Like most health systems across the United States, Pinehurst, North Carolina-based FirstHealth of the Carolinas has challenges with bed capacity and is always working on new and innovative ways to increase it in a safe and financially responsible way.

THE PROBLEM

This has been done through a few different venues. FirstHealth's extended care unit at its Richmond campus, among others, is a brick-and-mortar solution, whereas the observation at home (OAH) program helps with capacity challenges, but virtually.

PROPOSAL

The OAH program is designed to increase bed capacity across the health system by discharging stable patients who can be managed at home via the program but would otherwise need to have stayed in the hospital if taken care of by traditional medicine.

OAH offers multiple entities in the health system an alternative for some of the more stable patients occupying a bed. Once patients are referred to the program, a paramedic will visit them in their home the next day – exceptions are referrals from home health, which I will explain in a moment – where they will perform an in-person assessment that includes vital signs.

Once the assessment is complete, the paramedic connects to a provider to complete the remainder of the visit via secure tele-video. FirstHealth uses Epic for these sessions. While the paramedic is present in the patient's home, the provider assesses the patient by tele-video and includes input from the paramedic to continue the patient's care. During the visit, the provider can order medications or labs.

Of note, the paramedics do not use an ambulance for this program.

The provider also will determine if the patient should be seen again, or if they are stable enough to be discharged from the program. The purpose of the OAH program is to help patients get over the acute phase of their illness. The average length of stay in the program is just over three days.

After being released from the OAH program, patients already enrolled in home health will continue those visits. If the patient is not enrolled in home health, they will be transitioned to the virtual care at home program (VCAH). This program uses remote patient monitoring using devices from Health Recovery Solutions so staff can follow the patient's vital signs for the next few days and up to a couple of weeks.

Patients also have access to a registered nurse via telephone if needed while in the VCAH. The VCAH program is provided at no cost to the patient and is part of a larger effort to help manage bed capacity.

Staff see patients with the following diagnoses but can evaluate others on a case-by-case basis: CHF, COPD, pneumonia, influenza, COVID-19, asthma, need for IV antibiotics, cellulitis rechecks and abdominal pain rechecks.

Patients can be referred to OAH in a variety of manners:

• Inpatient referrals. Stable patients are referred to OAH by the hospitalist team. These are patients who remain stable and are enrolled into the OAH program to continue the remaining few days of care that would traditionally have been completed in a hospital bed.

• Emergency department referrals. Stable patients who would have traditionally been admitted to an in-hospital observation unit for a variety of reasons can now be discharged into the OAH program.

• Home health. Patients enrolled in home health who may have an acute issue arise. These are stable patients, but who normally would have been referred to the ED for further workup or treatment. Approximately 80% of patients sent to the ED by home health are admitted for observation. OAH is now an option for home health for their stable patients to be seen instead of having to send them to the ED. Patients with potential dangerous cardiac, pulmonary, neurological or other potentially unstable complaints are still sent to the ED immediately via 911. Patients typically seen in OAH from referrals by home health tend to be early onset COPD exacerbation, patients with CHF who have weight gain or increased shortness of breath but are not in respiratory distress, or patients with an upper respiratory infection who need further evaluation. For these patients, staff can intervene at an early stage of an exacerbation and help to keep the patient from needing to go to the ED. Patients referred to OAH are typically seen the same day as the referral.

• Primary care providers or convenient care providers. PCP or convenient care providers can also refer patients to OAH, where they are seen the next day, and assure their plan of care is effective and the patient is improving, but also to continue to provide care they may not have otherwise received unless being sent to the ER. The main referrals staff see from PCP and convenient care are COPD exacerbations and acute respiratory infections such as COVID-19, influenza or pneumonia in at-risk populations.

MEETING THE CHALLENGE

"We complete our telemedicine video visits using the Epic EHR," said Stephen Kapa, administrative director of telehealth services at FirstHealth of the Carolinas. "All information is relayed through that platform. For the patients who transition to the VCAH program, we use Health Recovery Solutions blood pressure cuffs and pulse oximeters. The patients download an app from the vendor on their phone and can upload their readings from their monitoring devices through the app.

"A nurse monitors those daily and calls patients directly if someone has vital signs out of range," he continued. "Patients can also call the nurse directly with any concerns. Occasionally, we need to initiate a tele-video visit where patients are either re-enrolled into the OAH program or advised to go to the ED."

FirstHealth has found keeping things as simple as possible is the best strategy, and that has worked since the COVID-19 pandemic. Too often, the more complicated things are made, the clunkier they become, resulting in more steps that are less likely to be used – keep things simple, he added.

RESULTS

"One of our biggest achievements in the past 14 months has to be the average daily census in the program," Kapa reported. "Our fiscal year runs from October to October. In the first week of October of 2023, our average daily census was under two. We have had our peaks and troughs over the year, but the trend line has always been positive. In the last week of our fiscal year, we averaged 13 patients per day.

"This has had a significant impact contributing to increased patient access and bed capacity as well as increased patient satisfaction and employee engagement," he continued. "We expect the average daily census to continue to climb, especially with the normal increase in volume of patients during the winter months."

Another success that staff are quite happy with is their 30-day readmission rate for heart failure and for all-causes.

"The average national 30-day readmission rate for heart failure and all-cause readmissions is approximately 20% and 14.5%, respectively," Kapa noted. "For patients admitted to the OAH program, the percentage for both heart failure and all-cause readmissions is under 10%. While this does represent a cost savings, more importantly it shows we can safely and effectively take care of patients with the OAH program.

"Lastly, a subjective measure we really can't keep track of is the appreciation of patients and family who are thankful to receive their care safely at home instead of having to be admitted to the hospital," he added. "We have had so many words of thanks and gratitude for what this program has done to help them be where they are most comfortable – at home."

ADVICE FOR OTHERS

"My advice is twofold," Kapa said. "Keep things as simple as possible and be persistent. As you can see by the growth of our average daily census, it didn't grow overnight nor on its own. You need to be very persistent in delivering your message about the program to all groups, especially providers and discharge planners.

"From a provider's perspective, many have been practicing medicine for some time," he continued. "They are used to doing things in a regimented and traditional fashion. I'm a physician assistant by training, so I understand this. Giving them the option of the OAH program gives them another option that hasn't traditionally been there. All you need is to be persistent and share the success stories. Share the data, as sparse as it may be in the beginning."

And go to all of the provider meetings possible, he added.

"Go to the discharge planner meetings, go to interdisciplinary rounds, speak about the program anywhere you can," he concluded. "Once the providers start to see the benefits of the program, see that their patients are being taken care of safely and see the readmission rates dropping, this will take on a life of its own. I'm hoping we are in this latter stage now."

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