At FirstHealth of the Carolinas, a health system based in Pinehurst, North Carolina, bed capacity always seemed to be at the forefront of challenges, a not uncommon situation in healthcare.

Having more bed capacity is always helpful, but that usually means construction of some sort. FirstHealth staff thought of a way to increase hospital bed capacity without laying a single brick.

"While there are many hospitals that have started a hospital at home program, we decided to look at this type of program from a different angle," said Stephen Kapa, administrative director of telehealth services. "The program we came up with is called Observation at Home.

"While a traditional hospital at home program looks to care for the sometimes sicker patients who would traditionally meet inpatient status and be admitted to the hospital, Observation at Home looks to enroll patients who don't quite meet inpatient admission criteria, but also aren't well enough to go home," he continued.

Telemedicine as the main vehicle to deliver care

These patients would traditionally be admitted to observation in-hospital. The Observation at Home program uses telemedicine as the main vehicle to deliver care to stable patients who can safely be treated and monitored from the comfort of their own home via an in-home visit by a paramedic that coincides with a telemedicine video visit by a provider with the paramedic on-site.

Patients with the following diagnoses, and who meet certain criteria, qualify: exacerbations of CHF, COPD and asthma; and patients with pneumonia, COVID-19 or influenza. While enrolled in this program, the patient can have blood drawn in the home and have medicines administered by the paramedic by orders from the provider, who is seeing them via a live telehealth video visit.

"Because these patients use fewer resources, it makes the program more sustainable."

Stephen Kapa, FirstHealth of the Carolinas

"This program can be used in lieu of the patient being admitted from the ER to an in-hospital observation bed," Kapa explained. "Patients who already are admitted as inpatients or as an in-hospital observation patient can be discharged a day or two earlier if enrolled in this program. The time in the program is expected to be 1-5 days.

"This program will help with ED throughput, decrease inpatient length of stay, decrease readmissions, and help increase hospital bed capacity by freeing up hospital beds," he added.

Hybrid care is safe care

Observation at Home is a simple program that shows how through a combination of in-person visits and telemedicine the health system can care for these patients safely at home.

An ED provider identifies a patient who would normally be admitted to the hospital in observation status. If that patient meets the criteria for this program, they initiate enrollment and the patient is then sent home.

A hospitalist can also decide to send an inpatient home a day or two early if they are stable. In addition to certain medical criteria, the patient must have an acceptable high-speed internet connection at their home, and must use their own device (smartphone, tablet or laptop). This is an important piece of the puzzle and helps with the program's return on investment and its sustainability, since the health system is not providing the patient with sometimes expensive equipment.

If the patient doesn't have acceptable internet connection nor a way of conducting the video visit, they are excluded from the program and will be cared for in the traditional way, in a hospital. During the pilot for the program, the health system has not had to exclude anyone yet due to a lack of a smartphone or device, or of high-speed internet in the home.

A paramedic leads the way

"The patient will be seen daily in-person by a paramedic, who will take the patient a remote monitoring kit that consists of a Bluetooth-connected BP cuff and pulse ox," Kapa explained. "We use Health Recovery Solutions as our vendor for these devices and integrate the readings into the Epic EHR.

"While in the home, the paramedic will assess the patient and get them ready for their telemedicine video visit," he continued. "The patient connects via their own device to our provider via Epic video technology.

"The paramedic, who remains on-site for the telemedicine video visit, can help with certain aspects of the assessment that sometimes can't be done by traditional telemedicine video, such as listening to lung sounds and performing physical assessment of the patient that is relayed to the provider," he said. "In this program we can draw blood for testing lab work, and administer both IV and oral medications."

This process repeats itself for the duration of the patient enrollment, with daily visits by the paramedic and daily telehealth visits. Expected duration of enrollment in Observation at Home is one to five days.

Success from the start

"Two success metrics were met by our very first patient," Kapa reported. "We were able to keep him home and not have a subsequent ER visit, and also were able to keep him from being readmitted within 30 days of his last admission for CHF exacerbation.

"Our first patient in the CHF Observation at Home pilot had frequent ER visits and subsequent admissions for CHF exacerbation," he continued. "That patient also had issues with compliance while at home. He was referred to our program from the ER. His last hospital admission for CHF exacerbation was about 10 days prior to that."

The ER physician recognized this patient would be a perfect candidate for the Observation at Home program, and the patient was enrolled. This patient was safely seen daily for the next three days from the comfort of home.

"We were able to draw blood to check labs and administer IV Lasix due to a weight gain and increased symptomatology on day two," Kapa recalled. "The patient remained in the program for three days and was then transitioned to the Virtual Care at Home monitoring program.

"He remained on virtual care at home for the next two weeks and had two in-person visits to the CHF clinic during that time," he continued. "The patient soon hit the magic number and had not been readmitted to the hospital for over 30 days at that point, which has big implications for reimbursement."

Still at home, no readmission

The patient continues to remain at home without a readmission. This patient also is being evaluated to be one of the first patients at FirstHealth to be in the new CardioMEMS program. The CardioMEMS HF System wirelessly measures and monitors pulmonary artery pressure and heart rate for patients with heart failure. The system consists of an implantable pulmonary artery sensor, delivery system and patient electronics system.

"This patient highlights the benefits of this program and shows how through the coordination of different telemedicine programs in conjunction with in-person visits, we can safely care for patients at home who would normally have been admitted under normal circumstances," Kapa said.

Kapa has plenty of advice for peers at other hospitals and health systems diving into hybrid telemedicine.

"Don't be afraid to think outside of the box," he said. "Don't exclude other possibilities, and instead of thinking why something can't be done, think of ways you can accomplish it. For instance, we needed to make Observation at Home sustainable and with an acceptable ROI.

"Because these patients use fewer resources, it makes the program more sustainable," he continued. "Traditional Hospital at Home programs are sometimes cumbersome and don't produce the best ROI, despite all of the resources and efforts put into them."

It's also because of the many resources put into a traditional Hospital at Home program that make it harder to sustain and produce a good ROI, he added.

Fewer resources, more patients

"Many of the Hospital at Home programs are in fact cost-prohibitive in this way," he explained. "Because observation patients are more stable and require fewer resources, we can enroll more of them. Enrolling more of them will allow for more open hospital beds and resources for the sicker patients. That is where the biggest ROI is."

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