successful implementation of the HaH program. This category was comprised of three subcategories: “support from high-level managers,” “establishing strong and logical partnerships based on service design” and “collective efforts of hospital unit managers.”

Support from high-level managers

Underlining the role of support from high-level health system managers, one participant stated that:

“… If I, as a hospital manager, want to implement a program for specialized home care, I must gain the approval and support of senior authorities. This is essential.” (P7).

Strong and logical partnerships based on service design

The participants stressed the importance of cooperation with various private and public organizations and centers toward creating strong and reasonable partnerships based on the service design of the HaH program.

One participant stated that:

“… Based on the services that are going to be provided in the patients’ homes, we need to determine which organizations and facilities, both private and public, we can collaborate with. For example, collaboration with laboratories, pharmacies, and imaging services, such as radiology and CT scan, is essential” (P3).

Another participant mentioned that:

“… To equip the patients’ homes, it is essential to cooperate with medical equipment suppliers, such as Tabe Motale, which provide services like beds and medical devices. Also, charity organizations and NGOs can contribute to providing the necessary facilities and services for HaH” (P1).

Collective efforts of hospital unit managers

With regard to the role of collective efforts of hospital managers, one participant stated that:

“… A hospice center was opened yesterday at Chamran Hospital in Shiraz. To open this center, the joint efforts of the hospital managers were essential; the people who cared were able to negotiate with the senior authorities and strike a deal” (P1).

Developing the essential infrastructure of HaH

The participants’ statements underscored the importance of developing “a legal & ethical infrastructure,” “a new organizational structure and protocols,” “financial structures,” “provision of resources and facilities” and “a monitoring and evaluation structure” in implementing the HaH program. These factors emphasize the need to develop or improve the Iranian healthcare system for effective implementation of the HaH program.

Developing a legal & ethical infrastructure

According to the participants, the legal responsibilities of those involved in the HaH program must be specified to ensure that their actions comply with the laws and regulations. One participant stated that:

“… It is necessary to define legal responsibilities for this program to make sure that the care providers are acting within the law …. Specific legal protocols for the program should be defined, such as the time when the nurse or doctor should be at the patient’s home each day and the duration of their visit, to ensure that the staff is acting legally” (P5).

Also, regarding an ethical infrastructure, the participants highlighted the importance of developing specific ethical codes and forming committees to monitor ethical issues in the program. According to one of the participants:

“… It is essential to observe ethical principles in the program, especially in the private settings of the patients’ home. Therefore, there is a need to define specific ethical codes and establish a monitoring committee to deal with complaints or ethical issues related to the staff or patients.” (P3).

Developing a new organizational structure and protocols

The participants stressed the importance of defining specialties, roles, and responsibilities in the program, as well as developing the necessary professional mechanisms. These findings underline the need for designing a new organizational structure and protocols for the HaH program.

As for defining specialties, roles, and responsibilities, a participant stated that:

“It should be determined what professionals are needed for this program, and what skills and expertise they should have… If the program is to be carried out by a team, the members of the team and the coordinating leader should be identified. The responsibilities of each member should be precisely defined” (P13).

The participants also referred to the need to develop professional mechanisms and clear guidelines for the staff, including how to carry out clinical procedures and manage unexpected situations. One participant stated that:

“…Nurses and doctors must have a clear understanding of how to provide their services correctly in the patients’ home…The individuals involved in HaH must know how to respond in the event of unexpected occurrences…” (P3).

Developing a financial structure

The participants also referred to various aspects of financing the HaH program. These aspects included “development of a new insurance infrastructure,” “development of specialized payment and billing mechanisms,” “development of a specialized salary structure,” and “funding contracts.” These factors are important in developing financial structures within the healthcare system to create an appropriate framework for successful implementation of HaH.

