Hospital at Home: Success Factors & Challenges

This is the second post in a four-part ACCCBuzz blog series on the hospital-at-home model. Before reading below, be sure to check out  the first post in this series.

During Modern Healthcare’s recent virtual briefing—Transforming Care Delivery with Hospital at Home—one session explored the current trends and models of excellence in at-home care. Tara B. Horr, MD, outpatient clinical service chief, Division of Geriatric Medicine and medical director, Vanderbilt Hospital at Home at Vanderbilt University Medical Center, shared insights on common characteristics of successful hospital-at-home programs. Further, Courtney Midanek, managing director at Kaufman Hall, and Cory White, chief commercial officer at Stericycle, both weighed in on the current obstacles to wider dissemination of this model.

What are the common characteristics to successful hospital-at-home programs? Dr. Horr highlighted three:

• Integration. Hospital-at-home programs must be integrated into health systems. They must also be recognized by patients and providers as an extension of the hospital for both to feel confident in engaging with the program. As such, these programs must maintain the same standards and level of care as those that are provided in the hospital. “It should be an extension of the four walls of the hospital,” she said.

• Flexibility. To succeed, these programs need to respond to the needs of a specific patient population, the institution, and the institution’s location. What are the patient populations that require and will benefit from a hospital-at-home care? Where are these services needed geographically?

• Good Communication. Among providers—both in the and outside of the hospital-at-home program—good communication is essential. This includes hearing what colleagues need and providing feedback to providers on how the program worked for their participating patients. Feedback from patients is also critical for program improvement and growth: What went well? What needs to be changed?

Significant Barriers

Looking to the post-COVID-19 future, what are some of the big picture barriers impeding wider dissemination of hospital-at-home care? Midanek cited three major hurdles:

• Lack of understanding on how to launch a hospital-at-home program due to the newness of the model

• Figuring out how to staff the program and optimizing staffing

• Uncertainty around the post-COVID-19 reimbursement outlook and long-term acceptance by payers.

Among concerns raised by White were issues around the complexity of managing acute-care supplies and medications in the home setting, including processes for safe disposal of pathogens and hazardous waste materials. Both Midanek and White noted that as home-based care becomes increasingly sophisticated, the level of investment required to advance the capability to deliver more services at patients’ homes may be a barrier for some institutions. In other instances, it is likely to drive more consolidation, joint ventures, and partnerships.

Dr. Horr agreed that patient and provider safety are the foremost priorities in establishing hospital-at-home programs, and she shared some strategies for success gleaned from Vanderbilt’s experience in extending hospital care into the home setting.

Define patient inclusion and exclusion criteria. The determination of patient eligibility must include an assessment of the home environment. Some questions to address include: Can care quality be preserved in the specific home environment, and is the home a safe space to receive care for both patients and providers? As part of the informed consent for hospital-at-home participation, there needs to be clarity that—should the need arise—patients are brought back into the hospital for care.

Benefit from collaboration. Dr. Horr praised the collaborative resources that are available and “allow institutions to work with other institutions that have been doing this or building their programs, maybe doing it longer, and learn from one another.” For example, resources on what patients succeed in this care setting and red flags that indicate patients who are not a good candidate for this model. “As we built our inclusion and exclusion criteria, we did a lot of collaboration with other programs and continue to do so on a regular basis,” Dr. Horr said.

Define performance metrics. While the Centers for Medicare & Medicaid Services outline some metrics that hospital-at-home program participants must report, Dr. Horr noted that guidelines are not clear state by state. Vanderbilt worked collaboratively with the state of Tennessee to determine what quality metrics needed to be reported back to the state on a regular basis.

Ensure analytics support to optimize learning from your data. To improve and grow these programs, analytics support like capturing all data needed to define the quality outcomes for the program is essential. Dr. Horr explained that Vanderbilt staffs a defined and dedicated morbidity and mortality quality team that reviews all outcomes data. With the data available in a systematic format, the team reviews each case and looks at quality metrics, such as patient escalation (i.e., return to the hospital), 30-day readmission, and adverse outcomes (e.g., falls, infections, wounds).

Focus on staff, structure, and training. Geographical considerations are important when developing and staffing a hospital-at-home program. The area that is being served needs to be “broad enough to capture a good range of patients and serve the institution,” said Dr. Horr. But the broader the range, the more staff efficiency may be compromised. Another balancing act that every program will face is determining which services to provide in-house and which to contract out to another healthcare agency or vendor, with the understanding that the institution will have less control over these services. 

Whether provider visits are conducted virtually or in-person varies. How these services are structured is a key component of hospital-at-home programs. Whatever the decision, Dr. Horr recommends that all programs have some capability to provide on-demand in-person provider visits when needed.

Which Staff are Appropriate for the Model?

Dr. Horr explained that the skillset needed for a successful program is unique. “It’s not quite inpatient care. It’s not quite home care,” she said. “In an ideal setting, healthcare professionals will have experience in both inpatient and home care settings.” If that’s not available, build this into staff training.

When it comes to staffing the model, Dr. Horr emphasized the need to set expectations. “It is a field of medicine that is growing,” she said. “Find team members who are committed to the growth of the program, believe in the patient benefits, and are flexible knowing that every day will bring different challenges.” Engage staff who are committed to learning from those challenges and growing the program.

Finally, prioritize cross-training. Though this model provides hospital-level care, Dr. Horr affirms that there will be fewer resources if someone is sick or has an emergency. Some program staff will be virtual, some will perform intake duties, and others will be in the field. Cross-training enables more staff to participate in all areas of the program and increases the likelihood of success.

As the discussion closed, Midanek ended the session on a positive note: “This feels like an inflexion point in an area where we really could change the dynamic and lower the cost of care in a major way by leveraging a new access point that, maybe, many of us, even a couple of years ago, didn’t think was possible.”

June 6 to 10 is Hospital at Home Week of Action. You can find more information, including event and educational resources, on developing and implementing hospital-at-home programs online.