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Maniaci MJ, Torres-Guzman RA, Avila FR, Maita K, Garcia JP, Forte AJ, Rutledge R, Dugani SB, Campbell SM, Pritchard IJ, Paulson MR. Development and evaluation of best practice advisory alert for patient eligibility in a hospital-at-home program: A multicenter retrospective study. J Hosp Med 2024; 19:165-174. [PMID: 38243666 PMCID: PMC10923137 DOI: 10.1002/jhm.13275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 12/09/2023] [Accepted: 12/22/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Hospital-at-home (HaH) is a growing model of care that has been shown to improve patient outcomes, satisfaction, and cost-effectiveness. However, selecting appropriate patients for HaH is challenging, often requiring burdensome manual screening by clinicians. To facilitate HaH enrollment, electronic health record (EHR) tools such as best practice advisories (BPAs) can be used to alert providers of potential HaH candidates. OBJECTIVE To describe the development and implementation of a BPA for identifying HaH eligible patients in Mayo Clinic's Advanced Care at Home (ACH) program, and to evaluate the provider response and the patient characteristics that triggered the BPA. DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective multicenter study of hospitalized patients who triggered the BPA notification for ACH eligibility between March and December 2021 at Mayo Clinic in Jacksonville, FL and Mayo Clinic Health System in Eau Claire, WI. We extracted demographic and diagnosis data from the patients as well as characteristics of the providers who received the BPA notification. INTERVENTION The BPA was developed based on the ACH inclusion and exclusion criteria, which were derived from clinical guidelines, literature review, and expert consensus. The BPA was integrated into the EHR and displayed a pop-up message to the provider when a patient met the criteria for ACH eligibility. The provider could choose to refer the patient to ACH, dismiss the notification, or defer the decision. MAIN OUTCOMES AND MEASURES The main outcomes were the number and proportion of BPA notifications that resulted in a referral to ACH, and the number and proportion of referrals that were accepted by the ACH clinical team and transferred to ACH. We also analyzed the factors associated with the provider's decision to refer or not refer the patient to ACH, such as the provider's role, location, and specialty. RESULTS During the study period, 8962 notifications were triggered for 2847 patients. Providers opted to refer 711 (11.4%) of the total notifications linked to 324 unique patients. After review by the ACH clinical team, 31 of the 324 referrals (9.6%) met clinical and social criteria and were transferred to ACH. In multivariable analysis, Wisconsin nurses, physician assistants, and in-training personnel had lower odds of referring the patients to ACH when compared to attending physicians.
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Affiliation(s)
- Michael J. Maniaci
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | - Karla Maita
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - John P. Garcia
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Antonio J. Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Rachel Rutledge
- Administrative Operations, Mayo Clinic, Jacksonville, Florida, USA
| | - Sagar B. Dugani
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Shannon M. Campbell
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Ingrid J. Pritchard
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Margaret R. Paulson
- Division of Hospital Internal Medicine, Mayo Clinic Health Systems, Eau Claire, Wisconsin, USA
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Wang X, Stewart C, Lee G. Patients' and caregivers' perceptions of the quality of hospital-at-home service: A scoping review. J Clin Nurs 2024; 33:817-838. [PMID: 37817557 DOI: 10.1111/jocn.16906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/22/2023] [Accepted: 10/02/2023] [Indexed: 10/12/2023]
Abstract
AIM This scoping review aims to provide an overview of patients and caregivers perceptions of hospital-at-home (HaH) services. BACKGROUND HaH services provide patients with hospital-level care at home and are central to integrated healthcare systems. Despite favourable data from individual studies in the literature, in-depth analysis from patient and caregivers perspectives is lacking. This understanding is essential for the dissemination and scaling of HaH services. DESIGN The scoping review was performed using the PRISMA-ScR checklist and PAGER framework for the findings report and research recommendations. METHOD Literature from PubMed, Web of Science, Ovid, CINAHL, Cochrane and Mednar databases were searched. Relevant studies published between 1st January 2005 and 31st December 2022 were identified. The conceptual model of the development of patient perceptions of quality was used for data extraction and tabulation. RESULTS The review included 24 articles. Expectation attributions were identified as needs, types of service, hospitalisation experiences, family care preferences, social-demographics and coping skills. From patient's and caregiver's perspectives, HaH was safe, effective and viewed positively. Perceived concerns/barriers and enablers/facilitators were associated with individual, caregiver and system factors, but demonstrated an overall satisfaction in the HaH service. CONCLUSION HaH provides an excellent service according to patients' and caregivers' perceptions. However, gaps in care were identified such as prioritising patient-centred care, along with improved multidisciplinary continuity of care and future studies should incorporate these into their research of HaH. RELEVANCE TO CLINICAL PRACTICE Patients' and caregivers' HaH needs should be embedded in the design, development and implementation of HaH services. PATIENT AND PUBLIC CONTRIBUTION Not applicable for the study design of this scoping review.
