Research has indicated that patients needing care prefer to receive it in their homes rather than in a hospital setting. Health care models like Hospital at Home (HaH) facilitate this preference, but how do providers ensure that patients’ homes are safe for delivering these services?

For this evolution to be successful, homes must adapt. They must be designed and modified to meet residents’ changing health care needs, as the boundaries between health care facilities and homes become less distinct.

Assessing patient eligibility for home-based care is a critical first step. Understanding the patient’s environment and family dynamics is crucial. Discovering these factors often requires a thorough assessment, which serves as a fact-finding mission.

“All patients admitted to the brick-and-mortar hospital through the emergency department undergo an automated eligibility assessment that is embedded in the electronic medical record,” Stephen Dorner, chief clinical and innovation officer for Mass General Brigham Healthcare at Home, told Home Health Care News. “This assessment includes inclusion and exclusion criteria such as age, location of residence and clinical conditions to help streamline eligibility and produce an automated flag. Patients identified as potentially eligible subsequently go through a clinical assessment by a team of nurse navigators to evaluate their clinical suitability for home-based care.”

Boston’s Mass General Brigham (MGB) Home Hospital program provides hospital-level care from providers to eligible patients in the comfort of their own homes.

Once patients are determined clinically stable, an in-person discussion occurs to inform them about their potential eligibility for HaH care, according to Dorner. During this time, the medical team assesses the patient’s understanding of the care model and their willingness to receive care in this way. If they are open to the prospect of shifting their care to the home, nurse navigators walk the patients through a social assessment to better understand home dynamics: stability of housing, type of residence, presence of roommates or pets and other aspects.

“During the patient assessment, our admitting team asks about the patient’s co-residents, caregivers, or non-cohabitating loved ones to ensure they are aware, engaged in the process and able to have questions answered,” Dorner said. “This often includes phone calls, video calls, or even waiting to complete the consent process until family members are present to meet our team and ask questions in person. We seek to ensure that everyone involved in the process is comfortable with the HaH care model and has their concerns addressed.”

These types of assessments between care teams, patients and families are usually held within the hospital setting before any steps toward HaH are taken to ensure everyone agrees on the type of care to be provided and on their roles in it.

“In our program, one of the hospitalists will approach the potential HaH patient in the hospital and ask them questions such as, is your home safe? Do you have running water and electricity? Do you have adequate toileting facilities?” Guadalupe Pantoja, a home hospital nurse at Health First, told HHCN. “Usually, the patient will answer yes to all these questions, and we go from there. We begin asking them a checklist of questions before starting the process of going home.”

Health First is a nonprofit community health system in Brevard County, Florida.

“Our community has older homes, and the equipment we need, such as oxygen, requires a safe outlet, but many of these homes might not have that. Therefore, we must also assess these factors before bringing patients home,” Pantoja said.

Health First care providers communicate with patients and focus on clearly instructing their families. Because families play a crucial role in supporting the patient, they need specific guidance on contacting the health care team, which is available 24 hours a day.

“There are hard yes or no questions, and then there are the ‘tell me about X, Y or Z,’” Dr. Michael Maniaci, an internist at Mayo Clinic in Jacksonville, Florida, told HHCN. “I’ve taught my team that the ideal sense of a home in their minds might not be where other people live.”

In addition to a social screening, Maniaci and his team complete an on-site safety assessment with the families in the patient’s home. They look for tripping hazards, decluttering needs and medication storage issues. They also discuss the family’s and care providers’ responsibilities and answer any questions or concerns.

“Caregivers absolutely should go into the home and conduct a visual assessment of the environment for any hazards and speak with family members who will be caring for the patient when the provider is not in the home,” Nancy Foster, vice president for quality and patient safety at the American Hospital Association, told HHCN. “When speaking with the family members, it must be determined that they are willing and able to take on the patient’s care in the home setting in partnership with the visiting clinicians.”

During these social and visual assessments, teams usually uncover behavioral modifications, such as smoking cessation when supplemental oxygen is deployed to the home, or agreeing to safeguard pets when home hospital staff are present, according to Dorner.

“Other modifications include recommendations to obtain grab bars, reduce piles of rugs, eliminate obstacles from primary walking routes and so on,” Dorner said. “While we do not perform those structural modifications to a patient’s residence, we make recommendations to improve patient safety. If a patient requires additional durable medical equipment support for safety, such as a cane, walker or wheelchair, we can provide that as well.”

After completing the assessments, Maniaci said his team installs their equipment and trains the family and caregivers to operate it.

“We walk anyone who might be there and wants to be involved through the technology,” Maniaci said. “We let them know how to contact us, how the Wi-Fi phone works, how to turn on backup power, and so on. We also let them know exactly what will happen in the home and who will be coming and going. Once we get into a home, the initiation process usually takes a couple of hours, setting up the equipment, getting medications squared away, getting the patients and family members involved, walking through the process and instituting the care.”

Involving family members in using this type of technology goes a long way toward creating an ecosystem that connects families, patients and health care providers. Integrating systems to collect data allows providers to understand patient needs and helps demonstrate value to payers. In addition, data can be used for predictive analytics, focusing on risk patterns to predict potential hazards before they lead to accidents.

Maintaining infection control in the home

One question that often stands out concerns keeping the patient free from infection. However, according to Maniaci, hospital-acquired infections are almost nonexistent in HaH models in the U.S.

“Most hospital infections that affect or kill people every year in hospitals come from other people’s bugs – going room to room and carrying supplies around,” Maniaci said. “That automatically is brought down to a bare minimum because, in the patient’s home, it is them, their families and no one else. So, infections are rare.”

Still, protocols must be in place to handle these infections if they do occur. Maniaci’s team is required to use the same infectious disease protocols and sterile precautions in HaH as they would in the hospital setting.

Each state is different regarding who is allowed in the home and what can be done there. Some states allow paramedics, some allow pharmacies and some allow nurses only. There are guard rails so that patients remain safe.

“We need to have two in-person visits daily,” Maniaci said. “I need to lay eyes and hands on the patient twice a day no matter where they are, rural or urban. If something goes wrong, you have to have a 30-minute or less response time to get emergency personnel to the house.

Regulations for HaH care

Care environment requirements associated with traditional hospitalization are waived as part of a Centers for Medicare & Medicaid Services (CMS) Acute Hospital at Home episode of care, which includes the Life Safety Code governing hospitals participating in CMS care delivery.

CMS waived certain provisions of the Life Safety Code, specifically those related to the physical environment requirements typically mandated for inpatient hospital settings. These include safety regulations, emergency lighting requirements in patient care areas, smoke barriers and compartmentalization requirements typically required in hospitals and building code requirements that ensure safety in larger hospital structures. These adjustments allow for flexibility in delivering care in a home environment while ensuring that hospitals comply with general safety and emergency protocols appropriate for home-based care settings.

CMS has approved 358 hospitals affiliated with 137 health systems in 39 states to participate in its Acute Hospital Care at Home program. However, unless Congress takes action, the number of HaH programs will fall dramatically. 

In March, the American Medical Association and more than 60 hospitals, health systems, and medical associations wrote a letter to congressional leaders urging them to extend the Acute Hospital Care at Home waiver program for at least five more years. The waiver “is the keystone to the future of home-based care delivery for Medicare patients and beyond,” the letter said.