Executive summary of the meeting of the 2022 ASHP Commission on Goals: Optimizing Hospital at Home and Healthcare Transformation

alternative sites of care, Commission on Goals, comprehensive medication management, hospital at home, medication-use process

Hybrid Live/Virtual Meeting

March 15, 2022

Overview of the Commission

Each year ASHP convenes a Commission on Goals, composed of thought leaders in healthcare and related fields, to review societal and healthcare trends and developments that may affect ASHP members and the patients they serve and to provide guidance to the ASHP Board of Directors about potential strategic areas of focus for ASHP.^1-4 The March 15, 2022, Commission meeting focused on optimizing the hospital-at-home (HAH) model of care and the ways it is expected to transform healthcare. Members of the Commission ( appendix) were selected from key leaders in pharmacy, medicine, nursing, government, other healthcare associations, and academia for their unique ability to discuss HAH models of care and changes in healthcare. This publication is intended as a general overview of the discussion among participants and does not represent the official position of any of the individuals or organizations involved.

Overview of HAH care

HAH care is a patient care model that provides acute-level care to patients in their homes. The first described HAH program in the US was originally developed by the Johns Hopkins Schools of Medicine and Public Health over 25 years ago,⁵ and the HAH care model has seen broader adoption by other hospitals and health systems in recent years.⁶ HAH care models may be broken down into 2 general types. Substitutive HAH programs admit patients to HAH care directly from an emergency department, clinic, or other healthcare facility, substituting HAH care for an inpatient stay.⁷ Early supported discharge or postacute transitional care programs transition patients from an inpatient acute care stay to HAH care.⁸ Both models have been shown to improve clinical outcomes, reduce length of stay, produce higher patient and healthcare provider satisfaction, and reduce costs, admission to institutional settings, and medical complications (eg, reductions in mobility, falls, and altered mentation).^7,9-12 Some studies have shown inconclusive or negative results, suggesting that HAH care is more appropriate for some conditions, patients, or healthcare organizations than others.^8,9,12-14 The model appears to be best suited for medium-acuity patients receiving treatment for conditions with well-defined treatment protocols and stable enough to be monitored from home.⁵ Examples of appropriate conditions known to date include cellulitis, pneumonia, heart failure, asthma, and anticoagulation management.¹⁵

HAH programs typically combine telehealth monitoring and in-person and video visits provided by a variety of healthcare providers, including physicians, paramedics, nurses, pharmacists, and respiratory, occupational, and physical therapists. Patients often receive daily nursing or paramedic visits with oversight by doctors or nurse practitioners, and providers are on call 24 hours a day, 7 days a week to respond to emergencies or other urgent care needs.¹⁶ Treatments provided to patients are similar to those they would receive in an inpatient setting (eg, intravenous fluids, antibiotics, oxygen therapy), as are the services (eg, diagnostic studies; skilled nursing and pharmacy services; and physical, respiratory, and occupational therapy).⁵ Commission members emphasized that a defining feature of HAH care that distinguishes it from other types of care (eg, home infusion, home health, palliative care, home hospice) is that patients require an inpatient level of care (eg, as determined using criteria such as those provided by InterQual or MCG [formerly Milliman Care Guidelines]) that would typically be delivered in a hospital.

Expansion during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic forced hospitals and health systems to explore new and innovative care models, with a heightened focus on remote care.⁴ In March 2020, the Centers for Medicare & Medicaid Services (CMS) announced its Hospitals Without Walls program, which resulted in broader regulatory flexibility in providing services beyond hospital walls.¹⁷ This program was expanded in November 2020 to include the Acute Hospital Care at Home program, which allows eligible patients to be treated for acute illnesses in their homes by waiving §482.23(b) and (b)(1) of the CMS Hospital Conditions of Participation, which require nursing services to be provided on premises 24 hours a day, 7 days a week and the immediate availability of a registered nurse for care of any patient.¹⁸ CMS has outlined more than 60 acute conditions such as heart failure, asthma, pneumonia, and chronic obstructive pulmonary disease that can be safely managed from a patient’s home with proper monitoring and treatment protocols.¹⁸ CMS provided a regulatory framework and payment mechanism for its beneficiaries; a waiver was granted to applicants that met conditions of participation, and participating institutions would be paid 1:1 for the diagnosis-related group.¹⁵ As of March 17, 2022, there were 92 health systems and 204 hospitals in 34 states participating in the Acute Hospital Care at Home program.¹⁹ Commission members agreed that regardless of potential changes in CMS policies that could occur when the COVID-19 Public Health Emergency expires, HAH programs will endure, given they existed long before the pandemic and their expanded use during the pandemic increased experience with the programs.