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Affiliation(s)
- Xiyi Wang
- School of Nursing, Shanghai Jiao Tong University, Shanghai, China
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Carolyne Stewart
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Geraldine Lee
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
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Schubert CC, Penney LS, Schwartzkopf AL, Damush TM, Preddie A, Flemming S, Myers J, Myers LJ, Perkins AJ, Zhang Y, Bravata DM. Expanding Access to Comprehensive Geriatric Evaluation via Telehealth: Development of Hybrid-Virtual Home Visits. J Gen Intern Med 2024; 39:36-43. [PMID: 38227169 PMCID: PMC10937878 DOI: 10.1007/s11606-023-08460-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 10/06/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND In response to the aging population, the Department of Veterans Affairs (VA) seeks to expand access to evidence-based practices which support community-dwelling older persons such as the Geriatric Resources for Assessment and Care of Elders (GRACE) program. GRACE is a multidisciplinary care model which provides home-based geriatric evaluation and management for older Veterans residing within a 20-mile drive radius from the hospital. We sought to expand the geographic reach of VA-GRACE by developing a hybrid-virtual home visit (TeleGRACE). OBJECTIVES The objectives were to: (1) describe challenges encountered and solutions implemented during the iterative, pre-implementation program development process; and (2) illustrate potential successes of the program with two case examples. DESIGN Quality improvement project with longitudinal qualitative data collection. PROGRAM DESCRIPTION The hybrid-virtual home visit involved a telehealth technician travelling to patients' homes and connecting virtually to VA-GRACE team members who participated remotely. APPROACH & PARTICIPANTS We collected multiple data streams throughout program development: TeleGRACE staff periodic reflections, fieldnotes, and team meeting notes; and VA-GRACE team member interviews. KEY RESULTS The five program domains that required attention and problem-solving were: telehealth connectivity and equipment, virtual physical examination, protocols and procedures, staff training, and team integration. For each domain, we describe several challenges and solutions. An example from the virtual physical examination domain: several iterations were required to identify the combination of telehealth stethoscope with dedicated headphones that allowed remote nurse practitioners to hear heart and lung sounds. The two cases illustrate how this hybrid-virtual home visit model provided care for patients who would not otherwise have received timely healthcare services. CONCLUSIONS These results provide a blueprint to translate an in-person home-based geriatrics program into a hybrid-virtual model and support the feasibility of using hybrid-virtual home visits to expand access to comprehensive geriatric evaluation and ongoing care for high-risk, community-dwelling older persons who reside geographically distant from the primary VA facility.
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Affiliation(s)
- Cathy C Schubert
- Geriatrics and Community Service, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lauren S Penney
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Ashley L Schwartzkopf
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Teresa M Damush
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - Alaina Preddie
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Soyna Flemming
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Jennifer Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Laura J Myers
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Anthony J Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ying Zhang
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dawn M Bravata
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.
- VA HSR&D Center for Health Information and Communication (CHIC), Indianapolis, IN, USA.
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.
- Regenstrief Institute, Indianapolis, IN, USA.
- Department of Biostatistics, Indiana University School of Medicine, IUPUI, Indianapolis, IN, USA.
