Some Medicare patients can receive hospital care at home through new program

Host Amber Smith: Upstate Medical University in Syracuse, New York. Invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

A special care program that allows certain admitted hospital patients to continue their recovery in their homes is now offered at Upstate University Hospital. And today I'm talking about this Hospital at Home program with one of the people who helped establish it. Diane Nanno a nurse who is director of nursing for Upstate's Transitional Care Services.

Welcome to "The Informed Patient," Ms. Nanno.

Diane Nanno: Thank you. Thank you for having me.

Host Amber Smith: I understand that this is not a program that everyone is going to qualify for, and I'm going to have you go over the specific criteria for patients who could consider participating.

But first, could you please explain what Hospital at Home is?

Diane Nanno: Absolutely. Back during the real surges of the pandemic, there were concerns about, and are still concerns about, hospital capacity and our ability to meet the needs of the community. So, CMS, which is the Center for Medicare and Medicaid Services, which is federal, came out with a waiver that was made available for applications for hospitals to be able to start a Hospital at Home program. There were a few hospitals throughout the country who were doing this program, but it was made more available to other hospitals, especially given our capacity issues and with the COVID pandemic. So we applied for the waiver, and we were accepted for the waiver. And the waiver is meant to serve Medicare patients, so they're Medicare fee-for-service patients, or straight Medicare is what it's normally called, and there are some managed Medicare plans also that are on board with us for Hospital at Home.

Host Amber Smith: So there's some experience, a track record in other cities or states. Other hospitals have had this underway for a little while.

Diane Nanno: Absolutely, and those hospitals that have had it underway for a while found that 30-day readmissions were reduced for patients who used Hospital at Home, as well as emergency department utilization. And patient experience was very high (good) with these patients, so yes, there is a track record. We know that certain patients can be taken care of at home, so we decided to start it in our own community.

Host Amber Smith: So does it overall save the hospital money?

Diane Nanno: Not really, because patients are still inpatients, and the costs that are associated with an inpatient stay remain. But what it does is it gives us the ability to increase capacity for our hospitals, so we can take more patients who cannot be taken care of at home.

Host Amber Smith: Now, Ms. Nanno, you're director of nursing for Upstate's Transitional Care Services, and people may not understand what that is.

Can you give us a quick explanation?

Diane Nanno: Sure. Absolutely. The definition of transitional care is actually the way people move across the health care continuum. So they might go from home to their physician's office, to the hospital and places in between. So it really means how patients transition throughout the continuum of care. Transitional care at Upstate really looks at patients as they enter our system, navigate through our system, leave our system, if they do, or if they're navigating through, making sure those navigations are as smooth as possible, because if they're not, it puts patients at risk of ending up in the emergency room or hospitalized.

Host Amber Smith: It seems like it makes a lot of sense for you to be involved in the Hospital at Home, even though it's not exactly transitional. I mean, I guess it is, sort of.

Diane Nanno: That's right. And the reason that it makes most sense to be under transitional care is it very much is about, and depends on, our relationships with post-acute partners in the community.

For instance, the nursing piece of Hospital at Home is done by Nascentia Health, um, which is a home care agency in the area. So transitional care just by definition has relationships with organizations within the community.

Host Amber Smith: Well, let's talk about which patients might be considered candidates for Hospital at Home. Are there medical criteria that the doctors and nurses consider before anyone can be recommended?

Diane Nanno: So these are patients who need to be stable. We would never send a patient who we're really worried about having an adverse outcome, we would never send those patients home, so they have to be stable, but they're still acute care, so they still meet criteria for hospitalization. They've got to have a home. They've got to have a safe home. They've got to have some sort of support at home, whether it's informal family support or some sort of formal support. Obviously, patients opt out or opt in, so we would never make someone do Hospital at Home, so that's a piece of it, too, and comfort level at being home, as well. It's a new program. So these are the patients that we're looking at. So they're not that sick, but they're sick enough to be in the hospital. They've got the support, and we can provide those services at home.

The other thing that we need to be sure of with patients we send home with Hospital at Home is that they're not necessarily needing very complex testing, because there's a lot of testing we can do at home, but things like CT scans, MRIs, things like that, we cannot, so we don't want to have to send them back in.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking with Diane Nanno. She's a nurse who directs transitional care services at Upstate. And she's telling us about a new program called Hospital at Home.

Now, is it evident from the time of admission if someone might be a candidate for this, or would potentially a patient's condition changed during their hospitalization so that they would qualify?