Benefits and challenges of HAH care

Commission members noted both the benefits of and the challenges presented by caring for patients in their homes. Patients may benefit from improved clinical outcomes, reductions in iatrogenic illnesses and complications, and lower care costs. Satisfaction with care is increased at least in part by receiving it in the comfort of one’s home and from family and other familiar caregivers. Health systems benefit from those same improved outcomes and reduced complications, and reduced costs due to shorter lengths of stay. Commission members suggested that interacting with patients and caregivers in their homes generates a great deal of professional satisfaction, provides healthcare professionals with helpful information about social determinants of health through direct observation, and offers an opportunity to develop lasting provider-patient relationships.¹⁵ One Commission member described the findings of American Nurses Association surveys on nurse satisfaction, which show that over 50% of nurses were planning to or considering changing jobs in the next year, and that 20% have done so within the last 6 months.²⁰ The member provided examples from personal experience of pandemic-related stressors on hospital culture and suggested that the job satisfaction provided by HAH care may help re-establish hope not just for nurses but for other healthcare providers experiencing occupational burnout.

Commission members also discussed the challenges presented by HAH programs, and some potential solutions. Those challenges include lack of standardization, identifying appropriate patients, and ensuring the safety and quality of medication management.

Lack of practice standardization. Commission members pointed out the wide variation in practices in HAH programs. While some of these differences stem from the different conditions being treated, the differing resources and goals of the healthcare organizations, and healthcare’s relative inexperience with HAH models, Commission members agreed that varying laws and regulations, especially regarding reimbursement and scopes of practice, create challenges to standardization. One Commission member who works in an institution that has branches in different states outlined wide variation in state requirements that contribute to differences in practices. Commission members described the different roles filled by physicians, advanced practice registered nurses, other nurses, pharmacists, paramedics, and other healthcare providers, suggesting that having those providers practice at the top of their licenses would be the ideal model, while acknowledging the need for all providers to perform duties below their highest level (eg, removing medical waste) to promote patient satisfaction and efficiency. The lack of standardization in scopes of practices among states creates challenges to developing optimal models of HAH care that could be more widely adopted. Lack of standardization in medication management by HAH programs was identified by Commission members as a particular challenge and is discussed in more detail below.

Identifying appropriate patients.

As noted above, CMS has outlined more than 60 acute conditions that can be safely managed from a patient’s home with proper monitoring and treatment protocols.¹⁸ More research needs to be done to identify the conditions most appropriate for HAH care and the characteristics that make patients good candidates. As hospitals have implemented HAH programs, wide variations in conditions treated and patients selected have emerged. This variation in practice is a contributor to access and equity issues, as patients who would be candidates for HAH care in one area might not have access elsewhere. For example, the technology used for remote monitoring in HAH programs requires broadband access, which is still not available in many parts of the country, particularly in rural areas, where HAH programs could expand the reach of small and critical access hospitals. Some patients face other access issues, such as lack of reliable utilities (eg, electricity for refrigeration of drugs, water for cleaning and bathing, heating/air conditioning), environmental conditions (eg, sanitation, adequate ventilation, bedding, rodent/insect infestations), or distance from the treating facility. One Commission member framed HAH as “a really long hallway,” and the length of that hallway needs to be considered when evaluating patient eligibility, as response time needs to be factored into patient evaluation. Another Commission member noted that a significant portion of their patients lacked a home, making HAH care impractical.

HAH programs also depend on caregivers (eg, family, friends, neighbors) to support the care provided. Commission members noted that the capacity of those people to provide support to a patient who needs acute-level care needs to be assessed and accounted for in HAH planning and implementation, although the amount of social support required has not been established.²¹ Commission members acknowledged the important role family has always had in care, including inpatient care, and lamented the restrictions on family visitation the pandemic has required, noting in particular the potential failure to rescue because visitors were not in a patient’s room when an emergency occurred.

Medication management.

Commission members discussed the wide variation in pharmacy services in HAH programs. Pharmacy services are provided by the inpatient pharmacy, specialty pharmacies, and community pharmacies, depending on the program’s needs and the legal, regulatory, and reimbursement structures in place. Pharmacists’ roles in HAH programs vary widely but may include prospective order verification, dispensing of medications, packaging of medication (eg, first doses), medication reconciliation, comprehensive medication management (CMM), clinical monitoring, pharmacokinetic monitoring, and medication counseling, sometime via virtual daily check-ins with the patient.¹⁵ The 4 challenges encountered by those providing pharmacy services mentioned most by Commission members were dispensing, storage, medication adherence, and medication safety.