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Shadbolt E, Paulson M, Divine LT, Ellis J, Myers L, Mucks K, Boustani M, Dumic I, Maniaci M, Lindroth H. Increasing Hospital at Home Enrollment Through Decentralization With Agile Science. J Healthc Qual 2024; 46:40-50. [PMID: 38147580 PMCID: PMC10758351 DOI: 10.1097/jhq.0000000000000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
LEVEL OF EVIDENCE 4, Descriptive quality improvement project.
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Elsener M, Santana Felipes RC, Sege J, Harmon P, Jafri FN. Telehealth-based transitional care management programme to improve access to care. BMJ Open Qual 2023; 12:e002495. [PMID: 37940335 PMCID: PMC10632879 DOI: 10.1136/bmjoq-2023-002495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/26/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND The transition from hospital to home is a vulnerable time for patients and families that can be improved through care coordination and structured discharge planning. LOCAL PROBLEM Our organisation aimed to develop and expand a programme that could improve 30-day readmission rates on overall and disease-specific populations by assessing the impact of a telehealth outreach by a registered nurse (RN) after discharge from an acute care setting on 30-day hospital readmission. METHODS This is a prospective observational design conducted from May 2021 to December 2022 with an urban, non-academic, acute care hospital in Westchester County, New York. Outcomes for patients discharged home following inpatient hospitalisation were analysed within this study. We analysed overall and disease-specific populations (congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and pneumonia (PNA)) as compared with a 40-month prestudy cohort. INTERVENTIONS Patients were identified in a non-random fashion meeting criterion of being discharged home after an inpatient admission. Participants received a telephonic outreach by an RN within 72 hours of discharge. Contacted patients were asked questions addressing discharge instructions, medication access, follow-up appointments and social needs. Patients were offered services and resources based on their individual needs in response to the survey. RESULTS 68.2% of the 24 808 patients were contacted to assess and offer services. Median readmission rates for these patients were 1.2% less than the prestudy cohort (11.0% to 9.8%). Decreases were also noted for disease-specific conditions (CHF (14.3% to 9.1%), COPD (20.0% to 13.4%) and PNA (14.9% to 14.0%)). Among those in the study period, those that were contacted between 24 and 48 hours after discharge were 1.2 times less likely to be readmitted than if unable to be contacted (254/3742 (6.8%) vs 647/7866 (8.2%); p=0.005). CONCLUSIONS Using a multifaceted telehealth approach to improve patient engagement and access reduced 30-day hospital readmission for patients discharged from the acute care setting.
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Affiliation(s)
- Michelle Elsener
- Transitional Care, White Plains Hospital, White Plains, New York, USA
| | | | - Jonathan Sege
- Transitional Care, White Plains Hospital, White Plains, New York, USA
| | - Priscilla Harmon
- Transitional Care, White Plains Hospital, White Plains, New York, USA
| | - Farrukh N Jafri
- Emergency Department, White Plains Hospital, White Plains, New York, USA
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Yadav RR, Mahyoub MA, Capriotti MW, Berio-Dorta RL, Dougherty K, Shukla A. The Impact of a Hybrid Hospital at Home Program in Reducing Subacute Rehabilitation. Risk Manag Healthc Policy 2023; 16:2223-2235. [PMID: 37927908 PMCID: PMC10625393 DOI: 10.2147/rmhp.s419862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
Purpose The purpose of this study was to compare health outcomes for patients receiving acute care in their homes through a Hospital at Home (HaH) program to outcomes for inpatients in the traditional hospital setting. Patients and Methods We compared outcomes for patients in a HaH program at Virtua Health in 2022 (N = 271) to traditional inpatients during the same year (N = 13,776) with the same diagnoses. We defined outcomes as recommendations for subacute rehabilitation (SAR) upon discharge as this recommendation indicates the need for additional therapy based on a physician's assessment of the patient. Specifically, we searched notes in the electronic medical records for terms related to recommendation for SAR using text mining algorithms and a natural language processing (NLP) model to confirm these recommendations. We then compared the proportion of patients within each group that had a SAR recommendation, and controlled for differences in sample size, age, and diagnosis using bootstrapping analyses. Results We observed that the proportion of patients in the HaH program that were recommended for SAR (0.148) was significantly different from the proportion of patients who remained in the traditional hospital setting (0.363), with a reduced need for SAR for HaH patients. We obtained qualitatively similar results when we controlled for sample size and diagnosis. Controlling for age yielded an older control population, and the difference in the proportion of patients with SAR recommendations between the groups widened. Conclusion The reduced need for SAR for HaH patients in this study suggests that HaH programs are a promising alternative care model. Future work may consider how health outcomes vary for patients with different diagnoses, clinical histories and demographics, which may inform how HaH programs operate moving forward.
