Multi-Year Evaluation of VA San Diego’s Hospital in Home (HiH) Program

There are few studies describing outpatient parenteral antimicrobial therapy (OPAT) for cellulitis treatment. The Hospital in Home (HIH) program is a multidisciplinary team at the Cincinnati VA Medical Center (CVAMC) that provides acute care in patients’ homes similar to inpatient hospital care for a variety of indications, including cellulitis. Efficacy of OPAT for cellulitis treatment in the HIH program has not been directly compared with inpatient treatment. The primary objective of this retrospective review is to compare the rates of efficacy of intravenous (IV) antibiotics for cellulitis treatment for patients followed by HIH and inpatient settings. Treatment failure was defined as a change in IV antibiotic medications prescribed. A retrospective chart review was completed at CVAMC for patients enrolled in HIH ( n = 111) and patients who received inpatient treatment at CVAMC ( n = 111) with IV antibiotics for a primary diagnosis of cellulitis from January 1, 2014, through June 30, 2018. Six patients in the HIH group experienced IV antibiotic treatment failure compared with 11 in the inpatient group. The HIH group showed non-inferiority in rates of treatment failure compared with the inpatient group ( p = .21). OPAT with the HIH program appears to be non-inferior to inpatient IV antibiotic treatment for cellulitis infections. Tolerance issues and rates of adverse events do not appear to be worse in patients treated with OPAT in the Veteran population.

Hospital In Home: An Alternative Model of Care to Decrease Heart Failure Readmissions

The complex nature of spinal cord injury (SCI) and the level of care required for health maintenance frequently result in repeated hospital admissions for recurrent medical complications. Prolonged hospitalizations of persons with SCI have been linked to the increased risk of hospital-acquired infections and development or worsening pressure ulcers. An evidence-based alternative for providing hospital-level care to patients with specific diagnoses who are willing to receive that level of care in the comfort of their home is being implemented in a Department of Veterans Affairs SCI Home Care Program. The SCI Hospital in Home (HiH) model is similar to a patient-centered interdisciplinary care model that was first introduced in Europe and later tested as part of a National Demonstration and Evaluation Study through Johns Hopkins School of Medicine and School of Public Health. This was funded by the John A. Hartford Foundation and the Department of Veterans Affairs. The objectives of the program are to support veterans' choice and access to patient-centered care, reduce the reliance on inpatient medical care, allow for early discharge, and decrease medical costs. Veterans with SCI who are admitted to the HiH program receive daily oversight by a physician, daily visits by a registered nurse, access to laboratory services, oxygen, intravenous medications, and nursing care in the home setting. In this model, patients may typically access HiH services either as an "early discharge" from the hospital or as a direct admit to the program from the emergency department or SCI clinic. Similar programs providing acute hospital-equivalent care in the home have been previously implemented and are successfully demonstrating decreased length of stay, improved patient access, and increased patient satisfaction.

New Centers for Medicare & Medicaid Services waivers created a payment mechanism for hospital at home services. Although it is well established that direct admission to hospital at home from the community as a substitute for hospital care provides superior outcomes and lower cost, the effectiveness of transfer hospital at home-that is, completing hospitalization at home-is unclear. To evaluate the outcomes of the transfer component of a Veterans Affairs (VA) Hospital in Home program (T-HIH), taking advantage of natural geographical limitations in a program's service area. In this quality improvement study, T-HIH was offered to veterans residing in Philadelphia, Pennsylvania, and their outcomes were compared with those of propensity-matched veterans residing in adjacent Camden, New Jersey, who were admitted to the VA hospital from 2012 to 2018. Data analysis was performed from October 2019 to May 2020. Enrollment in the T-HIH program. The main outcomes were hospital length of stay, 30-day and 90-day readmissions, VA direct costs, combined VA and Medicare costs, mortality, 90-day nursing home use, and days at home after hospital discharge. An intent-to-treat analysis of cost and utilization was performed. A total of 405 veterans (mean [SD] age, 66.7 [0.83] years; 399 men [98.5%]) with medically complex conditions, primarily congestive heart failure and chronic obstructive pulmonary disease exacerbations (mean [SD] hierarchical condition categories score, 3.54 [0.16]), were enrolled. Ten participants could not be matched, so analyses were performed for 395 veterans (all of whom were men), 98 in the T-HIH group and 297 in the control group. For patients in the T-HIH group compared with the control group, length of stay was 20% lower (6.1 vs 7.7 days; difference, 1.6 days; 95% CI, -3.77 to 0.61 days), VA costs were 20% lower (-$5910; 95% CI, -$13 049 to $1229), combined VA and Medicare costs were 22% lower (-$7002; 95% CI, -$14 314 to $309), readmission rates were similar (23.7% vs 23.0%), the numbers of nursing home days were significantly fewer (0.92 vs 7.45 days; difference, -6.5 days; 95% CI, -12.1 to -0.96 days; P = .02), and the number of days at home was 18% higher (81.4 vs 68.8 days; difference, 12.6 days; 95% CI, 3.12 to 22.08 days; P = .01). In this study, T-HIH was significantly associated with increased days at home and less nursing home use but was not associated with increased health care system costs.