Dispensing challenges include issues over which formulary better suits the program, as HAH patients may have different needs than inpatients (eg, a need for medications that are longer-acting or have greater stability for a longer shelf life). Inpatient pharmacies may not be able to respond to distant HAH patients as quickly as a nearby community pharmacy partner could, and the procedures of the nearby community pharmacy (eg, clearer labeling for patients rather than for administration) may be better suited as well. Conversely, a community pharmacy partner may lack procedures for prompt turnaround of urgent medication orders; may not stock the drugs, dosage forms, or strengths/concentrations needed, or may lack the equipment or expertise required to prepare them in the form needed; and may not be adept at the billing procedures required for HAH patients.

Storage challenges include the regulatory requirements for storing controlled substances (CS) in the patient’s home and ensuring proper storage and security conditions. Although some HAH programs rely on a lockbox for storing CS, accessing a lockbox requires a patient to wait until a provider is present. One health system has implemented use of personal automated medication dispensing devices that provide a digital photo of what was dispensed so that a nurse can verify the dispensed medication against the medication administration record (MAR).¹⁵ Proper storage conditions in the home (eg, temperature, humidity, darkness, lack of movement) may also present challenges to pharmacy in certain environments.

In inpatient settings, medication adherence is supported by around-the-clock availability of well-trained staff focused on that task. Even with daily visits from HAH providers, some medication administration will need to be managed by the patient and/or caregivers. This challenge is addressed through a combination of program design (eg, to reduce administration regimens), remote patient visits, and patient/caregiver education and training.

Commission members noted that different processes are needed to ensure medication safety in HAH programs. Inpatient care typically employs technologies such as electronic health record (EHR) and MAR systems, barcoding, and automated dispensing devices to track a patient’s every dose. Some health systems have successfully developed processes to incorporate HAH care into these systems, sometimes using models provided by home infusion and hospice programs.¹⁵ Commission members also discussed the challenge of integrating information into the inpatient EHR and MAR systems when medications are provided by a mix of entities (eg, inpatient pharmacy, community pharmacy, home infusion services).

Some HAH programs have addressed these challenges by embedding pharmacists in HAH programs. Embedding a pharmacist guarantees that a medication-use expert contributes to the HAH program’s design, is familiar with the patient and their environment, provides medication reconciliation, and is available to ensure CMM. One Commission member suggested that CMM should be considered as the standard of care in HAH programs. CMM is defined as the “standard of care that ensures each patient’s medications (i.e., prescription, nonprescription, alternative, traditional, vitamins, or nutritional supplements) are individually assessed to determine that each medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended.” ^22-24 CMM is an interprofessional team-based approach to optimizing medication therapy, and a central feature of CMM is having a pharmacist develop a plan with the patient or caregiver to optimize medication therapy, working in collaboration with the physician and other team members. Four pillars of CMM have been described and could be a good fit in HAH programs:

1. Practice and care delivery transformation

2. Use of health information technology to support that activity (eg, making clinical information available at the point of care to determine whether individuals have achieved the clinical goals of therapy)

3. Use of advanced and complementary diagnostic tools (eg, integrating pharmacogenomic testing results to reduce cost and improve patient outcomes)

4. Advancing the necessary policy reforms to promote CMM and fostering pilot programs and demonstration projects for those reforms²⁴

Other trends and opportunities in healthcare identified by the Commission

Each Commission member was asked to identify at least one major trend or opportunity that, from their unique vantage point, they believe will have a significant impact on healthcare over the next 3 to 5 years. Commission members identified pandemic-related changes in consumer expectations, disruptive technological and market changes, evolution of professional identity, and an increasing focus on health equity as trends worth considering.

