Five Risk Factors That Can Impact Hospital-at-Home Programs

By Solveig Dittmann, RN, BS, BA, BSN, CPHRM, CPPS, Manager of Risk Management and Analytics, Coverys

Healthcare leaders continue to push Congress to extend the Center for Medicare and Medicaid Services waiver for Medicare coverage for Acute Hospital Care at Home (HAH) program participants, allowing hospitals to receive Medicare reimbursement for at-home care services provided to patients for more than 60 conditions. Proponents assert that HAH has helped improve health outcomes, lower costs, and alleviate staffing shortages. Still, even with uncertainty surrounding the extension, healthcare organizations considering HAH adoption for their health system should consider the risk factors that can impact the success of these programs.

In the HAH model, patients are provided the equipment needed to administer hospital-level care in the home. Doctors and nurses treat patients through telemedicine, digital diagnostic devices, and in-person visits by paramedics or registered nurses. Studies show that this approach can be up to 38% less expensive than conventional hospital inpatient care.

A systematic review of nine studies published in the Journal of the American Medical Association revealed that HAH patients had a 26% lower risk of readmission and a lower risk for long-term care admission. Mayo Clinic reports that hospital-at-home patients’ 30-day mortality rate is less than 1%, less than the average national inpatient mortality rate of between 2% and 3%. 

It stands to reason that HAH is attractive not only to health systems experiencing capacity limitations, but to those that value innovation and are interested in exploring the potential quality and cost improvements in this new model of care. But before they jump headlong into the fray, organizations and providers must be aware of these five associated risks and mitigation best practices:

Not having a thorough assessment of a patient’s appropriateness to participate in the program

The greatest risk to patient outcomes, and the success of the program overall, is not starting with the fundamentals – in this case, a comprehensive assessment – beyond a medical assessment – of the patient’s appropriateness for the program. It is common for a patient to tell the hospital team that they ‘just want to go home.’ But how will the care team know whether the patient will be set up for success? 

In addition to a medical assessment, a thorough assessment should include a home environment review. It is here where critical consideration is given to the home setting’s safety, security, and accessibility. Qualified staff, such as a team of dedicated paramedics, must visit the home to make an honest assessment of any hazard that might put the patient at risk and ensure the physical environment is conducive to care. Concerns might include stairs or tripping hazards, for example. 

It is also essential to conduct a thorough social assessment to determine whether a home support system is needed. Can the potential patient perform their activities of daily living independently? If not, a dedicated caregiver must be available in the home to assist the patient. 

Inadequate training of the healthcare team providing in-home care

Successful HAH organizations must have a commitment from leadership and a team dedicated to HAH delivery. This includes physicians, nurses, paramedics, and staff trained in remote and at-home care nuances. This team must be solely dedicated to and responsible for implementing at-home patient care. 

In addition to having a clear understanding of how to operate the telehealth equipment, this team should be prepared to understand patient cues over telehealth devices – paying careful attention to the signs that the patient’s condition may be changing for the worse. They should be able to detect subtle changes earlier than they would in the hospital, as it may take 30 minutes to transport the patient from the home to the hospital.  

Some patients may be hesitant to receive care outside of the hospital

The HAH program is not for every patient. Organizations may find that patients who do not engage with their healthcare providers in a hospital setting are less likely to engage satisfactorily in a HAH program.

Some patients are only comfortable receiving acute care in a hospital and not willing to return home to continue treatment.  The patients who express that they feel safer in a hospital setting would not be the best candidates for the program. There is a risk that their anxiety will impact their compliance with their care plan, so there should never be a push to place the reticent patient within a HAH program.

Weather can impact the response time of paramedics dedicated to treating hospital-at-home patients

Ideally, patients participating in a HAH program should be located no more than 30 minutes from an acute care facility in the event of a sudden change in condition. Though this typically does not provide an obstacle for paramedics who are well-trained to respond in adverse weather conditions, providers should pay special attention to the home setting and potential hazards that might cause delays. 

Advantages of HAH care may include increased hospital bed capacity to treat higher acuity patients, extending care to patients in a lower-cost environment (the home), decreasing readmissions, and improved patient satisfaction. Healthcare systems that have decided to take the next step with HAH initiatives can help ensure the success of their program by considering these four risk factors. Careful planning that includes a commitment from leadership, a dedicated, fully trained team of providers, a defined medical, home, and social environment assessment process, and emergency planning can result in a successful and satisfying acute care at home experience for patients and their families.

About the Author

Solveig Dittmann, RN, BS, BA, BSN, CPHRM, CPPS, has more than 30 years of healthcare and administrative experience focused on risk management, patient safety, nursing management, and clinical quality improvement. She is a manager of risk management and analytics at Coverys