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Affiliation(s)
| | - Mohammed A Mahyoub
- Virtua Health, Marlton, NJ, USA
- Systems Science and Industrial Engineering Department, Binghamton University, Binghamton, NY, USA
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Felix HM, Paulson MR, Garcia JP, Dugani SB, Torres-Guzman RA, Avila FR, Maita K, Forte AJ, Maniaci MJ. Avoiding Escalation to the Emergency Department by Activating an In-Home Rapid Response Team in the 30 Days After Hospital-at-Home Discharge. J Emerg Med 2023; 64:455-463. [PMID: 37002160 PMCID: PMC10133039 DOI: 10.1016/j.jemermed.2023.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/07/2023] [Accepted: 02/17/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Mayo Clinic's virtual hybrid hospital-at-home program, Advanced Care at Home (ACH) monitors acute and post-acute patients for signs of deterioration and institutes a rapid response (RR) system if detected. OBJECTIVE This study aimed to describe Mayo Clinic's ACH RR team and its effect on emergency department (ED) use and readmission rates. METHODS This was a retrospective review of all post-inpatient (restorative phase) ACH patients admitted from July 6, 2020 through June 30, 2021. If the restorative patient had a clinical decompensation, an RR was activated. All RR activations were analyzed for patient demographic characteristics, admitting and escalation diagnosis, time spent by virtual team on the RR, and whether the RR resulted in transport to the ED or hospital readmission. RESULTS Three hundred and twenty patients were admitted to ACH during the study interval; 230 received restorative care. Seventy-two patients (31.3%) had events that triggered an RR. Fifty (69.4%) of the RR events were related to the admission diagnosis (p < 0.001; 95% CI 0.59-0.80). Twelve patients (16.7%) required transport to an ED for further treatment and were readmitted and 60 patients (83.3%) were able to be treated successfully in the home by the RR team (p < 0.001; 95% CI 0.08-0.25). CONCLUSIONS The use of an ACH RR team was effective at limiting both escalations back to an ED and hospital readmissions, as 83% of deteriorating patients were successfully stabilized and managed in their homes. Implementing a hospital-at-home RR team can reduce the need for ED use by providing critical resources and carrying out required interventions to stabilize the patient's condition.
