Delivering Hospital at Home Services Safely and Inexpensively through Community Partnerships E.A. Mann1; M.A. Haggerty2; A. Feinberg2; R.K. Miller,1,2;J. Hammond2; D Casarett; S Foster; B. Kinosian1,2 1University of Pennsylvania, Philadelphia, Pennsylvania; 2Philadelphia VA Medical Center, Philadelphia, PA

Financial Disclosures Ms. Haggerty, Feinberg, Mr. Hammond, and Drs Kinosian and Miller are employees of the Philadelphia VAMC Ms Foster and Drs. Casserett, Miller, Mann and Kinosian are employees of the University of Pennsylvania

Background Hospital at Home programs have been instituted nation-wide as an alternative to hospitalization These programs have been shown to be safe, effective, and reduce costs by 30% in both RCTs and subsequent experience. Patients are admitted through emergency departments (substitutive Hospital at Home) or by early discharge (complimentary Hospital at Home) Care teams include physicians, nurses, therapists, social workers and pharmacists.

How Hospital at Home Can Help Why We Need It How it Helps Spreading Success Case Studies How Hospital at Home Can Help Hospital at Home®

Hospital at Home is NOT acute care for homebound primary care patients. Differs from home based primary care providing acute care because it forms a new relationship between patient and provider in an acute context

Context VA has implemented the Hospital at Home programs at 5 Medical Centers, with each program employing the full program staff. 2 programs operate as pure substitutive H@H 3 operate with come complimentary component - Developed at the Portland VAMC as Program at Home.

More Context Typically takes a program 6-9 months to get started when hiring new staff within VA, with a start-up budget of nearly $500,000 supporting a similar comprehensive team. These programs have been implemented through the Home Based Primary Care (HBPC) programs at each medical center, an interdisciplinary team centered program providing primary and acute care to frail, homebound veterans.

Local Challenges VA has expanded Hospital at Home and other novel Non-Institutional Care programs through T-21, a special grant program At PVAMC barriers included: FTE cap (no net new hires) Slow HR department (> 6 months for new clinicians) Rigid internal Pharmacy divide (inpatient/outpatient) Interagency Partnership to complete the H@H team VA recently allowed provider agreements to pay for non-VA care, However, there was No existing comprehensive Provider Agreement for H@H

Objectives Create an interdisciplinary and interagency team to deliver acute in-home care Demonstrate Hospital at Home as a safe and effective alternative to hospital admission Demonstrate cost-savings to the VA health system through a partnership approach compared to a staff-model arrangement, using an internal business model.

Methods Created an inter-agency team linking nursing and infusion services through Penn Care at Home with medical care (HBPC) and oxygen and DME (Prosthetics) via a Provider Agreement. Designated specific nurses, pharmacist, PT for team from PHCHS. Customized Program at Home care protocols for local environment Designated specific VA providers (MD, NP, SW) Team bonding, culture blending--- talk and type

Enrolled patients from the Philadelphia VA Medical Center emergency department, clinics and inpatient medicine wards (through early discharge) EMR consult H@H team Social Worker conducted daily inpatient discharge rounds Periodic ED and housestaff education Provided daily physician and nursing visits, parenteral therapy, durable medical equipment and home oxygen, laboratory and radiology diagnostics.

Measures Clinical data: diagnoses, length of stay, prior hospitalizations, readmissions, CAM Financial data: direct variable costs per DRG, costs of hospitalization for those transferred to Hospital at Home from an inpatient ward, DSS costs of VA services Qualitative data: patient experience in the program

Finances For accounting we created a “Hospital at Home Fund”, to which we: credited revenue (as the Direct Variable Cost of the admission’s DRG). Deducted costs of all services (either VA provided or through the Provider Agreement) DSS source for all VA service costs, including local DRGs Full costs for H@H services were used, while Direct Variable costs for each DRG were used for inpatient care. -Fixed costs do not constitute “savings” in the short run

Process Results Program organized, provider agreement developed and signed, and first patient admitted within 5 months from award. 38 veterans admitted 48 times during the first three quarters; mean age 67 + 12; 100% male. Two patients (5%) had 8 (16%) of admissions 46 hospital admissions in the 6 months prior to initiation of the program.

Process Results 29 admissions to substitutive H@H (direct from ED or clinic)/ 19 admissions were in-patient transfers to H@H (mean pre-transfer LOS 5.5 d (range 1- 9 days) Majority (56%) of substitutive and complimentary admissions were CHF exacerbations Mean LOS on H@H 5.8 days (median 3.4 d) Mean PCP discharge contact 9.5 days; mean PCP follow up visit 26.5 days

# of admissions (Substitutive) Diagnosis # of admissions (Substitutive) CHF 25 (10) Pneumonia 5 (3) COPD exacerbation 5 (4) UTI 3 (3) DM 2 (2) Abscess/Cellulitis 2 (2) DVT 2 (1) Atrial fibrillation 1 (1) Upper GI bleed 1 (1)

Outcome Results 43% cost savings for all patients 82% cost savings for substitutive H@H admissions. 30d Readmisisons: 6 (12.5%) / PVAMC 19% 3/6 were for CHF, including MICU transfer MICU transfers: 1 CHF patient for ionotropic support Safety: no falls, no cases of delirium, no iatrogenic infections. Direct costs for H@H services averaged $240/day

Funds Flow Balance -- $185,077 Balance -- $185,077 Balance -- $185,077 Direct Variable Cost of DRGs $428,599 Balance -- $185,077 Total Cost of H@H services (VA and PennCare at Home) $243,522 ($158,180 for inpatient care) Balance -- $185,077 Balance -- $185,077

Limitations DRG assignment– Assignment retrospective; inadequate severity control Non-monetary costs– Inter-agency teams take time for care and feeding. Rubber VA staff The 3 assigned VA staff were concurrently fully employed and added H@H onto their current duties. Implication: Hospital is closed this week.

Conclusions Hospital at Home provides safe and efficient inpatient-level care either directly substituting for hospital admission, or as a complement to shorter hospital admission. Substitutive Hospital at Home has substantially greater cost savings per admission in a shadow “revenue” based business model. An inter-agency community partnership between VA and a community home health agency can effectively implement Hospital at Home with shorter start-up time and lower fixed costs. PVAMC returned $350,000 of start-up funds to the T21 program

Next Steps Costs of complementary Hospital at Home may also be reduced by earlier identification of eligible patients immediately after admission. Identified gaps include identification of appropriate patients by ED and inpatient providers, improved transition back to primary care development of structured discharge hand-offs, need for education of VA medical staff on capability of home-based hospital care