Using Hospital-At-Home Services to Lower Readmissions, Increase Capacity

As the Omicron variant drove COVID-19 case counts up, hospitals found themselves facing a familiar problem: caring for patients as inpatient capacity grew slim.

Many health facilities relied on systems set up during earlier stages of the pandemic, like telehealth and remote patient monitoring programs, to respond to growing case counts while preserving capacity and resources.

These programs were especially helpful for facilities in areas where hospital beds are already scarce, like in Central Massachusetts.  

UMass Memorial Health, a safety-net provider based in Worcester, Massachusetts, is one health system that reaped the benefits of having a hospital-at-home program to care for COVID-19 and non-COVID-19 patients alike.

"We saw an opportunity to better care for patients in our community," said Justin Precourt, chief nursing officer and senior vice president of patient care services at UMass Memorial Health, in an email. "Central Massachusetts is the least bedded region in the state per capita, and as the only academic medical center in the region, we are consistently challenged by our capacity constraints. This program [offered] an opportunity to provide care for more patients outside of our traditional settings."

How the program works

UMass Memorial Health began planning its hospital-at-home program in March 2021.

"Challenges with inpatient bed capacity, the COVID-19 pandemic, and the passing of the acute care CMS waiver for hospital-at-home [programs] in November 2020 — all three of those forces came together…[and] we said, 'This is the time to meet our community needs with this new and safe and effective service,'" said Constantinos (Taki) Michaelidis, MD, internal medicine physician and medical director of the UMass Memorial Health hospital-at-home program, in a phone interview.

The program began accepting patients on Aug. 3, 2021. Here is a snapshot of the patient journey.

Eligible patients — that is, those who require inpatient care and have specific social determinants of health available to them like safe housing and electricity — are asked if they are interested in the program.

If they are interested, they are transported home by ambulance, where they meet with UMass Memorial's hospital-at-home program nurses who have already been dispatched to the location.

On the same day, patients also meet with a hospitalist physician via telehealth.

The patient then receives hospital-level care at home over four or five days. Patients wear an armband that continuously measures their oxygen level, heart rate, and skin temperature during that time. They are also provided with an iPad so they can push a button and have 24/7 access to their nurses and doctors in the program, Michaelidis explained.

The daily routine for hospital-at-home care is similar to in-hospital care, with multidisciplinary rounds every morning. Nurses go to the patient's home at least twice a day, and physicians do video visits.

Considerations for program implementation

While setting up the hospital-at-home program, the health system found that several factors had to be considered. One was technology.

UMass Memorial's hospital-at-home services are underpinned by a platform provided by Current Health, its home care partner. Information flows from the platform to the Epic EHR system that the health system uses, Michaelidis said.

The hospital-at-home program is a separate unit within the EHR system, so information for all the patients in the program can be accessed in one place.

Another potential hurdle was the lack of seamless internet access in the patient's home. For example, there are certain parts of the Worcester, Auburn, Holden, Shrewsbury area that the health system serves that don't have great wireless internet, Michaelidis said.

To combat this issue, the health system brings their internet connectivity technology to the home, and the team works to ensure a secure connection, even if it means having to move hubs around or plug into cable modems, he said.

But it is rare to have a situation where the broadband issues are so challenging that the patient must be transported back to the hospital, he added.

UMass Memorial also examined the gaps in the home-based services it provided and partnered with community organizations to fill them in. The health system manages laboratory and imaging services for at-home patients, but they partner with ancillary service providers, like physical therapists for rehabilitation.

"You kind of have to do a whole needs assessment and figure out: What are the needs? What are the gaps? Because these are sick folks, and…you need the ability to stretch to meet their needs," Michaelidis said.

Program results and plans to grow

Currently, the health system is caring for about nine to 12 patients through its home hospital program, admitting and discharging around two patients a day.

Overall, data from the first six months of the program are encouraging. It shows a 20-to 30-percent drop in 30-day readmission rates, strong clinical outcomes related to deep vein thrombosis and other infections that can be acquired in a hospital setting, and lower rates of discharge to skilled nursing facilities, Michaelidis said.

The last measure is significant for UMass Memorial as the average age of their patients is 65 years.

"Many facilities [caring for] a geriatric population, they might send anywhere between 15 to 25 percent of their geriatric population to a skilled nursing facility," Michaelidis said. "We're sending around 1.5 percent."

Further, during the Omicron surge, the program helped care for COVID-19 patients.

"About half of our hospital-at-home patients have been COVID-positive," UMass Memorial's CNO Precourt said. "The program has provided exceptional care to COVID-positive patients in their homes that would have normally needed hospitalization in the traditional inpatient space."

Looking ahead, UMass Memorial plans to add a second team of hospital-at-home physicians and nurses to increase the number of patients receiving care through the program to 18 to 24 patients by early spring.

The health system is also advocating for making the CMS Acute Hospital Care at Home waiver permanent to ensure that vulnerable patients, like those with traditional Medicare coverage or Medicaid, continue to have access to hospital-level care at home.

The benefits of hospital-at-home programs are vast, and UMass Memorial's leaders urge more facilities to consider offering these services.

"Do not be afraid," Precourt said. "The patient and family feedback is incredible, the level of staff engagement is great, and you really do learn so much about these patients. The upfront costs will pay for themselves long term."