The Hospital-in-Home (HIH) model provides patient centered care, may reduce complications and costs. VA Boston Healthcare System (VABHS) planned its HIH program in 2018 and enrolled its first patient in May 2019. HIH provided care to 45 patients in 2019 which grew to 185 in 2022. The team is comprised of 2 clinicians (a hospitalist physician and a physician assistant), a nurse manager, 5 registered nurses (RN), a social worker and a pharmacist. The program practices complementary HIH (admissions from inpatient care) and substitutive care (all other admissions). At this time, majority of the recruitment comes from the inpatient services, followed by heart failure and primary care clinics. The program catchment area is about 25 miles from the West Roxbury campus of VABHS. A hybrid visit approach is taken for clinician visits - initially, the veteran is seen in person or by video by the clinician on admission to the program. Subsequent visits are done with RN assessments in the home and the clinician conducting the visit by telephone or video. In FY 2021, conditions of patients treated by HIH include congestive heart failure (50%), chronic obstructive pulmonary disease (14%), wound care (6%), diabetes (2%) and other conditions (20%). In FY 2022, the average daily census was 15.9 veterans and average visits per day 4.8. The HIH program outcomes include reduction of bed days of acute care in the hospital and reduction in the use of unnecessary medications through deprescribing which may translate to cost avoidance for the medical center.

Background and objectivesThe Department of Veterans Affairs (VA) Hospital-In-Home (HIH) program delivers patient-centered, acute-level hospital care at home. Compared to inpatient care, HIH has demonstrated improved patient safety, effectiveness, and patient and caregiver satisfaction. The VA Office of Geriatrics & Extended Care (GEC) has supported the development of 12 HIH program sites nationally, yet adoption in VA remains modest, and questions remain regarding optimal implementation practices to extend reach and adaptability of this innovation. Guided by theoretical and procedural implementation science frameworks, this study aims to systematically gather evidence from the 12 HIH programs and to develop a participatory approach to engage stakeholders, assess readiness, and develop/adapt implementation strategies and evaluation metrics.Research design and methodsWe propose a multi-phase concurrent triangulation design comprising of (1) qualitative interviews with key informants and document review, (2) quantitative evaluation of effectiveness outcomes, and (3) mixed-methods synthesis and adaptation of a Reach Effectiveness Adoption Implementation Maintenance (RE-AIM)-guided conceptual framework.ResultsThe prospective phase will involve a participatory process of identifying stakeholders (leadership, HIH staff, veterans, and caregivers), engaging in planning meetings informed by implementation mapping, and developing implementation logic models and blueprints. The process will be assessed using a mixed-methods approach through participant observation and document review.Discussion and implicationThis study will support the continued spread of HIH programs, generate a catalog of HIH implementation evidence, and create implementation tools and infrastructure for future HIH development. The multi-phase nature of informing prospective planning with retrospective analysis is consistent with the Learning Health System framework.

The Department of Veterans Affairs (VA) Hospital-In-Home (HIH) program delivers patient-centered, acute-level hospital care at home within a single-payer integrated health-care system. Compared to inpatient care, HIH has demonstrated improved patient safety, effectiveness, and patient and caregiver satisfaction. As of 2022, there were eleven HIH sites across the VA, evidence of modest adoption. This symposium presents findings from the first year of a 4-year project that aims to conduct an in-depth inquiry in to the most effective ways to implement, adapt and sustain HIH across the VA. We will present an overview of the VA HIH program, describe one HIH program in-depth, present a birds-eye-view of the national program, present comparisons of sites’ implementations in terms of structure, patient characteristics and outcomes, and conclude with an implementation-science framework to examine program adoption, adaptations, successes and challenges. National leadership will provide perspectives on management, planning and policy of Hospital-In-Home.

