Background: “Hospital at Home” (HaH) models of care have existed for over 20 years in the U.S. Demand for healthcare value, advances in relevant technologies, and the ongoing global pandemic have driven renewed attention to HaH models, by way of policy-based and academic pilot programs – and even commercialization attempts. Where studied, these models have had desirable impacts on readmission rates, adverse events, patient experience, and cost. Despite this, adoption and scaling of HaH models has remained difficult due to multiple factors: complex logistics and supply chain management, challenging clinical workforce coordination, and paucity of workable payment models.
Purpose: To innovate and scale a hospitalist-led model to provide safe and high-quality Advanced Care in patients’ homes.
Description: DispatchHealth has built an in-home medical practice model in more than 50 U.S. cities utilizing mobile teams of emergency physicians, advanced practice providers, and EMTs. While these teams provide a broad range of diagnostic and therapeutic services, 6% of patients seen require escalation to the Emergency Department (ED), and 75% of those are admitted to the hospital. Our innovation, called Advanced Care, leverages existing DispatchHealth practice infrastructures to support enhanced in-home care capabilities. Within 9 cities with a DispatchHealth presence, we built clinical teams consisting of hospitalist physicians, hospitalist-trained APPs, operations leaders, and nurse navigators. We designed standardized clinical work-flows and built processes for managing complex logistics (such as deploying just-in-time imaging, point of care mobile labs, IV medications, and supplemental oxygen). We initially developed evidence-based risk stratification protocols around 6 common clinical conditions: COPD, CHF, pneumonia, cellulitis, complicated UTI, and electrolyte abnormalities. We have since expanded our scope to treat over 40 DRGs. We utilize MCG criteria and payer utilization review to demonstrate inpatient level-of-care necessity. We have treated over 550 patients. 85% of our patients have been over 65, and carry an average Charlson Comorbidity index of >5 (highest risk category) and have an average 6.8 chronic comorbid conditions at the time of our episode. The care model consists of twice-daily nursing visits and once-daily hospitalist visits during the acute illness, followed by an extended period of post-acute remote nursing oversight. Our model has co-evolved with payer partners during a deliberately measured roll-outs. Tracked metrics include patient experience (NPS +97), care-associated adverse event rates (< 1%), ED escalation rates (~4%), 30-day readmission rates ~8%), and medical cost savings ($5000-$7000 per patient). Since launch, we have expanded our service lines in co-evolution with our partner needs, to also offer post-acute transitional care solutions and skilled nursing facility substitution in the home.
Conclusions: While providing advanced levels of care inside patients’ homes has shown promise, models to do so as an alternative to inpatient admission have proven difficult to adopt and scale. Hospitalists are uniquely positioned to design, lead, and innovate in providing advanced care in the home. Our model leverages an existing mobile in-home practice infrastructure to identify and treat medically complex patients. Co-evolution with payer partners has facilitated the expansion of this program to offer patients safe, effective, health care solutions in their home.