A Hospital at Home Program and the Role of the Care Management Team
For many healthcare systems, a hospital at home program was a necessity born out of COVID-19.
At Indiana University (IU) Health, a program that allowed patients to continue treatment and recovery at home after discharge had been discussed before the pandemic, but never put into action. That changed when the pandemic started. They went forward with the program, knowing it was the right time to try it.
“There are other programs that have been doing this longer than we have, mostly because we weren’t yet ready to do it,” says Michele Saysana, MD, vice president, chief quality officer, and chief medical officer for virtual health at IU Health. “There was a bit of resistance to doing it at first because so many wondered, ‘How could we possibly deliver care like this in the home?’”
To qualify for a hospital at home program, patients need a caregiver in the home 24/7. The caregiver must be physically able to assist the patient. Sometimes, this person meets with a physical therapist to determine any mobile barriers that would prevent them from serving as a caregiver. While the patient must be sick enough to qualify for the program, there also are limits on how much oxygen they can use at home. If a patient’s oxygen requirement is too high, they might not be accepted into the program.
As of August 2021, more than 940 patients participated in IU Health’s hospital at home program, which mainly focused on patients with COVID-19 who were discharged early. These patients were sick enough for hospitalization, but were set up with “wraparound support with monitoring, a nursing team, advanced practice providers, and hospitalists” at home to receive a similar level of care, Saysana says.
The hope was to return the patients “to the place where they’re most comfortable recovering, back to family and caregivers, to heal and get better sooner,” she adds.
Launching a program like this during a pandemic was no small feat. “Since it was something new that really started as a response to COVID — and felt rushed to begin with — there was hesitancy all around,” recalls Liz Fulford, MBA, MSN, RN, director of integrated care management for IU Health. “The patients said, ‘Yes, sign me up, get me out of this hospital.’ They wanted to go home, to be back with their families. It required a lot more involvement from families.”
Benefits All Around
Considering the initial 941 patients in the hospital at home program, the IU Health team noted overall greater patient satisfaction than that of inpatients.
Adria Grillo-Peck, MSN, RN, CNS, CMC, vice president of integrated care management for IU Health, explains that for older patients, “getting them home safely with wraparound services” made a huge difference in their experience and contributed to fewer readmissions.
The readmission data confirmed a seven-day readmission rate of 2% for hospital at home COVID-19 patients, while patients not in the program recorded a readmission rate of nearly 7%. They saw the same trend with their 14- and 30-day readmissions.
“We saw that our emergency department visits, too, are lower, at less than 2%,” Saysana adds.
With more available beds, the hospital served more people. “[Hospital at home] allowed us to open up beds for patients who we knew were waiting to get into the hospital,” Fulford explains. “We were also finding that there were not a whole lot of places for patients to go. Acute care couldn’t take some because of their oxygen needs and COVID status, and it didn’t feel safe to just send them home with traditional home care. The hospital at home option offered a safer discharge plan while also opening beds to those who needed them most.”
Keeping patients out of the hospital setting while still providing similar care at home also helped reduce the incidence of other hazards in the hospital experience.
“The longer patients stay in the hospital, the more sad things can happen, like falls,” Grillo-Peck says. “The benefits in having them at home were about attaining great outcomes for patients while also looking at value-based care and care in the most cost-effective manner.”
The patients were not the only ones experiencing positive outcomes from the program.
“It also provided a benefit to the workforce,” said Saysana. “We have nurses with tons of experience from previous years at the bedside who do not necessarily want to continue to work at the bedside. Their experience is invaluable in a program like this — it’s a way for them to provide direct patient care, but it works better for them and their lifestyle.”
Even the communities benefitted from this program, considering how it enabled the hospital to take in more patients who needed a hospital bed.
“As many hospitals were challenged with staffing issues, this was another place where patients could receive safe care at home while we took care of others who are post-surgical or need to be in the hospital,” Saysana notes. “So many people put off surgeries during the pandemic — this way, we were able to bring them back.”
Lessons From Challenges
Success like this does not come without great effort. “It took the involvement of 14 or 15 different departments for this initiative,” Grillo-Peck says. “Everyone had to be on board to make it successful.”
Of course, considering the situation, those departments had to meet virtually regarding the hospital at home program, and only recently met in person.
“We were never in a room together, and many of us had never even met,” Saysana notes. “Still, the team was not to be underestimated. Once we were able to get our heads above water and look up, we started making continuous improvement every day. We met at 3 every afternoon for 30 minutes. It all moved very fast and was very challenging. It wasn’t easy, but we were committed to the patients.”
The program shed light on what happens when patients are discharged. “Seeing what happens when a patient leaves the four walls of the hospital gave us some insight into what the reality is when a patient gets back home,” Saysana says. “They’re tripping over animals, maybe they have no internet, [and more]. There are things we never really knew about before. This experience has exposed challenges we have even in the discharge process.”
Some of those challenges include clearly and meticulously outlining the steps of the discharge plan. The discharge planner needs to think through nearly everything the patient might need since their healthcare experience and outcome depends on it. The caregiver at home also is critical.
“It’s a heavy lift at home,” Grillo-Peck notes. “There are so many things to remember, so making sure that you have an engaged caregiver is really important. They need to know the expectations up front.”
Caregivers might be shocked when they realize how much work goes into caring for a sick loved one at home. Not only that, Saysana adds, but with visitor restrictions during COVID-19, most family members “didn’t always have an appreciation for how sick they were.”
“They dropped their family member off at the ED and didn’t see them for a few days or a couple of weeks,” she says. “Because of that, they didn’t realize what the burden of care was for when they got home. We have to make sure we’re explaining what the [hospital at home] program is and what it isn’t.”
