Why the Hospital-at-Home Model is a High Priority for ChristianaCare

July 26, 2023 - Though hospital-at-home programs are becoming more widespread, implementing and sustaining one comes with numerous challenges.

The challenges of deploying these programs can range from developing new clinical workflows to social determinants of health issues, like internet connectivity. But the benefits of these programs, such as their ability to lower readmission risk and healthcare costs, appear to outweigh the challenges.

Hospital-at-home programs have been growing across the country since the launch of the Acute Hospital Care at Home waiver in November 2020. The waiver enables hospitals to furnish acute, hospital-level care in Medicare beneficiaries' homes. As of July 12, 290 hospitals across 37 states have been approved for the waiver.

Newark, Delaware-based ChristianaCare is one such health system, having launched its hospital-at-home program in December 2021 after receiving waiver approval in June 2021.

"We just want to serve our patients where they are, wherever that is," said Katie Muther, RN, director of nursing and strategic partnerships at ChristianaCare's Center for Virtual Health. "And home is, a lot of times, where you are when you're sick. So, bringing hospital care to our patients at home is a high priority, and we want to do that for as many patients as possible in our community."

Earlier this year, ChristianaCare was recognized with a Performance Excellence Award for Most Wired's acute and ambulatory categories. This recognition highlighted the launch of the health system's Hospital Care at Home program, which has thus far cared for more than 500 patients.

In an interview with mHealthIntelligence, Muther detailed the hospital-at-home program, implementation challenges and strategies for success, and the benefits reaped from the program since its launch.

HOW THE PROGRAM WORKS

ChristianaCare's hospital-at-home program grew from a longstanding dedication to digital transformation, according to Muther.

"At Christiana Care, we're really trying to break the mold and do something different using not just the standard encounter base over and over. You see your doctor; you go to the hospital; nothing is connected," she said. "Instead, we want to leverage digitally enabled care across the continuum."

The hospital-at-home program is one of the health system's many digital healthcare endeavors. Following an evaluation, the program admits patients from the emergency room or inpatient units. The evaluation, conducted by clinicians, determines whether the patient fits the criteria for the program.

"We evaluate them clinically — do they meet certain criteria to be cared for safely at home?" she said. "And then we also have a nurse reach out to them and work through a social stability screen. Is their home safe enough for them to be [able to receive care in their home,] because you have to make sure that they have running water, electricity, those types of things. And not everybody has that."

Once patients are deemed eligible, they are transported back home, where treatment begins. Clinicians put in the necessary orders for laboratory tests and other ancillary services, Muther said. The care team, which includes advanced practice providers, physicians, nurses, and paramedics, examines the patients in their homes and via telehealth.

Patients are provided with a tablet and telephone to communicate with their care team and their patient digital ambassadors, who help them navigate technology issues and support their journey through the program, Muther said.

In addition, patients are given access to numerous devices. These include Bluetooth-enabled devices to measure vital signs, such as blood pressure cuffs and thermometers, that connect to the tablet, Muther noted. They also have a personal emergency response system (PERS) that comes in the form of a wrist-worn device and call bell placed near them, which they can press if they need somebody from the health system urgently.

ADDRESSING IMPLEMENTATION CHALLENGES

Implementing the hospital-at-home program at ChristianaCare was not without its challenges, especially given that the health system undertook the implementation amid the pandemic and related public health emergency (PHE).

"The hospital side was very challenged with staffing and nurses and all of that," Muther said. "So, we had a very dedicated team, and we worked really hard to find the right people to work in this space."

Having a dedicated team for the program is critical because setting up an at-home hospital is much like raising a hospital from the ground up, sans bricks and mortar, she noted. It requires significant resources, including numerous caregivers, services, and technology.

"You're creating another hospital, and you need all the infrastructure just like you would in the hospital…And so you don't want to underestimate the amount of work and resources that you need," she said.

ChristianaCare hired more nurses and contracted with external companies to fill their staffing and technology needs.

Further, the health system created the patient digital ambassador role to help alleviate digital health literacy issues, which can adversely impact a patient's ability to participate in remote patient monitoring (RPM) programs like at-home hospital models.

Another major challenge was organizing the in-home support portion of the program.

"At Christiana Care, we partner with external folks to help us do some of this…We have lots of resources out there in this community, and we were able to leverage those connections to help care for these folks," Muther said.

Additionally, the hospital-at-home team partnered with the health system's paramedics team to support the in-home services provided through the program.

WHAT'S NEXT FOR CHRISTIANACARE'S AT-HOME HOSPITAL

According to Muther, the benefits of the program have been wide-ranging. One of the most significant has been a leap in patient satisfaction.

"[Patient satisfaction] is through the roof," she said. "We just looked at it in our staff meeting, and we pulled up some most recent NRC comments — we survey patients after they're discharged — and those comments were just amazing: 'I'm going to share this with everybody I know, all my neighbors; everybody should be able to have the option of being cared for in their home.'"

The health system also tracks numerous measures to assess patient outcomes. They found that the program has reduced hospital-acquired infection rates and readmissions to inpatient units and the emergency department.

ChristianaCare has plans to grow the program. It is currently being offered in the northern region of Delaware, but the health system aims to bring it further downstate. It also plans to grow the number of patients cared for through the program at a given time.

"We started with one patient, you know, you have to start with one," Muther said. "And then we moved to two patients and three patients, and now we're up to 10 patients at a time at home. Actually, today we have 12 patients at home, and we're pushing that. So, we're hiring more nurses, hiring more paramedics, working with new contracts within the community."

The health system has monthly and annual goals for growth, including caring for 25 patients at a time within the following year.

Fueled by the CMS waiver, hospital-at-home programs provide health systems with an exciting opportunity for digital transformation, and ChristianaCare is embracing it with arms wide open.   

"It's been an exciting project, and I would say, a program that we're going to do forever because home is the new venue of care here at ChristianaCare," Muther said.