Welcome to AJHP Voices, a series of discussions with AJHP authors and interviews focused on contemporary practice issues. AJHP is the official journal of ASHP, and its mission is to advance science, pharmacy practice, and health outcomes. Hi, this is Daniel Coba, the Editor-in-Chief of AJHP. Thanks for joining us in this episode of AJHP Voices. Hospital-at-home programs became more prominent during the COVID-19 pandemic as a strategy to manage hospital congestion. In some centers, these programs are transitioning from a novel idea to a standard approach for selected patients. Joining me today to discuss their article, the vital role of clinical pharmacy services within the hospital-at-home interdisciplinary team, are Dr. Leah Webster, pharmacist team leader, Mayo Clinic, and Dr. Corey Whackter, clinical pharmacist, Mayo Clinic. Leah, Corey, welcome, it's good to talk with you today. Thank you so much for having us. Yeah, thank you. I think for some of our listeners and for folks who have not had experience with hospital-at-home, it might actually be difficult for them to visualize, and in fact, I've heard conversations where people have had difficulty differentiating it from traditional home care. So Leah, what does hospital-at-home look like, and how does it differ from traditional home care? I think that is a fantastic leading question. Many people, even providers at our own institution, still don't quite understand the difference between our program and home care. The major difference is that home care is an outpatient setting. So hospital-at-home patients are hospitalized, and they have to meet inpatient criteria to be a part of the program. Hospital-at-home can be thought of as a virtual floor of the hospital where we're basically taking the hospital and putting it in the patient's home. So those patients have to have 24/7 access to their care team. They have to have inpatient needs. The monitoring and documenting is consistent with the inpatient practice, and we have acute and rapid response services available to meet those acute care needs. We're also sharing a common EHR with the brick and mortar hospital, which includes order sets and MAR documentation. And lots of questions in there to follow up on. And we'll get into some of those as we go along today in our conversation. At this point, how many hospital-at-home programs exist in the United States and post-COVID? Corey, what's the reason for continuation of hospital-at-home? It was to manage congestion, which was so prominent during COVID. Is that still the reason today? Currently, on the CMS website, there's actually 335 facilities across 136 health systems, which include 38 different states. So that's as of last week, which is an increase from 283 facilities when this paper was written in June. There's only a continually growing area of healthcare. One of the reasons, of course, as you alluded to with COVID and kind of that congestion, one of the reasons why these programs are continuing and growing and should continue to grow, in our opinion, is freeing up additional beds in the hospital for potential higher-accuity patients. And then there have been some studies with hospital-at-home programs since COVID that have showed improved patient satisfaction. Of course, patients would rather be at home than in the hospital generally as a rule of thumb and then increase physical activity, improve mortality on re-emission rates as well. So certainly an area that can continue to be researched as these programs grow. Got it. So Leah, for the Mayo Clinic program, how is eligibility determined for a patient to receive care through hospital at home? Mayo Clinic has an AI algorithm that we use with an EPIC to identify patients who are potentially eligible. And this is based on a series of clinical and geographical criteria that's built in. From that list, we have an acquisition team made up of advanced practice providers and nurses, and they will review the patients on that list to determine if they truly are clinically appropriate. If that is the case, then a nurse will approach them, discuss kind of like a social stability screening to make sure that they're socially acceptable as well. And at that point, it's just a joint effort between the attending physician, advanced practice provider, nursing to get the patient's consent. So Corey mentioned before that there's greater patient satisfaction with hospital at home because they can be at home. But can you talk a little bit more about the patient reaction, maybe the first time you approached them to consider this, how do they respond? So in the beginning, we did find quite a bit of, I don't want to say hesitation, but definitely caution. So in the past several years, we've developed strategies where we are beginning to educate these patients sooner and sooner. So we have information in the ED. We have our ED providers and ED case managers kind of already setting up this option for patients, the brick and mortar teams on the internal medicine side are doing the same thing. So we've done a lot of education with the provider teams across the hospital to, like I said, try to set up the expectation for the patients and let them know that this is an option for you. You can be comfortable choosing it if you wish. I would imagine that there could also be some anxiety for the family member or members, the caregiver at home that a lot of responsibility is shifting to them as well. Have you seen that? Yes. And that's a part of the social