(Management Case Study) Hospital Without Walls — A Community Hospital Inpatient Pharmacy Perspective in a Hospital at Home Model

Purpose: COVID-19 brought unprecedented strain to the United States healthcare system. To address future and current shortfalls, the Centers for Medicare and Medicaid Services (CMS) has issued new rules and waivers to ensure hospitals can absorb and manage potential surges in patients. A notable waiver being “CMS Hospitals without Walls,” a flipped healthcare system where the patient brings the hospital home. CMS requires significant planning before giving full approval and reimbursement for this program. A hospital must demonstrate the ability to provide the same level of pharmacy services to patients within this program.

Methods: A multidisciplinary team and pharmacy department leaders coordinated workflows and roadblocks on a path towards a hospital care at home program. A pilot program began with the first patient seen in May 2021.  Four disease related groups are included in the pilot: urinary tract infection, cellulitis, congestive heart failure, and pneumonia. Pharmacy leaders planned and implemented a successful pharmacy services structure to care for patients in this new setting.

Results: Planning and workflows were designed for the various care services required by CMS.  Once a patient is identified as a hospital care at home (HC@H) candidate, the provider releases orders to the pharmacy. Pharmacy coordinates a medication reconciliation interview and sends orders to the provider. A med box with unit dose packaging is delivered daily to the patient’s residence during routine care visits. Intravenous infusion medications that can be given via push, piggyback or elastomeric infusion devices are administered by RNs or community paramedics.  Utilization of the five rights of medication administration and barcode administration helps prevent errors and ensure proper dosing to each patient.  Workflows within this program’s pharmacy services closely match current inpatient pharmacy workflows.

Conclusion: As of March 2022, there are currently only 109 hospitals across 29 states approved by CMS for the hospital at home program. Evaluation, planning, and implementation of this non-traditional healthcare strategy requires a large time commitment from many stakeholders. An engaged pharmacy team is an important key to the success of a Hospital without Walls program in service to patients.