https://orcid.org/0000-0001-6672-0578
Abstract
Heatwaves and extreme heat already exert significant pressure on healthcare systems – a burden expected to intensify with climate change. During hot periods, ambulance callouts, emergency presentations, hospital admissions, and mortality all rise sharply. Hospital at Home (HaH) delivers hospital-level care in patients’ homes, replacing the need for an inpatient admission. HaH is now integral to many healthcare systems, accounting for up to 5% of bed-days in some settings. It alleviates hospital crowding, reduces costs, and provides high-quality care with outcomes comparable to inpatient care, alongside high patient and caregiver satisfaction. HaH serves as a critical pressure release valve for hospital bed demand – particularly during surge periods such as heatwaves – but its continued viability may be threatened by rising extreme heat. In this Essay, we examine key heat-related threats to HaH services, including direct impacts on patients and exacerbation of their underlying conditions, thermal instability of medicines such as intravenous antibiotics, and operational challenges related to staff safety and comfort during community visits. We conclude by outlining potential strategies to mitigate heat-related risks for HaH, including promoting evidence-based cooling for patients, developing novel technologies to keep HaH therapies cool, adjusting prescribing decisions and visit schedules during heatwaves, and embedding heat risk stratification and preparedness into HaH admission processes.
Citation: Loftus MJ, Cumming T, Nicolás D, Leder K, Rogers BA (2026) Home sweet home? The heat challenge to Hospital at Home services. PLOS Clim 5(3): e0000879. https://doi.org/10.1371/journal.pclm.0000879
Editor: Miguel Ángel Navas-Martín, Instituto de Salud Carlos III, SPAIN
Published: March 26, 2026
Copyright: © 2026 Loftus et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was supported by funding from the Royal Australasian College of Physicians (Research Establishment Fellowship 2025REF002; ML) and the National Health and Medical Research Council (Investigator Grant APP2017661 to BR; Investigator Grant APP2041635 to KL). The funders had no role in study design, data collection and analysis, the decision to publish or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Climate change is widely recognised as the greatest global health threat of the 21st century [1], with rising heat among its most visible effects. In 2024, global average surface temperatures surpassed 1.5°C above pre-industrial levels for the first time [2]. Climate change is driving longer, more frequent, and more intense heatwaves [3]. Already a leading reason for weather-related deaths [4], heat is projected to cause even more mortality and morbidity in the coming decades [5].
At an individual level, extreme heat places strain on the cardiovascular and renal systems, significantly increasing the risk of cardiovascular events or renal failure [6]. Heatwaves are often followed by sharp rises in deaths [7], even in high-income settings where access to air-conditioning is greater [8,9]. At a systems level, extreme heat places greater demand on healthcare services, with increases in ambulance callouts, emergency presentations and hospital admissions [10–12]. Beyond these surges in demand, extreme heat – including via related climate hazards such as wildfires, drought or cyclones – can also impair the delivery of healthcare services, just at the time they are needed the most. This may occur due to damaged physical infrastructure, breakdown in supporting services (such as supply chains), or extreme heat rendering some business as usual activities unfeasible [13].
Hospital at Home (HaH) – also known in some countries as Hospital in the Home (HITH) or virtual wards – is a service that provides patients hospital-level care at home, when they would otherwise need to be inpatients in hospital. Common clinical services provided by HaH include intravenous (IV) antibiotics, IV diuretics or complex wound care [14,15]. HaH care models are not suitable for all patients; they rely on careful patient selection by multidisciplinary teams, with specific admission criteria including clinical stability and adequate social support. Nevertheless, in some settings HaH is responsible for up to 5% of bed-days [16], representing a meaningful share of overall healthcare delivery.
As climate change intensifies and extreme heat places growing pressure on communities’ health and their healthcare systems, HaH offers a promising way to ease this burden and lower healthcare costs. HaH already has an established role augmenting bricks-and-mortar hospital bed capacity, and managing patient load during surge events (such as COVID-19) in many jurisdictions [17]. However, HaH faces its own distinct risks from extreme heat conditions. This Essay examines the specific challenges that rising temperatures pose to HaH services, and considers how this important care model can adapt, build resilience and continue to meaningfully contribute to healthcare in a warming world.
How does Hospital at Home (HaH) work?
In HaH services, nurses or doctors visit the patient at home regularly (typically daily), providing specialised care or treatments that are not available from existing community services. There are two main HaH models: ‘Early-supported discharge’ where hospitalised patients finish their acute treatment at home to shorten their inpatient length of stay, and ‘Admission-avoidance’ where suitable patients are admitted directly to HaH to avoid a hospital admission altogether [18].