The majority of the participants mentioned the structural challenges in the insurance sector and the need to revise insurance policies to create an insurance structure that supports the HaH program. One participant stated that:

“… With the present insurance policies in Iran, it seems that the execution of this program is impossible. Insurance policymakers need to create new insurance platforms that cover home-based hospital services” (P9).

The participants also mentioned the problem of cost differences between home healthcare services and hospital-based services, which can impact the acceptance of HaH. They emphasized the need to revise pricing mechanisms for home-based care services and to develop specialized and cost-effective reimbursement models for this program.

“…When the patients and their family caregivers see that they have to pay a high price for a simple IV or a routine visit from a doctor or nurse at home, while they can pay less for a similar service at the hospital, they prefer to take the patients to the hospital at night, even if the patients’ condition is poor…Therefore, the pricing of services needs to be adjusted to make them more affordable for the patients and their families.” (P2).

The participants highlighted challenges in the salary and payment structures for the staff providing home healthcare services in Iran and emphasized the need for a specialized salary framework. One participant noted that:

“… With the current pay for home-based services, this work is practically not feasible. For example, for providing chemotherapy services at home, care providers receive amounts ranging from 500,000 to 1.5 million tomans. However, if these services are provided in a program’s framework, they lose this money; so they prefer to offer services independently of healthcare centers” (P3).

The participants also referred to funding contracts to address financial challenges. One participant stated that:

“…As it is, many institutions deal with financial issues by attracting investors. In our home care institution, we have an investor who finances home-based wound dressing services. This financial support has been very effective. Although a percentage of the profit goes to the investor, having an investor has certainly helped greatly in advancing the work” (P3).

Provision of resources and facilities

With regard to providing resources and facilities, the participants mentioned “hospital equipment and facilities,” “advanced technological equipment and facilities,” and “human resources” as prerequisites for successful implementation of HaH.

The participants highlighted the significance of providing new hospital equipment and facilities to facilitate the delivery of healthcare services at the patients’ home. According to one of the participants:

“… Currently, many countries prepare antibiotics in diluted form (bag dose) within specialized packages. This practice helps nurses and even family caregivers easily administer the medications at the patients’ home… Also, vascular access ports are implanted on patients, which makes it easier to administer medication at home” (P13).

The participants also referred to utilizing advanced technological equipment and facilities, such as development of electronic medical records (EMRs) and telemedicine, to ensure the successful implementation of the HaH program. One participant stated that:

“… special electronic records should be prepared for the program and advanced systems should be made available to the doctors and nurses, such as special applications that are installed on mobile phones so that the nurse or doctor can access each patient’s electronic record” (P11).

Additionally, one participant emphasized the importance of health systems’ readiness to utilize telemedicine and telenursing technologies and stated that:

“…In this program, we definitely need to expand the use of telemedicine and telenursing in organizations that provide such services. Patients should be able to communicate with the treatment team remotely, and the healthcare professionals should have video meetings to receive reports on the patient’s condition and be able to visit the patients remotely” (P13).

The majority of the participants also highlighted the issue of workforce shortage and the need to address the human resource requirements of the program:

“…Under the current conditions, we do not have enough staff …. It is essential that the health system authorities make arrangements to provide the necessary workforce for the expansion of this program” (P1).

Developing a monitoring and evaluation framework

The participants stressed the need for developing an accreditation framework and specific criteria for comparing the outcomes of the HaH program with those of hospital-based care. Thus, for HaH to be implemented successfully, a structured monitoring and evaluation system for the program is required.

The participants’ statements highlighted the need for specialized committees to develop accreditation criteria for the HaH program and define key performance indicators (KPIs) for assessing the quality, safety, and effectiveness of services. They also stressed the need for conducting a preliminary evaluation during the pre-implementation phase and ongoing evaluations of organizations providing these services. In this regard, one participant stated that:

“… The issue of accreditation in hospital-at-home is also very important… just like what we have for hospitals. A committee should be formed, and the authorities should examine the basis on which accreditation for hospital-at-home units should be carried out, and what key performance indicators should be used to ensure that the organizations that provide HaH deliver care that is safe and of high quality…. I also believe that centers willing to offer hospital-at-home services should first be evaluated and then undergo periodic accreditation with much more specific criteria” (P4).

