Key Points

  • This paper describes the differences in how clinical care is executed in Hospital at Home (HaH); cases outlined are applicable to varied HaH settings in the United States and globally.

  • Multiple elements are considered in the orchestration of HaH care including the patient’s experience, evidence-based care planning, and the capacity of in-home clinical and non-clinical services across broad geographies.

  • HaH operational complexity requires mindful consideration of logistical practice differences as compared to facility-based hospital care, usually called brick-and-mortar (BAM) hospital care, while maintaining high quality of evidence-based care and patient experience.

Why This Paper Matters

The Hospital at Home (HaH) model of care has gained significant momentum in the United States, in part due to the Acute Hospital Care at Home (AHCAH) waiver of 2020 for federal payor reimbursement. As this model of care expands in the United States and globally, there is a need to define how HaH care is similar to and how it is different from brick-and-mortar BAM hospital care. While many elements of clinical care in HaH are unchanged, there are situations where Hospital at Home clinical operations may improve upon routine care practices used in many US and international hospitals to provide a better care experience to patients and caregivers. Additionally, there is a need to define the impact of the logistical complexities of HaH care delivery that differ from facility-based settings. Finally, certain technologies, such as point of care testing devices, may enable coordination of HaH care alongside application of different clinical practice patterns. The aim of this paper is to use a case-based format to describe situations where clinical care or logistical planning is different than care delivered in BAM hospitals and detail the potential impact of these differences in HaH clinical care.

Introduction

Hospital at Home (HaH) allows patients to receive hospital-level treatment in their own homes or residence instead of a traditional brick-and-mortar (BAM) hospital setting. Though this model of care has been employed since the 1960s internationally,1 the COVID-19 pandemic fueled dramatic expansion of HaH care due to increased demand for hospital beds. In the U.S., for example, the Centers for Medicare Services (CMS) responded to the COVID-19 pandemic with waivers to allow healthcare systems to respond to the changing care needs of patients and providers during the pandemic.2 One such waiver was the Acute Hospital Care at Home (AHCAH) waiver, which allowed hospitals to treat patients requiring inpatient-level care in their homes by amending the requirements of in-person nursing and several environment of care considerations.3 Broad HaH implementation has been bolstered by research studies that have demonstrated reduced 30-day readmission rates, hospital acquired debility, discharge rates to skilled nursing facilities and total cost of care within 30 days for HaH patient populations.4,5

The goal of Hospital at Home care is to deliver the same medical treatment that would have been conducted in the BAM hospital with a patient-centered approach that improves the overall quality of care. HaH care often consists of virtual care by nurses and physicians combined with in-home clinicians who deliver hands-on care in the home. Logistical execution is complex at high census, as the provision of clinical care services requires consideration of patient and clinician location, timing of shifts, consolidation of resources, and just-in-time geographic capacity of distributed clinicians.

Evidence-based care and practices beneficial to HaH patients should be maintained, recognizing that much of the evidence for acute care practice guidelines has been generated in BAM settings; high-quality, safe patient care should be the goal of all programs. However, there are current practices in BAM hospital care which were designed without contemplating patient experience, the home-based environment of care, or the logistical complexity of acute care in the home. This is an already established pattern via campaigns like Choosing Wisely which have now spread internationally. Research suggests that the patient experience is superior in HaH compared to BAM, in part from more patient-centered coordination of care in the patient’s preferred location.6–8 By critically evaluating BAM processes and clinical practice, HaH may develop more patient-centeredness while maintaining key standards for inpatient care. Below are case examples where HaH care requires re-evaluation of traditional acute care processes.

Adjusting Timing of Treatments

Case

A 46-year-old female with a history of kidney transplant on immunosuppression presents to the hospital and is subsequently admitted to the HaH unit from the Emergency Department for sepsis due to left lower extremity cellulitis from a skin abrasion. Her first dose of cefazolin is administered in the emergency department at 5:00 PM. Based on the initial administration, the typical BAM hospital schedule would be 0900, 1700, and 0100. Upon admission into the HaH unit, the nursing team works with the patient and pharmacy to re-time the infusions serially over the next 24 hours to move the doses to a schedule of infusions at 0700, 1500, and 2300. This approach aligns the administration schedule with the patient’s normal routine of early awakening, the timing of clinicians’ shifts, and the available capacity of in-home infusion resources throughout the day in the geographic location of her home.

