3 minute read
ED Admin & Clinical Operations Bringing Hospital Care into the Home
Bringing Hospital Care into the Home
By Yosef Berlyand, MD; Ryan Thompson, MD, MPH; and Brian J. Yun, MD, MBA, MPH, on behalf of the the Boarding and Crowding Subcommittee of the SAEM ED Administration and Clinical Operations Committee
Hospital overcrowding and boarding in the emergency department (ED) are major challenges facing hospitals in the U.S. and can negatively impact many aspects of care, from patient experience and quality of care to staff experience and operational efficiency. We’ve all felt this recently with hospitals shattering admission records and both hospitals and clinicians feeling stretched thin like never before. Driven by high volumes and boarding of patients in the ED for hours and sometimes days before receiving their inpatient bed, significant efforts have emerged to find alternative pathways to hospital admission, including Home Hospital.
Home Hospital is defined as the community-based provision of services usually associated with acute inpatient care. In practice this means mirroring services delivered in a physical hospital, including therapies such as IV medications and oxygen, daily lab monitoring, and continuous cardiac monitoring in the comfort of a patient’s home. This model has been successfully implemented in Australia and Spain, and has recently gained traction in the United States with innovative Home Hospital programs established at several academic medical centers including Massachusetts General Hospital, Brigham and Women’s Hospital, Mount Sinai, and Johns Hopkins. Home Hospital works particularly well for patients who do not anticipate the need for an inpatient procedure and are at low risk for decompensation
necessitating critical care. Common diagnoses for Home Hospital include COPD exacerbation, CHF exacerbation, community acquired pneumonia, and cellulitis. In combination with the Home Hospital team, emergency medicine (EM) providers help screen patients who may be appropriate for Home Hospital. Patients are cared for by a Home Hospital team comprised of a physician, a nurse, and an advanced practice provider. Patients are seen multiple times daily, at least once by the nurse and once by the advanced practice provider with supervision by a physician. In addition to IV infusions and monitoring, Home Hospital services include virtual specialty consults, case management services, and as needed services such as meals, physical therapy, overnight home health aide, and even portable radiology. CT and MRI imaging is available via roundtrip transportation to the hospital.
The benefits of Home Hospital are impressive: hospitalization at home saves money, maintains quality and safety, and improves patient experience while reducing the number of patients boarding in the ED awaiting admission. Patients hospitalized at home have the benefit of being in a familiar environment and undergo fewer laboratory tests, imaging studies, and consultations while remaining more mobile. Moreover, home hospital admissions have the potential to reduce the known risks of inpatient hospitalizations such as delirium, hospital-acquired infections, deconditioning, and falls. Not surprisingly, Home Hospital patients have been shown to have a significantly lower 30day readmission rate than traditionally hospitalized patients.
Now that the Center for Medicare and Medicaid Services announced a waiver to reimburse for Home Hospital services, Home Hospital programs are rapidly expanding around the country with over 166 waivers granted as of September 2021. Home Hospital is already changing the landscape of modern medicine; as capacity surges continue to plague U.S. hospitals, Home Hospital offers an innovative, safe, cost-effective, and patient-centered alternative to inpatient hospitalization. ABOUT THE AUTHORS
Dr. Berlyand is a resident physician in the Harvard Affiliated Emergency Medicine Residency at Massachusetts General Hospital and Brigham and Women’s Hospital. His academic work is in emergency department operations with an interest in improving patient experience and operational efficiency. Dr. Thompson is a general internist at Massachusetts General Hospital (MGH) and an assistant professor of medicine at Harvard Medical School. He currently serves as medical director of care continuum for MGH and the Mass General Physicians Organization. In this role he oversees MGH Home Hospital and admission/readmission avoidance programs. Dr. Yun is the director of clinical operations for the emergency department at Massachusetts General Hospital (MGH). Prior to this, he was the medical director of the 31-bed emergency department (ED) observation unit. He has expertise in implementing initiatives that improve ED throughput and developing alternative pathways to admission.
