The Center for Successful Aging: Subacute at Home Program

A Collaboration to Expand Home Health Services

BY BERNIE RAVITZ, MD, CHCQM-PHYADV, FABQAURPABAM, PAC-CDI

The Center for Successful Aging at MedStar Health Good Samaritan Hospital and MedStar Health Home Care have partnered to create the Subacute at Home (“SaH”) program. This initiative addresses disparities and gaps in elder care in Baltimore City, Maryland. The program focuses on the most vulnerable older adults, often in underserved communities, by providing an intensive 30-day post-acute hospital rehabilitation, nursing and medical treatment plan as an alternative to placement in a skilled nursing facility.

The program was first conceptualized out of delays in post-acute bed availability, particularly at skilled nursing facilities. MedStar was struggling to place patients out of the hospital and thus impacting the ability to care for patients requiring medically necessary hospital services. Conceptualized from a multidisciplinary team with the understanding that the SNF situation was likely not going to improve due to continued staffing challenges, they decided to come up with an alternative. In the discovery phase of this project, the team learned that the necessity of SNF often arose out of the lack of services in the home. The program was developed to fill this gap with the objective of creating Subacute at Home. The specific objectives included:

• Providing safe, high-quality medical care in the comfort of patients’ homes.
• Helping patients recover, build strength, and regain independence while surrounded by loved ones.
• Educating patients and their caregivers on managing complex health conditions.
• Improving the patient and family experience.
• Bridging gaps in elder care coordination.
• Decreasing the total cost of care by reducing hospital length of stay, readmissions and potentially avoidable emergency department visits.

Subacute at Home began in July 2023 and was fully operational by September 2023 as a MedStar Health Good Samaritan Hospital pilot program. The program is credited to the financial support from The Arthur E. Landers and Hilda C. Landers Charitable Trust who partnered with the MedStar Good Samaritan Hospital’s Center for Successful Aging. It has recently expanded to MedStar Health Union Memorial Hospital, with plans to extend to other MedStar Health Baltimore hospitals in early FY 25.

The program is a concentrated 30-day program available only to adults 60 years of age and older who meet specific criteria (see chart below). Patients are screened with the support of case management, who evaluate the patients’ current home situation, caregiver supports, and potential needs once admission. When enrolled, patients receive home visits from experienced geriatricians and geriatric nurse practitioners (in-home and/or via telehealth), as well as traditional in-home healthcare visits (physical therapy, occupational therapy, speech-language pathology) at a higher frequency with more intense visits. Additionally, patients receive ongoing support for social determinants of health factors (e.g., partnership with Meals on Wheels), pharmacist consultations, and have home care aides assist with personal and respite care. At the end of the program, patients are smoothly and efficiently transitioned back to their primary care providers. If a patient does not have a primary care provider, a MedStar Health geriatrician will be recommended.

Patient Criteria

Patient Eligibility	Exclusions	Other Considerations
Older adult, > 60 with insurance acceptable to MedStar Home Health Care. A list can be provided. Safe and accessible home environment within MedStar Health Home Care catchment area. Ability to ambulate with or without moderate assistance to bathroom, telephone, etc. Has in-home family or caregiver support. Patients must require physical therapy and may require additional occupational therapy and/or speech-language therapy, of at least 45-60 minutes, 3-5 days a week of combined therapy ordered. This is in addition to the in-home and/or telehealth visits provided by a geriatrician, nurse, and geriatric nurse practitioner. Internet and phone access.	Hemodialysis. Chemotherapy. Moderate to advanced dementia, without home support. Assessment of ability and capacity is determined by case management, PT/OT, and care team.	Prior medical and overall independence or caregiver compensation for any gaps. Desire and engagement to return and stay home, with reasonable assessment of self-capacity. Willingness and capacity of caregivers to provide safe and effective care (critical factor). Caregivers should be trained by professional staff to learn how to provide effective care. Technology assessment of home environment including the availability and ability to use technology (with help) or ways to mitigate gaps, including hot spots, iPad deployment or smart phone.

Subacute at Home collaborates with the MedStar Health Research Institute’s Center for Biostatistics, Informatics, and Data Science to gather data, build a dashboard and analyze outcomes to demonstrate the program’s success. Data points include patient demographics, patient satisfaction, hospital length of stay, readmissions, the percentage of patients who remain home for three, six, nine, and twelve months, and the total cost of care. Current outcomes show that 32 patients have been admitted to the program, with one patient requiring hospice care. The transition to hospice care was smooth, thanks to an established relationship with Gilchrist Hospice Care.

The program continues to strive in success for keeping more patients at home. The care team has learned through this process that ongoing leadership collaboration and weekly patient huddles have been key to monitoring and ensuring success of the program.

The Subacute at Home program by the Center for Successful Aging at MedStar Health exemplifies a progressive approach to elder care, addressing critical gaps and providing an invaluable alternative to traditional skilled nursing facilities. By leveraging multidisciplinary collaboration and focusing on patient-centric care, the initiative has shown promising results in enhancing the quality of life for older adults, reducing hospital readmissions, and cutting overall healthcare costs. The continued success and planned expansion of the program demonstrates its effectiveness and the potential to optimize home services for the elderly. Looking ahead, the ongoing commitment to innovation and compassionate care is pivotal to overcoming the skilled nursing bed staffing and admission challenges.

References

1. Augustine, M. R., Davenport, C., Ornstein, K. A., Cuan, M., Saenger, P., Lubetsky, S., Federman, A. D., DE Cherrie, L. V., Leff, B., & Siu, A. L. (2020). Implementation of Post-Acute Rehabilitation at Home: A Skilled Nursing Facility-Substitutive Model. JAGS, 68(7):1584-1593. doi: 10.1111/jgs.16474.
2. Federman, A. D., Soones, T., DE Cherrie, L. V., Leff, B., & Siu, A. L. (2018). Association of a Bundled Hospital-at-Home and 30-Day Post-Acute Transitional Care Program with Clinical Outcomes and Patient Experiences. JAMA Intern Med, 178(8), 1033–1040. doi:10.1001/jamainternmed.2018.256.
3. Malone, ML, Fain, MJ. (2020). Building the Infrastructure for Rapid Implementation of High-Value Home-Care Delivery Models. JAGS, 68, 1400-1401. doi: 10.1111/jgs.16473.

Bernard H. Ravitz, MD, CHCQM-PHYADV, FABQAURPABAM, PAC-CDI
Assistant Vice President of Medical Affairs, MGSH, MUMH
Founding Member, American College of Physicians Advisors (Emeritus Board of Directors)
American College of Academic Addiction Medicine Advisory Board

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