EXECUTIVE SUMMARY
During the pandemic surges, administrators realized they needed solutions for the overwhelming number of patients entering the ED. One solution was a program that sent some patients home to be monitored by staff with hospital-level care. This worked well at freeing hospital beds and providing safe and efficient care.
- One randomized, controlled study revealed patients who were monitored in their homes reported better experiences with their care team, sleep, and physical activity.
- A remote monitoring program created before the pandemic worked well when COVID-19 sent surges of patients to hospitals in Southern California.
- The hospital at home program relies on funding resources, multidisciplinary teams, and clinical expertise.
Early in the COVID-19 pandemic, it was clear patients would flood hospitals in large cities, overwhelming health systems and public health infrastructure. One health system quickly ramped up its home monitoring program to safely keep some patients out of the hospital.
The program proved successful. Of more than 10,000 enrolled patients, 95.5% recovered and completed the program. Only 10.6% were admitted to the hospital. The mortality rate was less than 1%.1
“This is the future of care,” says Dan Huynh, MD, FACP, regional assistant medical director and regional hospitalist for the Southern California Permanente Medical Group in Anaheim.
While many patients require discharge to a skilled nursing facility (SNF), hospital at home can eliminate many of those transitions and improve capacity at both hospitals and SNFs.
“If we do this right as an organization in the United States, I think patients are the ones who really will benefit,” Huynh says.
The hospital at home program received a third place 2021 Innovator Award for Kaiser Permanente Southern California and the Southern California Permanente Medical Group.2
The results of a randomized, controlled study showed patients who receive hospital-level care in their homes reported better experiences with their care team, sleep, and physical activity. The program also can free hospital beds during a crisis, such as the pandemic surges.3,4
Hospital care in patients’ homes is the future of healthcare, says David M. Levine, MD, MPH, MA, assistant professor of medicine at Harvard Medical School and medical director for strategy and innovation for Brigham and Women’s Home Hospital.
An important part of home hospital care is how it is tailored to the patient’s needs. “Patients presented to the emergency department needed either hospital acute level of care and would stay in the hospital, or they went home with our team,” Levine explains. “In the emergency medical room, we walked in with an envelope that said whether they would stay here in the hospital or would go home with the hospital team.”
The patients randomized to home received visits from the team for the duration of their acute illness, an average of four days. “Nurses came to the home twice a day, and doctors came once a day,” Levine says. “They had biometric skin sensors of their heart rate, and we did all lab tests and imaging in their homes.”
Pandemic Created Opportunities
Hospital at home patients received care until they recovered and could be discharged from the program. “The study had some positive findings in terms of large reductions in readmissions, increases in patient mobility, very high patient experience ratings, and reductions in direct costs of care,” Levine says.2,3
The pandemic created an ideal opportunity for physicians to study the program’s efficacy during a period of patient surges.
“Our group had piloted a remote monitoring program prior to the pandemic. We thought because we had experience with remote monitoring, we knew what would work, what didn’t work, and how to get the proper case management and care coordinators in the program to the home,” says Earl Quijada, MD, a physician in geriatric, palliative, and continuing care at Southern California Permanente Medical Group. “We used everything we learned, and slimmed down everything to make it easier.”
Before the pandemic, home hospital patients used a variety of remote monitoring devices, such as blood pressure technology, thermometers, scales, and pulse oximeters, for heart failure, COPD, and other conditions.
“Because COVID was so specific [medically], we sent out the basic, easiest package we could think of, and that was a pulse oximeter and a thermometer,” Quijada explains.
The pandemic’s silver lining was that it created a sense of urgency. This catalyzed innovation like never before, says Alyssa Millan, MPH, senior manager of health innovation at Southern California Permanente Medical Group.
“What I found to be a critical push needed during the pandemic was the sheer need, from a systems perspective, to increase hospital bed capacity and minimize hospital COVID bed burden,” Millan says. “This was clearly a way to not only unburden the system but to really support the patients and their families for recovery in a place where they were the most comfortable.”