stability screen. Our nurses are always communicating with the caregiver. We also have a case manager that's involved in communicating with the caregiver and really trying to read between the lines even and determine if it is somebody that is not comfortable or is worried about the workload, then we can offer home health aids to help for certain hours in the day, but definitely taking that into consideration. You mentioned the emergency department. So I'm curious, has hospital at home become part of the overall strategy as well for managing throughput from the ED and trying to manage the situation of boarding in the ED? Has it been part of what I imagine is probably a multi-pronged strategy there? Absolutely. Yes. We target ED, what we call acute substitution. So that's patients that get admitted to hospital at home directly from the ED. That's one of our performance measures that we're tracking and we have targets. We published a quality improvement study last year, actually, on increasing the number of ED acute substitutions that we're taking. So Corey, with all this in mind, what pharmacy services are provided through the Mayo Clinic Program? So essentially, at each of our sites, we have pharmacists integrated into the overall program's team, and so dedicated pharmacists stationed in the Agile Command Center for collaboration with the providers, nurses, everyone else that's part of the team. So part of that, we do through Mayo Clinic medication reconciliation interviews, as well as participation daily and rounds going through with the providers and the nursing staff, kind of all the patients for the day. We have, of course, complete clinical reviews of the inpatient medications and labs that are associated, as well as get clinical alerts through our EMR and kind of go through those with providers as needed. And then Mayo Clinic, as well, pharmacy groups do pharmacokinetic and anti-coagulation consults that providers can put in, so just another one of our services. And then, of course, around discharge, reviewing the medications for discharge and, again, answering provider questions. Leah, how would you expand on what Corey's described in terms of the pharmacy services that are offered? So we tend to teach that the clinical consultative services by pharmacy mirrors the institutional practice, but really with home hospital patients, it takes a little bit of extra care. So the pharmacists are very involved in the acquisition process. When they have a patient who's enrolled, they're often consulting with pharmacy to make sure the medication regimen is achievable in the home. We're also looking at deep prescribing, so if there's medications on the list that we're just added as a hospital order set, how can we kind of trim that down to what's absolutely necessary to deliver to the home? We also take that moment as an antibiotic timeout that typically probably in a regular hospitalized patient, you wouldn't have that specific point of transition to deescalate an antibiotic, reduce the frequency of administrations, which is another big part to reduce the service provider visits to the home. Yeah, can you describe for me, again, this goes to envisioning the practice, can you describe what does that typical patient who's getting their hospital care at home look like? What might be typical conditions that they have? You've talked about antibiotics, so I imagine folks who have some type of infection, but talk about that a bit more. Our most common diagnoses are infection related. So we've got cellulitis, bacteremia from various sources. I would say also heart failure, exacerbations is a very common diagnosis, acute kidney injury. So those patients, COPD exacerbations, we have bronchiectasis patients here at Mayo. We don't exclude patients based on their diagnosis code, so we have a heterogeneous group of patients, but I would say those are the most common for us. You know, I was fascinated at the beginning and just now you mentioned patients with heart failure who have had a heart failure, exacerbation. You mentioned at the beginning that there are systems in place for both acute and rapid response. Can you talk about that a bit more as well? Because as someone who's trying to get their head around this, even thinking about what acute and rapid response look like outside of the hospital setting when you're still trying to mimic the hospital at home, I find fascinating. Tell me more. Absolutely. So I would say that the acquisition piece is very important. So clinically, when we are taking these patients home, we are very focused on the safety of the patient, hema dynamically stable, not having life-threatening concerns, for example. So they're stable, but still sick. So acute care services, what I mean by that is frequent medication changes, IV, diuretic administration, we can collect blood cultures, we can do echoes, we can ultrasound in the field. So quite a few services that would not typically be available in home care. Rapid response services, we actually partnered with the paramedic team, which has been fantastic for our program. They're able to carry medication stocks, so we can respond to a critical electrolyte result, for example, if a patient is starting to decompensate, we can call a rapid response and have a paramedic sent to their house to address them. If it is a life-threatening emergency, we also have a relationship with local 911, and we have utilized them in the past as well. We are one of the things that I think