By Perry Kirwan
On April 30, 2020, the Centers for Medicare and Medicaid Services (CMS) published an interim final rule (IFR) that made regulatory changes and clarified certain policies in response to the novel coronavirus (COVID-19) public health emergency (PHE). The IFR’s changes include increased flexibilities for hospitals to provide and receive Medicare payment for hospital outpatient services to patients in their homes. This put a giant spotlight on topics like telehealth, telemedicine and hospital at home as health care organizations looked for alternative ways to deliver care during the pandemic.
This prompted many healthcare delivery organizations (HDO) to quickly pivot strategy to implement a technology-forward approach to care delivery with some the following goals:
What is telehealth, telemedicine and hospital at home? Telehealth refers broadly to electronic and telecommunications technologies and services used to provide care and services at-a-distance.
Telemedicine is the practice of medicine using technology to deliver care at a distance. A physician in one location uses a telecommunications infrastructure to deliver care to a patient at a distant site.
Hospital at home (H@H) is the practice of providing care to a patient in their home when the hospital considers the home to be a relocated outpatient location of the hospital.
Every health system has a unique workflow for staff, patients, caregivers and the system as a whole. Banner Health has deployed models of hospital at home since the mid-2000s and healthcare technology management (HTM) played a vital role in planning and implementing those models. As is typical, there are always lessons learned and the following are five important ones before implementing H@H programs.
(1) Set Clear H@H Program Goals: In order for a program to be successful, health systems must establish clear goals from the beginning. Goals can evolve and change once the program kicks off (and metrics start to accumulate) but launching the program with a clear set of goals is the best way to set up the program for success. Some example goals might be:
In addition to program goals, it is also crucial to determine which disease states a patient might benefit from the most. See the following table of potential uses cases along with potential exclusion from a program.
(2) Determine Patient Eligibility, Select Patients for the Program and Prioritize Patient Safety: Once goals are established, the next step is building the H@H program framework. Keeping patients at the center, health systems can build eligibility criteria based on the needs of unique patient populations and available resources. The goal is to offer the program to patients who are sick enough to require emergency departmentlevel care, but stable enough to be cared for at home
Common eligibility criteria include:
Once eligibility criteria are established, there are some operational considerations.
And lastly, it takes technology to help enable the clinical care delivery. The following are some considerations from that perspective:
What devices will be necessary to collect and deliver data to your organization in the home?
How will the patient’s assigned device connect and deliver data?
Where will the data generated by the home devices go (receive location) and how is that supported?
Avoid the trap of technology for the sake of technology. High-tech doesn’t always rule the day. Consider instead:
How is the technology sourced?
Out of the box solution
(3) Consider who the H@H Program Team Consists of and Provide Continuous Internal Education: Oftentimes, there are multiple interdisciplinary teams involved in managing H@H programs. Coordinating across teams is essential for success – and can also present challenges. The health system must consider (and plan for) all teams that are involved in the H@H program and ensure buy-in at every level.
Gaining program buy-in is key and that starts with demonstrating to internal stakeholders that the program works, that it’s beneficial and (most importantly) that it’s safe for patients who qualify and enroll. Buy-in for a H@H program starts at the very top of the health system leadership chain, and includes key leaders within each department, such as operational and front-line staff.
Every H@H same umbrella, highlighting the program benefits and providing transparency into how the Hospital at Home program can help improve outcomes.
Clinicians involved in a H@H program must be:
Comfortable with the H@H model, understanding why (and how) the program can benefit patients
Knowledgeable about technology, with the ability to use technology hardware and software to administer at-home care independently
Are there areas that make sense to engage partners? Technology? Call Center? Staffing? Home Health?
(4) Ask the Right Questions – and Plan Ahead for Challenges. In order to successfully launch a H@H program, health system leadership must ask fundamental questions about how the program will work:
Will the health system work with an affiliated home health agency or a third party to ensure care is delivered properly into the home?
Day-to-day, who is responsible for monitoring patients?
Who is in charge of overseeing the remote patient monitoring clinical dashboard?
Think on how to overcome logistical challenges for the H@H team. Some examples might be:
Arranging medication delivery
Ensuring a nurse or another clinician will be at the home at the right time, aligning with the patient’s schedule
How to manage and respond to abnormal test results
How will technology be delivered, supported, returned and reprocessed such as nebulizers, oxygen, X-ray machines or assisted devices
(5) The Do’s of a Telehealth/H@H Program: For patients enrolled in a H@H program, telehealth and remote patient monitoring is essential – and required, per the acute care at home waiver. Although every health system might leverage telehealth technology differently, there are a few common telehealth themes to improve care delivered across the continuum. Some examples include:
Daily check-ins with patients
Remote monitoring to track symptoms and vitals
Help with medication adherence and activity tracking
Promotion of patient education, helping patients become more involved in their own care
Direct contact with their provider should a patient have concerns about their health or condition
Looking ahead to the next pandemic – and to the future care of patients, all the time – there’s a need for health systems across the country to embrace these changes and explore H@H programs. The patient’s home should be considered an extension of the hospital, serving as a place for high-quality care to be delivered (for those patients that qualify), acting as an integral part of the larger health system.
– Perry Kirwan is the vice president of technology management at Banner Health.
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