Background: Hospital-at-Home (HaH) is a novel care model providing inpatient care for patients in their home through a combination of home visits and virtual care. Advanced Care at Home (ACH), UNC Health’s HaH program, launched in 2021, has facilitated over 2,000 admissions to date. The majority of HaH care is provided under the terms of the CMS Acute Hospital Care at Home (AHCAH) waiver issued in November 2020. This waiver removes the Medicare hospital condition of participation requiring 24-hour and seven-day-per-week onsite nursing. Among the stipulations of this waiver is that HaH patients can only originate from a hospital emergency room (ER) or hospital bed; patients cannot be directly admitted to HaH from home or a clinic. Bronchiectasis exacerbation is a diagnosis that can be well managed in HaH. IV antibiotics can be started, cultures and drug levels can be monitored, and airway clearance can be supported. UNC is a large bronchiectasis center and traditionally has directly admitted these patients when they require hospitalization. In the current hospital-capacity crisis, these direct admissions have become significantly more challenging, causing delays in necessary care.
Purpose: We aimed to use ACH as a solution to the bronchiectasis patient direct admission challenges. This needed to be accomplished while ensuring they were appropriate to get their care in HaH, meeting the requirements of the AHCAH waiver and minimizing the time spent in the brick & mortar hospital (B&M).
Description: A team was assembled with representatives from ACH, the outpatient pulmonology team, patient placement, and the bed coordinator for medicine admissions. A pathway was created to facilitate consistent coordination between these stakeholders. Once the outpatient pulmonologist determines that a bronchiectasis patient needs admission, ACH is introduced to the patient if meeting payor and service area. If the patient expresses interest, the physician refers the patient to ACH and writes a detailed treatment plan in the medical record. The ACH physician reviews the patient for their waiver-mandated clinical screen, and if appropriate, advances the patient to the ACH admissions officer. The ACH admissions officer calls the patient to discuss the program, conducts the waiver-mandated social screen and consents the patient. If the patient accepts, they are instructed when to present to the ER the next day. Their transportation home and ACH admission are prescheduled for later that day. On arrival to the ER, the ER physician implements any orders that needed completion before transport home (such as an initial tobramycin dose and level check), and a B&M hospitalist completes the waiver-mandated in-person assessment. If still clinically appropriate, the patient is transported home via the pre-scheduled transportation and on arrival home is met by an ACH paramedic for equipment installation. Once set up, the ACH hospitalist has a virtual admission visit with the patient, enters admission orders and completes an H&P. To date, ACH has successfully cared for 13 bronchiectasis patients.
Conclusions: This pathway demonstrates successful screening and arrangement of HaH before patients present to the B&M hospital, while still meeting the requirements of the AHCAH waiver. This tool can assist hospitals confronting capacity constraints to provide a better experience for patients and expedite their evaluation for bronchiectasis or other conditions.