about is, you know, you only think back to my practice as a hospital pharmacist, that the rapidly changing nature of what was going on with patients' medications, if it was an interval change or a dose change, and I'm wondering about how does that happen in the home setting? So you have a patient who's on a specific dose of an antibiotic, maybe it's in an interval, maybe it's a continuous infusion, how do you make that happen in the home environment in a way that mimics what would happen if they were in the hospital? So I think this is one of the key pieces that providers who are used to working in the brick and mortar hospital take for granted how much control we have in the hospital. They're so used to medications being available for them immediately in a pixis machine or very quickly from pharmacy. So what we do, it starts with the provider's order on the EHR, and once that's verified, the pharmacist is highly engaged in determining the best way to get that dose changed. So if it's a completely new change in dose, we may give them the next scheduled administration and change the regimen so that it has time to arrive to the home. If it's a medication that needs a dose increase like a cephaline that's given once a day, but now renal function is improved, and so we're going to bump it up to two times a day. The pharmacist is aware of how many doses are available in the home, and so we can usually utilize what's in the home to make that dose change, or we have a paramedic team that we can deploy to administer many of those critical antibiotics, electrolytes, diuretics, and things like that pretty rapidly. And so when the paramedic goes out and they're making maybe a change in the infusion rate, for example, if you have something that's infusing and the rate needs to be either increased or decreased, are there quality controls in place that help ensure that what the paramedic is doing out there in the home is exactly what needed to be done? Absolutely. We have all medication administrations, and dose changes are virtually witnessed by a command center nurse that is a Mayo employee. They have to witness that change, and we are capturing images to upload into our system so that there is an accountability, and at least me as a pharmacist, I will go in and spot check those things just to make sure that everything's being documented appropriately, and those are being followed up on. Got it. Corey, I imagine that as Mayo Clinic was envisioning this program, and even as you've invested in it further over time, that there were a lot of regulatory factors that had to be considered. So how are hospital at home services regulated by organizations such as CMS or State Boards of Pharmacy, and even how does the Joint Commission, as an accredited organization, look at hospital at home? So the CMS has a website that is dedicated for hospital at home users or members that list criteria for reimbursement, and it actually recently began requiring some quality data submissions, so that would include patient volumes, mortality, unanticipated mortality, escalation rates, as well as looking at safety committee reviews and patient lists, and so something that obviously with a new hospital program or type of program having these newer standards and kind of getting that data certainly is important, and sounds like it's expected that standards are going to be published before the end of this year actually. What about boards of pharmacy? So that certainly is tricky, especially, of course, with Mayo Clinic having the different sites and Lea and I practicing in different states. The state regulations, of course, with a newer program are coming along, however, a lot of states don't have much for regulations, just because even though we treat these patients as inpatient, and we started this program using inpatient standards for medications, of course there's the question of, you know, with them being inpatients, but their home is it kind of in between, you know, inpatient and outpatient, kind of where does that lie? So I think that'll be in the coming years with CMS and the states will be a huge, you know, changes as the programs continue to grow. Enjoy commission, or other creditors? Currently, we haven't really had a lot of regulation from Joint Commission, or haven't really had any standards that are set different than our inpatient standards. So again, I think it'll be something that will come sooner than later and we'll have to go off of any new standards or different standards than inpatient, but for now there are no set standards for us. Lea, at the beginning of your article, you spend a lot of time describing hospital at home, the drivers for it, really what it looks like as we were talking a bit before. That was all part of your introduction to your article, but then you move on to the actual study that you conducted. Can you talk about the purpose of the study, what you hope to achieve as you were looking at this patient population and the services that were provided? As we've alluded to several times, this model of care is completely new. It's largely dependent on states. So there's quite a bit of differences between programs, especially in different states. I think it's difficult for people to understand what pharmacy practices like in this setting. As Corey kind of said, it's inpatient, but it's also kind of outpatient. So what we were really trying to do is just talk about our program, describe the types of pharmacy services that we're providing