Hospital at Home is “a coordination problem disguised as a technology problem”

The pandemic may have pushed the concept of hospital care at home into the spotlight, but it’s health systems that have been taking the idea and running with it. Over the past six years, providers have been rapidly expanding their participation in the Medicare Hospital at Home program, which has been successful enough to secure a five-year extension from Congress. 

Now that reimbursement is more secure for the near future, the extension is likely to bring a new wave of health systems into the hospital at home ecosystem. It’s a hugely important opportunity for innovation – one that will require participants to deeply understand the challenges at hand and apply the right solutions at the right points in the patient care journey. 

Those challenges aren’t just about choosing and implementing the devices and platforms to provide adequate remote monitoring for patients. They’re about organizing and coordinating these tools to develop a truly proactive, wrap-around circle of care for the individual that ensures both patients and staff can communicate and act appropriately.  

“We don’t really have a technology problem. We have a coordination problem disguised as a technology problem,” said Mike Maniaci, MD, Associate VP for Virtual Health & Home-Based Care at Advocate Health, during a recent webinar hosted by the Hospital at Home Users Group and the American Academy of Home Care Medicine.   

“When clinical staff are acting as human routers between digital systems, we don’t have a digital hospital: we’ve just got a lot of tools with a lot of workarounds. We need to fix those coordination gaps so that we can really take advantage of the technology we have.” 

Turning a tangle of technology into coordinated care

Hospital at home care enables some patients with moderate-to-high acuity to receive care in their own homes rather than in the inpatient setting. These patients are equipped with a variety of remote patient monitoring (RPM) devices to help continually monitor their status, but most also require additional support in the form of in-home visits from nursing staff, frequent communication with care teams, and access to medical supplies or durable medical equipment as part of their treatment. 

There’s plenty of administrative and clinical activity that takes place on the provider side, too, explained moderator Jared Conley, MD, MPH, PhD, an emergency physician, and Associate Director of the Healthcare Transformation Lab at MGH.  

“When we talk about technology in hospital at home, we’re not just talking about RPM devices. We’re talking about the entire ecosystem, from patient selection, diagnostics, and drug delivery to supply chain and care coordination. It’s the whole kit and caboodle. And the future of this model depends on how well we can bring all of those elements together.” 

For Shiv Sutaria, MD, Assistant Chief Medical Information Officer for Healthcare at Home at Mass General Brigham Home Hospital, appropriate organization of these tasks and technologies is key to successfully scaling a hospital at home initiative.  

“I think about it in three buckets: remote monitoring, logistics and care coordination, and EHR integration,” he said. “All three of those have to work seamlessly for a program to function well. And right now, a lot of what we’re doing, especially on the coordination side, is still manual. We’re using Excel, Microsoft Teams; lots of different tools. There’s a lot of human involvement because there isn’t a single platform that brings it all together.” 

“If you’re not able to integrate clinical and logistical care delivery, it’s going to be next to impossible to scale or even run a successful home hospital program,” he continued. “Every program, whether it’s ten patients or a hundred, needs some form of orchestration platform.” 

An optimized platform has to be intuitive to use while solving for interoperability between the numerous systems that surround a hospital at home patient, added Mandy McGowan, RN, Director of Home-Based Care at UW Health. 

“One of our biggest challenges right now is that information is fragmented,” she observed. “Patients and care teams have to go into multiple places to find what they need. That’s not a good patient experience, and it’s not a safe situation for clinicians either. There’s too much room for error when information isn’t integrated into a single, cohesive view.” 

“We’re taking time to evaluate what’s actually most important – not just for the care team, but for the patient and caregiver as well. The process has to work for all three groups, otherwise it’s not going to be sustainable.” 

Building a coordinated system that makes the most of remote monitoring tools 

Improved coordination in the provider environment can help patients feel more secure and get more effective care in the home, the panelists agreed. 

“Continuous monitoring at home done correctly is like a digital hug,” said Maniaci. “I can turn on a device and say they have a heart rate; they have a good pulse ox; they’re moving around. That’s how we’re going to take care of sicker and sicker patients in the home setting: being able to check on people without having to physically see them or disturb them, while still maintaining that sense of safety.” 

It’s almost like a “security blanket” for everyone involved, agreed Sutaria. “It helps patients feel safe; it helps providers feel safe – and importantly, it helps the referring clinicians in the brick-and-mortar hospital feel safe,” he said. “RPM technology, especially the dashboards that assist with monitoring, help to build trust and make providers more comfortable sending patients home.” 

However, the key to scaling a Hospital at Home initiative from one-off remote monitoring to a fully successful program for patients is the care orchestration component, he stressed.  

“The first thing on my wish list is a true clinical and logistical platform that can orchestrate care,” he said. “I think every home hospital program will need something like this, whether it’s a small program of 10 patients or whether it’s a hundred patient program. If you’re not able to integrate clinical and logistical care delivery, it’s going to be next to impossible to achieve what you’re hoping.”  

Fostering success in the emerging home-care environment

To bring hospital at home to life, health systems need to allocate resources to both the technology and the process in appropriate measure, advised McGowan. 

“It’s very easy to get overexcited with what’s possible from a technology standpoint. There’s a lot of incredible innovation out there,” she said. “But my recommendation is to start with what your program actually needs and think about how you’re going to deploy it, not just what you’re going to buy.” 

For example, UW has found that hiring a dedicated staff member to handle supplies and logistics has been most helpful for keeping track of items going in and out while effectively communicating with the rest of the remote care team, she said. 

“Overall, you need to focus on reliability, redundancy, communication, and ease of use,” McGowan concluded. “Without those foundational pieces, you can add all the advanced technology you want, but your program is going to struggle to scale in a meaningful way.” 

Jennifer Bresnick is a journalist and freelance content creator with a decade of experience in the health IT industry.  Her work has focused on leveraging innovative technology tools to create value, improve health equity, and achieve the promises of the learning health system.  She can be reached at [email protected].