Development and Implementation of a Hospital at Home Program in Wake County

Barriers during the pilot

• Duke Raleigh Hospitalists felt it was right for their care model to require daily in-person physician visits. They were motivated by the desire to connect well with patients, ensure high-quality satisfactory care, and increase patient safety. However, this reduced scalability.
• Coverage by the patient-admission team for the hospital-at-home pilot excluded weekends. Therefore, we could not seek patients from Friday to Sunday; even Thursday afternoon was questionable. Weekend coverage alone would have increased our patient eligibility by 146%.

Narrow patient eligibility criteria for the sake of safety and insurance coverage

• At the time, only Medicare and NC Medicaid supported Hospital at Home patients, which limited the volume of prospective patients.
• We limited care to the treatment of Asthma, COPD, PNA, UTI, Cellulitis, or CHF. Care for these conditions was demonstrably successful at other institutions providing hospital-at-home care. Hospitalists intended to prove the hospital-at-home concept for these conditions before scaling to others. 
• Geographic limitations. We wanted to be especially safe while we proved the acute-care-at-home concept to our health system. Therefore, the geographic limits were narrower than what Duke Home Health and Home Infusion could feasibly cover. They were limited so that the hospitalist could make a daily visit and still treat patients in the hospital. They were limited so that a patient could be quickly transferred to an intensive care unit (ICU).

Care Process Inertia

• Imaging had to be completed before admission. We began partnership discussions with mobile radiology vendors but did not secure them or implement the downstream processes quickly enough to sustain the pilot.
• The majority of eligible patients were direct admission patients on general medicine floors. Their care process had already begun by the time they were interviewed by the hospital-at-home team. By the time their admitting attending was ready to make a hand-off to the hospital-at-home attending physician, the patient was almost ready to be discharged.

• It took us too much time to identify, enroll, and admit a patient to the home. We might have identified the patient in the morning, but we weren’t ready for in-home care until late evening. Slow steps included ensuring a safe home was ready, prior authorizations, information handoffs, nutrition planning, and transport. Our infusion nurses caring for our first patient in the home were extraordinarily patient and servant-hearted.
• We’d thought that care process inertia could be reduced by identifying and admitting patients from the Emergency Department. However, hospitalists were reluctant to insert themselves into emergency care processes or to be sure the patient in the ED patient was a safe candidate for acute home care.

1. Changes in operational leads. All proposals for DIHI funding are required to have a DUHS operational lead as a cosponsor to be accepted for review. The Operational Lead is the project champion from within Duke Health who is needed for integration between internal divisions, collaboration with external partners, leading change management, and sustaining the operations. Shortly after the project was funded and accepted, the proposal’s operational lead, the Hospital President, had an excellent opportunity and left Duke. We successfully regained our footing thanks to the Chief Medical Officer.
2. Shoe-string budget with no one person who could contribute a majority of their hours a week to the project. Fortunately, Duke HomeCare and Hospice offered uncompensated time, staff, and medical devices. Project leadership continued their regular full time work, caring for patients or managing other products, while developing acute hospital care at home. For a sustained and scaled acute hospital care at home, full-time project management was recommended. Even when CaroNova and Ariadne Labs were interested in collaborative sprints to accelerate acute-care-at-home, no one could commit the requested time.
3. The intertwining of finance, regulations, and electronic medical record systems. Regulatory and billing systems pair site-of-care requirements with service-level requirements: A multitude of inpatient-level hospital services were not certified within the home setting, and therefore not reimbursable. Typically, a team could solve this problem through IRB-approved research funding, but that pathway is designed to test single and incremental new drugs, procedures, or methods. Research-led funding and regulatory mechanisms were unpermissible because Hospital at Home required various tests and procedures over several consecutive days in a new type of location. Furthermore, the Electronic Health Record (EHR) design rigidly tied financial and legal codes to inpatient and outpatient care sites with little provision for this hybrid system of care delivery. Regulatory challenges generated reluctance to address technology challenges in parallel, rather than in sequence – individuals were understandably reluctant to work on a solution while other questions went unanswered or did not have guarantees. Support for incremental building and testing was slow due to beliefs that hospitalists could not provide safe or certifiable care without being able to type and store comprehensive EHR documentation.