Background: “Hospital at Home” (HaH) models of care have existed for over 20 years in the U.S. Recent demand for healthcare value and advances in relevant technologies have driven renewed attention to HaH models, including from the Center for Medicare and Medicaid Services (CMS), and have spawned several pilots within the U.S. Where studied, these models have had desirable impacts on readmission rates, care-acquired adverse events, patient satisfaction, and cost. Despite this, adoption and scaling of these models remains difficult due to a number of factors: complex logistics, cumbersome supply chain management, coordinating the appropriate clinical workforce, and lack of a workable payment model.
Purpose: To create and deploy a sustainable and scalable model for hospitalists to provide safe and high-quality advanced care in patients’ homes.
Description: DispatchHealth has built an in-home medical practice model in more than 15 U.S. cities utilizing mobile teams of emergency physicians, advanced practice providers, and emergency medical technicians. While these teams provide a broad range of diagnostic and therapeutic services, 6% of patients require escalation to the Emergency Department (ED), and 75% of those are admitted to the hospital. Our innovation, called AdvancedCare, leverages existing DispatchHealth practice infrastructures to support enhanced in-home care capabilities. Within a city with a DispatchHealth presence, we built a clinical team consisting of hospitalist physicians, hospitalist-trained APPs, an operations leader, and a nurse navigator. That team designed standardized clinical work-flows and built processes for managing complex logistics (such as deploying just-in-time imaging, IV medications, and oxygen). We developed evidence-based risk stratification protocols around 6 core clinical conditions: COPD, CHF, pneumonia, cellulitis, complicated UTI, and electrolyte abnormalities. We paired risk assessments with MCG criteria to demonstrate level-of-care necessity. The care model consists of twice-daily nursing visits and once-daily hospitalist visits during the acute illness, followed by a 14-day period of post-acute remote nursing oversight. Beginning in mid-November 2019, we aligned with a single payer partner for a deliberately measured roll-out. While we projected a patient volume of 2 patients in the first 30 days, we on-boarded 3 patients in the first 12 days of service. 1 additional patient was evaluated but fell outside of risk stratification parameters. Conditions treated to date are COPD with pneumonia, COPD exacerbation, and hyponatremia. All 3 patients have successfully transitioned out of the acute illness phase. Tracked metrics include length of stay, patient satisfaction, care-associated adverse events, ED escalations, readmissions, and cost of care. Average length of the acute phase for the first 3 patients was 3.3 days. Anecdotal satisfaction from patients and caregivers has been highly positive and the measured net promoter score (NPS) +100. Since launch, we have partnered with an additional payer to begin patient care in December 2019.
Conclusions: While providing advanced levels of care inside patients’ homes has shown promise, models to do so have proven difficult to adopt and scale. Hospitalists are uniquely positioned to design, lead, and provide advanced care in the home. Our model is unique in that it leverages an existing mobile in-home practice infrastructure to identify and treat appropriate patients.