5 Lessons from Building an Acute-Care-at-Home Program

New programs like Hospital-at-Home and Acute-Care-at-Home are giving health systems an opportunity to reduce inpatient traffic and give patients the care they need in their own homes.

Editor's note: Stephen Parodi, MD, is executive vice president of The Permanente Federation and associate executive director for The Permanente Medical Group. He is also the national infectious disease leader at Kaiser Permanente. 

Hospitals are on precarious footing. After nearly three years of a pandemic that pushed capacity and resources to their limits, rising inflation, and healthcare workforce burnout, many hospitals are finding it difficult to deliver the lifesaving care their communities need. In fact, many hospitals again faced bed shortages during the recent “tridemic” – a collision of RSV (respiratory syncytial virus), influenza, and COVID-19.

In the face of these monumental challenges, health systems must seek innovative solutions to ensure that patients have affordable access to physician-led, hospital-level care, even if it means rethinking how and where it is delivered.

Stephen Parodi, MD, executive vice president of The Permanente Federation and associate executive director for The Permanente Medical Group. Photo courtesy Kaiser Permanente.

One movement that gained traction during the COVID-19 pandemic is the delivery of hospital-level care directly into a patient’s home. Thanks to waivers put in place by the federal government at the outset of the pandemic, 114 health systems across 37 states implemented an advanced care at home program, including Kaiser Permanente.

The ability to provide hospital-level care in the homes of patients is essential when brick-and-mortar hospitals are inundated with patients, as they were during the COVID-19 pandemic. And it is reasonable to anticipate that we will continue to see more high acuity illness related to deferred and delayed care.

What’s more, health systems see advanced care at home as a sustainable delivery model for the future. The aging baby boomer population has expressed clear preferences for receiving care in their homes. This demand comes at a time when the cost of building a new hospital can range from $60 million to more than $1 billion. Not only does in-home hospital care deliver care where patients want to receive it, it also has the potential to make care more cost-effective if it is sufficiently scaled.

However, building a program that brings hospital-level care directly into the home is not for the faint of heart. It requires vision, fortitude, and significant investment. In the more than three years we’ve spent planning, developing, and implementing an acute-care-at-home program, we’ve learned multiple lessons that we believe can help other health care organizations develop their own care-at-home programs:

1. Put the patient at the center of the program’s design. Our first step was to conduct focus groups with patients and find out what they might look for in this type of program, and what would make them feel safe and supported. One of the concerns was usability. That’s why the technology in patients’ homes is simple: the touchpad has one call button to contact a physician and care team. Each morning, care teams and patients discuss the day’s schedule so a patient knows each of the appointments and visits during the day, and the care team even knows when a patient will wake up with their morning coffee.
2. Align key quality, operations, and marketing functions. Understand that building an advanced care-at-home program takes a village. You need your quality, compliance, operations, marketing, and communications all aligned in understanding the goals of the program. This starts at the top with buy-in from leadership. By sharing stories about why this is the care of the future and what physicians and clinicians would want for their own families, leaders can rally teams from across the healthcare delivery system to collaborate to build this new model of care.
3. Pressure-test the program before launch. We practiced admissions into a home with our multidisciplinary team. We would simulate problems that could arise in the supply chain, lab, pharmacy, and other functions so that when we were ready to go live with our first patient, we were confident that we would have a very stable, secure program supported by technology with multiple redundancies.
4. Show healthcare workers how the program can improve their work life. We’ve learned that our program helps retain and improve job satisfaction for healthcare workers, from nurses to hospitalists. A hospitalist is a clinician whose primary professional focus is the general medical care of hospitalized patients. Hospitalists providing care in this program have said the program gives them joy and meaning because in addition to healing, they are able to communicate with satisfied patients and family members who feel they have more control in the comfort of their home, vs. in a hospital. That experience has been a big selling point for our program at a time when health care worker burnout is rampant nationally.
5. Understand that change management takes time. When we initially scoped the program, we thought we could get 20 to 25 patients in the program in relatively short order. We have learned that it takes time for the physician and the team to gain confidence that a new program will provide high-quality care consistent with the traditional hospital. We have conducted case conferences, town halls, video production, and testimonials, and are transparent with the data with our physician teams. All these elements are essential to have physicians, care teams, administrators, and ultimately patients and families embrace this new care concept.

To commit fully to advanced care at home models, systems programs and regulators will need to develop specific quality measures to ensure that patients receive care safely.

Recent passage of the $1.7 trillion omnibus bill that extends the Centers for Medicare and Medicaid Services (CMS) hospital-at-home waivers through the end of 2024 provides assurance over the next two years that there is an opportunity to develop a regulatory framework that healthcare organizations will need to initiate, grow, and mature hospital-level care-at-home programs.   

These programs' growth will enable us to collect more data on their quality, safety, and efficiency. Just as important, we will learn more about how to build and scale such programs more efficiently and effectively.

The waivers extension also offers the opportunity to create more benchmarks for the performance of these programs. That will enable us to compare more of these innovative programs to brick-and-mortar facilities and identify new measures for the programs that will be unique as we move more care into the home.

In addition, extending the waivers opens the door to expand services beyond the hospital. For example, the waivers support the provision of lower-acuity emergency care for patients outside a hospital setting and for more complex needs care in the home.

The investments that are likely to follow the waivers extension will enable healthcare systems to deliver safer, more convenient, and patient-centered care and improve the long-term outlook for patients and the health systems that serve them.

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