Across the United States, healthcare systems and hospitals face extraordinary pressure to provide affordable care. As 2022 and 2023 progressed after the pandemic, hospital leaders faced an opaque climate around the sustainability of care delivery because of healthcare inflation, staffing challenges and salary increases, all of which continued to pressure operating margins. Despite these headwinds the demand for hospital services continues to increase, although the staffing challenges of the COVID-19 pandemic linger—exacerbated by healthcare workers burnout and departures, hospital closures, hospital acquisitions by private equity firms, and consolidations.
In addition, while hospitals have made significant strides to improve the quality and safety of the care they deliver, the Centers for Disease Control (CDC) estimates that on any given day, 1 in 31 hospital patients and 1 in 43 nursing home residents will acquire a hospital infection while being treated in a medical facility. Healthcare leaders and providers navigating through this myriad of challenges face a stark reality – we need to provide hospital care differently in the future. Part of this acute care transformation is the reimagination of acute hospital-based care to environments outside of the traditional brick and mortar medical wards. Indeed, acute hospital care in a patient’s home was first described nearly 30 years ago, but widespread adoption in the United States was hindered by reimbursement and regulatory limitations. During the COVID-19 Public Health Emergency, the Centers for Medicare & Medicaid Services lifted the regulatory barriers to providing hospital care outside of the physical hospital and announced the Acute Hospital Care at Home Program Waiver, offering hospitals an opportunity to expand capacity beyond their physical footprint and explore how to shift appropriate high acuity care into the home.
Having patients who would normally require inpatient care in a brick-and-mortar facility receive care within the home, and at a sustainable scale, is radically different to historical practice, however, and needs to be carefully explored to prove effectiveness and safety. With these factors in mind, three years ago we began to explore opportunities to reimagine acute hospital care delivery beyond our physical footprint with the goal of improving quality and safety of patient care, improving the work environment for healthcare providers, and developing a more sustainable delivery model for patients, hospitals, and the healthcare community at large. The culmination of this effort, Cleveland Clinic Hospital Care At Home, admitted the first patient in April 2023. Since the opening of our “virtual hospital,” we have admitted more than 500 inpatients with greater than 60% of these admissions transferring directly from our emergency department, bypassing the medical wards entirely. Like results from other early adopters of hospital at home, patient experience scores surpassed those from the brick-and-mortar hospital. Our patients report high satisfaction with the in-home technology and the ease of its use, improved communication with their doctors, and an overall higher rating of their hospital care. Additionally, the Cleveland Clinic Integrated Virtual Command (CIVC) Center has received a surplus of nursing applicants as nurses reimagine what it means to deliver acute “hospital” based care without the same physical demands of caring for patients within the brick-and-mortar hospital.
Since the founding of the Immaculate Conception Hospital and the Saint Lazarus Hospital in the early 16th century, acute care within North America has been established within physical hospitals. Thus, the operating complexities and change management required to move acute care out of the brick-and-mortar hospital is significant. Recognizing the deep social roots of receiving acute care in the brick-and-mortar hospital is an important first step in helping shape a change management strategy to complement the many operational decisions needed to execute this acute care model.
Initiating our health systems evaluation of hospital-at-home was a commitment by senior leaders across the Cleveland Clinic to establish a pilot that might reimagine the future of high-quality hospital care at scale and ultimately incorporate this into future organizational objectives. Determining how home-based hospital care aligns with future patient, society, and organizational needs, and aligning hospital leadership around these goals was key to enabling this change. How could we “bend the curve” to enable more sustainable acute hospital care? At the heart of these sustainability discussions was the consideration of increasing bed capacity without the prohibitive capital costs of building new hospitals, improving staff productivity while reducing emotional and physical burnout, while providing more capacity in our hospital facilities for conditions that require complex surgical and intensive medical care.
As part of this journey to open the virtual hospital, we determined a partnership would better facilitate and accelerate the shift in care from the hospital to the home, while delivering on the organizational objectives we set around patient quality and safety, provider satisfaction, and organizational sustainability. The ecosystem required for hospital-at-home is sizable and health systems will have to balance the desire to internally develop a comprehensive virtual hospital program against the size of the investment and know-how required to develop this model of care for patients at scale. Developing this ecosystem requires a myriad of services with reliable redundancies to deliver safe and efficient care across broad geographic and demographic areas. These services, routinely accessible within the hospital, are not available on-demand within each community. Developing this clinical ecosystem outside of the hospital therefore requires a rethink around developing highly reliable decentralized core clinical services including advanced nutritional services, wound care teams, occupational and physical therapy, mobile diagnostic and imaging teams, speech therapy, social services, and case management to name a few.
Hospital at home care requires structured education and support for both patients and providers as they learn a new way to deliver acute care. Physicians and nurses, putting their patients first, will appropriately question the safety and quality of this new paradigm of care. Healthcare leaders must be both deliberate and thoughtful in messaging the why and sharing their early outcomes both good and bad with their healthcare providers to facilitate acceptance of this new environment of care. Engaging physicians, nurses, and ancillary staff early is critical to the success of the under-appreciated change management required. With these principles in mind, our nursing team became very engaged in a renewed focus on patient needs and the richness that came from the in-home virtual interaction with their patients. Currently, our nursing and physician teams care for patients virtually from the command center where they can also interact with each other. It has been interesting that the intimacy of the nurse-patient interactions created real openness to remotely caring for patients within their homes. Today, our nurses and physicians within the CIVC care for patients with complex medical illnesses and co-morbid conditions including exacerbations of acute chronic heart failure and those from underlying lung disease, pneumonia, diseases of the small and large intestine, and skin and soft tissues infections. Some of our most vulnerable patients with cancer already burdened by multiple medical facility visits and compromised immune systems from their treatment can now receive hospital level care within their home without the burden of additional facility stays.
In summary, the careful thought and planning invested in starting a pilot to develop a safe, patient-focused model of hospital care-at-home has resulted in a high-quality environment that both patients and caregivers appreciate. This is a differentiated model of care that may offer a more sustainable framework for the acute care of selected diagnoses and improve the experience for patients and caregivers alike. Hospital care at home will enable healthcare systems to provide care across the geographies they serve, while empowering teams to reimagine hospital care delivery.
Dr. Conor Delaney is Florida market president for Cleveland Clinic Florida and Dr. Richard Rothman is vice-chief at the Integrated Hospital Care Institute at Cleveland Clinic Florida