Background: Hospital at home (HaH) programs have provided critical inpatient-level care to acutely ill patients throughout the COVID-19 pandemic.1 Despite the documented benefits2-5, referral rates for HaH often mirror capacity demands. The pattern reflects implementation barriers including the tendency to default to usual care and time constraints.6 Continued success of HaH hinges on the question we are addressing in a 2-year implementation evaluation of Atrium Health’s HaH program (REACH-IT; Realizing Equitable and Accessible Care Through Hospital at Home Implementation and Testing): How do we sustain consistent referrals when capacity urgency is low?
Methods: We report a retrospective cohort study of Atrium Health HaH (AH-HaH) weekly Physician Connection Line (PCL) call data from 1/1 – 11/18/2021. Referrals consist of patient transfer to AH-HaH, patient refusals (data starting 8/15/2021), and physician consults (no transfer due to unmet eligibility criteria or questions in patient management).
Results: Patient transfers to AH-HaH fluctuated, with increases in capacity constraints reflecting COVID-19 surge in the system (Figure 1). Referrals were lowest in the first week of March, 1 year after program launch. Following each surge, referrals stabilized, creating a new baseline, and highlighting increased acceptance and utilization of the program over time. Sustained referral frequency was partially due to decreased physician consults and patient refusals. In weeks 13 and 14, physician consults were more frequent than patient transfers. Consults decreased significantly in the last 6 weeks. Patient refusals also consistently declined throughout the study period.
Conclusions: Referral data highlight the following lessons learned to sustain consistent referrals:1. Remove barriers to referrals: Proactive evaluation of overnight admissions, conducted early in the shift allows providers to evaluate patients for AH-HaH eligibility, leading to less confusion about patient eligibility. Conduct scrubbing early in hospitalization to combat the tendency to toward usual care patterns and interject a new support service in a way that is more acceptable to providers and fits more easily in their workflows. 2. Consistency and workflow ease facilitates provider understanding of eligible patients and a shift towards sustained referrals with decreased consults for ineligible patients and patient refusals. 3. Provide high quality service that generates patient satisfaction and positive press: AH-HaH providers are noticing an increase in patients asking to be referred. We suspect this is due to high satisfaction rates recorded in our REACH-IT implementation evaluation.