and just shed light on the complexity of the logistics and how critical pharmacists are to the success of these programs. I know programs are popping up all over the country and pharmacy directors and just pharmacist in general have been reaching out asking questions. So I think that it's an unmet need and hopefully our paper will provide some knowledge. So you had 221 patients that you included in this study. Those are 221 people who were admitted to the hospital at home during the study period. We talked about this a bit before, but for the population, what was the severity of illness? We collect severity of illness and mortality index scores by APR DRG, which is the standard scoring system across the United States for classifying hospital and patients. It rates patients on a score from one to four minor, moderate, major or severe. And our mean severity of illness score for the combined cohort was 2.94 with mortality risk mean of 2.77. So there is a figure in the paper breaking that down and showing a pie graph 53% of our patients were classified as having a major severity of index and 22 of them was extreme. So I think it was important to highlight this information to kind of show that hospital at home truly is treating acutely ill patients and it is not home infusion services. That's really helpful to understand it. Now you compared with this study descriptive findings from two sites, what did you find? As we mentioned in the paper, the states that Corey and I practice that have wildly different interpretations of pharmacy permitting laws and such. So our dispensing models are very different. Corey's site dispenses all the medications from the inpatient pharmacy. They're using an automated dispensing cabinet in the home to dispense medications to patients, whereas at our practice site, we were at the time unable to dispense from our inpatient pharmacy routinely. So we were using a third party vendor to dispense both IV and internal medications. So what we found was by the nature of our dispensing policies and the way that it was set up at my practice site, many of the pharmacy services were really just managing reconciliation of two orders. So for each medication, a provider would have to enter the hospital medication order and then also a prescription. And so pharmacy, very tasked with making sure that the medication that was going to arrive in the patient's home was reflected accurately on the MAR. Also just the nature of how tedious that process is. You can imagine a prescribing error. So we were heavily involved in those type of interventions, whereas Corey's team, they have much more control over their dispensing practices. So many of their interventions really seemed, in my opinion, to be patient centered. So they were able to video in with patients in the home and do medication inventory visits in the home, which is, you know, that's an area in hospitalized patients we don't typically have access to. They were able to do discharge counseling, for example. And so I guess that to me was kind of the difference that stood out the most. Also just the sheer volume, Corey's program is a lower census. But the volume of interventions that we saw at my site was more than I would have expected to see. Corey, what would you add? I think that she hit it right on the head. I think just again, the differences between the sites and certainly interesting to see just how much, even with both sites, of course, with theirs, with the kind of dual orders at the time, and then their third party vendor versus us, kind of ours more mimicking our inpatient dispensing, but still just the amount of interventions and kind of order touches per se, certainly was eye opening for the census that we had. I can imagine that it just required on an ongoing basis, an enormous amount of planning to get this right. And I'm wondering if you can talk about that, Corey. Mayo Clinic made this decision during a national health emergency and at a time where there were a lot of stresses. Can you talk about the overall planning efforts who led it and really how that played out to bring this to fruition? I was a little bit of a late add-on to the ACH program itself, but I can speak to kind of the ongoing, you know, after the initial ACH group leadership between pharmacy, the providers, of course, nursing as well. And ACH stands for? Advanced care at home. And so the hospital at home here at Mayo Clinic, essentially all those groups coming together to create this program took a ton of planning and it's something that I'm sure Leah can speak to as well, but just the continual ongoing committees that we have with this program in order to, you know, whether there's a reoccurring error or, you know, near-miss type of scenario where now we're looking at a workflow or just creating new workflows that we think will increase the quality of care that we're given to these patients on an ongoing basis is great to see. And it is a lot, of course, to grow a program like this certainly needed. Leah, maybe you could add to it your thoughts on the complexity, what the processes looked like, who was involved? I heard recently someone described this as we're flying an airplane that we're building at the same time. And that really resonated with me, so enormous amount of planning. I was not here for the planning of the initial program. I was told that this was actually planned before COVID and then COVID was kind of the catalyst to get it off the ground and going, which is amazing. But