Several Commission members noted that patients have become accustomed to remote care during the COVID-19 pandemic and will continue to demand more-accessible care options. Healthcare organizations are examining how more care can start and stay at home, and like other healthcare providers, the pharmacy workforce will need to consider the impacts of moving from brick-and-mortar to remote care. New organizations such as CostPlus, Amazon Pharmacy, DiRX, Capsule, and others have the potential to disrupt long-standard models of pharmacist care. One particular concern is how pharmacists can adapt to providing patient-centered care remotely while simultaneously retaining and taking advantage of the increased focus COVID-19 has brought to the care pharmacists provide in person. While some of the changes provided by remote healthcare may be beneficial, healthcare providers must be alert to potential dangers. Commission members also noted the other opportunities provided by healthcare technology such as wireless biomarker monitors (eg, glucose monitors), increased connectivity (ie, the internet of things), and artificial intelligence. Commission members recognized the effects these changes and the devastating impact of the COVID-19 pandemic are having on the professional identity of healthcare providers and suggested that keeping the patient at the center of that identity will be essential to managing change. Finally, the Commission noted 2 areas of progress that need to be maintained and pursued. First, healthcare and wellcare have resulted in better aging for many people, who have seen extended wellspans rather than just extended lifespans. Second, the COVID-19 pandemic has raised awareness of the need to promote health equity, which Commission members hoped would continue beyond the COVID-19 Public Health Emergency.

Conclusion

The Commission on Goals: Optimizing Hospital at Home and Healthcare Transformation identified important trends in the evolving area of HAH care. Commission members discussed the benefits of HAH care, identified some challenges presented by caring for patients in their homes (eg, lack of standardization, identifying appropriate patients, and medication management), and explored potential solutions. The Commission outlined 4 broad areas of opportunity for ASHP and other stakeholders in advancing HAH models (providing resources, education, research, and advocacy) and briefly described other major trends or opportunities that may have a significant impact on healthcare over the next 3 to 5 years.

Appendix—Roster of 2022 ASHP Commission on Goals: Optimizing Hospital at Home and Healthcare Transformation

Kelly M. Smith, PharmD, FASHP, FCCP

Commission Chair

Dean and Professor

University of Georgia College of Pharmacy

Thomas J. Johnson, PharmD, MBA, BCCCP, BCPS, FACHE, FASHP, FCCM

Immediate Past President, American Society of Health-System Pharmacists

Commission Vice Chair

Vice President of Hospital Pharmacy

Avera Health

Paul W. Abramowitz, PharmD, ScD (Hon), FASHP

Chief Executive Officer

American Society of Health-System Pharmacists

Commission Participants

Katherine Capps, BS

Co-founder, Executive Director

GTMRx

Ivan P. Cephas, PharmD

Chief of Pharmacy Services

Veteran Affairs Medical Center

John V. Cocchiara, RPh

Lead Regional Pharmacist for Medicare Health Plans Operations

Centers for Medicare and Medicaid Services

Loressa Cole, DNP, MBA, RN, FAAN, NEA-BC

Chief Executive Officer

American Nursing Association

CAPT Darin D. Daly, MS, MT (ASCP)

Senior Public Health Analyst

Hospital Administrator at Health Resources and Services Administration

Department of Health and Human Services

Mary Beth Lang, ScD, MPM, RPh

Chief Pharmacy Officer

Kaiser Permanente

Susan M. Mashni, PharmD, BCPS

Senior Vice President, Chief Pharmacy Officer

Mount Sinai Health System

Margaret Paulson, DO, FACP

NWWI Medical Director – Advanced Care at Home & Home Health

Mayo Clinic Health System

Margaret (Maggie) Peinovich, PharmD, BCPS

Director of Pharmacy Services

Medically Home

Brock Slabach, MPH, FACHE

Chief Operations Officer

National Rural Health Association

Annie Walker, MSN, APRN, FNP-BC

Clinical Director, Care Management

Contessa/Asencion

Kasey Thompson, PharmD, MS, MBA

Commission Secretary

Chief Operating Officer & Senior Vice President

American Society of Health-System Pharmacists

Commission on Goals Observers

Christene M. Jolowsky, MS, RPh, FASHP

Treasurer, American Society of Health-System Pharmacists

System Pharmacy Director

Hennepin Healthcare

Linda S. Tyler, PharmD, FASHP

President, American Society of Health-System Pharmacists

Chief Pharmacy Officer

University of Utah Health

Paul C. Walker, PharmD, FASHP

President-elect, American Society of Health-System Pharmacists

Assistant Dean of Experiential Education and Community Engagement

University of Michigan

Acknowledgments

ASHP and the author gratefully acknowledge the following individuals for reviewing drafts of this document: Marissa Brooks, PharmD, MBA; David Chen, BSPharm, MBA; Daniel J. Cobaugh, PharmD, FAACT, DABAT; Anna Legreid-Dopp, PharmD; Bayli J. Larson, PharmD, MS, BCPS; Eric Maroyka, PharmD, BCPS; and Douglas J. Scheckelhoff, MS, FASHP.

Disclosures

The author has declared no potential conflicts of interest.