The Future of Home Hospital: A Conversation with International Fellow Michael Montalto

Ariadne Labs’ Home Hospital program recently announced Michael Montalto, MBBS, PhD, as its first Home Hospital International Fellow. The Fellowship was developed to advance the field of home hospital care internationally by providing a space for current clinicians and researchers to conduct research, share experiences, build new partnerships, and actively advise and mentor students and new scholars in the field. 

Dr. Montalto is currently the Unit Head of Hospital in the Home at Epworth Healthcare, a large not-for-profit hospital group in Melbourne, Australia. He previously worked in the public sector as the Director of the Royal Melbourne Hospital Hospital in the Home and the Frankston Hospital Hospital in the Home. He has developed and introduced a medical model of Hospital in the Home to each of the three hospitals, including creating the first Hospital in the Home registrar positions in Australia, and has provided care for thousands of patients under these models. He also serves as executive advisor to the Australasian Hospital in the Home Society and is a founding Scientific Co-Convener of the World Hospital at Home Congress.

We had a chance to sit down with Dr. Montalto and discuss the fellowship and what lies ahead for the growing field of home hospital. 

What led you to apply for the international fellowship with Ariadne Labs?

Well, the short answer is fear of missing out. Here in Australia, we’ve had more than a quarter of a century of stable funding for hospital in the home. It’s let us develop this thing on the ground slowly but steadily, while experiencing the occasional setbacks.

But we’ve lacked a dedicated research body. Most research here has been done by individual clinicians on their individual units. We haven’t had what Ariadne is putting out there, which is a dedicated research portfolio for hospital in the home. And as far as I know, that doesn’t exist anywhere else either. So when that’s happening, people like me will gravitate to it. We want to be in the room where that happens.

It’s not just about working out the clinical how-to of managing acutely unwell people at home, but it’s about getting the message out there and winning hearts and minds. I think what’s kept me in the field is still seeing all of the potential of what this could be for patients and for systems. We’re nowhere near close to tapping into that full potential, and I think it’s important enough and worthwhile enough to keep going. 

What do you feel you’ve gained through the fellowship?

I’m really seeing the advantage of having a dedicated research line for home hospital, and I’m also seeing what that requires on Ariadne’s part. If ever there was the opportunity to replicate that research line here, then I’ve had a peek at what it might take. Similarly, I’ve seen firsthand the complexity of running an international multicenter trial, and now it’s about not just saying it’s difficult, but trying to work around those things to get something done.

And I have had a good grounding in the context of U.S. home hospital. There will be more research output on this subject from the U.S. than from anywhere else, so it’s important for us outside of the U.S. to have some deep understanding of the context where that research is coming from.

What advice would you have for future fellows?

Be ready to listen and learn. I would say come with some ideas, have some things that you’ve been working on that you’ve stored on the shelf – but be prepared to either defend them or throw them out if they don’t fit. 

I’m hoping that these aren’t just one off individual fellowships. I’m hoping that we all can develop a relationship around building research and policy into the future. This is still a very small field, and everyone is usually toiling away on their own, quite separate from each other, within their own national context. So it’s important to bring people together to get some kind of momentum.

We still have to convince a lot of good, skeptical people. There are skeptical people you’ll never convince, but there are a lot of people who just need to be convinced properly. I think that’s basically at the core of what we’re doing. And if Ariadne can play a role in pulling together people from around the world, then that really gives an impetus to do some work that might modify those people’s views of home hospital.

What do you think the next steps are to winning over more of those skeptics?

One of the things that I’ve noticed is that we don’t get a lot of public criticism. And in some respects, that’s a problem, because we can’t address what people are thinking about if they don’t tell us what they’re thinking about. 

One answer to that is publishing more. We can do great work, and the patients kind of generally are very appreciative of what we do, but if we don’t put stuff out there in that competitive marketplace of ideas, we just don’t thrive. The more we publish, I think when people see that there’s a momentum here, hopefully they will say, well, we’re reading what you’re saying, but we don’t agree with you or we don’t like it because ABCD. And once we know what ABC and D are, we can work on those issues. So we kind of, in some weird way, have been the beneficiary of people’s good intentions, but I’m not sure that that’s always good.

So I’m actually also hoping that over the next little while, we do get some blowback so that we can better focus on addressing those critical concerns.

What do you see as some of the biggest opportunities in home hospital in the next few years?

Firstly, we need to put our overall mission clearly: that mission is about improving the lives of people who need hospital care. I think that resonates with the community and with physicians.

Then we can look into almost every specialty and be able to say, you know what, that thing that you do there, we can do that for you at home. It’s about us engaging, on a specialty by specialty basis, to be able to convince them that there’s both the tech and the reimbursement structure and the clinical structure to be able to do that. My analogy is that we will be like the intensive care unit. Every specialty puts patients in intensive care, and they do a great job at a particular point in time. We’re doing the same thing. I could go down the list of each specialty and say, here’s what we can do in cardiology, here’s what we can do in infectious disease, here’s what we can do in emergency medicine, here’s what we can do in pediatrics, here’s what we can do in oncology, and we can. In all of those areas.

Hopefully, we’re going to be seen as the group that can look after your patient, who doesn’t need to be physically in the ward, can be at home, but will nevertheless still be treated like they’re in the hospital.