The participants also recommended establishing precise criteria for evaluating the outcomes of the HaH program compared to those of traditional hospital stays. One participant stated that:

“… In my opinion, it is necessary to define criteria to compare the results of this program with inpatient hospitalization and assess whether it truly has the necessary efficiency and effectiveness in our healthcare system. If a patient receives medical services at home instead of in the hospital, will his costs be reduced? Or won’t there be a greater risk of infection” (P13).

Discussion

The present study aimed to explore the perspectives of the key stakeholders of the HaH program regarding the necessary requirements for the implementation of HaH in the Iranian society. From the participants’ viewpoint, aligning the macro policies of the society with the HaH program and incorporating HaH within Iran’s healthcare system were essential prerequisites for the successful implementation of the program in the country.

The participants highlighted the necessity of alignment and support in the economic, legislative, socio-cultural domains and the policies of MOHME as one of the fundamental requirements for the HaH program’s successful implementation in Iran.

The alignment of socio-economic matters with the HaH program was recognized as a key factor in promoting HaH. This finding is consistent with the results of previous studies in this area. Voudris suggests that innovation in healthcare economics, which facilitates and promotes the provision of new care models, is one of the main factors in the success of HaH [32]. Likewise, Levi et al. emphasize the role of appropriate financial measures by governments in the development and success of this program [33]. The participants also highlighted the necessity of aligning the legal system with the HaH program. The findings of the present study agree with the results of Brody’s study which identifies overcoming legislative barriers as one of the essential facilitating factors in the successful implementation of HaH [34]. According to another study, during the preparation phase of HaH, the challenge of aligning healthcare regulations with the program is one of the major obstacles to its implementation [35]. From the participants’ perspective, the alignment of socio-cultural factors was another critical requirement for the successful implementation of HaH. A study in the United States found that the cultural norm of hospitalization could be a barrier to the expansion of the HaH program in rural communities [36]. Levi et al. viewed cultural transformation among stakeholders as a necessary condition for the development of HaH [33]. Furthermore, research in Canada shows that HaH, as a new initiative in the community, requires informing and educating the public about its benefits and safety for patients, and such efforts are essential for the long-term success and social acceptance of the program [21].

In the present study, the participants emphasized that the policies of the MOHME should be aligned with the HaH program as another essential measure for preparing for its implementation in the Iranian society. This finding of the study is consistent with previous research. For example, some studies highlight that in the early stages of preparing for the HaH program, providing comprehensive training for the healthcare personnel and revising the academic curricula are crucial [21, 33, 37, 38]. Furthermore, another study indicates that for the development of this program within healthcare systems, HaH must be considered as a part of healthcare policies and the strategic planning of hospitals [39]. This approach could establish the HaH model as a complementary option to inpatient care within healthcare systems.

Contrary to the findings of the present study, a study in Singapore, which is the first Asian community to explore individuals’ perspectives and attitudes toward the HaH program, reported that, contrary to the researchers’ expectations, many of the predicted associations between demographic, social, and economic factors on the one hand and patients’ acceptance of HaH on the other were not observed in regression analysis. This study emphasized that government financial support policies are a key factor in the expansion of HaH [40]. This discrepancy may be due to differences in research methodologies. The Singaporean study employed a survey method with pre-established standard tools, whereas the present study used a qualitative approach with in-depth interviews to explore the participants’ perspectives. In addition to methodological differences, the cultural, social, and economic contexts may have influenced these results: Singapore, as a developed country with an advanced healthcare and social infrastructure, may have a different perspective on the HaH program. In contrast, Iran, as a developing country, faces certain economic and cultural challenges that could complicate the acceptance and implementation of this program. These differences suggest that for the development and expansion of the HaH program, healthcare policies need to be localized and designed according to the specific characteristics of each community.

