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The American Journal of Managed Care October 2015
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Scalable Hospital at Home With Virtual Physician Visits: Pilot Study
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Scalable Hospital at Home With Virtual Physician Visits: Pilot Study

Wm. Thomas Summerfelt, PhD; Suela Sulo, PhD; Adriane Robinson, RN; David Chess, MD; and Kate Catanzano, ACNP-BC
Results suggest that this scalable model of Hospital at Home is safe, feasible, highly satisfactory, and may be associated with substantial reductions in hospital readmissions.
Intervention: The Hospital at Home, Central Station, and Home Monitoring Station
The current HaH model of care was based on the previously described Johns Hopkins Hospital at Home model,7,21 but introduced 2 innovations. First, it employed a “central station” and home monitoring station that allowed physicians to make virtual, rather than in-person, home visits to patients. This also allowed for remote and continuous monitoring of patients by the care team. Physical in-home visits were made by nurse practitioners and physician assistants. The Central Station was a fully capable call center with 2-way tele-video and voice capability; it also had security, privacy, and patient data redundancy with multiple system backups. The Home Monitoring Station allowed the Central Station to connect fully to patients’ homes through a standard telephone land line and for continual monitoring of vital signs, 2-way tele-video conferencing for patient/provider/caregiver interactions, and facilitated responses to situations of clinical concern. Biometric measures were obtained using wireless devices (ie, pulse oximetry, blood pressure, pulse, and weight scales), and when activated, they automatically sent information through a hub to a website (which was linked to the Central Station). Patients received Personal Emergency Response System wristlets that allowed for immediate connection to emergency care. If a scheduled vital sign was not obtained, the system alerted the Central Station prompting a care coordinator call. If there was no response, 911 was called.
 
The second innovation was for HaH to assume responsibility for a 34-day episode of care, which consisted of an acute and a transition phase. In the acute phase, hospital-level care commensurate with illness acuity was provided. The “greeter,” a licensed practical nurse, visited the patient at home immediately after their return from the hospital. Greeters made final assessments of the adequacy of patients’ home safety and support, installed and introduced patients and caregivers to the home-based technology, reinforced their training, and activated the Home Monitoring Station. Patients received needed diagnostic studies and therapeutics in the home, including intravenous fluids and medications, oxygen therapy, nebulized bronchodilators and respiratory therapies, and basic radiography and ultrasound. Illness-specific protocols and checklists provided caremaps, which integrated care from multiple providers (ie, hospital, central station, primary care, and home) and allowed for patient-centered, individualized care. Caremaps provided a clinical infrastructure modeled from the airline industry, with checklists, redundancies around potential failure points, and feedback loops. Virtual physician visits were provided using the central station 2-way tele-video system. Physical home visits were made on the day following admission and on day 3 of the admission, in addition to whenever clinically indicated. Licensed practical nurse care coordinators, in coordination with the HaH physician, followed up on all details of care delivery and care coordination. The timing of discharge from acute phase was analogous to discharge from the traditional acute hospital, and then care shifted into the transition phase.
 
In the transition phase of HaH, patients had daily contacts alternating between the HaH physician via tele-video monitoring and the care coordinator via telephone until their first visit with their primary care physician (PCP). Nurse practitioners or physician assistants were available to make home visits at the request of HaH physicians, if clinically indicated. When patients saw their PCP, the HaH physician transferred case authority back to patients’ PCPs. However, after the visit with the PCP and through day 34 of the admission, at least once a week—and as frequently as every other day, depending on the support required—care coordinators would call patients using scripted protocols to track clinical issues. Positive or concerning findings were communicated to PCPs; such findings would be acted upon by the HaH physician if the PCP could not be reached. For patients who refused follow-up care with their PCP, the approach was modified and they were monitored daily by the Central Station staff until the end of the transition phase. At the conclusion of the transition phase, the patient was fully discharged from HaH care and a final report summarizing the transition phase of care was sent to their PCP.
 
Medical Record Reviews and Baseline Interview
Medical records were abstracted using a standardized instrument that captured baseline sociodemographic and medical characteristics, as well as treatments received and the patient’s hospital course, including complications of care. Study subjects completed a baseline interview that included sociodemographic characteristics, living arrangements, and functional status.
 


 
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