Addressing Hospital-at-Home Implementation Hurdles

April 21, 2023 - With the advent of virtual care technologies, healthcare has increasingly become available outside the four walls of the hospital. One of the significant ways this has been accomplished is through hospital-at-home programs, where hospital-level acute care is provided in patients' homes.

Though the concept has been around since the mid-2000s, providers have embraced the model en masse in the past few years, particularly amid the COVID-19 pandemic. The in-person care constraints imposed by the pandemic prompted the Centers for Medicare & Medicaid Services to launch the Acute Hospital Care at Home initiative in November 2020. As of March 20, 277 hospitals in 37 states were participating in the program.

The Ohio State University Wexner Medical Center (OSU Wexner) joined the ranks of hospitals offering hospital-at-home programs earlier this year. It is the first health system in central Ohio to be approved for the CMS initiative.

OSU Wexner launched the program on Jan. 4. In an email interview with mHealthIntelligence, Christy Murdock, director of post-acute operations at the health system, shared the reasoning behind the decision to launch the program.

First, OSU Wexner wanted to differentiate the services offered by the health system and "develop an innovative care model for the future," she said. Second, the organization wanted to improve care outcomes and patient satisfaction. And third, OSU Wexner hoped to free up inpatient bed capacity and reduce emergency department (ED) boarding.

But as with any program implementation, this one, too, came with its share of challenges and lessons learned.

HOW THE HOSPITAL-AT-HOME PROGRAM WORKS

The first step in the program is selecting the right patients. Murdock said that the OSU Wexner team reviews the medical charts of patients within the hospital's geographic service area and identifies those who qualify. Additionally, patients can be referred to the program by care teams.

"Once we've determined the patient is a good fit for the program, we discuss with the patient and gather their consent," she said. "The team then arranges for transport home and any other items that are needed in the home."

An in-home care team conducts an initial visit with the patient. After that, patients receive at least two in-home visits by care team members daily and a remote visit with a physician. Patients can also connect with their care team through a 24/7 command center. Remote patient monitoring (RPM) technology supplied to the patients automatically connects to the command center, transmitting relevant data.

Following discharge from the hospital-at-home program, patients receive 15 more days of home-based transitional care.

"Patients are contacted virtually each day to identify any post-discharge needs, ensure no acute medical issues go unnoticed, and support a smooth transition to their outpatient providers," Murdock said.

For any further at-home care needs post-discharge, OSU Wexner collaborates with in-home medical services provider DispatchHealth.

OVERCOMING IMPLEMENTATION HURDLES

The implementation of the hospital-at-home program was a cross-team collaborative effort.

"We worked with individuals from more than 30 departments to launch the program and, by getting them involved early in the process, had great engagement and support throughout our implementation," Murdock said.

But the program design proved challenging. New clinical workflows had to be developed for in-home care delivery, including workflows for identifying and moving patients home, providing in-home care and ancillary services, and moving patients back to the hospital if their medical needs escalated.

Developing these workflows involved an open dialogue among various stakeholders, as the workflows needed for hospital-at-home care could deviate significantly from those used in-hospital, Murdock said.

Through a series of meetings and conversations, the key stakeholders decided on at-home care processes that worked for all involved. Murdock also noted that hosting simulations and tabletop demonstrations to refine workflows and discussing worst-case scenarios to develop mitigation strategies was helpful.

Additionally, OSU Wexner tested workflows with small numbers to ensure efficacy as well as good patient experience.

One of the more complex workflows to develop was pharmacy services. This was due to state regulations, Murdock said. The hospital worked closely with the Ohio Board of Pharmacy to ensure the program met all requirements.

Other challenges to implementation included provider engagement and technology workflows, Murdock noted.

To boost awareness and engagement, the hospital provided education on the program and its benefits to its clinicians. And hospital-at-home program leaders worked closely with IT to ensure the technology infrastructure could support this type of care delivery.

"We worked closely with our IT team to incorporate a new virtual hospital floor service within the Epic EHR system to ensure the workflows remain consistent and documentation was seamless during the transition into the home," Murdock said. "Being able to properly identify these patients as unique in the system but also keep many longstanding workflows was challenging but successful."

PROGRAM BENEFITS

Previous research has been largely supportive of hospital-at-home models. One 2021 study shows that patients in hospital-at-home programs had similar mortality risk, a 26 percent lower readmission risk, and a lower risk for admission into a long-term care facility compared with their in-hospital counterparts. But on the other hand, hospital-at-home program participants had an average length of treatment that was 5.4 days longer than in-hospital patients.

Though OSU Wexner has yet to conduct research on its program, Murdock noted that the model has been well-received among patients.

"When we introduce this program to patients, most are excited about the prospect of getting home early," she said.

In addition, providing care at home allows providers to pinpoint care gaps — such as whether patients are adhering to their medication regimen — and close them.

Another significant benefit of the program is that it has helped the hospital manage resources more efficiently.

"Providing inpatient-level care in the home has allowed us to free up inpatient bed capacity and improve accessibility for acutely ill patients needing the resources of an inpatient, brick-and-mortar hospital," Murdock said.

The 15-day transitional care period following discharge from the program has also helped prevent unnecessary ED visits and readmissions, she added.

Looking back at the implementation and launch of the program, Murdock has a few words of advice for providers looking to establish hospital-at-home services. She recommends that provider organizations develop a rigorous process to identify eligible patients and maintain the same level of expectations for hospital-at-home quality and safety with integrated reporting to ensure consistency.

But above all, providers must be flexible and agile as they go through the implementation process.

"Understand that, even with all your planning, there will be things you didn't think of when you launch your program," Murdock said. "Workflows will need to be updated, and new ones may need to be developed. Keeping your key stakeholders engaged throughout the process will allow you to work through any issues in real-time and ensure the safety of your patients and continued success of your program."