key: cord-0731786-tjvbduqh
authors: Heller, David J; Ornstein, Katherine A; DeCherrie, Linda V; Saenger, Pamela; Ko, Fred C; Rousseau, Carl‐Philippe; Siu, Albert L
title: Adapting a Hospital‐at‐Home Care Model to Respond to New York City's COVID‐19 Crisis
date: 2020-07-07
journal: J Am Geriatr Soc
DOI: 10.1111/jgs.16725
sha: 1ffb5b420b7b71557b36fde9d509844be67f656e
doc_id: 731786
cord_uid: tjvbduqh

nan

The COVID-19 pandemic has strained hospital capacity and increased the risk of nosocomial infection worldwide. Surging demand for providers' time and shortages of personal protective equipment (PPE) threaten care quality and safety 1 . Yet decades before COVID-19, the hospitalat-home (HaH) model -which brings inpatient-level care to the patient's homeemerged to tackle such challenges. Research demonstrates HaH exceeds usual hospital outcomes, while improving the patient experience 2,3 . Our own HaH program has treated ~1000 patients since 2014 and is no exception 4,5 .

As hospital care becomes precarious or even unavailable, COVID-19 brings new urgency to the HaH mandateand highlights how this care model is uniquely positioned to respond to the pandemic. We describe our experience adapting HaH care from 19 March to 18 April, during the peak of the COVID-19 pandemic, at two hospitals in New York City.

To relieve bed shortages from COVID-19, we augmented our HaH programin which patients select home inpatient care instead of the hospitalwith the Completing Hospitalization at Home (CHaH) model. CHaH permits patients already admitted to the hospitaland with ongoing hospital-level care needsto complete their inpatient care at home. We developed CHaH in two weeks, collaborating with health system leadership; its legal team; a private home care partner; and the hospital pharmacy. Our team worked with inpatient clinicians and case managers to identify hospitalized patients with ongoing inpatient needs (such as intravenous medication) but This article is protected by copyright. All rights reserved.

Accepted Article not needing procedures or imaging unavailable at home (e.g., computed tomography scans). Our hospitals billed insurers for a standard inpatient stay as per the admission's Diagnosis Related Group (DRG), and reimbursed the CHaH program a portion of that DRG payment, using the state's emergency regulations to facilitate inclusion of all insurances.

Following pilot-testing in patients without confirmed COVID-19, we expanded the program to include patients with COVID-19 infection, either as their primary diagnosis or an incidental condition. Initially, we required patients with COVID-19 to be ≤65 years old; afebrile for ≥48 hours; ≥8 days since symptom onset; and with improving inflammatory serologies. We excluded immunocompromised patients and those requiring extensive assistance with activities of daily living, to prevent disease transmission. However, two weeks after accepting COVID-19 patients, we waived these age and functional status criteria, in order to expand care to older adults and/or those with increased care needs. We made this decision due to the higher risk of hospitalizationassociated complications such as delirium and falls in this vulnerable population, and in response to the demographics of referrals to our service. Patients received twice-daily in-person visits from nurses and daily telehealth visits from nurse practitioners or physicians.

We admitted 24 patients in total; 12 were COVID+. Among persons without COVID, the most common diagnosis was pneumonia. The mean length of stay (excluding the hospital) was 3.1 days, representing 75 potentially averted hospital days overall. Further details of the patients' attributes and outcomes appear in Table 1 below. This article is protected by copyright. All rights reserved.

Priorities for the US health community responding to COVID-19

Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients

Hospital at home versus in-patient hospital care

Association of a bundled hospital-at-home and 30-day postacute transitional care program with clinical outcomes and patient experiences

Hospital at home-plus: a platform of facility-based care

US field hospitals stand down, most without treating any COVID-19 patients. NPR.org (online)

The authors thank Eddie Wang and Sara Lubetsky for help with data preparation, and DianaMotti and Suzanne Gilleran for help with data review and cleaning. This article is protected by copyright. All rights reserved.Accepted Article