As the pandemic continues, some healthcare facilities worldwide are providing acute care to patients in their homes. This is a necessity in places where the health systems have been overwhelmed. In other places, it is a way to provide care that might even be safer for certain medically stable patients.
“The Centers for Medicare & Medicaid Services calls it Hospitals Without Walls,” explains Chrissy Finn, RN, BSN, MSN, director of InterQual Content Products at Change Healthcare in Nashville, TN. “It was something that was initially trialed in the United Kingdom. They looked at cardiac heart attack patients initially, and it’s something that quickly gained traction.”
Australia implemented a hospital at home program that affects a small proportion of its overall hospital days, she adds.
Screen for Eligibility
Physicians, nurses, case managers, and other team members can screen patients for hospital at home eligibility and handle transitions of care. “Hospital in the home is just starting to gain traction here in the United States,” Finn says.
Early research showed this acute care model can increase patient satisfaction and decrease nosocomial infections.
The pandemic has played a role in bringing this model to more people’s attention. “In the COVID-19 pandemic, hospitals are looking at how to manage keeping older and sicker, frail patients out of the hospital, where they could come into contact with COVID,” Finn says.
Managing them in the safety of their homes is an option that has been explored by hospitals around the world. “And how do we manage COVID patients who have a longer length of stay [LOS]?” she asks.
Once a COVID-19 patient is stabilized, but perhaps needs a longer course of intravenous treatment, they could be managed at home, as long as they are stable. “People are looking at hospital in the home as a LOS reduction tool,” she adds.
When patients are sick with the disease, they need the hospital’s acute care setting. But once they are stable, they could be a candidate for hospital at home with its close monitoring and intermittent nursing visits. Some organizations have moved in that direction.
“Certainly, the pandemic has forced us all to think creatively about how to best manage patients and where we’re at from a technology standpoint,” Finn says. “It’s opening doors and making a lot of things possible that were not possible before.”
Post-baby boom populations also are more interested in alternative models for acute care. “I think people in my generation, and I’m in my 40s, really don’t want to go to the hospital,” Finn says. “I want to stay in the comfort of my own home with my bathroom. It’s promising that healthcare is trending in this direction.”
Funding this type of care model is one crucial issue. “The biggest barrier is the payment component. We need a reimbursement model for it,” Finn adds.
Patients who would traditionally be managed on an acute care floor in a hospital are provided the same level of care in their home. Typically, patients have presented to the emergency department or a primary care provider with a medical complaint. Then, based on their clinical stability, the suitability of their home setting, and their condition, they could be triaged into the hospital at home model.
“Do they have electricity, a caregiver? How easily can we get them set up with this technology?” Finn asks. “[Providers] make sure patients have adequate bandwidth to hook up to remote monitoring, and they arrange nursing visits, physical therapy visits, lab draws, medications, linen, and a bed.”
Even meals can be provided in the home setting. “Some of our local customers were starting a hospital-in-the-home pilot program in 2017,” Finn says. “They were utilizing the level-of-care screening guidelines we have to support their pilot to make sure they were truly admitting acute-level patients to the pilot program.”
They wanted to compare outcomes, and used InterQual’s criteria to support the pilot’s screening process, she adds.
“We released hospital in the home screening guidelines in 2018,” Finn says. “Our content is to look at who belongs in the hospital and who doesn’t, and to make sure we are admitting patients on severity of how ill they are and the intensity of services we provided as part of their hospital stay. We provide guidance or a framework to make sure they look at all these components,” Finn says. “Did they appropriately screen the patient? Is the patient stable enough to be managed in the home setting? Does the patient agree to participate?”
They also ensure the patient’s level of service is appropriate for a home setting, based on clinical findings and the physician’s orders.
“The future of hospital in the home will be based on setting up programs and protocols and following those steps to make sure you’re admitting the right patients to your program,” Finn says. “You have to follow discharge protocols to see when patients might be ready to enroll in a hospital in the home program, or when they are ready to be discharged from the program once they’re in one.”
It is not a fit for every patient who meets the criteria. “If you have a patient who lives alone and is highly anxious, they might not want to sign up for this program,” Finn says. “The best way to describe it is that you have the ability to be in your own home, be comfortable sleeping in your home with your own pillow, have your own private bathroom, and being with your family on a day-to-day basis.”