Acute care hospital at home has grown from an experiment during the pandemic to a clinical model that many health systems have come to rely on to ease hospital capacity constraints. During a recent webinar discussion, Daniel Davis, M.D., medical director of continuing health at Atrium Health, described how Atrium has scaled up its program by making it part of a larger integrated care-at-home strategy.
Atrium is a large integrated healthcare system that is headquartered in Charlotte, N.C., and is now part of a larger organization known as Advocate Health, which has 68 hospitals and more than 1,000 sites of care. It spans from Milwaukee to Chicago and then down into the Southeast, including North Carolina, South Carolina, Georgia and Alabama.
Davis was speaking during a recent webinar put on by the Hospital at Home Users Group, a collaborative of hospital-at-home programs around the United States and Canada. He has medical oversight responsibility for multiple home- and community-based programs such as hospital at home, mobile, integrated health, transition services and home health. As medical director of Atrium Health’s Primary Care Connect program, he spearheaded the development and implementation of a virtual nursing care coordination program across the health system’s footprint in North and South Carolina, Georgia and Alabama.
Davis began by explaining that the initial hospital-at-home program was started in March of 2020 in response to the COVID-19 pandemic and the subsequent in-patient capacity crisis. He said the program was created quite rapidly because they already had an existing infrastructure of community paramedics in their mobile integrated health program. But scaling up the program required making it part of their overall home care program.
“We develop this integrated care-at-home strategy,” Davis said. “The game changer for us is that we pulled our hospital-at-home toward a larger care-at-home strategy to make sure that we're moving our patients along the care continuum. We are not just focused on providing acute inpatient level of care at home, but what is the appropriate level of care that we can provide for our patients?”
After the initial roll-out in 2020, Atrium was able to leverage its existing programs to scale up relatively quickly. “We were able to build and scale from Mecklenburg County, which is the county that Charlotte is in, into 10 surrounding counties over the coming months,” Davis explained. “Of course, the census did wax and wane with the pandemic. We had a short period of time when the program was actually closed for a few weeks prior to a surge in mid-2020.”
Eventually, Atrium had permanently assigned hospital-at-home staff and expanded to non-COVID diagnoses starting in September of 2020. They implemented the CMS acute hospital care at home waiver in their first three facilities in March of 2021 with the expansion to all 10 of their facilities in the greater Charlotte market over the next six months. Their census waxed and waned over the next two and a half years. “Ultimately we were able to get to the point where we've been able to expand and now have a budgeted census of 60 that began in October of 2023,” Davis said.
In mid-2023 Atrium developed a more comprehensive program for care in the home. “We intentionally placed hospital at home in this same strategy with our transition clinic. We pulled in mobile integrated health leadership, as well as our home health leadership and other primary care strategies to have a more cohesive strategy toward how are we going to grow hospital at home, how we are going to leverage these resources,” he said.“Subsequently, we were able to start to increase our census over the coming months to end the month of December with an average daily census in the high forties.”
Atrium has taken care of more than 9,400 patients since inception in March of 2020 and has saved greater than 33,000 brick-and-mortar bed days for its patients. The average length of stay is around 4.6 days. “From a quality perspective, our readmissions rate is 0.8, which is better than our brick-and-mortar facilities. We've had a mortality rate of less than 1 percent and our return to brick and mortar escalation rate is 5 percent. Currently, we do all this with very good patient experience,” he said.
One of the reasons the program has succeeded is the ongoing acute care facility capacity constraint. “We’ve been able to maintain our program over the last four years, despite the waning of COVID, because we have a rapidly growing population. We don't have the ability to continue to build brick-and-mortar facilities to keep up with our population growth. Our acute care facilities are under significant capacity constraints., so we have that as a primary driving factor for us to maintain our hospital-at-home program but also to drive the growth of our program,” Davis said.
Atrium has extended the infrastructure to other care-at-home strategies including a transition clinic and other programs such as the community paramedicine program. “We've also been able to utilize providers when census is varied in a flexible model where we have a dedicated provider staff. So we have dedicated hospitalists, both physicians and APPs, but we also have the ability to flex and use some of our brick-and-mortar hospitalists,” he explained. “Our financial model is based on capacity. We just simply don't have enough beds to be able to take care of all the inpatients that we have. We also developed an incremental growth plan this year. We were approved to have a budgeted census of 60 starting in October but we did that in an incremental way. So we developed an incremental plan by which to grow both the provider staff, our nursing support staff, our mobile integrated health staff and all the ancillary staff that we need to be able to maintain that census.”
Davis also mentioned that part of the waxing and waning of their census has to do with the culture within their facilities. “We have certain facilities that are incredibly engaged in the hospital-at-home program and refer patients regularly; then we have many facilities where we lag in engagement of the providers. We developed some facility-specific internal marketing to target the facilities that have the greatest capacity crisis, which actually were not always the facilities that were the most engaged, but also to try to dig into the rate-limiting steps. What is the culture that is difficult to change to get the referrals from the ER, hospitalist staff and also our subspecialists?”
Atrium’s hospital-at-home team also began working with their oncology colleagues to develop some specific use cases to take care of oncology patients in hospital at home. “We've been working with our surgical colleagues to identify patients who would be ideal candidates for hospital-at-home level service,” he said.
Although all their beds since March of 2021 have been technically meeting the criteria of the acute care home waiver, Atrium is now working on developing an outpatient component to expand their census and to expand their reach into being able to take patients directly from ambulatory clinics as well as free-standing emergency departments and create unique care strategies and service lines. “One of those is with our oncology colleagues, and we've developed a process by which we adapt taking care of patients who are receiving specific antibodies,” Davis explained. “We are moving toward doing that for Car-T therapy as well. Those are outpatient, but they're receiving hospital-at-home level care in a modified fashion that allows us to be able to take care of them.”
