Hospital at Home helps patients recover comfortably

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. If you've been hospitalized because of illness or injury, and it's going to take some time to recover, how would you like to do that in your home while still under the care of the hospital? Here to explain the Hospital at Home program are Dr. Basel Abuzuaiter, an assistant professor of medicine, and nursing administrator, Diane Nanno. They work together overseeing the program at Upstate. Welcome to "The Informed Patient," both of you.

[00:00:38] Basel Abuzuaiter, MD: Thank you, Amber. Thanks for having us.

[00:00:41] Diane Nanno: Amber, thank you for having us.

[00:00:44] Host Amber Smith: Ms. Nanno, we spoke with you about this program a few years ago when it was just getting underway at Upstate. I think at that time it was only for people on Medicare and it was still proving itself. Is that right?

[00:00:57] Diane Nanno: That's right. So last we spoke, we were just getting our program off the ground. And just for a rreminder: Our Hospital at Home program is a result of a waiver that we applied for and were granted. Within the COVID-19 pandemic, there was a potential for a surge, and we were concerned about our ability to take care of all of the patients that we need to take care of. And so Hospital at Home and the waiver that allows us to take care of inpatients in their own homes, in their own beds is what we applied for and is what we're talking about today.

So at that time, it was for Medicare patients only. That was who the waiver was granted for, but since that time, we've been able to add patients who are insured by commercial payers as well.

[00:01:53] Host Amber Smith: So it's available today to adults, children..?

[00:01:59] Diane Nanno: The program today is available to adults. We've talked about, and our future plans are to be including children, but at this time it's for adults under Medicare or a commercial payer who live within a geographic area that we have determined, which is Onondaga County.

[00:02:21] Host Amber Smith: Now I understand how a program like this would be essential during a pandemic. Does a program like this, in normal times, is it designed to save the patient and the hospital money?

[00:02:34] Diane Nanno: Interestingly, we're still feeling the effects of the pandemic, and in many ways that's about staffing, both hospital bed staffing -- although things are much, much better than they were -- but also within the community, post-acute partners where patients go after discharge.

So we really continue to need beds at any one time. We always have patients who are waiting in our emergency departments for acute care beds. So our ability to shift these appropriate patients to acute care in their own homes is a really important capacity strategy for us.

[00:03:15] Host Amber Smith: Dr. Abuzuaiter, are there medical benefits to recovering in your own bed?

[00:03:22] Basel Abuzuaiter, MD: Yes, Amber. So Hospital at Home is an innovative program that allows admitted patients to continue recovery from the comfort of home, supported by the comprehensive hospital level of care, assisted by their loved ones. Evidence has shown that Hospital at Home patients have better clinical outcomes, fewer hospital readmissions and fewer emergency room visits.

Also, there is nothing like home, right? So patients feel better at home. Being at home reduces the patient's distress. Patients when they are at home, they have lower risks of getting infections. And also it has its own cost effectiveness.

[00:04:11] Host Amber Smith: Which type of patient has the most ability to have this option? Because I know not every patient is appropriate for this. But which ones are?

[00:04:21] Basel Abuzuaiter, MD: So we have our own selection criteria. So in general, as Diane said, so far, patients who are aged 19 and older, who live within the county, our county, Onondaga County, our patients must be competent. They should be physically able to ambulate, to avoid the risk of falling. Also, we prefer if patients have 24-hour caregiver at home, or at least some support at home.

In the time being most of our patients who we treat at home, we have specific conditions like patients who have lung infections, we call it in pneumonia, who need IV antibiotics, patients who have skin infections, or what we call cellulitis, who also need IV antibiotics to improve, patients who have heart failure and in this condition, they accumulate fluids in their bodies and they need some sort of medications that's given intravenously to get rid of the extra fluids, patients who have chronic lung infection, or inflammation, also known as COPD, who need IV antibiotics. So these are the patients we target so far.

[00:05:49] Host Amber Smith: So I was going to ask about which patients might not be candidates. You mentioned they have to be able to walk on their own and kind of get around on their own. Are there other conditions that just really need to be within the walls of the hospital?