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Affiliation(s)
- Heidi M Felix
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | - Margaret R Paulson
- Division of Hospital Internal Medicine, Mayo Clinic Health Systems, Eau Claire, Wisconsin
| | - John P Garcia
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Sagar B Dugani
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Karla Maita
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Michael J Maniaci
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, Florida
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Paulson MR, Torres-Guzman RA, Avila FR, Maita KC, Garcia JP, Forte AJ, Matcha GV, Pagan RJ, Maniaci MJ. Severity of illness and risk of mortality in Mayo Clinic's virtual hybrid advanced care at home program: a retrospective cohort study. BMC Health Serv Res 2023; 23:287. [PMID: 36973689 PMCID: PMC10041490 DOI: 10.1186/s12913-023-09333-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND In July 2020, Mayo Clinic launched Advanced Care at Home (ACH), a high-acuity virtual hybrid hospital-at-home model (HaH) of care at Mayo Clinic Florida and Northwest Wisconsin, an urban destination medical center and a rural community practice respectively. This study aims to describe demographic characteristics of ACH patients as well as their acuity of illness using severity of illness (SOI) and risk of mortality (ROM), to illustrate the complexity of patients in the program, taking into account the different diagnostic related groups. METHODS Mayo Clinic uses All Patient Refined-Diagnosis Related Groups (APR-DRG) to calculate SOI and ROM on hospitalized patients. APR-DRG data, including SOI and ROM, were gathered from individual chart reviews from July 6, 2020, to March 31, 2022. RESULTS Out of 923 patients discharged from ACH, the average APR-DRG SOI was 2.89 (SD 0.81) and ROM was 2.73. (SD 0.92). Mean age was 70.88 (SD 14.46) years, 54.6% were male patients and the average length of stay was 4.10 days. The most frequent diagnosis was COVID-19 infection with 162 patients (17.6%), followed by heart failure exacerbation (12.7%) and septicemia (10.9%). The 30-day readmission rate after discharge from ACH was 11.2% (n = 103) and the 30-day mortality rate was 1.8% (n = 17). There were no in-program patient deaths. CONCLUSIONS SOI and ROM from patients at the ACH program have been shown to be in the range of "moderate/major" according to the APR-DRG classification. The ACH program is capable of accepting and managing highly complex patients that require advanced therapeutic means. Furthermore, the ACH program has an in-program mortality rate of 0 to date. Therefore, ACH is rising as a capable alternative to the brick-and-mortar hospital.
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Affiliation(s)
- Margaret R Paulson
- Division of Hospital Internal Medicine, Mayo Clinic Health Systems, Eau Claire, WI, USA
| | | | | | - Karla C Maita
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - John P Garcia
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Gautam V Matcha
- Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Ricardo J Pagan
- Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Michael J Maniaci
- Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
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Torres-Guzman RA, Paulson MR, Avila FR, Maita K, Garcia JP, Forte AJ, Maniaci MJ. Smartphones and Threshold-Based Monitoring Methods Effectively Detect Falls Remotely: A Systematic Review. SENSORS (BASEL, SWITZERLAND) 2023; 23:1323. [PMID: 36772364 PMCID: PMC9920087 DOI: 10.3390/s23031323] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 06/18/2023]
Abstract
In the US, at least one fall occurs in at least 28.7% of community-dwelling seniors 65 and older each year. Falls had medical costs of USD 51 billion in 2015 and are projected to reach USD 100 billion by 2030. This review aims to discuss the extent of smartphone (SP) usage in fall detection and prevention across a range of care settings. A computerized search was conducted on six electronic databases to investigate the use of remote sensing technology, wireless technology, and other related MeSH terms for detecting and preventing falls. After applying inclusion and exclusion criteria, 44 studies were included. Most of the studies targeted detecting falls, two focused on detecting and preventing falls, and one only looked at preventing falls. Accelerometers were employed in all the experiments for the detection and/or prevention of falls. The most frequent course of action following a fall event was an alarm to the guardian. Numerous studies investigated in this research used accelerometer data analysis, machine learning, and data from previous falls to devise a boundary and increase detection accuracy. SP was found to have potential as a fall detection system but is not widely implemented. Technology-based applications are being developed to protect at-risk individuals from falls, with the objective of providing more effective and efficient interventions than traditional means. Successful healthcare technology implementation requires cooperation between engineers, clinicians, and administrators.