Self-administered outpatient parenteral antimicrobial therapy (S-OPAT) for infective endocarditis: A safe and effective model

Heart Failure Nurse Navigator Program Interventions Based on LACE Scores Reduces Inpatient Heart Failure Readmission Rates

Introduction: Noncardiac organ failure is a frequent complication in non–acute myocardial infarction (non-AMI) cardiogenic shock (CS), which accounts for a substantial proportion of CS hospitalizations. Although overall outcomes in non-AMI CS have improved, the effect of noncardiac organ failure on post-discharge outcomes remains understudied. Methods: Using the Nationwide Readmissions Database (2016–2021) we included non-AMI CS index hospitalizations among patients ≥ 18 years. Index hospitalizations were defined as patients discharged alive and prior to December of that year. After identifying acute kidney injury (AKI), acute neurological failure, acute hematologic failure, acute respiratory failure (ARF), and acute liver failure (ALF) during the index hospitalization, admissions were stratified into: no organ failure, single-system organ failure (OF), and multi-system OF (≥2 systems). Primary outcomes were 30-day all-cause and heart failure (HF) readmission rates. Logistic regression was used to assess the association between OF and all-cause readmissions. Results: We identified 170,247 index non-AMI CS hospitalizations. The median age was 66 years (IQR 56–75); 63% were male, and 69% had chronic heart failure. AKI (59.96%) was the most common organ failure, followed by ARF (50.96%) (Fig 1A). In total, 48.22% developed multi-system OF, 35.96% had single-system OF, and 15.82% had no organ failure. The overall 30-day all-cause and heart failure readmission rates were 18% and 4.9%, respectively. AKI was associated with the highest all-cause (19.85%) and HF (5.89%) readmission rates, followed by ALF (19.04% and 5.18%, respectively) (Fig 1B). All-cause readmissions were highest in patients with multi-system OF (18.75%) compared to those with no organ failure (15.64%) (p < 0.001), while HF readmissions were highest in single-system OF (5.27%) (p < 0.001) (Fig 1C). After adjustment, both multi-system OF (aOR 1.11; 95% CI 1.04–1.18) and multi-system OF (aOR 1.09; 95% CI 1.02–1.15) were independently associated with increased odds of all-cause readmissions (Table 1). Conclusion: Noncardiac organ failure during index non-AMI CS hospitalizations is linked to higher 30-day all-cause and HF readmission rates, with AKI showing the highest readmission rates. Both single and multi-system organ failure were independent predictors of all-cause readmissions, underscoring the importance of early post-discharge follow-up and multidisciplinary care planning for these high-risk patients.

The relationship between the Charlson comorbidity index (CCI) and short-term readmission is as yet unknown. Therefore, we aimed to investigate whether the CCI was independently related to short-term readmission in patients with heart failure (HF) after adjusting for other covariates. From December 2016 to June 2019, 2008 patients who underwent HF were enrolled in the study to determine the relationship between CCI and short-term readmission. Patients with HF were divided into 2 categories based on the predefined CCI (low < 3 and high > =3). The relationships between CCI and short-term readmission were analyzed in multivariable logistic regression models and a 2-piece linear regression model. In the high CCI group, the risk of short-term readmission was higher than that in the low CCI group. A curvilinear association was found between CCI and short-term readmission, with a saturation effect predicted at 2.97. In patients with HF who had CCI scores above 2.97, the risk of short-term readmission increased significantly (OR, 2.66; 95% confidence interval, 1.566-4.537). A high CCI was associated with increased short-term readmission in patients with HF, indicating that the CCI could be useful in estimating the readmission rate and has significant predictive value for clinical outcomes in patients with HF.

The purpose of this quality improvement project was to evaluate the impact of a nurse discharge navigator on reducing 30-day readmissions for the heart failure and sepsis populations. The 238-bed community hospital in central Virginia is part of a health care system that encompasses 13 acute care facilities. The aim of this project was to identify, implement, and evaluate the transition of care of high-risk readmission patients from January 2019 to April 2019. Inclusion criteria included patients who were 55 years and older, English speaking, diagnosed with heart failure and/or sepsis, discharged to home with or without home health, and/or consults received from case management and social services. Forty-one potential participants were identified with 28 consented. Readmission data were collected pre- and postintervention. The pre-/postanalysis consisted of descriptive statistics, readmission rates, and cost avoidance. Out of the 28 participants, 7 participants were readmitted within 30 days. The heart failure readmission rates during the project implementation were as follows: January 24.05%, February 20%, March 19.75%, and April 11.11%. After the project completion the readmission rates were 22.97% for May and 26.03% for June, respectively. The potential cost avoidance with sustained gain from the project is $405,316.00. This project demonstrated that a discharge navigator had an effect on 30-day readmissions for high-risk heart failure and sepsis populations, as evident by a steady decline in overall heart failure readmission rate during project implementation. The sepsis population needs further research. The discharge navigator project added to the body of knowledge for comprehensive discharge planning, coordination, and education that is needed for these types of patient populations that have a great deal of medical complexity.