That was the beauty of the system, she adds.
The program relies on funding resources, multidisciplinary teams, and clinical expertise. The pre-pandemic advanced medical care at home program was tightly connected with the home health program, and the volumes were modest, says Angel Vargas, FACHE, vice president of Care at Home of Kaiser Permanente Southern California and Hawaii and market lead and executive sponsor for KP Veterans Association in Southern California and Hawaii.
“All of a sudden, as we’re about to start our expansion to hospital at home, COVID hit and we had to put those ambitions on pause,” Vargas explains. “However, we did not stop because COVID led to an evolution in COVID home monitoring.”
The preparation for hospital at home worked well when health system leaders realized they could soon see a huge wave of COVID-19 patients.
“COVID hit us early in 2020, and that was a time when we started hearing about the first cases of COVID coming to the United States,” Huynh says. “We heard horror stories from Italy and China, New York and New Orleans, and we heard how overwhelmed those hospitals were. In March 2020, we got our first forecast of what the surge may look like in California, and it was very daunting. It had everyone overwhelmed.”
The predictions were that thousands of COVID-19 patients would hit hospitals and ICUs, and no health system had enough beds based on those projections.
“New York and New Orleans were pleading with people to think about how we could treat COVID differently, managing patients at home,” Huynh explains. “Based on what we learned from New York, New Orleans, and Italy, we learned that many of these patients could be safely cared for in the home, and we’d have to create a new model of care.”
There were no COVID-19 programs in those early months. Huynh and colleagues began creating one. “We came up with this program that put together clinical guidelines for what we needed to do for safe care for patients in the home,” he says.
The clinical guidelines showed physicians how to find the right patients for management at home. They also guided case managers, ambulatory staff, and other healthcare professionals involved in care. (For more information, see the story in this issue on how hospital-at-home program worked.)
The health system also handled the scarcity of personal protective equipment (PPE) with volunteers who made 4,000 masks by hand during the first wave.
“We maintained tight PPE in the home,” Vargas explains. “I made staff wear goggles and face masks before they were required, and our leadership team decided to be stringent and give staff as many masks and N95s as we could find.” Although the early word was that COVID-19 would spread through droplets, they took airborne transmission precautions.
The chief goal was to create a safety net for patients who were cared for at home. Especially with COVID-19, it was important to monitor patients for signs their condition was worsening.
“We were capturing patients with silent hypoxia that we would not have caught if we had not enrolled them in the program,” Huynh notes. “We caught many cases where the patient was deteriorating or didn’t realize they were hypoxic, and we sent about 10% of patients back to the hospital.”
They learned a lot from the experience of managing patients at home during the pandemic. “What this program demonstrated is we can leverage remote patient monitoring, telehealth, and provide high-quality care for patients in their home,” Huynh says. “Many of these patients were high acuity and probably would have been in the hospital if we had not implemented the program.”
Since the program worked well during COVID-19 surges, it has set the foundation for future hospital at home programs, Huynh adds.
REFERENCES
- Huynh DN, Millan A, Quijada E, et al. Description and early results of the Kaiser Permanente Southern California COVID-19 Home Monitoring Program. Perm J 2021;25:20.281.
- Hagland M. The 2021 Innovator Awards co-third-place winning team: Kaiser Permanente Southern California and the Southern California Permanente Medical Group. Healthcare Innovation. July 21, 2021.
- Levine DM, Pian J, Mahendrakumar K, et al. Hospital-level care at home for acutely ill adults: A qualitative evaluation of a randomized controlled trial. J Gen Intern Med 2021;36:1965-1973.
- Filipek D. Healthcare news of note: Brigham and Women’s home hospital program freed up 419 beds during early COVID-19 surge, study shows. Healthcare Financial Management Association. Aug. 24, 2021.
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