Background: In 2020 due to the COVID-19 pandemic, the Centers for Medicare & Medicaid Services approved the Acute Hospital Care at Home Waiver allowing hospitals to be reimbursed for hospital-level care for patients in their own home. Almost 300 hospitals across 37 states have been approved to launch their own Hospital at Home (HaH) programs. Our state has the fewest hospital beds per capita in the US and novel ways to expand capacity to meet demand are urgently needed. In November 2021, our organization implemented a HaH program to address these capacity constraints while providing patient-centered care.
Purpose: Implementing a HaH program in response to urgent capacity constraints requires innovation and continuous process improvement. We describe our experience with implementation and provide guidance for embarking on this journey.
Description: HaH provides inpatient-level of care with continuous nursing and physician oversight via telemedicine. Technology and necessary supplies, including medications, are delivered to the patient’s home and clinicians deliver hands-on care as needed. In the initial model, HaH telemedicine duties were folded into the responsibilities of our on-service hospitalist teams. Initial admission diagnoses were limited to a predetermined list of common conditions (heart failure, cellulitis, etc.). The first patient was enrolled on the 25th day of the program. Patient enrollment increased to 19, 42 and 82 at 100, 200 and 300 days, respectively. To date, we have had over 450 admissions, with a total of 3196 patient bed days, resulting in 492 additional admissions in the physical hospital. Using a rapid cycle improvement approach, adjustments were made within the first year of the program to incorporate lessons learned. Hospitalist engagement varied in telemedicine adoption, and we recognized that considerable provider time is required to identify patients who are eligible which limited engagement. We added a dedicated virtual hospitalist and underwent an internal recruitment process to solicit interested hospitalists. First patient enrollment to the program took several weeks. In response, we removed the admission diagnosis restrictions. Now all patients are considered and screened for whether their individual care needs can be met by HaH. This individual patient needs approach to drive programming allowed for other innovations as well. In early 2022, our region faced severe outpatient dialysis nursing staffing shortages leading to significant prolonged delays in hospital discharges. By leveraging HaH, these patients were able to transfer their inpatient care to home while still returning to our inpatient dialysis unit three times a week. This resulted in capacity for 167 additional inpatient admissions in 6 months. Additional expansions to the original model included the addition of TPN and tube feeds, incorporation with our inpatient addiction team to allow patients with substance use disorders to be enrolled in the program, and partnering with a nearby hotel to provide housing for patients out of service areas.
Conclusions: Implementing a HaH program has been a successful mechanism that we have deployed to address our capacity crisis. Contracting with a commercial vendor allowed us to launch our program quickly. Early and ongoing flexibility was key, and led to rapid adjustments that allowed us to adapt to specific patient needs. The change for opt-in participation of staff created a group of dedicated clinicians that bring critical support and advocacy of this innovative care model.