To evaluate community-specific nursing home performance with community-specific hospital 30-day readmissions for Medicare patients discharged with acute myocardial infarction, heart failure or pneumonia. Cross-sectional study using 2009-2012 hospital risk-standardised 30-day readmission data for Medicare fee-for-service patients hospitalised for all three conditions and nursing home performance data from the Centers for Medicare & Medicaid Services Five-Star Quality Rating System. Medicare-certified nursing homes and acute care hospitals. 12,542 nursing homes and 3,039 hospitals treating 30 or more Medicare fee-for-service patients for all three conditions across 2,032 hospital service areas in the United States. Community-specific hospital 30-day risk-standardised readmission rates. Community-specific nursing home performance measures: health inspection, staffing, Registered Nurses and quality performance; and an aggregated performance score. Mixed-effects models evaluated associations between nursing home performance and hospital 30-day risk-standardised readmission rates for all three conditions. The relationship between community-specific hospital risk-standardised readmission rates and community-specific overall nursing home performance was statistically significant for all three conditions. Increasing nursing home performance by one star resulted in decreases of 0.29% point (95% CI: 0.12-0.47), 0.78% point (95% CI: 0.60-0.95) and 0.46% point (95% CI: 0.33-0.59) of risk-standardised readmission rates for AMI, HF and pneumonia, respectively. Among the specific measures, higher performance in nursing home overall staffing and Registered Nurse staffing measures was statistically significantly associated with lower hospital readmission rates for all three conditions. Notable geographic variation in the community-specific nursing home performance was observed. Community-specific nursing home performance is associated with community-specific hospital 30-day readmission rates for Medicare fee-for-service patients for acute myocardial infarction, heart failure or pneumonia. Coordinated care between hospitals and nursing homes is essential to reduce readmissions. Nursing homes can improve performance and reduce readmissions by increasing registered nursing homes. Further, communities can work together to create cross-continuum care teams comprised of hospitals, nursing homes, patients and their families, and other community-based service providers to reduce unplanned readmissions.

Introduction: Heart failure (HF) is associated with significant mortality and hospital readmissions. High quality health care is associated with improved outcomes in HF patients. A widely used metric to assess the quality of health care provided by hospitals is patient satisfaction. However, the relationship between a hospital’s patient satisfaction scores and that hospital’s mortality rate and readmissions for HF patients is unclear. Methods: We used most recent publicly available data from the Hospital Compare website to examine the relationship between patient satisfaction and 30-day unplanned readmissions and mortality for HF patients. Readmission and mortality rates are reported after adjusting for clinical risk factors. We used multivariable linear regression to explore the relationship between patient satisfaction and HF readmissions and mortality adjusting for hospital and local characteristics (hospital ownership, provision of emergency services, teaching hospital status, survey response rate, percentage insured and poverty). Results: Of the 3595 hospitals, 965(27%) were teaching hospitals. Mean (SD) survey response rate was 31.6%(7.3), satisfaction 69.8%(8.7), readmission rate 22.7(1.6) and mortality rate 12.0(1.5). In unadjusted regression, lower 30-day readmission rate but higher mortality rate were associated with high patient satisfaction (-1.4%/unit increase in readmission rate, p&lt;0.001 and 0.2%/unit increase in mortality rate, p=0.03). After adjusting for potential confounders, the readmission rate remained a strong negative predictor of patient satisfaction (-0.75%, P&lt;0.001), however, there was no significant association with mortality (-0.09%, P=0.26). Conclusions: We found that 30-day readmission rate, but not mortality rate, in HF patients is a strong negative predictor of patient satisfaction with hospitals. Strategies aimed at reducing HF readmissions may increase patient satisfaction with hospitals.

Background: Heart failure (HF) is a common cause of hospitalisation and mortality in elderly. The frequent rehospitalisations put a serious burden on patients, health-care budgets, and health-care capacity. Frequent hospital admissions are also associated with a substantial additional hazard for serious complications and reduced quality of life. The NWE-Chance project will explore the feasibility and scalability of providing home hospitalisation supported by a newly developed digital health-supported platform and daily visits of specialised nurses. Methods/Design: Hundred patients with chronic HF will be recruited over a 1-year period. The digital health-supported home hospitalisation strategy will be tested in 3 hospitals with different experience in delivering home hospitalisation: Isala Zwolle, Maastricht UMC+, both in The Netherlands, and Jessa Hospital, Hasselt in Belgium. The home hospitalisation intervention will have a maximal duration of 14 days. Feasibility will be measured with acceptability, satisfaction, and usability questionnaires for patients, nurses, and physicians. Furthermore, safety and costs will be assessed for 30 days after the start of the home hospitalisation intervention. Discussion: The NWE-Chance project will be one of the first studies to examine the feasibility of a digital health-supported home hospitalisation platform for HF patients. It has the potential to augment current standard HF care and quality of life of HF patients and to innovate the standard HF care to potentially lower the hospitalisation-related complications, the burden of HF on health-care systems, and to potentially implement more patient-centred care strategies.