Previous studies have addressed various factors in the success of the HaH program at the macro-community level, and the review study by Casteli et al., aimed at identifying these factors, did not mention the necessity of aligning policies at the social level [7]. However, the findings of the present study suggest that, since the characteristics of healthcare systems and the cultural, economic, political, and social conditions of each community can present certain barriers to home-based care [41], and since the implementation of any new program is affected by the local context of the society in which it is launched [34, 42,43,44], for HaH to be properly implemented in Iran, policies in economic, legislative, and socio-cultural domains should be adopted by MOHME to supports this program and facilitate its implementation.

From the participants’ perspective, organizing the HaH program within the Iranian healthcare system is one of the key factors in preparing for its implementation. This organization requires three key components: configuring HaH within the healthcare system, executive support from managers and beneficiary units, and development of the program’s infrastructure.

The participants in the present study mentioned that configuring the HaH program within the healthcare service was necessary. This configuration should be executed in a way that ensures the program’s comprehensive coverage by specifying the target patient population, types of interventions, the duration of patient follow-up, the geographic coverage area, and the patients’ journey from admission to discharge in a systematic and standardized manner within the framework of the national healthcare system. Previous studies have also highlighted the importance of defining the HaH program’s coverage. According to Voudris, one of the most critical factors in the program’s success is accurately identifying the patient population that would benefit most from HaH and developing a well-defined care model that ensures services are provided to those who genuinely need them [32]. Similarly, Gorbenko et al. emphasizes the need for a clear and specific definition of the care provided within the HaH program [35]. The findings of the present study also indicated that, in addition to identifying the target population and types of interventions, defining the geographic area covered by the program and the duration of patient follow-up is also important. This finding is consistent with the results of Knight’s study, which highlights these factors as key features of the HaH model [45]. Since defining the program’s coverage is influenced by local demand and the existing healthcare infrastructure in each community [35], and it also requires a fundamental reassessment of what is currently provided at the hospital level [45], it is essential to conduct a thorough evaluation of the current hospital-level services in Iran. Key factors in implementing HaH in Iran include specifying the target patient population, types of therapeutic and care interventions, geographic coverage, and the duration of patient follow-up.

The participants also emphasized the importance of mapping the patients’ journey in order to configure the HaH program within the healthcare system. While no study has specifically addressed the significance of mapping the patients’ journey in HaH, previous research indicates that implementing HaH can have significant impacts on workflows and care service processes [3, 34, 38]. Process mapping (PM) is recognized as an efficient tool for redesigning healthcare processes as it can provide insight into the challenges in service delivery [46,47,48]. It can also assist in restructuring the patients’ journey through a healthcare program, from the initial admission point to discharge, with an understanding of how a target population receives the necessary services [49]. Therefore, using PM can enhance the management of the patient pathway, from admission to discharge in the HaH program, help identify challenges and suggest strategies to improve service delivery. Furthermore, process mapping can help healthcare teams design new methods of providing clinical care services by fostering better coordination of interdisciplinary actions, increasing effectiveness, and improving healthcare service efficiency [50,51,52]. In a study conducted by Abuzied et al., which aimed to identify and manage the causes of delay in discharging patients from the medical specialties department at a tertiary care center in Saudi, one of the interventions considered by the researchers was to map the patient flow through the hospital’s current processes, which helped identify barriers to operational processes that may cause patient discharge delays [53]. Thus, since one of the critical elements in developing a new care model is defining patients’ access, referral, service provision, and discharge, mapping the patients’ journey in HaH can provide a two-way visualization of organizational and client interactions. This allows stakeholders to gain an overall perspective on the program and identify organizational gaps prior to implementation [54, 55]. Accordingly, in preparation for the implementation of the HaH program and configuring it within the healthcare system of Iran, creating a map of the target patients’ journey can help provide details regarding access points, referral points, service provision methods, and discharge points. This approach will not only help identify organizational gaps, but also provide practical strategies for improving care processes based on local contexts.

