(Management Case Study) Sick Enough to Stay Home: Trailblazing Acute Hospital at Home

Purpose: The global pandemic and local severe nursing shortages require reinventing the traditional inpatient hospital care model. A large, multisite healthcare organization obtained a Centers for Medicare and Medicaid Services (CMS) waiver to provide Acute Hospital at Home (AHH) services to appropriate patients utilizing a multidisciplinary, remote model of care. Our goal is to provide comprehensive, inpatient care within the patient’s home for waiver-eligible patients across the 18-hospital health system. During the height of two Covid-19 surges between 2021 and 2022, AHH services decanted the inpatient hospital units and admission to the program is increasing.

Methods: Remote nurses review patient eligibility for admission to AHH.  Interested, eligible patients are accepted by the attending physician, and transported home by paramedics.  Secured, web-based messaging alerts the entire AHH care team of the admission for coordination of care.  Live admission teleconferences include the patient, family, and paramedic within the home and remote pharmacists, prescribers, and nursing for an interactive and comprehensive admission visit. The pharmacy team provides the same level of care for AHH patients as inpatients.

Initially, our home care services managed all medication ordering and distribution while clinical pharmacy specialists at two community hospitals provided the clinical pharmacy-related services.  Inefficient, complex, manual transcription from the inpatient electronic health record into the home care dispensing system led community hospital pharmacies to absorb the dispensing responsibilities. This includes medications and necessary ancillary supplies with the exception of medications requiring administration via infusion pump.  AHH medications are prepared and labeled according to the Board of Pharmacy’s outpatient labeling requirements, packaged for delivery, then transported to the patient’s location.  Patients are billed via medication administration during remote visits.  Controlled substances are filled via electronic prescribing to retail pharmacies due to technological and reporting constraints. Dispensed medications are collected and destroyed upon patient discharge.  Patient bills are reconciled post-discharge for accuracy.

Results: We applied for the CMS waiver in November, 2020 and received approval April 15, 2021.  State outpatient labeling requirements apply to AHH, necessitating new policies and standard operating procedures. Admitting diagnoses and the number of admitted patients were capped during our pilot phase with the expansion of both as the proof of concept materialized. As of this writing, AHH admitted 238 patients with a lower than budgeted adjusted length of stay. Primary admission diagnoses include COVID-19, congestive heart failure, chronic obstructive pulmonary disease, skin and soft tissue infections, pneumonia, transcatheter aortic valve replacement, diabetes, and asthma exacerbations. Admission location, discharge disposition, 30-day readmissions, and deaths are reported. Patient satisfaction, program costs, and other patient outcomes are under review.

Challenges arise with innovations and new care models. Pharmacy staff burnout is a result of on-call requirements and late evening admission teleconferences. Secure-messaging communication is routed to all team members regardless of call schedule.  Without dedicated AHH Staff, the primary job responsibilities of pharmacy team members are affected. AHH requires an alternative approach to patient management compared to traditional inpatients due to significant coordination of care and the lack of medication accessibility within a patient’s home.

Conclusion: Available literature demonstrates AHH care delivery models decrease costs, improve patient outcomes, and enhance the patient/family healthcare experience. Providing hospital care within an individual’s home requires retooling and reevaluating current care models and necessitates innovative collaboration across the care continuum. Allowing patients to choose where to receive their hospital care safely and effectively is an opportunity for health care systems to differentiate themselves and innovate with the patient’s experience in mind.