lots of pharmacy input providers, nursing leadership, all the way up the leadership chain, working with vendors in the community because we have virtual support from our Mayo Clinic staff stakeholders, but then our hands in the community are the community nurses. So lots of vendor relationship, team building, and such. I'm sure that part of the overall approach and one of the things that I would imagine keeps you up at night a bit is thinking about the risk for medication errors in the home setting. How does Mayo Clinic manage that? And what are the systems that are in place to try to minimize the risk of a medication error as well as to monitor and respond when they do occur? medication errors, very, very important for this type of program. Medication safety, predictably so, is highly scrutinized for this model of care. We are monitoring safety events just like we would in the brick and mortar hospital. So our program, which we call ACH, it's our home hospital program, is listed in our incident reporting system as another floor of the hospital. So we have the ability to place patient safety reports within the patient's chart in Epic. The framework is aligned with the institutional framework. We have a home hospital specific medication errors committee that is a subgroup of our quality committee. All of the incident reports are reviewed by risk, not affiliated with the home hospital program, but just the general institutional process for reviewing medication errors and the institutional practice as a whole, tracks our errors in the home hospital program along with the other floors. So Corey, where does hospital at home go next to Mayo Clinic? Yeah, I think the kind of overwhelming majority wants the expansion of the programs and to the different sites. Of course, we have three sites currently, but several more Mayo Clinic sites. And then, of course, the expansion at these sites that currently have the program for hospital at home. But again, with expansion, of course, is improving quality and kind of keeping quality that we have as the program grows. And so I think with those two things in mind, that's kind of everyone's goal and what we all think about in different committees when we're looking at what staffing we need in order to get to a certain census for the different sites while, of course, maintaining the quality and safety for all of our patients. And so certainly very exciting. And we've continued to grow and hopefully continue to do that. As you think about growing and expanding to other sites, I would imagine that there are experiences from your implementations at two sites already. And one that I'm interested in is actually the reaction of pharmacy staff, pharmacists, pharmacy technicians, and their initial comfort level with doing something that is very different, very outside of literally the box outside of the brick and mortar box of a hospital. How did the staff react and how have they come along? Yeah, I think initially there's for sure some not necessarily hesitation, but definitely caution when considering, you know, we're treating these patients like inpatient, but they're not really in the brick and mortar. So then especially during the after hours, kind of what's our process for new medications and, of course, with new providers there in the hospital home program as well. So certainly the beginning, there was a lot of caution, but I think it's one of those things where as you continue to grow a program and, you know, pharmacist and pharmacy technicians get more used to those patient orders coming through the queue, I think it's only gotten better and the satisfaction has gotten better, but certainly an area at the beginning where there was some caution. I know Leah probably can speak to some of that as well. And a previous podcast with ASHP, that was one of the things that I wanted to highlight was for leaders to plan for this. In the beginning, it was rough. It was a challenge to have staff accept it mostly just because it was so difficult. There's so many nuances. The practice is, as Corey said, it's really outpatient meds is how they were thinking of it. As we have grown, we have really created a pharmacy practice at our program. And by creating that practice, we have definitely garnered more support with the inpatient pharmacy team. So one of the huge improvements that we actually just implemented is the inpatient e-prescribing functionality in Epic, so we now, instead of having two orders for each medication, the inpatient and outpatient orders, they're fused into one order. And so this allows the pharmacist to focus more on those clinical reviews than sitting down, you know, making sure that these orders match. So yes, it is definitely improving. And with that, that's all the time we have today. I want to thank Dr. Leah Webster and Dr. Corey Whaptor for joining us to discuss their article, the vital role of clinical pharmacy services within the hospital at home interdisciplinary team, which was recently published on aghp.org. Please join us here each month for discussions on contemporary pharmacy practice issues and interviews with age P authors. If you enjoyed this podcast, please share it with your colleagues and via your social media of choice. Thank you for listening to aghp voices. For more information about aghp, the premiere source for impactful, relevant and cutting edge professional and scientific content that drives optimal medication use and health outcomes, please visit aghp.org.