Typical therapies offered by HaH include IV antibiotics (for a range of different infections, including those such as endocarditis or osteomyelitis that may require six weeks of IV therapy), IV diuretics (for exacerbations of heart failure) or complex wound care (including the use of negative pressure devices to promote wound healing). However, HaH services are offering increasingly advanced treatments, expanding into areas such as blood transfusions [19], immunotherapy [20], chemotherapy [21], complex post-surgical care [22] and certain acute medical conditions [23]. HaH programs are not typically suitable for clinically unstable patients such as those with new haemodynamic instability, active bleeding or uncontrolled sepsis. Similarly, conditions requiring immediate access to hospital diagnostics or interventions (such as suspected acute coronary syndrome or stroke) or those at risk of sudden deterioration (such as severe asthma or unstable cardiac arrhythmias) may also be excluded.
It is worth noting that most HaH services and published evidence stem from high-income countries [24–26], especially those like Australia and the United Kingdom with a single-payer model and greater focus on cost containment. Currently there is a relative lack of either published or grey literature about the availability of HaH services in low- and middle-income countries (LMICs), suggesting uptake has been lower than in high-income countries. Most HaH services in LMICs are delivered through the private sector and financed directly by patients [27,28], limiting access to those with sufficient means. These models emphasise meeting client-driven expectations rather than system-level efficiency and often provide higher-acuity care – including home-based ventilatory support – than is typically available in high-income settings [29].
HaH: lower cost, lower emissions and liked by patients
Although not appropriate for all patients and all medical conditions [30], HaH services can free up physical hospital beds and reduce the cost and burden on healthcare services [31]. In some Australian states, HaH services account for 5% of all hospital bed-days – the equivalent of having another 500-bed hospital for a catchment of 7 million people [16]. In the United Kingdom, there are 20 HaH beds (also known as ‘virtual wards’) for every 100,000 GP-registered people [32].
HaH care models have several advantages for patients, their caregivers and the broader healthcare system. In high-income public healthcare systems, HaH has been shown to reduce healthcare costs by up to 50%, largely through reduced expenditure on staff, infrastructure and catering [33–35]. During periods of great disruption (e.g., extreme weather, pandemics), where staffing and infrastructure may be stretched, this allows finite public resources to go further and care for more patients. A report on the recent expansion of HaH care in the United States identified significant reductions in 30-day post-discharge Medicare spending compared to bricks-and-mortar inpatient stays [36]. The financial implications of HaH are less clear in LMICs, where HaH services are typically private and paid for directly by patients. HaH results in higher rates of satisfaction with care, not only for patients themselves but often for their families as well [16,37–39]. Importantly, this can be achieved without compromising patient outcomes: HaH services, when applied to appropriately selected cohorts, are associated with rates of hospital readmissions and mortality that are comparable to traditional inpatient care. This holds true across a range of patient groups, including those with heart failure [40], chronic obstructive pulmonary disease (COPD) [41] and individuals presenting with at least one chronic condition [42]. Additionally, HaH models have a carbon footprint that is 4–5 times lower than traditional inpatient care [43].
Given HaH’s increasingly prominent role in healthcare provision, any threats to the viability of HaH will have substantial flow-on effects throughout the healthcare system. Emergency presentations and hospital occupancy surge during heatwaves [10], with HaH providing an important release valve for this build-up of patients. If HaH cannot provide relief for overcrowded hospitals – at the very moment that it is needed most – we risk seeing a compounding of heat’s negative impacts on the healthcare system.
How does heat pose a threat to HaH patients and services?
Patient-related threats
Common HaH diagnoses impacted by heat.
Some of the most frequent clinical syndromes cared for by HaH programs include exacerbations of heart failure or COPD, infections requiring IV antibiotics, and anticoagulation for either the management or prevention of deep venous thrombosis [44,45]. Heat can negatively affect all these conditions – either directly or indirectly – increasing the risk of clinical deterioration, hospital readmission, or death.
Extreme heat places substantial strain on both the cardiovascular and renal systems, and is associated with significant increases in mortality and morbidity [46]. The body’s primary responses to excess heat include redirecting blood flow towards the skin and producing sweat. However, this redistribution of blood increases cardiac workload while reducing ventricular filling pressure, raising the risk of cardiac ischaemia (insufficient oxygen supply to the heart) and heart failure (insufficient pumping capacity) [47]. Concurrently, sweating leads to fluid losses which, if not adequately replaced, can cause volume depletion, further compromising cardiac output, and contributing to acute kidney injury [4]. In the HaH setting, undetected kidney injury heightens the risk of treatment toxicity. Commonly used HaH therapies – such as antibiotics and anticoagulants – require dose adjustment during kidney injury; if this condition is unrecognised or develops rapidly, avoidable drug toxicity may result.