[00:06:04] Basel Abuzuaiter, MD: Yes. This is a very good question. We have, also, an exclusion criteria. So Hospital at Home targets patients who are acutely sick, meaning they need hospital care, but also they don't need higher level of care, like intensive care unit, where patients need continuous monitoring, they need medications every one hour, they need to be observed by a nurse around the clock. These patients will not be suitable for Hospital at Home.

Again, we exclude patients who need physical support, like patients who are not able to ambulate by themselves. There is risk of fall, despite being at, you know, young age. These patients will not be safe at home, so we prefer to treat them at the hospital. So there is a big list, but this is mainly the things we look at.

[00:06:57] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Basel Abuzuaiter and Diane Nanno from Upstate's Hospital at Home program.

Ms. Nanno, if a person wants to be involved in this program, but they live in an assisted living facility or a nursing home, is that a disqualifier?

[00:07:20] Diane Nanno: Typically we look at people who live in their own homes and are not cared for by other medical folks.

Nursing home is definitely not appropriate. They certainly can get their care in a different way. Patients who, though, live in independent livings or assisted livings where their nursing care is not provided for them, it would be appropriate. We also look at things like group homes, things like that, because these folks are cared for after discharge, but when they're acutely ill, we can continue to go in because that is their home, just like a private home is someone else's.

And if I could just add a little bit to what Dr. Abuzuaiter said about the patients we look at, it used to be in the Hospital at Home world, we only looked at the types of patients that Dr. Abuzuaiter is talking about. I think Dr. Abuzuaiter would agree that we're able to expand the types of patients that we can take care of based on our capabilities.

So what is it we can do safely at home? And that really opens us up. For instance, we're looking at do we start taking care of surgical patients as well? So it really allows us to take care of a greater number of patients with a host of different clinical conditions.

[00:08:52] Host Amber Smith: Dr. Abuzuaiter, if a person that's at home, in the Hospital at Home program, has a setback, do they have to go be readmitted to the hospital?

[00:09:05] Basel Abuzuaiter, MD: So patients with the Hospital at Home service, they are considered hospitalized despite being at their home. ,

[00:09:15] Host Amber Smith: They're under an admission still, when they're home?

[00:09:17] Basel Abuzuaiter, MD: They are. And we provide the same care we do for patients at the physical hospital. We give them the same kind of medications, same monitoring, but these patients are of lesser acuities, meaning they are not very sick to be in a different service, like intensive care unit. For example, if the patient is in any medical ward at the hospital, physical hospital who progresses and needs higher level of care, mandating transfer to the intensive care unit, we do that for our patients who are at their homes. But thankfully, so far this has never happened.

[00:10:04] Host Amber Smith: So let me ask you how medical care is provided when it's remote like this. What can a person who is receiving Hospital at Home services expect?

[00:10:14] Diane Nanno: Every patient under the waiver -- remember we're still operating under the waiver -- receives two in-person nursing visits a day at home. Those visits tend to be about an hour each. So if you think about bedside nursing spending two hours at the bedside, there's an incredible amount of education that's done during that time.

In addition to those two nursing visits that are in person, there is a provider visit, and Dr. Abuzuaiter does most of those visits. And that visit can be in person or virtual. We, in our program tend to, see patients on the day of transfer, meaning the day they come from the brick and mortar hospital to their home, and the day of discharge. And then visits in between tend to be virtual unless there's a problem.

Patients get 24-hour monitoring. Patients get transportation from the hospital to their home and then back to the hospital if there's any concern at all, or if there's any kind of diagnostic testing that's needed. Patients get their labs drawn. It comes The specimens come right to theUpstate hospital, and then Dr. Abuzuaiter and his team are able to see the results right in our medical record.

[00:11:37] Diane Nanno: Any durable medical equipment that's needed. Typically we look at things like a hospital bed. Does the bed have to be on the first floor? Not necessarily. It really depends on what the patient needs and what is safest for the patient. We tend to order hospital beds for our folks because it's just easier for them. In addition, any infusions that they need are brought to the home, and the infusions are deliveredby our Nascentia nurses, who are our partners in this. Any physical therapy, occupational therapy, any kind of therapy that's needed in the home are also provided. Medications in addition to those infusions that I mentioned. If there are oral medications, they are set up for the patients, and the patients, actually virtually the nurses watch the patients take their medications.