Lessons Learned

When patients are admitted into a BAM hospital, the timing of subsequent infusions continues based on the time of the initial infusion and based on pharmacy staffing support. This results in infusions occurring at all hours with some occurring in the early hours of the morning, often resulting in sleep disturbance and poor patient experience. Most inpatient policies and procedures support medication administration within a one- or two-hour window of administration time, without needing to alter the physician’s order, but rarely are significant changes made to infusion times. Limited literature is available on practices to re-time medications in the BAM setting, though one study highlights an attempt to re-time oral medications in pediatrics to improve sleep.9 On the other hand, sleep disturbance during hospitalization increases risk of harm to patients and definitively impacts care experience.10,11

HaH must have a process for adjusting the timing of infusions to benefit patients’ sleep schedules, while optimizing for the availability of distributed, in-home clinicians at particular times of day. This facilitates capacity management of visits across HaH’s geographic network of resources, while adhering to standard clinical parameters. Capacity management of medication administration is a challenge for centralized resources in the facility-based hospital setting; this challenge is compounded by geographically distributed HaH beds in the community. Collaboration between HaH and pharmacy leaders in the design of HaH policy or protocol, as well as HaH clinicians’ daily capacity management of IV medication infusion, is key. Often this results in nursing, pharmacy and logistical staff coordinating for appropriate re-timing of medication without the physician having to re-write any orders. Daily capacity adjustments create efficient use of resources and allow for high-value utilization of in-home visit capacity as HaH census grows.

Practice Recommendations:

  1. Collaboration between HaH clinical and pharmacy leadership to support policy and protocolization to adjust timing of medications can be useful for capacity management and patient-centered care when patients require high frequency infusions.

  2. Leveraging other systems for medication delivery including continuous infusions utilizing pumps or elastomeric balls can provide a mechanism to ease administration while maintaining medication administration standards.

Point-of-Care Laboratory Testing

Case

A 78-year-old female with a history of chronic diastolic congestive heart failure, hypertension, hyperlipidemia, diabetes mellitus, and obesity is evaluated in the Emergency Department for increasing dyspnea on exertion, bilateral leg edema and weight gain. After evaluation and some treatment, it is determined she will need inpatient hospitalization for several days of intravenous diuretics to treat an exacerbation of congestive heart failure. As part of the treatment plan, she will be given intravenous diuretics twice daily, scheduled potassium repletion, and will need ongoing lab monitoring to ensure her kidney function and electrolytes remain stable. Each morning, her furosemide is dosed based on her current weight, electrolytes, and renal function, the latter of which are measured with point-of-care (POC) lab equipment in the home prior to medication administration. She undergoes successful diuresis titrated to her clinical status and is discharged once euvolemic.

Lessons Learned

The timing and coordination of venous blood sample collection, processing and analysis in HaH requires the coordination of resources in the home to draw blood samples prior to sample processing and analysis at licensed laboratory processing facilities. Point-of-care (POC) venous blood sample testing can be employed, allowing for shorter processing turnaround time and earlier adjustments to care plans. This is especially useful considering the clinician obtaining the labs is often able to administer any needed treatments immediately after POC test result analysis via the use of a mobile formulary carried by in home clinicians. Rapid lab analysis followed immediately by appropriate treatment creates an efficient use of finite in-home services capacity.

The use of point of care testing is not without issue or challenge. POC equipment may have challenges with extremes of temperature, and the limited number of laboratory tests available for POC devices in the United States require additional workflow development for facility-based laboratory processing as a redundancy. In Europe, there is broader use of POC testing in different care settings along with broader test availability; this could serve as an area for future innovation in other global HaH settings.12 In the United States, for example, though the POC devices used have been approved for use by the United States Food and Drug Administration, clinicians may still encounter variability of results between POC and facility-based laboratory processing that influences broader clinical acceptability.

Practice Recommendation:

  1. During development of POC workflows, integrate this lab modality for particular conditions where the utility can help facilitate care. Congestive heart failure exacerbation and acute kidney injury are two conditions which are ideal.

  2. If POC device results drive changes and decisions, have providers adopt “if-then” orders based on the results to reduce time from result to decision. These could even be developed into a protocolized version for nursing teams to utilize.

  3. Virtual clinicians and providers should be given education and training on the devices to increase comfort and assist in change management for using POC devices.

  4. Use of an in-home clinician formulary can expedite care in the home and minimize the need for courier services to treat simple lab abnormalities like hypokalemia.

