Scaling Hospital at Home: Lessons Learned from UMass Memorial Health
Facing ongoing capacity challenges, UMass Memorial Health launched a Hospital at Home program in 2021. In its first year, the team scaled its model to one of the most extensive programs in the country.
UMass Memorial Health Overview
UMass is a provider in Worcester, Massachusetts. They launched their Hospital at Home program in March 2021, and admitted their first patient six months later.
Overall, the UMass program’s admission rate is only 7.9% for dual-eligible patients (those who use both Medicare and Medicaid), and 11.1% for all other patients, which is 20% to 30% lower than bricks and mortar admission rates.
The UMass Hospital at Home program goals are two-fold:
- Increase hospital capacity (add 50 new beds)
- Promote health equity
Capacity: According to Dr. Constantinos (Taki) Michaelidis, this program serves more than half of the Medicare population in their region, and consistently operates at or near capacity.
Equity: The diverse community has many dual-eligible patients, so the team at UMass also focused on building a program to safely care for everyone, including patients facing complex social drivers of health (SDoH), multiple co-morbidities, and language and access barriers.
Their program development began with equity and scale as core design principles:
- Providing all the technology needed (internet, tablet, monitoring)
- Bringing food, therapies, and DME into the home
- Relying on an integrated platform with smart alarms, risk stratification, and integrated video translation services
- Building an innovative culture focused on problem-solving
- Engaging referring providers early and often
Having a flexible model that could care for a variety of diagnoses and needs for high-acuity patients was critical to building the patient census for Hospital at Home.
In addition to addressing SDoH, UMass also aimed to address and improve the following:
- Lack of connectivity access
- Technical illiteracy
- Language barriers
Connectivity: Roughly one-third of low-income households lack high-speed internet. UMass sought a way to deliver in-home connectivity for telehealth and monitoring devices.
Technology: Technical literacy is low among older, low-income patients, so technology needs to be as intuitive and user-friendly as possible.
Diverse languages: Over 23% of the Worcester community does not have English as their primary language. UMass needed to find a way to deliver care using each patient’s primary language.
With these goals and challenges, the UMass team partnered with Current Health to create a technology-enabled Hospital at Home program that was built to scale. The solution includes a Clinical Command Center, a home hub to support connectivity, a tablet, a blood pressure cuff, wearables for remote monitoring, and a clinical dashboard for providers.
UMass Memorial’s Strategies to Scaling the Hospital at Home Patient Census
In the first year, UMass’ Hospital at Home program achieved a daily patient census of 12 to 16, and continues to grow.
Their program relies on a team of field nurses and the organization’s mobile integrated health (MIH) paramedics to achieve each patient’s required two in-home visits per day.
1. Broad patient eligibility criteria
The UMass team set out to deliver hospital-level care at home for the sickest and most complex patient possible. To this end, they kept their eligibility criteria focused on the few things they could not overcome.
Patients are excluded if they do not have:
- Running water
- A working bathroom
With these simple exclusion factors, they broadened their pool of potential patients as much as possible, and they see an escalation rate for their Hospital at Home patients of 9%.
2. A “can-do” culture and a focus on growing risk tolerance
Accompanying their minimalist approach to exclusion criteria is a culture of commitment to the care model and confidence that they can safely care for almost anyone in the home:
“Many people believe Hospital at Home is only for the wealthy, but that’s absolutely not true. We really had a can-do attitude that will solve every challenge. We had our naysayers, but failure and defeat were never in our playbook. We were going to make this happen. If you had asked me at the beginning if this was possible, I would have said no way. But it is incredibly possible. And we’re very proud of that.”Candra Syzmanski, AVP, Hospital at Home, UMass Memorial Health
The leaders at UMass looked primarily to their pool of emergency department nurses to build their nursing team. Many of the nurses who had clocked years in the ED and navigated multiple COVID-19 surges, had strong clinical and diagnostic skills, a high tolerance for risk, and were ready for a change. Getting these clinicians to help build the new program re-energized their passion for delivering care and served as a retention strategy.
3. Proactive Patient Recruitment
Having a broad patient inclusion philosophy and innovative culture alone isn’t enough to grow a patient census. The Hospital at Home team still has to get patients and providers to consent to enrollment in the program.
For UMass, this took the form of passionate nurses in the role of Clinical Coordinators, who had the responsibility of scrubbing ED and inpatient lists each morning. Then one of the coordinators went to the hospital to discuss the care of each eligible patient with the provider overseeing their care. These nurses refined their “sales pitch” to address the most common concerns of patients, providers, and caregivers:
- Support, including in-home visits and virtual visits with the physician
- What’s required of the patient and their family caregiver (if present)
4. 24/7 Clinical Support
To scale Hospital at Home and keep the team engaged, it’s vital to have sufficient support for monitoring patient data, triaging alarms, engaging patients, and responding to questions.
The Current Health Clinical Command Center provides this first level of support for the UMass program. Through daily huddles with the UMass team, the virtual Current Health nurses act as a workforce extension, enabling an always-on, cohesive patient experience. This support enabled significant program growth, more than doubling daily admissions in 4 months.
5. Flexible clinical pathways
The UMass team is clinically nimble, so their technology must be, too. They leveraged numerous clinical pathways within the Current Health platform to be able to scale care across diagnoses and curate monitoring and alarming for each patient’s needs.
Current Health’s continuous and intermittent monitoring kits are configured based on each patient’s diagnosis, with intelligent alarms indicating deterioration according to each patient’s relevant risks.
6. Data and workflow integrations with the EHR
Finally, scaling patient census requires data and workflow integration. All relevant patient care notes and monitoring highlights flow back into their Epic environment, for easy viewing by both the Hospital at Home team and their referring provider. Patient demographic information is brought from Epic to Current Health, and patients can be both enrolled and discharged from either location.
The deep integration with Epic prevents duplicate work and simplifies providers’ referral and enrollment process, which helps to incentivize the inclusion of more patients within the Hospital at Home program.
The Hospital at Home program at UMass Memorial became one of the nation’s largest in its first year, treating more than 500 patients, showing improved clinical outcomes, and saving more than 3,000 bed days.
The potential of the Hospital at Home model to revolutionize high-acuity care is enormous, but broad-scale impact requires these models to scale to the point that they play a strategic role in the health system’s future development. Ultimately, scaling acute care at home is the result of people, processes, and technology consistently driving toward a common goal.