Another drawback is the accessibility of resources in the home. Fulford explains some physicians got creative with home care since they do not always have every necessary item at their fingertips.
The team also noted a final challenge: ensuring patients in the hospital at home setting take their medications, and take them on time.
“When the patient is in the hospital and they don’t take their medications, it’s a safety issue, so we make sure they take them,” Saysana says. “But when patients are in the home, they decide if they’re going to take their medications. COVID-19 patients often have comorbidities, so to not take their insulin is a big deal. We don’t have the same level of control that we have in the hospital. We have to be creative and motivating and know what to do as they make their own choices at home.”
Monitor at Home
According to CMS, hospitals should meet these requirements to participate in a hospital at home program:
- Use appropriate screening protocols to assess both medical and nonmedical factors;
- Schedule daily evaluations, either in person or remotely, with a physician or advanced practice provider;
- Assign a registered nurse to evaluate each patient once daily, either in person or remotely;
- Schedule two in-person visits daily by either registered nurses or mobile integrated health paramedics based on the patient’s nursing plan and hospital policies;
- Ensure the patient has reliable remote audio connection with an Acute Hospital Care at Home team member who can immediately connect the patient with a nurse or physician;
- Respond to a decompensating patient within 30 minutes;
- Track patient safety metrics with weekly or monthly reporting;
- Establish a local safety committee to review patient safety data;
- Using an accepted patient leveling process to determine level of care;
- Provide or contract for other services required during an inpatient hospitalization.1
Adapting the Role of Case Management
Treating patients in the home rather than the hospital requires some slight adaptations to the way the acute care case manager’s role is handled, but the role largely stays the same.
“Once you have a patient who is accepted into the hospital at home program, you really have to make sure all of the discharge needs are met: oxygen, therapy, all of those wraparound services they’ll need to stay safe at home,” Grillo-Peck explains. “But in either case, you’re still working with the interprofessional team to discuss patient needs.”
Fulford agrees, adding that “with the COVID [hospital at home] program, you also need to provide the caregiver with isolation supplies like masks, gloves, and gowns, some of which was hard to find in the beginning of pandemic.”
In addition, “case managers may need to include items in their assessment or in their discussions with family members that they wouldn’t typically have to address, like educating the caregiver on isolation and keeping themselves safe,” she says.
A caregiver assessment for a hospital at home patient typically is more robust than usual since that caregiver must meet certain qualifications to ensure they are physically able to provide care.
Another consideration is the role of social determinants of health. It is not just about the medical diagnosis, Saysana explains. Social workers might be needed to determine any social issues that could affect the quality of care.
A New Perspective
When working with a hospital at home program, case managers can gain new insights into what happens when the patient goes home. With typical discharges, the case manager and patient do not stay in touch. With hospital at home, that connection continues as the acute care case manager remains available to assist in ensuring all the patient’s needs are met.
“It’s a much closer communication loop,” Grillo-Peck says. “When a patient goes to another facility or other home care, we didn’t used to stay much in touch. Now, we’re more aware of what’s happening when they leave the four walls of the hospital. It’s different from a traditional discharge, and it’s definitely opened our eyes to how things could potentially fall apart when people leave the hospital. It’s strengthened our perspective on how our partners are so important.”
Saysana notes it harkens back to the days of house calls. “What I can see in your environment is so much more important than what I see in my office,” she notes. “I see the rug that you might trip over when you lose your balance, or what’s in your refrigerator. I now have a window into the patient’s life.”
“When we can see the home environment, it’s obvious when social workers may need to be more involved,” Fulford adds. “They can identify if a patient doesn’t have the finances to eat the way they’re supposed to be eating in order to recover. We need to learn how to ask more questions to help overcome barriers. Case managers may struggle at first to find the words. But asking questions like, ‘How can we help you be successful at home?’ can help us determine which wraparound services are needed.”
Case managers also can see firsthand how patients attempt to return to regular life after discharge.
“People go home and think they can go back to work,” Saysana says. “We’ll call and can’t reach them because they went to work. This gives you an interesting picture of what patients think they can do when they go home. Some people feel that they have to go back to work, and this can result in ED visits. I never dreamed I’d have a nurse tell me in the morning, ‘Mr. Jones was at work today, on his oxygen.’ It’s something we need to address.”
Making It Work
Creating a hospital at home program is not easy. Flexibility is key to making it work. A successful program relies on honesty, holding tough conversations with patients and caregivers, and clear communication with the healthcare team.
“Don’t be afraid to ask the hard questions,” Fulford advises. “It’s setting the stage for what needs to happen at home. You have to ask, ‘Are you truly going to be the caregiver or are you just saying that? If you’re not able to care for them, then we will need to keep them here for their safety.’ These deep-dive questions can be difficult, and some patients and caregivers don’t always want to let us know about barriers. In either case, you need to educate them on what to expect, and sometimes you have to say the same thing four, five, six times in order for it to be heard.”
Watching the data closely also helps the team change course and adjust the program where needed. “We review all readmissions with the team of clinicians to learn what worked and where to course-correct,” Grillo-Peck explains.
There is no shame in humbly adapting a hospital at home program, even if it means admitting the initial plan was not the best way.
“The way you design it is not how it will end up,” Saysana says. “Expect to learn from patients along the way and know that just because you change things doesn’t mean you failed. We are learning and growing. Making changes doesn’t mean that the program doesn’t work. When you’re committed to making it work, you’ll always see continuous improvement.”
- Centers for Medicare & Medicaid Services. Acute Hospital Care at Home program. April 5, 2021.
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