Patient-Centered Care Planning

Case

A 95-year-old male with severe Alzheimer’s dementia, benign prostatic hypertrophy, recurrent urethral strictures requiring a chronic indwelling Foley catheter complicated by recurrent urinary tract infections is admitted to HaH for sepsis due to a urinary tract infection. He exhibits mild hypoactive delirium on admission and is treated empirically with meropenem. His care plan includes such delirium precautions as promotion of sleep/wake cycle regulation, so his end-of-day, in-home and virtual visits are timed right before his usual bedtime, and he is not awoken until the morning absent urgent concerns. For example, instead of being woken between 4 and 6 AM for vitals and phlebotomy in the BAM, his first HaH visit is set at 8AM for obtaining vitals and phlebotomy. Unlike prior BAM admissions, he does not develop agitation or worsening delirium, and he does not require restraints or pharmacologic treatment. Adhering to the expected length of stay for his HaH episode and experiencing more mobility in the home, he is also not discharged to a short-term rehab facility.

Lessons Learned

HaH offers an opportunity to re-evaluate BAM practices that do not prioritize patient experience. Hospital at Home generally utilizes Age-Friendly health system principles, which use evidence-based elements in four categories: what matters to patients, medications, mobility and mentation (4Ms).13 Additionally, there are emerging recommendations on geriatric patient care in HaH, using comprehensive geriatric assessments to impact patients and caregivers during and following hospitalization.14 Adapting hospital process to incorporate these elements in HaH may improve the care for geriatric patients during and following the HaH episode.

One impactful area for evaluation is the timing of care planning for HaH patients, in part to honor the evidence demonstrating that sleep disturbance for inpatients may detract from healing and cognitive status in cognitively impaired individuals.15,16 For example, 1 in 5 patients are awoken by hospital staff during sleep hours in facility-based settings.15 Intentional design to keep the patient’s sleep schedule in mind requires planning for labs to be collected during a patient’s normal wake cycle.

Additionally, HaH is a way to provide care experience that is superior to BAM hospitalization for both patients and caregivers.17 To avoid caregivers becoming overwhelmed with new information and multiple daily visits, involvement of caregivers in the timing of scheduled virtual and in-home HaH services contribute to positive experience, alongside shared decision-making and collaborative care plan education.18

Practice Recommendation:

  1. Protocols and culture of HaH programs should aim to schedule in-home visits according to age-friendly principles with optimal circadian rhythm management for older adults.

  2. HaH teams should engage early and often with caregivers in HaH education in BAM and on transfer to HaH with continued shared decision-making regarding appropriate scheduling of virtual and in-person visits.

Glycemic Management

Case

A 56-year-old male with a history of severe obesity, hypertension, hyperlipidemia, and poorly controlled diabetes mellitus is admitted to Hospital at Home after developing sepsis due to left lower extremity cellulitis. During the hospitalization, the patient has elevated blood sugar and elevated Hemoglobin A1c. Since the patient is familiar with using his glucometer and injecting insulin, the patient himself checks his blood sugar four times daily and administers long- and short-acting insulin pens, under the care and orders of the attending physician. During his admission, the care team observes a non-traditional meal pattern, as well as limited access to foods with low glycemic index due to financial instability. A diabetes educator and nutritionist conduct virtual visits with the patient to provide education, and the physician adjusts the insulin plan based on these learnings. With titration of insulin and adjustments to his diet, improved blood sugar levels are attained, and the patient is discharged on a new regimen that he has already self-administered successfully.

Lessons Learned

HaH presents an opportunity to provide education and guidance using familiar medications and equipment; there is great benefit in allowing patients to use their own glucometer and familiar insulin products. Most BAM inpatient units administer insulin drawn up from vials as they are less expensive than insulin pens. Not all health systems may permit use of home insulin process during HaH, but education may still occur referencing patients’ home materials during in-home and virtual visits. For health system policies that permit the use of patient-owned glucometers, these should undergo comparison to a POC glucometer or venous blood sample for calibration. Insulin is a high-risk medication and needs to be administered utilizing best practices for safe medication administration, even if a patient is performing the subcutaneous injection. Competence of patient self-administration must be validated according to health system policy; if competency is not validated, in-home clinicians will need to be present for insulin administrations that may require multiple visits per day.

Secondly, the hospital pharmacies that supply medications for the HAH units should consider stocking insulin pens. HaH leaders should lobby pharmacy formulary review committees to permit use of insulin pens for patients they have assessed can self-administer insulin or for expanded inpatient use of oral hypoglycemics aligned to evidence-based guidelines; these changes may realize efficiencies in capacity management of in-home services while improving patient education of home-based medication regimens. Additionally, the process of titrating insulin doses is easier for patients and clinicians, leading to less clinical risk compared to insulin vials with syringe administration. Lastly, for well-controlled diabetic patients on oral hypoglyemic agents and not presenting with hyperglycemia, clinicians may consider continuing oral agents in HaH to avoid the use of sliding scale insulin. Guidelines support the consideration of continuing oral agents during hospitalization when contraindications do not exist.19

Practice Recommendation:

  1. Protocols and policies for glycemic management unique to HaH programs, including whether patients can use their own glucometers and if they are capable of doing so, will be necessary.