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Affiliation(s)
| | - Margaret R. Paulson
- Division of Hospital Internal Medicine, Mayo Clinic Health Systems, 1221 Whipple St., Eau Claire, WI 54703, USA
| | - Francisco R. Avila
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Karla Maita
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - John P. Garcia
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Antonio J. Forte
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Michael J. Maniaci
- Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
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Felix HM, Cowdell JC, Paulson MR, Maita KC, Dugani SB, Avila FR, Torres-Guzman RA, Forte AJ, Matcha GV, Maniaci MJ. Impact of an Acquisition Advanced Practice Provider on Home Hospital Patient Volumes and Length of Stay. Healthcare (Basel) 2023; 11:healthcare11030282. [PMID: 36766857 PMCID: PMC9914253 DOI: 10.3390/healthcare11030282] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/19/2023] Open
Abstract
In July 2020, Mayo Clinic introduced a hospital-at-home program, known as Advanced Care at Home (ACH) as an alternate option for clinically stable medical patients requiring hospital-level care. This retrospective cohort study evaluates the impact of the addition of a dedicated ACH patient acquisition Advanced Practice Provider (APP) on average length of stay (ALOS) and the number of patients admitted into the program between in Florida and Wisconsin between 6 July 2020 and 31 January 2022. Patient volumes and ALOS of 755 patients were analyzed between the two sites both before and after a dedicated acquisition APP was added to the Florida site on 1 June 2021. The addition of a dedicated acquisition APP did not affect the length of time a patient was in the emergency department or hospital ward prior to ACH transition (2.91 days [Florida] vs. 2.59 days [Wisconsin], p = 0.22), the transition time between initiation of the ACH consult to patient transfer home (0.85 days [Florida] vs. 1.16 days [Wisconsin], p = 0.28), or the total ALOS (6.63 days [Florida] vs. 6.34 days [Wisconsin], p = 0.47). The average number of patients acquired monthly was significantly increased in Florida (38.3 patients per month) compared with Wisconsin (21.6 patients per month) (p < 0.01). The addition of a dedicated patient acquisition APP resulted in significantly higher patient volumes but did not affect transition time or ALOS. Other hospital-at-home programs may consider the addition of an acquisition APP to maximize patient volumes.
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Affiliation(s)
- Heidi M. Felix
- Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Jed C. Cowdell
- Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Margaret R. Paulson
- Division of Hospital Internal Medicine, Mayo Clinic Health Systems, 1221 Whipple St, Eau Claire, WI 54701, USA
| | - Karla C. Maita
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Sagar B. Dugani
- Division of Hospital Internal Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Francisco R. Avila
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | | | - Antonio J. Forte
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Gautam V. Matcha
- Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Michael J. Maniaci
- Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
- Correspondence: ; Tel.: +904-956-0081; Fax: +904-953-2848
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11
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Paulson MR, Torres‐Guzman RA, Matcha GV, Avila FR, Maita KC, Garcia JP, Forte AJ, Maniaci MJ. Treatment of a high healthcare utilizer with sepsis in a virtual hybrid hospital-at-home program. Clin Case Rep 2023; 11:e6806. [PMID: 36619489 PMCID: PMC9811058 DOI: 10.1002/ccr3.6806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/16/2022] [Accepted: 12/17/2022] [Indexed: 01/05/2023] Open
Abstract
High healthcare utilizers are often chronically ill patients who require aggressive hospital and outpatient care. We describe a patient with septic shock who was stabilized in the intensive care unit, then transitioned to a virtual hybrid hospital-at-home to complete both inpatient care as well as outpatient wound and rehabilitation therapy.
