Ballad Health’s Leap Into Hospital-at-Home for an At-Risk Population

On Tuesday, April 18, at the HIMSS23 Conference, being held at Chicago’s McCormick Place Convention Center, two senior leaders from the Johnson City, Tennessee-based Ballad Health integrated health system and a consultant who has been working with them, presented a case study entitled “A Hospital-at-Home Journey: One Year Later.”

Mark Wilkinson, M.D. is Ballad Health’s CMIO and its vice president of hospital-based programs; Penelope (Penni) Kyte is the health system’s chief digital strategy officer; and Tina Burbine is the vice president of care innovation at the St. Petersburg, Florida-based HealthLink Advisors consulting firm, which is involved in many care delivery innovation projects. Ballad Health encompasses three tertiary care hospitals, 12 community hospitals, three critical access hospitals, a children’s hospital, and a behavioral health facility.

As the organization’s website states, “Ballad Health is an integrated community health improvement organization serving 29 counties of the Appalachian Highlands in Northeast Tennessee, Southwest Virginia, Northwest North Carolina and Southeast Kentucky. We're dedicated to improving the health of the people we serve. Our system of 21 hospitals, post-acute care and behavioral health services, and a large multi-specialty group physician practice works closely with an independent medical community and community stakeholders to improve the health and well-being of close to one million people.”

As the session’s description noted, “Hospital-at-Home care is a combination of pre-hospitalization, acute, post-acute and ambulatory services focused on a patient’s individualized care needs in their own home and replaces hospital admission through a direct admit to home from the community or ED. The goals for this type of care include earlier acute care discharge, a reduction in readmission rates and improving the quality of patient care by extending hospital-level care beyond the walls of the hospital. At HIMSS22, Ballad Health shared the foundational elements for establishing a Hospital-at-Home pilot program. Now, one year later, Ballad is excited highlight the results of the Hospital-at-Home pilot and how the team used their acute-care experience to scale. Ballad Health will also share valuable insights about increasing provider adoption, incorporating patient techquity, and building a financially sustainable program.”

As Dr. Wilkinson told the audience, “There have been a lot of successful hospital-at-home programs in hospitals and health systems in large cities; but when we talk about providing the hospital-at-home level of care to our patients, we’re talking about a challenging population. We have a very high rate of Medicaid; and we’re in the Appalachian Mountains. We have a significant number of patients living in homes lacking either electricity or running water, or both.” And the high level of poverty in the area, and the challenge of delivering care in a mountainous, sometimes-remote geographical region, have both shaped how Ballad Health’s hospital-at-home program has evolved forward, through challenges and discoveries along the way.

What was it like to bring together the various people and areas, what was needed? “We have a progressive leadership team,” Wilkinson continued. “And we began talking about hospital-at-home in 2020. Folks were looking for alternate modalities. Leadership strongly supported this initiative. We had to build our core team of folks, including Penni.”

“And what we did,” Kyte said, “is that we built clinical protocols for four disease areas: COPD, CHF, cellulitis, and community-acquired pneumonia.” Per those specific disease areas, Wilkinson said, “We focused on those because we thought that those four conditions could be managed well at home.” That said, Kyte added, “We had to do a lot of educating of clinicians and others” on the concepts of hospital-at-home.

Identifying which patients would best quality for hospital-at-home care was extremely important, they agreed.

The criteria the team developed became very specific, focusing on patients with conditions involving specific DRG codes, geographic location relative to specific hospital facilities, and an occurrence of three or more readmissions in the previous six months.

“The care coordination has to be rigorous; but it improves social care, too,” Kyte noted. “If patients come to the ER and don’t have electricity or running water, we’re trying to connect that. We can’t put a patient in hospital-at-home if they don’t have electricity and running water.”

Per that, Wilkinson said, “We used a previously established program of ours, ‘Safe at Home,’ as a steppingstone for hospital-at-home. What we learned in developing hospital-at-home is that patients can be getting calls from a whole bunch of people—from people at primary care offices, from Ballad Health itself, and so on. And the reality is that patients don’t like to be called at home; they like to have access to the care team, but don’t want to be called at home regularly.” So it was important to streamline provider-patient communications.

More broadly, Wilkinson continued, “Our plan was to try to mitigate a hospital admission first, if possible.” In fact, he said, clinically speaking, “There are many options. You have to decide what to choose. So patients come into the ED, and we do an evaluation.”

In all this, Wilkinson said, “The challenge is workforce. We invested in paramedics, because we didn’t have enough nurses. We got the paramedics licensed for nursing to be our boots on the ground for patients in the home. It does take an investment in making sure the paramedics are skilled and competent. Having been in emergency medicine for decades now, it’s a significant proposition for the healthcare provider to go into someone’s home, especially in Appalachia. Some organizations that have tried to employ bedside nurses, have struggled. Some nurses are uncomfortable delivering care in the home.”

In fact, said Burbine, “What’s being learned is that hospital-at-home is of course very different from traditional home healthcare; it’s a much higher level of acuity. And so we learned that traditional home health nurses were simply not trained for this level of acuity. And what we came to realize was that we needed to consider encouraging our critical care nurses to engage, so that’s who we’re encouraging to participate as clinicians in hospital-at-home.”

Indeed, Wilkinson said, “We’ve struggled with a shortage of both nurses and IT professionals. We do have Epic. We spent a good deal of time optimizing that solution. We didn’t want to have a bolt-on hospital-at-home EHR.” Meanwhile, he said, “We had planned on launching last July; we didn’t make that deadline. The delay was mostly around building out the software.”

One thing that needed to be built, Burbine noted, as “a centralized operations center for patient flow.”

As a result, Kyte noted, when a patient comes into urgent care or the emergency department, they are evaluated for potential admission to the hospital-at-home program, using the clinical criteria and protocols that have been developed.

The program has already logged 32,000 virtual health visits, with 62 percent by phone and 38 percent by video.

And, Kyte said, “It’s important to understand the financial dynamics and elements in this. Everyone already understands the clinical elements.”

All three presenters agreed that there is tremendous potential going forward, both at Ballad Health specifically, and across the U.S. healthcare system. But mining that potential will require strategy, thought, and effort.