  2. HaH leadership should advocate for formulary review committees to permit use of insulin pens in HaH programs as it allows for easier dose adjustments, reduces waste, and increases the likelihood that patients or caregivers can administer the medication without assistance from an in-home clinician.

  3. HaH teams should adopt practice principles aligned with Choosing Wisely campaigned and ADA principles to leverage use of oral hypoglycemic regimens and avoiding sliding scale insulin where appropriate.

Venous Thromboembolism (VTE) Prevention

Case

An 80-year-old female with a history of chronic obstructive pulmonary disease (COPD) with chronic hypoxic respiratory failure on home oxygen is admitted to HaH with an exacerbation of COPD. She requires more oxygen than baseline but is able to ambulate. She is prescribed once daily subcutaneous enoxaparin on admission to HaH for VTE prophylaxis. Within 48 hours of admission, she is ambulating three to five times daily to the restroom and between her living room and bedroom throughout the day. She waters her plants, feeds her cat, and moves between a couch, armchair, and bed. After her second day of admission, the attending physician discontinues chemoprophylaxis for VTE after mobility assessment.

Lessons Learned

For hospitalized patients, guidelines do not offer strong recommendations for discontinuation of chemoprophylaxis for VTE initiated on admission.20 Risk assessment models do risk stratify patients for VTE during and immediately following admission.21–23 Electronic health record (EHR) admission tools often leverage these and other models then requiring documentation of VTE risk and choice for therapy due to regulatory requirements in the United States.

Evidence suggests that patients are more mobile in HaH than in BAM.8 However, there are no studies that indicate what level of ambulation is a minimum threshold for discontinuation of VTE chemoprophylaxis, and mechanical prophylaxis via sequential compression devices (SCDs) is often impractical in the home setting. Increased levels of activity categorize patients as low risk for DVT; in the home setting, less use of chemoprophylaxis may reduce the risk of adverse events associated with anticoagulation, such as bruising at injection sites. For patients who require chemoprophylaxis, enoxaparin is recommended over unfractionated heparin for acutely ill medical patients20; this is preferred in HaH due to daily dosing regimen. When unfractionated heparin is required, twice daily dosing may be preferred over three times daily dosing. As is the case for insulin administration, virtual and in-home clinicians should assess patient competency for self-administration as needed.

Practice recommendation:

  1. HaH programs should evaluate current BAM practice, EHR tools, and policies related to VTE prophylaxis and determine the best approach.

  2. HaH admitting teams should leverage current mobility levels and evidence-based risk stratification tools to assess a patient’s risk level and determine whether pharmacologic prophylaxis is needed.

  3. When required, the choice of pharmacologic prophylaxis should follow principles of optimal HaH medication administration, inclusive of choosing the lowest frequency of dosing feasible and timing aligned to patients’ preferences.

Discussion

These cases highlight areas within HaH that offer opportunities to rethink clinical practice in ways that provide a better care experience and person-centered plans. Table 1 provides a concise summary of the area of focus and contrasts the differences between BAM and HAH practice. The process of coordinating the timing and logistics of visits is a complex exercise. HaH programs should evaluate their processes including the retiming of clinical care to allow for more even distribution of visits in the home and efficient use of staff. The use of point of care testing saves on travel and courier costs, creates an opportunity to get blood samples at more reasonable times, allowing for more continuous sleep, and means timelier results and care plan changes. The use of an IHC formulary also supports efficiency and cost reduction in HaH. The management of diabetes mellitus and VTE prophylaxis also present opportunities to implement care plans unique to HaH. Whether allowing patients to use their home glucometers and insulin or using supplies provided by the hospital pharmacy, there are considerations that must be undertaken to reduce risk, ensure safe medication administration and empower patients to participate in their own care. VTE management should leverage evidence-based risk assessment models and the increased mobility of patients in HaH to reduce the number of patients who require pharmacological prophylaxis. This in turn can lead to less risk of harm from bleeding or bruising and an improved care experience, as patients may prefer to avoid subcutaneous injections.

