Why It Matters
HealthPartners in Minnesota, an IHI Strategic Partner, is advancing the movement towards value-based, patient-centered care with programs dedicated to helping seniors age successfully. Starting in 2013, the HealthPartners home-based care team worked to expand their suite of home-based services, aimed at helping patients age safely in place. The team began with a program called Hospital+Home (H+H) that focused on managing congestive heart failure exacerbations in the home.
Using the blueprint from this pilot, the team developed a program to better manage acute events in the home. This program, Home-Based Acute Care (HBAC), addressed the need for earlier access to care and medical decision-making for a broader diagnosis range of acutely ill patients 55 years and older. The HBAC program included same-day physician home visits, Community Paramedicine (CP) visits, nurse telephone encounters, ancillary support services such as lab draws, diagnostic testing, and mobile imaging, as well as in-home hospital level care as needed. We describe the challenges and evolution of the HBAC program because we hope our lessons learned can help advance the work of others.
Challenges to Implementation
The HBAC program was slow to start. The team was challenged financially to create a home-based program that was budget neutral since any new expenses would not be covered by the organization. The team had to get creative and use existing infrastructure, staff, and resources from different departments and programs to operationalize the HBAC program.
The program tapped into several key service lines from throughout the organization:
- Physicians from the hospital medicine department
- Care managers from the hospital and emergency departments
- Paramedics from the community paramedicine program
- Triage nurses and administrative support from the home-based medicine service line
Triage nurses and case managers referred patients to the HBAC program using existing HealthPartners programs’ patient pools. They also adapted the operational platform and home visit processes from other programs to schedule, bill, and update medical records. Key processes were improved upon using IHI’s methodology of rapid-cycle testing to develop scheduling and deployment of urgent in-home responses within the HBAC program.
There were four main challenges to operationalizing the HBAC program:
- Lack of a department structure — The HBAC team consisted of professionals from across the organization, each with ongoing primary obligations, without dedicated time allotted for the new HBAC program. With resources being shared among many programs and departments and no dedicated leader responsible for the program’s outcome and progression, prioritizing the HBAC workflow was challenging.
- Operations and logistical issues — There were many difficulties related to the manual and cumbersome processes of scheduling, EMR documentation, coordinating ancillary services (e.g., lab and imaging), and obtaining diagnostic results. For instance, imaging orders required the primary care provider to call the home-based medicine office which then faxed an order to the radiology vendor. The vendor had to go to the patient’s home to perform the imaging study and fax the results and interpretation back to the home-based medicine office. Finally, administrative staff would scan and upload the results into the patient’s EMR. The inefficiencies led to delays in treatment, which slowed enrollment into the HBAC program. Providers often opted instead to send the patient to the hospital where the process was faster and less fragmented.
- Physician coverage — HBAC providers were primarily physicians who were willing to perform home visits during their off hours. This limited the number of providers and hours available and reduced the capacity for home visits due to the geographic range of the program. However, the team looked to Regions Hospital Community Paramedic Program to hire additional paramedics to work in the field. Additionally, more hospitalists were recruited to do home visits and a dedicated core group was created, which still exists in the current model of the program.
- Slow and inconsistent service activations — HBAC services were initially activated only when a patient called to request urgent care. However, very few patients called and, when they did, triage nurses and scheduling staff were unclear about use cases and criteria to activate HBAC services. This resulted in treatment delays, gaps in care continuity, and, consequently, fewer patient referrals.
The Impact of COVID-19
HealthPartners deployed more resources to the HBAC program to help address community needs as COVID-19 cases began to rise in 2020 and to free up capacity in the hospital. The increased support, along with shifts to better accommodate the health care landscape, helped to overcome the challenges posed by limited resources previously mentioned.
The program made several improvements:
- HBAC referral orders and lab requests were streamlined, and additional physicians were deployed.
- The relaxation of telehealth restrictions expanded physician capacity (addressing staffing gaps) by leveraging telemedicine for acute visits. This allowed providers on quarantine or with COVID-related work restrictions to conduct patient visits from home. Physicians could see patients virtually in partnership with the CPs in the home and could bill for virtual services at the same rate as in-person visits.
- The HBAC program became a priority to leadership and the broader organization. Consequently, it was assigned a departmental home in the hospital medicine service line.
As regional cases of COVID-19 slowed in the summer of 2020, the HBAC program shifted to enroll chronically ill patients who could be safely treated at home either to prevent an ED visit or have an early discharge from the hospital. The program in its newer, more robust form (now called Hospital@Home) leverages the lessons and improvements described above to continue to meet patients' needs and support successful aging in place.
Rory Malloy, MPH, West Health Institute consultant; Camille McBride, MPH, Research Manager, Chronic Care & Telehealth; Amy R. Stuck, PhD, RN, Senior Director, Value-based Acute Care; Tia Radant, MS, NRP, Director, Community Paramedicine; and Chrisanne Timpe, MD, Medical Director, HealthPartners Hospital@Home program.
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