Diane Nanno: Absolutely. So what happens is there's an automatic list generated for us in our electronic health record for patients who meet criteria for Hospital at Home. And then we're looking at every one of those patients throughout their hospitalization. Some patients may be appropriate for Hospital at Home when they're still in the emergency room, so they never actually make it up to an inpatient bed. So for those patients, we're avoiding the entire inpatient hospital stay in the brick-and-mortar building and sending them home. Some patients, what we're doing is, identifying them on the (inpatient) unit, either because they needed some testing, (or) they needed some assessment, and then we decide that this would be a good or appropriate patient for Hospital at Home. And we're transferring them home from there, and that decreases the length of stay in the brick-and-mortar hospital.

Host Amber Smith: Now what if a patient requires some hospital equipment? Are there things that would go home with them on loan?

Diane Nanno: Yes. We have community partners that are working with us at Hospital at Home. We have a DME provider, so durable medical equipment provider, that is our preferred provider, that delivers whatever equipment is needed. So we have delivered things like hospital beds, commodes, rockers, canes, oxygen, things like that, in addition to the medications that are needed, so we can do intravenous and really have with pretty much all of our patients, intravenous medications at home, typically antibiotics, but they could be other things. So there's another vendor that we use for that piece of it.

Host Amber Smith: So how does the patient stay in contact with their doctor or their nurses from Upstate? Is there any interaction?

Diane Nanno: There's a lot of interaction. So, patients getting in-person nursing visits twice a day, typically in the morning, and then later in the day. Each patient has an iPad with a call button, essentially. So if there's an issue, a question, really anything that the patient wants to communicate, they're pushing that button, that communication then goes to nursing, and then if it needs to, it's then escalated to our physician. The physician, or advanced practitioner, is connecting with the patient and or family once a day, at least once a day, either in person or virtually.

Host Amber Smith: What happens if someone who is doing Hospital at Home starts deteriorating, do they return to the hospital itself?

Diane Nanno: Absolutely. So we haven't run into that yet, knock on wood, but yes, that is considered, in CMS terms, an escalation. So say patient becomes more short of breath at home, and we're concerned about their status. We would bring them back in to the hospital. It's not a readmission because they're already admitted.

We have a workflow, so patients don't have to go through the emergency room if that were to happen. And then that patient could be cared for in the brick-and-mortar hospital and sent home again, if that's appropriate. If not, we would just continue their hospitalization.

Host Amber Smith: Well, I know this is a relatively new program. How have the doctors and nurses responded to this concept in general?

Diane Nanno: Very favorably. What we have found is, I'm going to be honest, there was some concern, in the beginning, this is not something we've ever done taking care of hospitalized patients in their own homes.

I would say we have reached that comfort level now. We understand that the patients that we're sending home are stable, that they're able to reach us if they need to. There's lots and lots of oversight, and so the physicians and nurses and NPs (nurse practitioners) that are working with this program really like it.

Host Amber Smith: What sort of patient feedback have you received?

Diane Nanno: Very, very positive feedback.Patients are very happy to be home. They're happy to be comfortable in their own beds. They are happy with the oversight and comfort level of those that are taking care of them. And I can't stress enough the importance of a collaboration between the nurses and the physicians, our own pharmacy, the infusion company, the durable medical equipment company -- it's really, at this point, a well-oiled machine, and there's much patient satisfaction.

Host Amber Smith: I'm wondering, do you think the concept of Hospital at Home is pointing us toward the future of hospital care? Do you think there'll be more things like this as we go forward?

Diane Nanno: I do. Really by virtue of what we do in transitional care, we see the importance of community-based organizations and really taking care of patients, meeting them where they are. So if we can look at care individualized like this, as we were saying, this program is not for everyone, but it's for a lot of patients.

So I definitely see us increasing doing care outside the hospital.

Host Amber Smith: So if a patient is admitted and is interested in this, is it something they could just bring up with their provider to find out whether it might be something they qualify for?

Diane Nanno: Absolutely, so they could bring it up with their provider, they can bring it up with their case manager. Every patient has a case manager, which is a nurse who helps with discharge planning. They can bring it up with their bedside nurses. And then we would just go up and talk to the patient and family, talk about whether it's appropriate, if they're eligible and then work to get these patients.

Host Amber Smith: Well, Ms. Nanno, I appreciate you making time to tell us about this.

Diane Nanno: Thank you for having me.

Host Amber Smith: My guest has been Diane Nanno. She's a nurse who is director of nursing for Upstate's Transitional Care Services. And she's one of the people who helped establish the Hospital at Home program at Upstate University Hospital. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.