BY SANDRA ZAWALSKI, MSN Ed, RN, CRRN, CCM, ABDA, MSCC
A new level of care has emerged in the healthcare world called Hospital at Home, despite this level being used for several years. Hospital at Home (HaH), is a healthcare model designed to provide acute-level services in a home environment that clients would normally receive in a hospital setting. This trend accelerated when the Centers for Medicare & Medicaid Services (CMS) launched its “Hospitals without Walls” initiative in March 2020. Under that program, hospitals could transfer clients to other healthcare-providing facilities (i.e., ambulatory surgery centers, inpatient rehabilitation hospitals) and included hotels, skilled nursing facilities (SNFs) and patients’ homes with the hospital still receiving Medicare payments for the care provided.
These programs enable patients to receive acute care at home and have proven to be effective in reducing complications while decreasing the cost of care by 30% or more (B. Leff, L. Burton, S. L. Mader et al., December 2005). This type of program has been adapted worldwide; however, in the United States, physicians’ concerns about client safety, legal risks and the reluctance of payers to reimburse providers for delivering care in home settings has delayed its widespread use.
Such programs are established in England, Canada, Israel and other countries where payment policies do not discourage the provision of healthcare services in less costly venues. There are specific conditions where the use of HaH is higher, such as deep vein thrombosis (DVT) and cellulitis.
How does this level work, and how is it different from a brick-and-mortar hospital? Usually, when a client enters the emergency department, the physician will assess the client to determine if they are ill enough to be hospitalized yet stable enough to be treated at home. This type of criteria is narrowly defined and utilized to separate clients who need intensive services and/or multiple visits from specialists, and should remain in the hospital setting, from those whose needs may be able to be met at home with visiting physicians, nurses and other members of the multi-disciplinary team. The hospital must have a formal process in place that includes well defined treatment protocols for specific diagnoses such as congestive heart failure, pneumonia and chronic obstructive pulmonary disease.
The home must be assessed to ensure it is suitable to care for the client, including confirmation of running water, heating/cooling system and cleanliness. The case is assigned to a physician who meets daily with the caregiver and patient at their home. This can be done in person or virtually. The conversation includes discussion of the treatment protocol, arrangement of meals, if needed, and electronically monitored vital signs. Other members of the team will also meet with the client such as respiratory therapists, physical therapists and nurses, all of whom will administer the necessary, ordered care and monitor the patient’s progress in person. When clinicians are off-site, the clients are monitored with the use of telemedicine. Once the client is stabilized and well enough to return to activities of daily living, their care is transferred to their primary care physician.
What does this mean to the case manager? There is a wealth of opportunity for the case manager to “bring this all together.” The case manager should be involved from the start of this program to organize any potential equipment needs, assist with the home evaluation by completing a social determinants of health assessment, offer recommendations to ensure a smooth transition into a HaH setting and follow the client to discharge from the program. Once the client is discharged, the case manager should monitor for any adverse reactions that may signal the client needs to return to the emergency department. Daily conversations with the client should take place to assess their condition, feelings about the program and progress made, with reports back to the other members of the treatment team.
A whole new world is emerging in the United States, and case managers could/should be at the forefront, helping to lead the charge. What client would rather be treated at a hospital versus at home where they have familiar settings and can see family members? Case managers can empower their clients by thoroughly explaining the program and ensuring the client is comfortable with this emerging level of care.
References
- Leff, L. Burton, S. L. Mader et al., “Hospital at Home: Feasibility and Outcomes of a Program to Provide Hospital-Level Care at Home for Acutely Ill Older Patients,” Annals of Internal Medicine, Dec. 2005 143(11):798–808.
- Montalto, “The 500-Bed Hospital That Isn’t There: The Victorian Department of Health Review of the Hospital in the Home Program,” The Medical Journal of Australia, Nov. 2010 193(10):598–601.
- Leff, Burton, Mader et al., 2005.
- Celynne Balatbat, Kushal T. Kadakia, MSc, Victor J. Dzau, MD, and Anaeze C. Offodile, MD, MPH, “No Place Like Home: Hospital at Home as a Post-Pandemic Frontier for Care Delivery Innovation”, August 23, 2021.
Sandra Zawalski, MSN Ed, RN, CRRN, CCM, ABDA, MSCC, is a registered nurse with almost 40 years of experience in a variety of clinical settings that include orthopedics, brain injury rehab and neonatal intensive care. Currently employed by MCG Health, she has extensive experience in case management leadership positions including owning her own case management consulting business. Sandra has a master’s in nursing, is a board-certified case manager through CCMC, certified rehabilitation nurse, certified as a Medicare Set Aside Consultant, a member of the American Board of Disability Analysts and a designated ATD Master Trainer. She has published numerous articles in case management professional journals and is a regular contributor for Just Begin magazine. Sandra is a former commissioner for CCMC, a former chair and has had the privilege of speaking at multiple case management national conferences.
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