Respiratory disease (such as COPD) is the second largest source of morbidity and mortality following heatwaves [6]. Increased temperatures are associated with higher levels of particulate matter, ozone and nitrogen dioxide – all of which can lead to acute exacerbations of asthma or COPD [48]. Heatwaves increase the possibility of wildfires, which pose significant additional risks to patients with respiratory disease mediated by smoke and associated fine particulate matter [49].
Social and housing factors vulnerable to heat.
Unlike climate-controlled hospitals, patients’ homes may expose them to health risks during extreme heat. Even in countries like Australia with a high prevalence of residential air-conditioning, high running costs mean that two-thirds of people report limiting its use due to financial concerns [50]. Compounding this problem, low-income households are more likely to live in homes that lack energy and thermal efficiency, meaning they are more expensive to keep cool in summer [51]. While no systematically collected or published HaH data is available, anecdotal observation supports these concerns. In Melbourne, Australia, our HaH staff have experienced infrared thermometers no longer working in patient homes in summer due to very high indoor temperatures. Extreme heat may also limit the availability of regular services or informal carers, making discharge to HaH unfeasible – even if typically viable under normal conditions.
Therapeutics-related threats
Common HaH therapies impacted by heat.
Treatment of bacterial infection with IV antibiotics is one of the most common reasons for admission to HaH. To facilitate delivery in an ambulatory environment many HaH antimicrobials are administered via a continuous infusion using a portable device worn by the patient. In ambulatory devices, antibiotics are subjected to ambient temperatures for 12–24 hours, rendering them vulnerable to heat-related instability from prolonged exposure to uncontrolled environments. Currently, antibiotics in infusers are only tested for heat stability at temperatures of up to 32°C for 24 hours [52–54], due to literature (largely from the northern hemisphere) suggesting that drug solutions in infusers worn by patients do not exceed that threshold [55,56]. However, in many parts of the world indoor temperatures may routinely exceed 32°C during summer months, and for infusers this is compounded by the patient’s own body heat [57]. There is a risk that rising extreme heat will render treatments ineffective, causing sub-optimal antimicrobial exposure, and potential treatment failure and increased toxicity from degradation products [53]. Importantly, drug stability is non-linear: degradation accelerates exponentially with increasing heat, with rapid breakdown once critical thresholds are crossed [58].
Common non-pharmacological HaH treatments – such as complex wound dressings – may hinder patients’ ability to cope with extreme heat. A major challenge is limited access to community cooling centres or alternative accommodation during heatwaves, which are central to public health responses [59]. For patients with large wounds, the size, location, and movement restrictions (required for healing) can pose a direct physical impediment. This difficulty is further compounded by negative pressure wound therapy, where a suction pump is attached to the dressing. In addition, patients may struggle to employ personal cooling techniques. Two evidence-based, low-cost strategies – effective even without air-conditioning or during power outages – are self-dousing (applying water to the skin) and extremity immersion (submerging feet or hands and forearms in cool water) [60,61]. Both, however, may be contraindicated in the presence of complex skin wounds.
Operational threats
Operational risks and impacts from heat.
Extreme heat poses an occupational risk to HaH staff members, who are required to work on the road and spend time in the outdoor environment travelling between patient homes. In just five minutes parked at an ambient temperature of 30°C, the inside of a car can heat up to between 57°C and 68°C [62], presenting uncomfortable conditions for staff who visit up to a dozen homes per shift and are regularly parking, alighting and re-entering a car.
Extreme heat may reduce the capacity of HaH services to deliver care – some large HaH services mandate that staff see fewer patients during very hot weather. Additionally, studies show that healthcare staff are more likely to request more time off for caregiving during heatwaves, further depleting workforce capacity [63]. This is consistent with the broader climate change literature demonstrating rises in forced or voluntary absenteeism during climate-related events [64].
In addition to the risks to staff, extreme heat is already necessitating review and modification of equipment and infrastructure used to deliver care. Temperature control during medication transport has been identified as an issue, with medications left in a hot care at risk of exceeding the prescribed range [65]. Some Australian HaH services have already transitioned to powered refrigerated transport boxes (rather than passive insulated carriers) to protect medications from overheating on route to patients’ homes [66].
Potential solutions to protect HaH from impacts of heat
Patient-focused solutions
Fan-first or subsidised cooling.