Table 1.Differences Between BAM and HAH Practice
Area BAM Practice HaH Practice
Timing of clinical care Timing of clinical care often not adjusted and does not consider patient experience Clinically appropriate adjustments to timing of clinical care incorporate care experience as well as in home clinician capacity
Point of care lab testing Limited utilization in the United States with some broader use internationally Utility can help simplify lab result collection and resulting, making timely decisions and keeping overall cost in mind
Patient-centered care Many practices do not consider the patient experience when executing clinical care tasks while caregivers often must give in to the timing and schedule of providers in BAM hospital Care plans can be adjusted within clinically appropriate windows to accommodate patient-centered experience and model allows for more involvement and autonomy from patients and caregivers
Glycemic Management Common practice is holding oral agents and utilizing sliding scale insulin with high frequency of glucose checks Continuing oral agents when appropriate, limiting use of glucose checks, and using insulin pens makes for an improved experience when managing glucose in HaH
VTE Prophylaxis Due to less mobility, patients are more likely to require pharmacologic prophylaxis Leveraging risk scores can determine those who are at lower risk and may not need prophylaxis, though when needed would require clinicians to administer

HaH offers a way to take lessons learned from BAM hospitalization and improve care experience. Through the Age-Friendly Framework and a multidisciplinary approach to care for geriatric patients, there can be real impact on outcomes during the hospitalization and afterward. The model is shown to be a positive care experience and there is continued opportunity to further refine how the patient and caregivers are supported during the HaH episode.

Conclusion

As the number of HaH programs expands and the body of literature about this model of care grows, there is a continuing need to better understand optimal clinical care delivery and how it differs from BAM hospital care. This paper highlights several different opportunities for future research. We need to evaluate whether the approach of allowing for more restful sleep creates any increased risk for delayed notification of deterioration, ensuring that these patient-centered practices are not inadvertently introducing patient safety risk. Additionally, the use of point of care testing on timeliness of care as well as complexity of care coordination should be further examined. Further, there is ongoing need to assess the impact of the HaH model on patients and caregivers.

The clinical practice of care for HaH is unique. With the expansion of the HaH model comes an opportunity to reevaluate current hospital-based practices as well as incorporate concepts from the Age-Friendly Health Systems framework and the larger evidence-base in order to improve outcomes for patients. While there is still more to understand about the model and its impacts, the literature to date demonstrates consistent results in improving quality, a more positive patient experience compared to BAM, and reducing the 30-day cost of care; the practice changes highlighted in this paper are almost certainly contributing to those outcomes.

Acknowledgments

All authors for this paper contributed to the content and structure of the submission. No authors for this manuscript have any conflicts of interest to disclose though all authors currently work or have worked in the past for Medically Home Group, Inc. There is no sponsor for this paper.

Funding Statement

There are no funders to report for this submission

Data Sharing

Not applicable

Conflicts of Interest

No authors for this manuscript have any conflicts of interest to disclose though all authors currently work or have worked in the past for Medically Home Group, Inc. There is no sponsor for this paper.

Author Contributions

Data curation: Matthew Richards (Supporting), Pamela Saenger (Supporting), Stephanie Murphy (Supporting), Linda V. DeCherrie (Supporting), Jacob Keeperman (Supporting), Greg Snyder (Supporting), Eliza Shulman (Supporting). Writing – original draft: Matthew Richards (Supporting), Pamela Saenger (Supporting), Stephanie Murphy (Supporting), Linda V. DeCherrie (Supporting), Jacob Keeperman (Supporting), Greg Snyder (Supporting), Eliza Shulman (Supporting). Writing – review & editing: Matthew Richards (Supporting), Pamela Saenger (Supporting), Stephanie Murphy (Supporting), Linda V. DeCherrie (Supporting), Jacob Keeperman (Supporting), Greg Snyder (Supporting), Eliza Shulman (Supporting). Project administration: Matthew Richards (Supporting), Pamela Saenger (Supporting), Stephanie Murphy (Supporting), Linda V. DeCherrie (Supporting), Jacob Keeperman (Supporting), Greg Snyder (Supporting), Eliza Shulman (Supporting). Conceptualization: Matthew Richards (Supporting), Pamela Saenger (Supporting), Stephanie Murphy (Supporting), Linda V. DeCherrie (Supporting), Jacob Keeperman (Supporting), Greg Snyder (Supporting), Eliza Shulman (Supporting).

Not applicable

Ethics Approval

Not applicable

Not applicable

Statistical Analysis

Not applicable

Administrative, Technical, or Material Support

Matthew Richards, Pamela Saenger, Stephanie Murphy, Linda DeCherrie, Jacob Keeperman, Greg Snyder, Eliza Shulman

Study Supervision

Not applicable

Corresponding Author

Matthew Richards: matthew.richards12@gmail.com