Understanding Acute Care at Home and the Case Manager's Role
Healthcare has been searching a long time for a care delivery model that improves outcomes, reduces costs, and enhances the patient experience. With the Centers for Medicare and Medicaid Services (CMS) assistance and some innovative healthcare systems, that model may have been born—acute care at home. This model of delivering inpatient services and treatment to moderately ill patients at home is an encouraging blueprint to advancing health care for the future beyond the pandemic.
Acute Care at Home Framework
As part of an integrated care delivery system, several hospitals and health systems either implemented portions of acute care at home or the entire process. The most notable organization are Kaiser Permanente, VA, Mount Sinai, Johns Hopkins, Brigham and Women's Hospital, and Mass General. Utah Health and Ariadne Labs developed Rural Home Hospital Program to test the model in rural areas.
However, with the onset of the pandemic, hospitals started acute care at home programs because of the high volume and minimal capacity.
In November 2020, as an extensive and all-encompassing endeavor to increase hospital capacity, optimize resources, and battle COVID-19, CMS initiated the Hospitals Without Walls expansion. This program would allow hospitals the flexibility to provide healthcare services in the patient's home. There are currently at least 44 systems, 103 hospitals in 28 states in CMS' program.
Hospitals Without Walls requires the following:
The patient must be evaluated by a physician before transferring from the emergency department or an inpatient unit to home. Integration between the hospital and program is essential in the event the patient decompensates.
The program must have screening protocols and clinical pathways in place before beginning acute care at home. The screening protocol must assess both medical and non-medical issues the patient is experiencing.
With the appropriate (virtual) monitoring and pathways, CMS believes there are minimally 60 conditions that can be effectively treated within this model. Some of those illnesses are asthma, congestive heart failure, pneumonia, and chronic obstructive pulmonary disease.
Assessment of non-medical factors, includes working utilities, environmental barriers, and domestic violence concerns, is required before the patient transfers to home.
A physician or advance practice provider must evaluate the patient daily. This evaluation may occur in person or remotely.
In addition to the physician or advance practice provider, the patient must have two in-person visits daily. A registered nurse or paramedic (recognized by an official body, Mobile Integrated Health/Community Paramedicine) may conduct these visits to the patient's home. It is important to note, a registered nurse must daily evaluate the patient. The evaluation may be accomplished either in person or remotely. All visits need to follow the patient's nursing care plan and hospital policies.
The program must provide the patient with the capability to immediately, on-demand remote audio connection to a treatment team provider.
Hospitals must use appropriate and Utilization Review Committee-approved medical necessity to ensure patients continue to meet acute care level of care.
Hospitals may use other agencies (such as home health) to assist with the treatment or provide the necessary staffing; however, the other agencies must not bill separately for the services.
The quality department/committee must require the tracking, reporting, and reviewing of patient safety metrics at least monthly.
Hospitals desiring to take advantage of this waiver must obtain permission from CMS to participate in Hospital Without Walls
Case Management Role
The case manager's role in acute care at home is similar to that in the hospital. There is, however, one unique consideration that needs addressing before implementation. That consideration is:
Remote or in-person visits?
Typically, since the population that participates in acute care at home is an older population, Integrated Care Strategists recommends, at least, an initial in-person visit with the patient and primary support person. An in-person meeting always promotes trust, which is essential in obtaining better clinical outcomes and patient experience. This first meeting will provide an opportunity for education on the principles and set expectations of acute care at home for the patient and support system. Informing patients of the expected course of therapy helps manage the course and minimizes issues.
While most of the case management processes will not change, there are a few procedures that need a review to ensure their adaptability and readiness for this setting:
Initial and continued medical necessity reviews;
Assessment of the home environment with particular attention to available utilities, e.g., internet accessibility and availability, electric voltage, etc.;
Patient's primary support system and availability;
Assessment of any domestic violence in the home or otherwise;
Goals of care discussion with the patient;
Interactions on a regular and consistent basis with the patient and primary support system to answer questions, offer emotional support, update on the transition plan, and reinforcement of the treatment plan;
Rounds with the treatment team and assuring the coordination of care among the various providers; and
Patient preparation for discharge from acute care at home to transition to home or home with home health.
With any change, it is incumbent upon leadership to prepare the team emotionally and structurally. A good primer for leaders to help guide their team through the expected change is Achieving Successful and Sustainable Transformation. Following the article's recommendations will make achievement and success easier for the leader and case management team by reducing anxiety and stress created by the change process.
Lastly, Integrated Care Strategists recommends checking with the hospital or health system's managed care team to review third-party payor contracts. Some commercial contracts include language and obligations that require the health plans to cover and pay the same as Medicare.
Conclusion
Adding acute care at home as part of an integrated care health system benefits everyone. Since the patients tend to be older, they usually are more comfortable in their home setting, where everything is familiar and loved ones surround them. In support of providing care at home, a recent study revealed that 35% to 40% of patients are interested in acute care at home, provided they receive education on what to expect and its importance.
Recent evidence indicates a 20% lower mortality rate, less utilization of sedating medications and restraints, better functional outcomes, fewer and less inappropriate diagnostic tests, and improved patient and family satisfaction. While most third-party payors do not cover this program, Humana, in conjunction with Dispatch Health, is entering the market with this benefit and care coverage in a few locations. Nevertheless, it is still important from a financial perspective to realize there are cost savings. On average, the hospital can actualize a cost savings of 25% compared to inpatient care and a decrease in the average length of stay. Additionally, acute care at home can lower readmission rates.
Acute care at home is a navigable venture that is worthy of exploration.