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Affiliation(s)
- Margaret R. Paulson
- Division of Hospital Internal MedicineMayo Clinic Health Systems, Eau ClaireMenomonieWisconsinUSA
| | | | - Gautam V. Matcha
- Division of Hospital Internal MedicineMayo Clinic, Jacksonville, FloridaJacksonvilleFloridaUSA
| | - Francisco R. Avila
- Division of Plastic SurgeryMayo Clinic, Jacksonville, FloridaJacksonvilleFloridaUSA
| | - Karla C. Maita
- Division of Plastic SurgeryMayo Clinic, Jacksonville, FloridaJacksonvilleFloridaUSA
| | - John P. Garcia
- Division of Plastic SurgeryMayo Clinic, Jacksonville, FloridaJacksonvilleFloridaUSA
| | - Antonio J. Forte
- Division of Plastic SurgeryMayo Clinic, Jacksonville, FloridaJacksonvilleFloridaUSA
| | - Michael J. Maniaci
- Division of Hospital Internal MedicineMayo Clinic, Jacksonville, FloridaJacksonvilleFloridaUSA
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12
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Maniaci MJ, Cowdell JC, Maita K, Avila FR, Dugani SB, Torres-Guzman RA, Garcia JP, Forte AJ, Paulson MR. Diagnosis Related Groups of Patients Admitted from an Urban Academic Medical Center to a Virtual Hybrid Hospital-at-Home Program. Risk Manag Healthc Policy 2023; 16:759-768. [PMID: 37113313 PMCID: PMC10128872 DOI: 10.2147/rmhp.s402355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/20/2023] [Indexed: 04/29/2023] Open
Abstract
Background The diagnosis related group (DRG) is used as an economic patient classification system based on clinical characteristics, hospital stay, and treatment costs. Mayo Clinic's virtual hybrid hospital-at-home program, advanced care at home (ACH), offers high-acuity home inpatient care for a variety of diagnosis. This study aimed to determine the DRGs admitted to the ACH program at an urban academic center. Methods A retrospective study was performed on all patients discharged from the ACH program at Mayo Clinic Florida from July 6, 2020, to February 1, 2022. DRG data were extracted from the Electronic Health Record (EHR). Categorization of DRG was done by systems. Results The ACH program discharged 451 patients with DRGs. Categorization of the DRG demonstrated that the most frequent code assigned corresponded to respiratory infections (20.2%), followed by septicemia (12.9%), heart failure (8.9%), renal failure (4.9%), and cellulitis (4.0%). Conclusion The ACH program covers a wide range of high-acuity diagnosis across multiple medical specialties at its urban academic medical campus, including respiratory infections, severe sepsis, congestive heart failure, and renal failure, all with major complications or comorbidities. The ACH model of care may be useful in taking care of patients with similar diagnosis at other urban academic medical institutions.
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Affiliation(s)
- Michael J Maniaci
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
- Correspondence: Michael J Maniaci, Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA, Tel +1 904-956-0081, Fax +1 904-953-2848, Email
| | - J Colt Cowdell
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Karla Maita
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Sagar B Dugani
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - John P Garcia
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Margaret R Paulson
- Division of Hospital Internal Medicine, Mayo Clinic Health Systems, Eau Claire, WI, USA
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13
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Paulson MR, Eldaly AS, Avila FR, Torres-Guzman RA, Maita KC, Garcia JP, Serrano LP, Emam OS, Forte AJ, Maniaci MJ. Small Bowel Obstruction Conservatively Managed in Hospital-At-Home. Case Rep Gastrointest Med 2022; 2022:1969040. [PMID: 36398066 PMCID: PMC9666016 DOI: 10.1155/2022/1969040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/24/2022] [Accepted: 11/02/2022] [Indexed: 01/21/2024] Open
Abstract
In 2020, Mayo Clinic established an Advanced Care at Home (ACH) program. ACH is a virtual hybrid hospital-at-home (HaH) program that combines telemedicine with in-home care services by utilizing a state that is software-driven, vendor-mediate medical supply chain. The program initially focused on acute medical diagnosis but has expanded to oversee surgical and postsurgical patients with continued inpatient needs. Here, we report the first case of a small bowel obstruction (SBO) managed under a HaH program. A 52-year-old lady presented to the emergency department with symptoms suggestive of mechanical SBO. The diagnosis was confirmed with an abdominopelvic computed tomography (CT) scan, and the patient was admitted to the hospital. Based on the patient's presentation and laboratory results, the care team proceeded with conservative treatment including nasogastric tube (NG) placement and suctioning, intravenous (IV) fluid replacement, and daily laboratory studies. She spent the first hospital day in the physical hospital ward so that the surgical team could ensure stability clinically and no urgent need for surgical intervention. On hospital day two, she was transferred home with ACH where the NG suctioning and IV replacement therapy could continue, while the medical team conducted daily virtual visits to ensure continued improvement. Additionally, a paramedic and a nurse performed an in-person, head-to-toe assessment and administered medications to the patient twice daily. She spent 5 days in ACH getting acute care and then was discharged into a postacute phase equivalent to outpatient monitoring called the restorative phase. She was monitored remotely for the duration of the restorative phase for 10 more days, and then she recovered fully. This case highlights that high-acuity patients with SBO can receive invasive treatments like NG tube suction as well as be appropriately monitored for clinical decompensation by a virtual hybrid home hospital program which combines virtual care providers with an in-home vendor-mediated supply chain.
