Resilient Healthcare, a high-acuity home-based care provider, recently partnered with Medical City Healthcare in order to offer hospital-at-home services.
Through the partnership, eligible patients are connected to a live remote patient monitoring (RPM) device that continuously tracks blood pressure, before they leave the hospital and transition to their home.
“They’re identified at the hospital as a good candidate for hospital-at-home,” Jackleen Samuel, president and CEO of Resilient, told Home Health Care News. “We get them set up with a tablet and our RPM device. We remotely monitor them the whole way home and the entire time they’re on our service. They are connected to a 24/7 nurse station that is out of our command center.”
As a company, Resilient has a traditional home health arm, as well as a hospital-at-home model. Resilient’s interdisciplinary team includes PTs, OTs, speech therapists, dietary specialists and more.
Meanwhile, Medical City Healthcare is one of the largest health systems in North Texas. The organization includes 16 hospitals, 11 ambulatory surgery centers, four off-campus emergency rooms and CareNow Urgent Care clinics. Medical City Healthcare’s team includes roughly 5,000 physicians, 6,000 nurses and 17,000 employees.
Medical City Healthcare is the first network of hospitals in Texas to receive approval from the U.S. Centers of Medicare and Medicaid Services (CMS) to participate in its Acute Hospital at Home Program. As of Nov. 8, 83 health systems and 187 hospitals across 34 states had been accepted as participants in the waiver program.
Typically, COPD and CHF patients are deemed good candidates for hospital-at-home care, according to Brian Chace, vice president of operations at Resilient.
“These are diagnoses where oftentimes patients go back in and out of the hospital due to exacerbations,” Chace told HHCN. “Those are the patients we’re definitely able to help get home and on services that will keep them from having to rehospitalize within 30 days.”
Once a patient is at home, if there are any questions or concerns, the nurse station coordinates with the physician.
Under the program, the patients are receiving medications, IV infusions, in-person nurse visits and meals, if needed.
“We have 14 different vitals and are monitoring them the entire time continuously, and we get their activity level as well,” Samuel said. “I think our patients are probably better monitored on our services than the traditional metrics for hospitals because we are getting their vitals, sometimes, every five seconds.”
Additionally, if patients have dietary needs, therapy needs, or if they want to see a social worker, clinicians are sent into the home as well.
Like the rest of the program, the discharge process also models itself after what would take place in a hospital.
“When they’re stable enough and the physician says they’re good, we can take them off services, and we do a full discharge with them,” Samuel said. “The nurse goes back to the home, collects the equipment and makes sure the patient is safe. We help them navigate getting any post-acute prescriptions that the physician writes. Our social workers work with the case managers at the hospital to make sure the patient is also placed correctly post-discharge.”
Although Resilient has been providing high-acuity care since its inception, Medical City Healthcare is the first hospital the company has partnered with to deliver the care under the CMS waiver program.
That said, Resilient is in talks to form similar partnerships with a few other hospitals and health systems.
“Even past COVID, there is a new landscape of health care here,” Samuel said. “ Technology has been improved in the last two years, probably more so than in the last 20 years. Reimbursement for virtual care has increased, and patients can use technology to get the care that they normally might have had to drive 45 minutes to see a doctor for.”
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