Acute Care @ Home

Advanced Care at Home Cheat Sheet

Eligibility criteria: - Meets criteria for inpatient hospital-level care - Lives within 30-minutes of UNC Medical Center, UNC Hillsborough, Rex, or Rex Holly Springs - Located in UNC Medical Center or Rex ED or inpatient unit (we hope to add Hillsborough soon) - Has Medicare, Medicare Advantage (Humana, United, Aetna, Alignment), BCBS NC, Medicaid or all Managed Medicaid plans, or Self-Pay - Does not require telemetry or stepdown/ICU level of care - Has a supportive home environment such that can take care of basic needs in-between visits (patient either strong enough or has family/aide support – we can sometimes arrange some aide coverage to fill gaps) - No specific diagnosis eligibility criteria, but common diagnoses that fit well include CHF exacerbation, COPD exacerbation, COVID infection, infections requiring IV antibiotics (PNA, UTI, cellulitis, bacteremia) Common exclusions: - SNF resident (ALF residents can be considered on case-by-case basis if their ALF is agreeable) - Substance abuse or heavy alcohol use - Unsafe or unstable home environment - Requiring frequent IV prn medications - No longer requires hospital-level care What patients receive: - At least twice daily home visits by community paramedic or RN (can be more often if required by care needs such as more frequent IV antibiotic dosing) - Multiple virtual touchpoints with Mission Control RN through the day - At least daily virtual visits with a physician or APP In-home services that can be provided in the program: - IV antibiotics, IV Remdesivir, IV steroids, IV diuretics - Lab work - ECGs, xrays, venous dopplers - PICC lines - Oxygen, foley catheter placement - PT/OT/SLP - Home health aide - Wound care - Virtual and e-consults from some sub-specialties - Patients requiring other diagnostics, procedures, dialysis, or blood transfusions can be brought to the hospital and return home once the study or procedure is complete

Hospitalist role in Advanced Care at Home admissions in the ED:

CMS requires that patients being admitted to a “hospital-at-home” program from the emergency department get an in-person assessment from a provider who otherwise would have admitted that patient to the hospital. The admitting hospitalist may be contacted by the MAO to do this in-person assessment.

Key points about this assessment: - This should not be a full H&P (the patient will get a full H&P with a home medication reconciliation from the virtual hospitalist once they arrive home) - This is most useful if you can: - Make sure the diagnostic impression of the ED / virtual hospitalist align with your impression - Make sure nothing was missed that would make receiving care at home problematic - Document a good physical exam, focusing on cardiac, pulmonary, and volume status - Talk to the virtual hospitalist about your impressions (either by secure chat or by phone) - Document BRIEFLY using the template .ACHHPQUICK

Hospitalist role in Advanced Care at Home transfer back to brick & mortar hospital Some patients will need to be transferred from Advanced Care at Home to a brick & mortar unit. This could be by patient request (the program is voluntary) or could be because the patient’s needs exceed what can be provided at home. - We will coordinate with the MAO when this happens. They will consider both the Medical Center and Hillsborough. - If a bed of the appropriate type is available, the MAO will assign a team to receive the patient. In this scenario, it is considered a transfer and can be treated as any other transfer between units/teams. - If an appropriate bed cannot be arranged quickly enough for the needs of the patient or if the patient needs a rapid assessment/stabilization, the patient will be brought to the emergency department. In this situation, the patient will be discharged from Advanced Care at Home and would be an admission if called to an inpatient team. - At times, patients return to the hospital as a “day trip” for dialysis, transfusions, or other assessments. During this time, the cross-covering hospitalist (often the provider carrying the Hospitalist-New Admit pager) will be added to the treatment team in the event an on-site urgent need arises. There is not a requirement to assess the patient by the cross-covering hospitalist, and the ACH provider will communicate with the DHM provider if any touchpoint with the patient is required (ex. Rapid response, nursing concern, patient prefers to remain) Need more info? See the abbreviated PowerPoint presentation.