Background: Constraints on resources require healthcare systems to implement alternative and innovative means for delivering care. The COVID-19 pandemic amplified this issue throughout the world, leading to shortages of ventilators, hospital beds, and healthcare personnel. We report the results of an Acute Care at Home (ACH) program’s response to COVID-19, providing in-home hospital-level care to patients with stable, acute symptoms, preserving in-hospital beds for more serious illness.Patients with COVID-19 are selected for ACH after undergoing risk stratification for severe disease, including oxygen evaluation, time course of illness, and evaluation of comorbidities. Patients admitted to ACH require oxygen supplementation of ≤4 liters, meet InterQual® inpatient criteria, and receive insurance approval. In addition, patients are screened for a suitable home environment. Services are provided consistent with best practice of inpatient care, including 24/7 provider availability via Telemedicine. Bedside care, such as physical assessments, pulse oximetry and medication administration, is provided by advanced practice providers, paramedics, and nurses, along with radiology and laboratory services. Protocols exist for patient transfer to hospital in the event of clinical deterioration.
Methods: ACH management of COVID-19 patients has been in place over a year. This is a descriptive study of the program, with retrospective data collected on the patients from October 1, 2020 to November 15, 2021. Demographics information, health history, disease progression and treatment were evaluated. Outcomes assessed include ACH length of stay (LOS), transfer to hospital, complications, and mortality. This project built on a previously presented cohort which included the first 61 patients of the program.
Results: A total of 120 patients were admitted to ACH for COVID-19 care during the study period—68 directly from the ED, and 52 after an initial stabilizing hospital stay of 5.6 days, on average. A low-moderate Charlson Comorbidity Index mean of 3.4 indicates these patients had some underlying conditions, but were primarily not high risk. Overall mean ACH LOS was 4.5 days; 4.2 days for patients admitted from ED, and 5.1 days for those admitted from inpatient hospitalization. Of the total cohort, 107 (89.2%) were discharged from ACH in stable condition. Thirteen patients (10.8%) were transferred to the hospital for lack of improvement, worsening symptoms, or complications related to underlying conditions. Of these, 2 returned to ACH after stabilization, 9 were discharged home, one went to inpatient rehab, and one patient expired during admission. One patient who was discharged after 14-day hospitalization, then 7-day ACH, was readmitted and expired within 30 days. Both mortalities involved patients who were immunocompromised at baseline.
Conclusions: Acute Care at Home is an effective substitute for traditional inpatient hospital care for patients with stable acute COVID-19 illness. This study illustrates that hospitalist home management of these patients with standard treatment protocols can be safe and appropriate. A thorough patient screening process is paramount to positive outcomes. ACH preserves inpatient hospital beds and allows infectious disease specialists to focus on the more seriously ill. Future research should evaluate the financial impact of this care delivery model on the healthcare system.