By Randena Hulstrand
An NYU Langone Hospital—Long Island patient battling a urinary tract infection was so grateful for how her Hospital at Home experience helped her heal more comfortably and quickly, she wrote a "thank you" poem to her caregivers.
"Home, where I could sleep in my bed … where I didn't have to share a room … where only my germs were … where I could water my plants … where my grandsons could visit …"
NYU Langone's Hospital at Home program was launched in September 2021 after earning approval from the Centers for Medicare & Medicaid Services (CMS). In response to the pandemic, in 2020, CMS provided regulatory flexibility, allowing hospitals to offer inpatient-level care outside the traditional hospital setting — including within people's homes — and be reimbursed for doing so. The initiative expanded to the Acute Hospital Care at Home waiver program and Congress extended it through Dec. 31, 2024.
"Like many healthcare organizations across the country post pandemic, our occupancy rates for medical-surgical patients were at 100% for close to two years — a resurgence of people who didn't get healthcare during the pandemic," said Jeanmarie Moorehead, senior director of home health operations and Hospital at Home program at NYU Langone Hospital—Long Island. "But we soon realized this wasn't a temporary blip but a new constant with an aging baby boomer population. Through the support of senior leadership, we sought out to find a different model of care."
Innovative model of care
According to the 2023 Impact of Change Forecast by Sg2, a Vizient company, continuing hospital capacity challenges over the next decade will lead to care-at-home innovation driving increased utilization. It's predicted that the volume of healthcare services provided at home will increase 20%, driven by a culmination of advances in remote monitoring and digital health capabilities, more favorable payment and lower acuity care shifting to the home setting, enabling reduced patient length of stay and cost avoidance.
After a year of organizing a task force and conducting extensive research to review other programs, NYU Langone Health created a Hospital at Home — one that was uniquely their own.
"We were committed to quality and excellence in the high-quality care that our organization delivers so we decided to develop the Home Hospital program on our terms," Moorehead said.
Their model — different from most — utilizes 100% registered nurses in the patient's home as well as at the hospital navigating patients through the process and remote patient monitoring. After a field nurse admits the patient in their home and gets them synced up to the virtual command center, they visit at least twice daily to provide hands-on care. Additionally, a dedicated hospitalist provides a daily evaluation, either in the home or remotely, and coordinates consultations with other specialists as needed.
To be eligible for the voluntary program, patients must meet inpatient criteria with acute but stable conditions — such as congestive heart failure, pneumonia, COVID-19, asthma exacerbation or cellulitis — and are screened by a registered nurse and physician in the emergency department. After using a predictive model to anticipate patients that should be excluded, the team conducts a social screening to assess factors such as whether the patient's home has running water, heat and AC, and if they care for another family member at home.
"As outlined by the CMS waiver, we have to be able to respond to a decompensating patient within 30 miles via EMS," said Jenna Blind, director of education, professional development and quality improvement, Home Healthcare and Hospital at Home program at NYU Langone Health.
Unlike most other programs, NYU Langone Health has tapped its own physicians and nurses to build the program and manage patient care rather than outsourcing staff.
Each patient enrolled in the Hospital at Home program receives a tablet for conducting video visits and a wearable device that tracks vital functions like pulse rate, oxygen saturation and temperature. Their data is transmitted in real time to the program's command center, which can coordinate streamlined access to NYU Langone physicians, nurses and specialty consultations 24 hours a day, seven days a week.
"Our goal from the start was to build a program where patients receive the same high-quality care in their homes as they would in the brick-and-mortar hospital," Blind said, adding their focus on equitable care in the home includes leveraging the newest technologies and ancillary support such as the ability to conduct imaging with a mobile radiology team and offer infusion therapy. "It's an entire team of people to get these patients home safely and take care of them."
Since launching, the program has broadened inclusion and exclusion criteria to serve up to 12 people at a time and now can take care of very sick medical-surgical patients in their home from the age of 23 to 103. Upon discharge, patients get an appointment with their primary care physician within five days.
During their quality and care redesign Power Huddle presentation "There's No Place Like Home: Serving Acute Care Patients Where They Belong" at the 2023 Vizient Connections Summit, Moorehead, Blind and other teammates shared the path they took to create the program along with key takeaways and lessons learned. Also, in collaboration with the Home Care Association of New York State and the Greater New York Hospital Association, they continue to share their experiences and advocate for the collective resources and funding needed to implement this model on a wider scale throughout the healthcare industry and for their own program.
"We hope to grow our population of patients who can safely be cared for in their homes," Moorehead said.
Promising outcomes
NYU Langone's Hospital at Home program has seen tremendous success in its first year.
"We're committed to quality — it's our No. 1 value at NYU Langone. It drives our work, which is why we track our metrics and analytics through Vizient closely to ensure the Hospital at Home care we're providing is top notch and equitable to inpatient care," Moorehead said. "We continuously measure both models with the same metrics."
In the beginning, patient criteria included having Medicare fee-for-service insurance, exclusively. Since then, NYU Langone's Hospital at Home has expanded its payer mix as many commercial payers have come to understand the value of hospital at home and are covering services.
In addition to reductions in readmissions and length of stay, the Hospital at Home program has significantly increased staff engagement — eight points higher than the organizational average.
"Seeing nurses in the program really practice to the full extent of their license is very exciting," Blind said. "They have autonomy working one on one with patients, but at the same time are part of a collaborative care team and our physicians respect them immensely."
But Blind and Moorehead say the ultimate testament to the program's success is their patient experience and satisfaction, which is at a 100% overall rating of care.
"The psychological mindset of a patient who is sick and afraid, thinking they could die from their disease when they're in the hospital can be paralyzing," Moorehead said. "But moving them into their home environment surrounded by their loved ones helps them heal faster in a more holistic way."
Blind describes the program as "getting back to the roots of a human care model," which also can access underserved communities and offer caregivers a glimpse into social factors that can impact wellbeing, such as food insecurities and lack of transportation.
"We know we have an aging population from all backgrounds," she said. "Patients deserve to be cared for in their homes with quality care where they're comfortable and safe."