Exploring Automation for Hospital-at-Home Care Coordination

This article was originally published in Population Health Learning Network/First Report Managed Care on January 19, 2024

Automation solutions to solve hospital-at-home care implementation barriers are explored with Cindy Gaines, Chief Clinical Transformation Officer at Lumeon.

Please introduce yourself by sharing your name, title, organization, and experience.

My name is Cindy Gaines, and I am the chief clinical transformation officer for Lumeon, a workflow automation company where we orchestrate care. I also am a nurse and have been for about 36 years. I spent most of my career on the health system side leading nursing, I was the population health president of a medical group, I’ve done a bit of everything.

Why is there a growing focus in the health care industry on hospital home care and alternative care models?

It’s interesting, most people don’t realize hospital-at-home care has been around since like 1995. The first pilots were in 1996 and showed some great results. While it’s been around for a long time, it’s not been well adopted. Why the interest now is because, frankly, there are many organizations lacking beds and struggling to staff the beds they have. And they’re struggling with just having enough beds because of the overflow of patients who are coming into the hospital, censuses are up. So, when you start to think about an alternative level of care, you start to think about patients who are lower risk and could be better managed at home.

Hospital at home is not like you’re being discharged from the hospital. Instead, you’re being treated as an inpatient in your own home. There’s a huge number of benefits that people get very excited about. One, it frees up those hospital beds for higher acuity patients. We also recover so much better in our own home environments. It’s where we are happy. It’s where you have your own bed, your pets who make you happy and help in your recovery.

We also know that patients doing hospital at home experience a lot less delirium. When you’re in a hospital environment you are also more likely to be exposed to viral bugs and infections and other hospital-acquired issues. And these risks are not because of bad hospitals, they are just the risks of being in an environment like that.

For patients, hospitals can also be overwhelmingly stimulating with lights, sounds, and activities. People don’t rest well and end up needing sedation to help them sleep. Sedation, along with all those lights and sounds, can lead to delirium and delayed recovery.

People are getting excited about letting patients recover in their homes and the question is how can we better help patients complete their hospital stay in their homes? I’ve believed for a long time we should eliminate the term discharge from hospital care and think of home as the transition to a different level of care.

What are the main challenges for effective hospital-at-home coordination?

Coordination of care is key because we need to provide patients with the same level of service as in the hospital. Medication management is not enough, I have to think about delivering meals and medications, arranging for a physical therapist to visit, how often nursing needs to visit per day to assess the patient, etc. If a CAT scan is necessary, we need to arrange transportation like ambulance transport to come, pick you up, and take you home without interrupting other coordinated care.

It starts to become complex and when we’re already short-staffed in our hospitals, it’s difficult to imagine how I am supposed to send people and services for home care when I’m already trying to care for the people who are physically in the hospital, too.

How has technology enabled better home care integration? Do you have any specific examples to share?

I’m very excited about a partnership that we’re doing with NTT DATA, a technology strategy company that works to enhance the capability to build systems based on the understanding of their customers and their needs. They have started a hospital-at-home program that they’re making available to organizations who manage exactly what we just talked about: the logistics, the communications, and even the partnerships to get things to happen.

We need to think about community partners that we could work with, and NTT is creating a program with the ability to not only help manage those partnerships but also have a dashboard of all the patients in the program. A dashboard helps us to know exactly what’s going on with patients so that we can ensure they have a high standard of care.

We are partnering with NTT to automate workflows and logistics communication. Right now, the level of care coordination needed requires a lot of calling, paging, and faxing and that’s not an effective use of anyone’s time. Automation is very important. We’re very excited about what we can do to support an organization with this technology because as a previous health care executive on the delivery side, I can say that to do a program like this is overwhelming to jump into.

HFMA reports that shifting the focus from ‘discharge planning’ to ‘home care orchestration,’ can reduce cost of care by 20% for health systems and payers and reduce complications and earn favorable feedback from patients, caregivers and providers. Why does this shift result in such positive results?

