Lessons Learned in ChristianaCare’s Hospital at Home Program

The goals of hospital at home programs include better patient satisfaction, better quality, fewer readmissions and lower costs. Patricia Resnik, vice president of the Center for Virtual Health at Delaware-based ChristianaCare, recently described some lessons learned since launching their program in December 2021.

Speaking at a recent meeting of the National Association for Healthcare Quality (NAHQ), Resnick said ChristianaCare believes the future of healthcare is virtual and that anything that can be done virtually will be done virtually. ““Our virtual health vision and strategy includes being able to drive value-based care and population health initiatives through a wide variety of digital solutions. We're transforming the way care is delivered, including leveraging the home as the new venue,” Resnick said.

Delivering care to the patient where they prefer gives caregivers insight into the social determinants of health in their home setting, she added. “We're able to connect and leverage to other community services in ways that we are unable to do when the patient is in a brick-and-mortar setting. It allows seamless transitional care management because that care management and that transition occurs in the patient's home. We can avoid readmissions and escalations by providing that seamless transition with the patient's primary care physician and handing off in that home setting.”

The acute hospital care at home waiver for ChristianaCare was approved in the summer of 2021. It's operationalized through the health system’s Center for Virtual Health. They admitted their first patient on Dec. 14, she said, “so in a short period of 25 weeks we stood up an entire hospital program in a patient's home, and that's from contract execution with our partner Medically Home through intensive design sessions all the way through three weeks of patient simulations to ensure that all those standardized workflows that we designed work according to how we designed them.”

The waiver approval was for two acute care facilities, the Newark and Wilmington campuses. “There was a lot of work that needed to be done in that very short time frame,” Resnick said. “We were really starting from a blank piece of paper. We had to design our whole program. We started with hiring caregivers. We had to hire our nurses, physicians, our support team, our patient digital ambassadors, who play a very important role supporting our clinicians. They had to be recruited, hired, on-boarded and go through orientation. At the same time, we were doing our hospital care at home design.”

Part of the challenge was finding about 20 suppliers to help support hospital care in the home. “From a workflow and processes perspective, we had to create every workflow for not only our internal processes, but also every workflow for all of our suppliers, and then also develop all those key policies and procedures from an environment perspective,” she said. “We were still in the public health emergency. This was impacting supplies availability, and then we had the COVID surge return in the latter part of November. We entered into three weeks of intensive live patient simulations. And that's where we had to test every single supplier process and workflow. Our caregivers volunteered to allow all the suppliers come into their homes, and we tested every process in homes to identify and fix any opportunity related to those workflows and processes. Every supplier and every process had to pass before we admitted our first patient on December 14.

The first way they get patients is called acute substitution, where after a thorough evaluation, if the patient’s situation is deemed appropriate, they are offered the option of acute care at home. If the patient agrees to be admitted to the hospital care at home program, then the hospital care at home team makes all those arrangements and they transition the patient to their home via ambulance.

The other way they acquire patients is through a reduction in brick-and-mortar length of stay. This is where a patient is admitted as an inpatient and may need more intensive services initially in their care treatment plan. But after that is all completed, maybe within the first day or two of their admission, there's also consideration that the patient could continue their inpatient stay in their home.

Since December 2021, ChristianaCare has cared for 124 total patients in its hospital care at home program, with an average length of stay of 6.3 days. “From our patient safety measures, we've had zero hospital-acquired infections; our 30-day inpatient readmission rate is currently at 8 percent against the national rate of around 13 percent. We continue to look for opportunities to drive that readmission rate even lower,” Resnick said.

“We're a little bit longer than the national rate at 6.3 days, but with a lower readmission rate. That's not causing us any concern,” she added. “Our 30-day return to the emergency department is at 4.4 percent and we do not have a benchmark for that. Our net promoter score, the likelihood our patients will recommend the program, is at 83.3 percent. We've received tremendous positive feedback from our patients about their satisfaction. We've had patients who've come back for other services and who have requested to be admitted to hospital care at home.”

“We don't have our cost outcomes yet. We are working in collaboration with our finance team. They are leading the efforts here designing a total cost of care model,” she explained.

As far as lessons learned, Resnick said they have found that patient acquisition is harder than they expected. “We are a very large health system with over 1,200 beds. We thought patient acquisition would be easier. We have a lot of work going on in this area. We have placed our clinicians on site at the hospitals, with a lot of education, a lot of engagement with our colleagues on the acute-care side to explain the hospital care at home to patients to increase our patient acquisition,” she said.

The logistics of managing 18 to 20 suppliers in the external market can be challenging at times, she added, “but we have really a great team managing those logistics. For the primary in-home clinicians, we are currently using nurses in that model. We are working with the State of Delaware on a mobile integrated healthcare model, leveraging the talents and expertise of paramedics.”

From a social determinants of health perspective, she said, they really get a view of the patient's life “because they've invited us into our into their home and it's truly a privilege to be able to come into someone's home and care for them. We really have been able to help connect patients and their families with other community services and get a view that we would not otherwise get if the patient was in the brick-and-mortar hospital.”

From a health equity perspective, she said, they are working very closely with the health system health equity team to ensure that every patient who meets the criteria for hospital care at home can access this program. “We're particularly looking at the stability of housing, and patients who may not have stable housing or may not have any housing — ensuring that those patients can take advantage of the hospital care at home.”

“I can’t stress how important data analytics and rapid cycle improvement is to be able to set up standard workflows and processes and to be able to in a very standardized fashion measure our performance so that we can rapidly improve where we need to improve,” she said. “We will continue to grow our quality competencies and our quality structure as our program grows and our average daily census grows. We are completing and we will continually monitor the total cost of care analysis, and will continue our focus on health equity, and are starting to explore some potential opportunities for offering hemodialysis in the home.”