There's typically a tuck-in visit. So it's although the patient's going to be monitored 24 hours overnight, just kind of making sure that things are going well, there aren't any questions or anticipated concerns from the patients and families. Are pets okay? Absolutely. I'm a dog person. I feel a lot better when my dog's around, and I certainly feel better when my family's around. So that's certainly a positive.

[00:12:57] Host Amber Smith: Well, let me ask you if I can, you've mentioned that there's 24 hour monitoring. Is that done by telephone, or is there a camera? How is that done?

[00:13:06] Diane Nanno: Dr. Abuzuaiter, do you want to take that one?

[00:13:08] Basel Abuzuaiter, MD: Yes. So we provide patients with a tablet that is connected to the internet through an application where we do the telemedicine visits. This is done every day by an advanced practitioner or by me, and if the patient has any question and would like to contact a provider, we can do that through this tablet.

[00:13:35] Diane Nanno: It's like an old fashioned call button only, only high tech.

[00:13:40] Host Amber Smith: So, DrAbuzuaiterum, I'm curious about the doctor-patient relationship or the nurse-patient relationship. Does that change when you have the remote built into this, a little bit?

[00:13:53] Basel Abuzuaiter, MD: Yes. All of our patients we have taken care of, they were surprised and happy with this kind of care. Some of them got very emotional when they saw and they practiced and they experienced this kind of care, and they were like, "we did not expect this high level of care at home," and this makes us very happy that we were able to do something and add in the process of healing to the patients.

[00:14:26] Host Amber Smith: And we should make it clear. You've talked about patients who are really glad that something like this is available, but no one is forced to do this. If there's somebody who doesn't want to go home, that's perfectly fine, right?

[00:14:39] Basel Abuzuaiter, MD: Yes, absolutely. When we do the screening process, we talk to the patient ahead of time. We explain to them about the service, the Hospital at Home service, what are the services we do at home, what they expect, what are the outcomes, and we take their opinion if they are in agreement of going home with the Hospital at Home service, we proceed with the process. Otherwise, we give them the freedom to decide if they want to continue the care at home, at the hospital, or get discharged home.

[00:15:13] Diane Nanno: Ms. Nanno, do you know how many other hospitals across the U.S. are doing a program like this? Three hundred and thirty health systems in our country. Interestingly, Hospital at Home has actually been, they've been doing this in other countries for years and years and years, and we're late to the game. And it's going very well. There are some systems that have been doing this ahead of the waiver, with CMS (Centers for Medicare and Medicaid Services) innovation grants, and those are the systems that really have kind of figured this out.

And the Hospital at Home really is a movement. What's really, really nice about it is, we are able to connect with other systems that are doing this, to help us understand how to better care for our patients within Hospital at Home and care for more patients within it.

A really important population of patients that we care for, and I'm sure Dr. Abuzuaiter wants to add to this as well, is end-of-life patients. So, patients who are "comfort care," they're no longer curative. They're bridging to hospice services in our area, aren't necessarily ready for the patient at discharge. So what we do is we bridge those folks to hospice with our comfort care patients with the collaboration of our palliative care team. Sometimes patients pass away before hospice is even able to enroll. We're just so grateful that we're able to get these patients home. And so are they.

[00:16:49] Host Amber Smith: Well, for anyone listening, if they were a patient in the hospital, how would they find out if they would qualify, or if their loved one would qualify for a program like this, or how would they ask about it?

[00:17:02] Diane Nanno: Every patient in the hospital has a case manager, so the best way, probably the quickest way, is for the patient to talk to their case manager, bedside nurse, their provider, really anybody who's on their care team if the patient or the family is interested in learning more about Hospital at Home, they can ask their care team as well.

[00:17:25] Host Amber Smith: Well, thank you both for taking the time to talk about this innovative program.

[00:17:31] Diane Nanno: Thank you.

[00:17:32] Basel Abuzuaiter, MD: Thank you, Amber.

[00:17:33] Host Amber Smith: My guests have been Dr. Basel Abuzuaiter, and Diane Nanno. Dr. Abuzuaiter is an assistant professor of medicine, and Ms. Nanno is a nursing administrator. They work together overseeing the Hospital at Home program at Upstate. "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. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple podcast, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.