Research suggests that about 30% of older patients have conditions that would be appropriate for hospital at home. We have eligible patients, and we know from that early research that you can reduce inpatient costs by about a third through hospital-at-home services. This is due to reduced delirium, sedation, hospital stays, and complications like hospital-acquired infection.

Patients’ family members are more satisfied with taking care of the patient in their home because it lowers the stress of worrying about going home at night. I experienced this with my own father when he was in the hospital. One of us was always asking who could stay overnight to keep an eye on him. When they’re in the home, it takes a lot of stress off the family because they are in a safe and comfortable environment they can control.

How can automating manual workflow processes, tasks, activities, and events enable care at home via remote monitoring devices and telehealth visits? What about in- home care, social services, and non-clinical services?

There are some rules with hospital at home about what has to be done physically in person, such as nursing needs to come in and do a physical assessment of the patient. But you can also use technology to do remote visits for social work and anything that involves just talking to the patient and getting information.

Through telehealth, you can do things like blood pressure checks. However, there are rules around this. If you must check something more than every 2 hours or more frequently, they’re not eligible for hospital at home. To qualify, patients need to be more stable.

We have a lot of technology in our world today and it can feel very disparate. Remote monitoring is for monitoring a patient who’s been discharged from the hospital and telehealth is for their primary care visit. And I think what I love about hospital at home is it says we can use that in this program, how do we marry these components together to create the best environment? Often our technology works in silos and it’s time to pull that together and ask how we can provide the best care for the patient in the right environment and at the right time.

Does technology literacy ever become a part of that process, especially for older people who qualify for this home hospital care?

That’s a great question. I think there are two points to identify a patient as being eligible for hospital home. First is in the ER before they’re ever admitted. The second is towards the end of their stay. But we can’t just ask if they are eligible based on their based on their condition. We also need to ask if they are eligible based on their home environment. A patient may not be eligible if they’re homeless or don’t have certain technology in their home such as Wi-fi.

That’s why there’s a home assessment.

In an assessment of the patient, we also make note of if they can’t read or can’t work with technology. These factors could mean they’re not going to be a good candidate. And then, finally, even if they qualify a patient may not be interested.

I’ll use my father as an example. He was blind for the last 20 years of his life. While he might have met other criteria, that might have made it the wrong choice for him.

When I was president of a medical group my providers were very resistant to telehealth and were concerned that my older patients would not be able to use it. Pre-COVID-19, I think about 17% of providers across the country did telehealth. Suddenly, we’re at 75%. They got thrown off the dock into the deep end and told to swim. What was amazing about that is that so many of our older generations not only used telehealth, but they liked it. Even when we started to open things back up, many said like I’d like to continue to do telehealth visits.

How can other health care providers learn about, and effectively expand, their hospital at home care services?

Do your research. I think sometimes people assume that hospital at home is a rural health care solution. But it’s not made for rural health because you have to define a catchment area, meaning you have to have services available within a certain distance for emergency care. You find yourself in a very small geographical area of patients eligible for the program.

So, you want to do your research about how big of an attachment area you can have for your patient population. You should also ask if you have patients who appear to meet these requirements and your staffing ability. Understand what’s paid for, not paid for. Do your homework and then talk to organizations like NTT that have created these programs and find out how they can support you.

I think when you get into huge health systems, they obviously have different resources, but I think they’re the exception and not the rule. And I think there are a lot of organizations who’d like to jump in and do this, but they’re not sure how to get started. Reaching out to NTT is a great way to learn more and doesn’t mean you have to sign up but they can help you to understand what they do and how to be partners. You’re also going to start small, maybe with 5-10 patients with a hospital-at-home program, and build from there.

Is there anything else you’d like to share?

Though hospital at home has been around a long time, I feel like it was ahead of its time and now feels very timely based on where we’re at in our world today. Think of it as another tool in your arsenal to care for patients. Hospital at home doesn’t replace the need for traditional care, but it is a great way to extend what you do into the home. We’re excited about how we can make a difference and making this more attainable for other organizations to do.

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