• Marc Kowalkowski, Casey Stephens, Timothy Hetherington, Hieu Nguyen, Henry Bundy, McKenzie Isreal, Colleen Hole, Padageshwar Sunkara, Raghava Nagaraj, Kranthi Sitammagari, Marvin Knight, Susan Marston, Pooja Palmer, Andrew McWilliams, and Stephanie Murphy.
• Department of Internal Medicine, Section of Hospital Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA. mkowalko@wakehealth.edu.
• J Gen Intern Med. 2024 Oct 1; 39 (13): 249625042496-2504.

BackgroundThe number of Hospital-at-Home (HaH) programs rapidly increased during the COVID-19 pandemic and after issuance of Centers for Medicare and Medicaid Services' (CMS) Acute Hospital Care at Home (AHCaH) waiver. However, there remains little evidence on effective strategies to equitably expand HaH utilization.ObjectiveEvaluate the effects of a multifaceted implementation strategy on HaH utilization over time.DesignBefore and after implementation evaluation using electronic health record (EHR) data and interrupted time series analysis, complemented by qualitative interviews with key stakeholders.ParticipantsBetween December 2021 and December 2022, we identified adults hospitalized at six hospitals in North Carolina approved by CMS to participate in the AHCaH waiver program. Eligible adults met criteria for HaH transfer (HaH-eligible clinical condition, qualifying home environment). We conducted semi-structured interviews with 12 HaH patients and 10 referring clinicians.InterventionsTwo strategies were studied. The discrete implementation strategy (weeks 1-12) included clinician-directed educational outreach. The multifaceted implementation strategy (weeks 13-54) included ongoing clinician-directed educational outreach, local HaH assistance via nurse navigators, involvement of clinical service line executives, and individualized audit and feedback.MeasuresWe assessed weekly averaged HaH capacity utilization, weekly counts of unique referring providers, and patient characteristics. We analyzed themes from qualitative data to determine barriers and facilitators to HaH use.ResultsOur evaluation showed week-to-week increases in HaH capacity utilization during the multifaceted implementation strategy period, compared to discrete-period trends (slope-change odds ratio-1.02, 1.01-1.04). Counts of referring providers also increased week to week, compared to discrete-period trends (slope-change means ratio-1.05, 1.03-1.07). The increase in HaH utilization was largest among rural residents (11 to 34%). Barriers included HaH-related information gaps and referral challenges; facilitators included patient-centeredness of HaH care.ConclusionsA multifaceted implementation strategy was associated with increased HaH capacity utilization, provider adoption, and patient diversity. Health systems may consider similar, contextually relevant multicomponent approaches to equitably expand HaH.© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.

21 keywords...

hide…