Hospital-level Care Comes to Patients at Home

Hospital-level Care Comes to Patients at Home
Pandemic pressures accelerate movement toward hospital services in a home setting.

A new program lets patients and their families choose whether they will receive hospital care in the traditional manner, as an in-patient, or opt for hospital-level care in their own home.

“Our goal is to bring healthcare to the patient where they want to be treated, when they need to be treated,” said Victor Legner, M.D., an associate professor of medicine at Vanderbilt University Medical Center. “The patients love receiving the care they need at home. Their satisfaction is through the roof.”

Working closely with the Hospital at Home Users Group, Vanderbilt created the Hospital at Home program over the course of about two years.

Expanding Its Reach

The program was launched with a staff to care for five patients; there have usually been two to four patients participating at a time, with a total of 60 patients participating so far, explained Tara Horr, M.D., medical director for Vanderbilt Hospital at Home.

“We care for patients with a broad range of medical conditions, most commonly infectious processes, including pneumonia, cellulitis, and UTIs; also some COPD and heart failure patients,” she said. The program will soon start working with Vanderbilt’s neurology team to care for optic neuritis patients too.

“Our goal is to bring healthcare to the patient where they want to be treated, when they need to be treated.”

Hospital at Home team members educate acute-care specialists about the details of the program to help them gain confidence and refer their patients, Legner explained.

“An ED doctor or a hospitalist may ask, ‘Really? I can treat them at home?’” Legner said, noting that the program does represent an alternative to the usual hospital workflow.

Prior to its launch, the program had an entirely new platform built in the Epic medical records system with a virtual hospital floor to assist in order entry, consultations, medication delivery, medical equipment, admissions, and discharge.

“The platform includes everything you’d need in a hospital room, but now the room is the patient’s home address,” Legner said.

Demand Growing, Beds Decreasing

Since the 1970s, about 1,000 U.S. hospitals have closed, Legner explained.

“With hospitals consolidating and closing while our population has been growing, we don’t have the beds we need,” Legner said of the nationwide problem. “Providing hospital care at home frees up beds for those who really need them.”

The pandemic has only highlighted the urgency of the situation.

“COVID-19 has forced people to think about where we can care for patients who are at a higher acuity,” Horr said. “It has also given us an opportunity to show that higher acuity care can be provided safely in the home setting.”

While Hospital at Home is an inpatient program, Vanderbilt also runs a separate COVID-to-Home program that has cared for nearly 840 patients with COVID-19. The latter is an outpatient home-based program offered by Vanderbilt Home Care and Vanderbilt Health OnCall.

Selecting Patients Carefully

The Hospital at Home team closely considers each patient’s particular situation to identify those who can participate safely and successfully. The physicians also weigh the complexity of each patient’s care and the safety and suitability of the home environment.

“The platform includes everything you’d need in a hospital room, but now the room is the patient’s home address.”

In cases where a caregiver’s support is needed, they factor in the availability of a willing relative or friend who can provide assistance in the home, just as such a supportive person might do if the patient was at the hospital.

Extraordinary Oversight

Each patient receives three in-person visits per day, two from a nurse and one from an advanced practice clinician.

“If a patient needs specialty care, we arrange a telemedicine visit with a specialist,” Legner said.

The program has even arranged for an orthopaedic attending physician to perform a procedure right in a patient’s home, he added.

The telemedicine nurse will use the video communication system if they believe that a patient may have fallen or is otherwise in distress, Legner explained. Staffers at the hospital also have a backup phone number to use if two video calls go unanswered. If no one answers these calls, the program sends an ambulance.

The program includes two plans or pathways, called “urgent” and “emergent,” to enable the patient to return quickly to the hospital, if necessary. These pathways ensure medical care givers see that the program is flexible enough to handle each patient’s needs, she added. And each case provides the program with more information to work with.

“We do a full interdisciplinary debrief whenever a patient has to return to the hospital,” Horr said. “Higher acuity care can be provided safely in the home setting.”

Future Directions

Nationally, providing hospital-level care at home has grown as a trend because of the need to serve more acute-level care patients without expanding brick-and-mortar hospitals, Legner explained.

“We’re making healthcare more personal, like it was in the ’50s, when doctors routinely made house calls,” Legner said. “I think this kind of program will be usual practice in about five years.”