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Hospital at Home: Innovation in Delivery of Home-Based Care

For many, the words ”hospital at home” are met with confusion at the seeming oxymoron. What they may not know is the positive impact it is making on healthcare delivery in the Worcester region.

The Hospital at Home (HAH) program is a healthcare initiative aimed at providing hospitallevel care for medically appropriate patients within the comfort of their own homes. It involves delivering acute care services, typically provided in a hospital setting, to patients in their residences. This model allows patients to receive necessary medical attention while avoiding the inconvenience and potential risks associated with a hospital stay.

Research suggests that patient outcomes are comparable or with improved clinical metrics…

Our program here at UMass offers daily physician visits with patients and family via telehealth, at least twice daily in-home nursing or paramedic visits, twice daily multidisciplinary team huddles, urgent rapid response services, continuous remote vital sign monitoring, in-home diagnostics including point of care lab testing, send-out laboratory testing, electrocardiogram, mobile x-ray, and ultrasound. The program accommodates transportation for advanced imaging (CT, MRI) as required, and even specialty provider consultation. We are able to deliver all the usual therapeutics including oral, inhaled, and intravenous medications, oxygen, durable medical equipment. When needed, we are able to provide interventional radiology or surgical procedures.

Brick-and-mortar facilities offer a full spectrum of medical services ranging from emergency care to acute medical care, to intensive care. Given the full spectrum of care provided in brick-and-mortar facilities, there is rarely a concern for accessibility to diagnostics or therapeutic medical equipment, logistical, or staffing issues that prevent or delay providing timely care.

Since HAH programs are designed to provide acute medical care for patients who would otherwise be admitted on a med-surg floor in the hospital, they are not well equipped to handle emergent situations or situations that warrant more intensive care. There are also numerous logistical challenges that require innovative solutions since the patient is not physically located down the hall from a provider.

HAH care requires a lot of planning and coordination among different providers. For this reason, our program offers multidisciplinary synchronous rounding with the patient, family, nurse/paramedic in the home, and physician (joining via telehealth). This is in contrast to asynchronous rounding with nurses and physicians in the hospital where there is very little input from the patient’s family and caregiver. As a guest in our patient’s home, we get more insight into how they are taking their medications, what they are eating, when and how they are sleeping. All these little things really allow a hospital-at-home provider to provide holistic care.

Research suggests that patient outcomes are comparable or with improved clinical metrics, including reduced mortality rates, lower rates of hospital readmission, and higher patient satisfaction levels when compared to brick-and-mortar care.

So far we have received overwhelmingly positive feedback from our patients and their families. They often send us letters, cards, notes, and emails expressing gratitude for their care and allowing them to live their life in the comfort of their home while receiving medical care. Some patients who end up getting readmitted often ask for our program by name as soon as they get to the emergency department because of their trust in our program.

Ironically, the biggest challenges for this program do not come from health system leadership or costs, but from the cultural change within the institution. We have made significant progress over the past few years. When this program was first starting, we were struggling to get patients referred to us; now we get so many referrals per day that we are not able to take all the patients. We are likely at least the 6th largest program in the country based on the average daily census quoted in the article in Becker’s Hospital Review (1). Strikingly, despite outreach and the cultural change, there are still many providers and patients who are hearing of the program for the first time.

While such a program sounds promising, successful execution relies on several key factors. Our program has been well supported by visionary executive-level support. This enables alignment of institutional resources and goals without which the program could not deliver this carefully coordinated care at home. The program design centers on equitable delivery with telehealth equipment designed to be able to be used by anyone and in any home including those without a tablet device or internet. Patient referral to the program can be a limiting factor as it is a complex and dynamic process, which is under constant improvement. Similarly, accommodating the program scale as referrals increase, while providing robust ancillary services and supply chain support for increasing patient acuity, are critical for implementation success.

We would like to continue growing this program and offer more services to our patients. For instance, we recently started offering patients blood transfusions. Before this, we had to temporarily transfer the patient back to the hospital to transfuse blood and then bring them back home. We also recently partnered with the OB-GYN team to transfer patients who are at least two days post cesarean section for ongoing care with our team. To my knowledge, we are the first HAH program in the country to offer these types of services.

The UMass Hospital at Home program delivers hospital-level care to patients in their homes. Delivery is made equitable by designing a program that can be implemented in nearly any home environment. We have achieved broader recognition in our health system and I would like to keep seeing this team continue to push boundaries and offer care to more and more people.

Shiv Sutaria, MDVirtual Home HospitalistAssociate Medical Director, Hospital at Home, UMass Memorial Medical CenterAssistant Professor, UMass Chan Medical School

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