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Affiliation(s)
- Margaret R. Paulson
- Division of Hospital Internal Medicine, Mayo Clinic Health Systems, Eau Claire, Wisconsin 2321 Stout Road, Menomonie, Wisconsin 54751, USA
| | - Abdullah S. Eldaly
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, Florida 32224, USA
| | - Francisco R. Avila
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, Florida 32224, USA
| | | | - Karla C. Maita
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, Florida 32224, USA
| | - John P. Garcia
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, Florida 32224, USA
| | - Luiza Palmieri Serrano
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, Florida 32224, USA
| | - Omar S. Emam
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, Florida 32224, USA
| | - Antonio J. Forte
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, Florida 32224, USA
| | - Michael J. Maniaci
- Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, Florida 32224, USA
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Paulson MR, Torres‐Guzman RA, Avila FR, Maita K, Forte AJ, Butera JE, Maniaci MJ. Telemedicine allows for effective communication between a medically complex cancer patient and his virtual hospital medical team. Clin Case Rep 2022; 10:e6456. [PMID: 36245470 PMCID: PMC9552987 DOI: 10.1002/ccr3.6456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/30/2022] [Indexed: 11/09/2022] Open
Abstract
Good physician-patient communication is key for effective hospital care. We describe a patient diagnosed with an acute pulmonary embolism and bacteremia who was treated in a virtual hybrid hospital-at-home program. Constant communication with the virtual and in-home healthcare teams enabled a unified knowledge of the patient's wishes.
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Affiliation(s)
- Margaret R. Paulson
- Division of Hospital Internal MedicineMayo Clinic Health SystemsEau ClaireWisconsinUSA
| | | | | | - Karla C. Maita
- Division of Plastic SurgeryMayo ClinicJacksonvilleFloridaUSA
| | | | - Julie E. Butera
- Division of Hospital Internal MedicineMayo Clinic Health SystemsEau ClaireWisconsinUSA
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Colectomy Complicated by High-Output Ileostomy Managed in a Virtual Hybrid Hospital-at-Home Program. Case Rep Surg 2022; 2022:3177934. [PMID: 36213589 PMCID: PMC9537035 DOI: 10.1155/2022/3177934] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/21/2022] [Indexed: 11/30/2022] Open
Abstract
Chronically ill patients with superimposed acute illness requiring hospitalization are more likely to develop an extended length of stay, hospital-acquired infections, and adverse events throughout their hospitalization. An excellent alternative to managing this population of patients in the traditional bricks-and-mortal (BAM) hospital is the hospital-at-home (HaH) model. The Advanced Care at Home (ACH) program is Mayo Clinic's HaH model that provides acute and postacute care to high-acuity patients in their homes rather than in the traditional hospital and skilled nursing facility. We report a case of postoperative care through the ACH program of a patient suffering from short gut syndrome, high-output ileostomy, and severe protein-calorie malnutrition in the setting of previously diagnosed triple-negative invasive ductal carcinoma (IDC) of the right breast complicated by lung and brain metastasis. The patient had multiple complications that required repeated scare escalations directed by a multidisciplinary virtual care. Despite these complications, the ACH model of care was able to keep the patient in the home setting the majority of the time, limiting BAM hospital days, and eliminating the need to use the emergency department for acute escalation for 3 months. The patient was able to recover during this time period and proceed to successful take-down of the ileostomy. This case highlights the benefits of the ACH program by offering high-acuity hospital-level care to severely ill patients in the comfort of their homes. Highly qualified providers paired with curated technology in the home allowed for prompt identification of patient decompensation and timely initiation of treatment while avoiding institutionalization.
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