Based on the findings of the present study, executive support from managers and beneficiary care units is one of the key arrangements for the implementation of the HaH program in Iran. Previous studies also confirm the significance of this support. According to the literature, successful development of the HaH program requires substantial teamwork, including the involvement of enthusiastic clinical leaders and continuous communication with policymakers and external partners [34, 56]. Collaboration with home healthcare agencies, physiotherapy centers, laboratories and imaging facilities, as well as psychological and social counseling centers, can enhance rapid access to diagnostic tests and hospital services, which decreases the burden of caregiving on patients’ families [45]. A systematic review identified the development of ties among stakeholders prior to the program’s implementation as a key factor in maintaining hospital-at-home services on a larger scale [57]. Likewise, Brody emphasizes that engaging internal stakeholders to ensure compliance with regulations and collaborating with external partners are essential to successful implementation of HaH [34]. Therefore, for the successful implementation of the HaH program in Iran, it is essential to pave the ground for effective relationships and coordination between executive managers, clinical leaders, and internal and external stakeholders, thereby ensuring high-quality services and the sustainable development of the program.

Based on the findings of the present study, the creation or development of a foundational infrastructure for the HaH program, including development of legal and ethical frameworks, development of new organizational and financial structures, provision of resources and facilities, and the development of monitoring and evaluation frameworks, is an important step in preparing for the successful implementation of HaH within Iran’s healthcare system.

The participants stated that developing legal and ethical frameworks can ensure the protection of patient rights and compliance with professional standards in the HaH program. In this regard, a study by Leff et al., conducted at the First Global HaH Congress in Spain, showed that ethical issues are a key aspect of this program, and that HaH may involve unique ethical challenges, which should be studied further [37]. Similarly, another study points out that one of the major challenges in HaH is legal issues, including negligence by the healthcare team, which could pose risks to patients [3]. Therefore, it appears that to prepare for the implementation of the HaH program in Iran and to overcome these challenges, a legal and ethical infrastructure should be created by formulating clear and specific legal and ethical frameworks. These frameworks could include close supervision of professional performance, defining laws related to the responsibilities of the care team, and developing ethical standards for service delivery. This would help enhance the quality of HaH services and increase patient trust in these services.

The participants also highlighted the need for developing a new organizational structure for the HaH program. A study shows that, when multiple professionals are providing care to the same patient, lack of proper communication and coordination can be overwhelming for the patient and his/her family, undermining the quality of services and patient safety [34]. Previous studies have also pointed to the importance of developing protocols, guidelines, and clinical decision-making support tools tailored to the needs of the HaH program [3, 34, 56, 58]. These protocols and tools can assist clinical care teams in optimizing healthcare processes and services according to shared standards. Therefore, successful implementation of HaH in the Iranian healthcare system entails creating a cohesive organizational structure along with effective protocols and decision-making tools which can reduce coordination and communication challenges and enhance the safety of services.

The findings of the present study indicated that the development of financial structures is crucial for the successful implementation of HaH. Previous studies have similarly stressed the need for appropriate financial measures within the HaH framework, including the creation of new insurance platforms and reimbursement models designed based on value-based models [3, 34]. Additionally, research results show that, in models of payment and billing based on received services, the patients ended up with multiple bills from each service provider, leading to frustration and confusion for the patients and their families, ultimately decreasing their interest in home care services [34]. Another study has shown that ensuring the affordability of services is one of the leading factors in the positive experience of patients and their caregivers in the HaH model, which necessitates adoption of appropriate financial strategies [59]. Moreover, alongside the matter of service affordability for patients, it is essential to ensure the appropriate reimbursement of care costs for service providers [45]. Therefore, implementation of HaH in the Iranian healthcare system requires insurance platforms which ensure the affordability of services for the patients and their families, while motivating healthcare professionals to deliver services to patients at home by offering them financial incentives. Additionally, to ensure adequate funds for the HaH program in Iran, funding can be secured through value creation and strategic interactions with commercial investors and charity organizations [35] and the establishment of precise and well-defined budgetary structures [45].

