By Dorothy Brooks
Two EDs in Madison, WI, are serving as origination points for the University of Wisconsin (UW) Health’s new hospital-at-home program, an initiative that began in July. As such, emergency providers at University Hospital and East Madison Hospital are playing a pivotal role in identifying good candidates for the new program among patients requiring inpatient-level care.
“From the beginning of our project planning, we had two provider champions from the ED involved. As we created the beginnings of our workflows, patient identification process, workflow transfers, and things like that, we had an advanced practice provider and a physician leader from the ED as a part of that,” explains Mandy McGowan, RN, director of home-based programs for UW Health. “They helped us talk through scenarios and workflows, and really became champions of the program — a message that they took back to their peers in the ED.”
In fact, a key part of some of this early planning focused on devising ways to streamline the process emergency care providers use to identify patients eligible for the program. “We worked with our IS [information services] department and our analysts to build some of the criteria [for the hospital-at-home program] directly into our electronic medical record [EMR] to aid ED staff with the identification of potential candidates,” McGowan says.
For example, some high-level requirements pertain to basic information, such as where a patient lives, their insurance status, and age, since only certain payors are involved in the program currently. “We worked with IS to build those into the existing patient identification process in the ED. Once a provider determines that a patient needs to be admitted to the hospital, our program comes up as an option, along with other programs in our system of care in Madison,” McGowan says. “That will immediately trigger the provider to consider that this patient, at least at first glance, qualifies for home-based hospital care.”
From there, the program will automatically notify the home-based hospital care team, who then will partner with the providers in the ED to further assess the patient. “If the patient then meets second-line criteria, then our staff come on site to the ED, meet the patient, interact with the staff, and do a truly warm handoff from the ED to our staff as we take that patient home to have their inpatient care episode at home,” McGowan says.
Patients who qualify for the program must meet inpatient criteria and be considered general medicine patients. Those who require surgery or some type of procedural intervention would not be eligible for the program. Similarly, patients requiring continuous telemetry or repeated advanced imaging, such as a PET scan or an MRI, are excluded. “Patients who generally fit into our criteria for the program are patients who are having an exacerbation of a chronic disease, such as chronic obstructive pulmonary disease or congestive heart failure, or perhaps patients with an infection, such as pneumonia or cellulitis,” McGowan notes.
Eligible patients can decide whether they want to receive their hospital-level care at home. Thus far, the option has been received well. “Patients have been incredibly grateful to be able to have people come to them in their own homes,” McGowan says. “We’re there to be of service, and we really function on their timeline, in their environment, and we’re the ones who adapt to them.”
While in the hospital-at-home program, a physician will visit patients at least once per day. Nurses will visit the home at least twice a day. “In addition, we have wraparound services that come to the home in the form of a phlebotomist to draw labs and a mobile imaging company that is capable of getting X-rays, ultrasounds, and echocardiograms,” McGowan says. “We also have physical therapy, occupational therapy, speech therapy, and wound specialist nurses who can make home visits.”
Further, each patient is equipped with a tablet computer they can use to access the inpatient module of the health system’s EMR or to communicate with the hospital-at-home care team.
“They can see all of their medications, and they can see their schedule for the day,” McGowan says. “They can see photos of the care team members who are coming to see them ... and we can also push patient education to them through the tablets.”
The tablets can be linked with peripheral devices, as needed, for each patient’s care. These may include a blood pressure cuff, pulse oximeter, a scale, or a thermometer. “Our care team uses those items when they go out to see the patient and collect vital signs,” McGowan explains. “Those vital sign readings then go directly into the patient’s EMR.”
Initially, the hospital-at-home program is only serving a maximum of four patients at a time. Patients are admitted under a Centers for Medicare & Medicaid Services (CMS) waiver that enables hospital-at-home as a substitute for a traditional inpatient hospital stay.
However, McGowan hopes to eventually also include patients under a different type of CMS waiver. ED patients would first spend time as traditional inpatients in the hospital, then transition to the hospital-at-home program, during which they would finish the remainder of their hospital-level care encounter. Also, the health system hopes to expand the number of payors that are working with the program.
Ultimately, project planners intend to care for hundreds of patients per year in the hospital-at-home program, thereby offloading some of that capacity from UW Health’s inpatient hospitals. “Patients come from all over the state and the Midwest to seek care here,” McGowan explains. “If we can move the care of some of those patients to the home ... we are freeing up beds for UW Health to be able to take on more patients from around the region.”
Project planners intend to care for hundreds of patients per year in the hospital-at-home program, thereby offloading some of that capacity from inpatient hospitals.
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