While air-conditioning can provide fast and effective relief from heat, the aforementioned high running costs limit use. In contrast, fans have minimal running costs and are safe to use up to temperatures of 37°C to 39°C (depending on an individual’s underlying health status) [67]. A fan-first approach involves initially turning on fans as temperatures rise, before turning to air-conditioning. Fan use can make a room cooled to 27°C feel just as comfortable as a room cooled to 23°C without a fan [68], allowing air-conditioning to be set higher and reducing energy use and cost without sacrificing comfort or safety.
During future heatwaves, patients admitted to HaH could routinely be provided with evidence-based cooling strategies from local public health departments, and potentially provided with low-cost, battery-operated, portable fans (ensuring they will still work during power outages) and instructions on how these can be used effectively. This can be supplemented by daily reminders and check-ins from visiting HaH staff. For patients who are able, self-dousing and extremity immersion can be employed.
Additionally, some health insurers or public health coverage programs, like Medicaid in the United States, are assisting vulnerable individuals with the cost of air conditioning in order to protect their health [69]. Expansion of such programs by governments and insurers could help overcome potential barriers to discharge from hospital onto HaH.
Therapeutics-focused solutions
Novel cooling strategies for medicines.
As temperatures rise, novel devices and strategies may be required to ensure that HaH medicines are being kept sufficiently cool, especially those that are given as 12- or 24-hourly infusions. Australian researchers are developing a new vacuum insulated flask to maintain medicine temperatures in a safe range, while also incorporating further design features in response to patient feedback [70].
Alongside cooling of therapies, HaH programs should help generate more real-world data around heat exposure and infuser temperatures during use in hot climates and in heatwaves. This is required to ensure that drug stability testing can then be conducted to reflect real-life use conditions.
Adjusting antibiotic prescribing decisions.
In future climate change scenarios, antibiotic prescribing decisions could potentially be altered during summer months or periods of extreme heat, to give preference to agents that are either more heat-stable or can be given as a brief daily infusion by nurses (rather than a 12- or 24-hourly slow infusion) to reduce the heat exposure of therapies.
Antibiotic prescribers on HaH are already carefully weighing up many relevant factors, such as spectrum of antimicrobial activity, cost, previous adverse reactions, and anticipated side effects – some of which come into conflict (e.g., choosing narrower spectrum despite higher cost) [71]. During periods of extreme heat, the stability of drugs and the feasibility of service delivery may need to be further considerations to be factored in to decision making. These additional, emerging challenges again highlight the crucial role of pharmacists in supporting effective decision-making within HaH teams [72].
Operational solutions
Changing hours and schedules of home visits.
The impact of climate change on workplace heat stress was the focus of a recent combined report from the World Health Organization and World Meteorological Organization [73]. It advocates for rescheduling tasks or entire shifts to cooler periods of the day, where feasible. Moving HaH visits to earlier or later hours of the day may reduce healthcare workers’ heat exposure, however, there may be negative flow-on effects on patient satisfaction and also staffing costs (if rates of pay differ outside of standard hours) and staff availability.
Improved risk stratification and preparedness.
Currently, HaH programs do not formally consider heat risk during their intake assessments. Procedures should be implemented so that HaH services understand the relative heat risk faced by each of their patients (due to factors such as medical history, housing quality, air conditioning access), so that they can easily identify and protect more vulnerable patients during heatwave events. Additionally, HaH programs could prepare for extreme heat events by developing a relevant business continuity plan. This would involve mapping out implications for their staffing, their transportation, their clinical workload and the availability of appropriate resources and supplies. During high-risk periods, HaH teams can also provide vulnerable patients and caregivers with educational materials and practical supports, such as fans (as outlined above in Section 1). Linking HaH services to local or regional heat early warning systems, where such systems exist, can help determine when continuity plans should be activated.
Conclusions
Current and future climate change, and the associated rise in ambient temperatures, will have profound implications for human health and healthcare systems. Climate-driven increases in morbidity and demand for health services will necessitate adaptation of already strained systems. HaH is an established component of many countries’ healthcare systems, providing a key pathway to simultaneously free up physical hospital beds, reduce the cost of care and improve patient experience. However, the viability of HaH is threatened by increasing extreme heat, which can worsen HaH patients’ health, compromise the stability of temperature-sensitive therapies, increase occupational risks for HaH staff, and potentially reduce the accessibility of HaH for disadvantaged patients. We outline potential solutions to these challenges, to safeguard HaH services and bolster healthcare system resilience during extreme heat.
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