In the present study, it was also found that ensuring the provision of resources and facilities is essential for the implementation of the HaH program in Iran. In the HaH program, the use of technological facilities, such as telemedicine, telecommunication, and virtual nursing [38], is crucial for establishing direct and effective communication with the patients’ clinical team. This will contribute to more precise monitoring of patients at home. Furthermore, providing hospital facilities, such as ready-to-deploy human resources, mobile diagnostic equipment, and medications, is necessary for delivering home care services. The provision of these resources is facilitated through engagement with suppliers to maintain an adequate supply chain, thereby delivering faster response services to patients at home [35, 60]. In Iran, shortages in human resources and equipment have been identified as major barriers to providing home care [61]. Additionally, the expansion of telemedicine in Iran faces certain challenges [62], and while the electronic health record system was launched in 2015, it continues to face structural challenges [63]. Therefore, for the effective implementation of HaH in Iran, the development of such technologies as telemedicine and EMRs, aligned with the needs of the HaH program, as well as the necessary provisions of human resources, equipment, and hospital facilities in collaboration with both private and public centers, are essential.

The findings of the present study demonstrate that establishing appropriate structures for monitoring and evaluating the HaH program is essential to implementing this care program. However, it appears that the existing literature in this area is limited, and effective frameworks for assessing the quality of services in HaH programs have not yet been developed. Therefore, since the implementation of HaH requires protocols, processes, and procedures which align with the requirements of home-based care, there is need for methods of accreditation of HaH clinical units different from the accreditation of traditional hospitals [64, 65]. Additionally, the present study emphasizes the need to develop specific criteria for evaluating organizations which are willing to offer HaH services before receiving the necessary licenses. It is essential to define these criteria so that eligible healthcare organizations can provide care services as a complementary option alongside other healthcare services to their patients and clients. Setting specific criteria can also ensure the quality and safety of services provided in these settings. It is recommended that future studies investigate the necessary measures for preparing healthcare organizations to implement the HaH program and the development of specific criteria for evaluating them.

Limitations

The HaH program is a new topic in Iran, and it is possible that the participants did not address all the key aspects of preparing for the implementation of this program. Therefore, a comprehensive assessment or the possibility of transferring the results to other healthcare systems may be limited. However, the researchers made an effort to mitigate this impact by conducting in-depth interviews with experts in various fields to gather more comprehensive views.

Conclusion

The findings of this study indicate that the implementation of the HaH program in Iran is influenced by macro-level societal mechanisms in economic, legal and legislative, and socio-cultural domains and the policies of the MOHME. Therefore, there is need for a comprehensive and integrated approach in which the existing challenges in these areas can be identified and addressed with appropriate solutions to facilitate the implementation of HaH. Furthermore, readiness for the implementation of this program depends on its precise structuring within the healthcare system. This structuring requires extensive collaboration among the healthcare system authorities to integrate the program into the existing care processes, receive executive support from managers and beneficiary care units, and develop or improve the fundamental infrastructure for the program. Addressing these factors can pave the ground for the successful implementation of HaH in the healthcare system and the sustainable development and success of this program. Ultimately, the implementation of HaH can improve the quality of home healthcare services, reduce treatment and care expenses, contribute to better management of hospital bed capacity, reduce pressure on the healthcare system in caring for hospitalized chronic patients and the elderly, and eventually contribute to the enhancement of public health in Iran. The findings of this study may prove useful to managers, policymakers, and key stakeholders in healthcare systems across various societies by providing insight into what needs to be done to implement the HaH program. Awareness of the influential factors in making HaH operational can facilitate the successful design and execution of this program as a complementary option alongside routine healthcare and medical services.