Like most healthcare systems in the United States, Pinehurst, North Carolina-based FirstHealth of the Carolinas has had bed capacity issues and is always working on new and innovative ways to increase it in a safe and financially responsible manner.
THE PROBLEM
This has been done through a number of different locations. FirstHealth’s extended care unit on the Richmond campus is, among other things, a physical solution, while the home observation program helps with capacity issues, but virtually.
PROPOSAL
OAH offered to help increase bed capacity across the healthcare system by being able to discharge stable patients who could be treated at home through the program and would otherwise have had to remain in the hospital if cared for by traditional medicine.
OAH is a program that provides multiple entities in the healthcare system with an alternative for some of the more stable patients occupying a bed. Once patients are referred to the program, a paramedic visits them at their home the next day – there are exceptions to this referrals from home care, which I will explain in a moment – where they will carry out a personal assessment, including vital signs.
Once the assessment is complete, the paramedic will connect with a healthcare provider to complete the remainder of the visit via secure televideo. FirstHealth uses Epic for these sessions. While the paramedic is present at the patient’s home, the healthcare provider assesses the patient via televideo and takes input from the paramedic to continue care for the patient. During the visit, the provider may order medications or labs.
Please note that the paramedics do not use an ambulance for this program.
The provider will also determine if the patient needs to be seen again, or if they are stable enough to be discharged from the program. The goal of the OAH program is to help patients overcome the acute phase of their illness. The average length of stay in the program is just over three days.
After discharge from the OAH program, patients already enrolled in home health care will continue these visits. If the patient is not enrolled in home care, they will be transitioned to the Virtual Home Care Program (VCAH). This program uses remote patient monitoring using Health Recovery Solutions devices to allow staff to monitor the patient’s vital signs for days to weeks.
Patients also have access to a registered nurse by telephone if necessary during their stay at the VCAH. The VCAH program is offered at no cost to patients and is part of a larger effort to help manage bed capacity.
The staff sees patients with the following diagnoses, but may assess others on a case-by-case basis: CHF, COPD, Pneumonia, Flu, COVID19, Asthma, need for IV antibiotics, cellulitis rechecks, and abdominal pain rechecks.
Patients can be referred to OAH in several ways:
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Referrals to inpatients. Stable patients are referred to OAH by the hospital team. These are patients who remain stable and are enrolled in the OAH program to continue the remaining few days of care that would traditionally be completed in a hospital bed.
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Referrals to emergency care. Stable patients who would traditionally be admitted to a hospital observation unit for various reasons can now be admitted to the OAH program.
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Health at home. There are patients who are registered in home care and who may have an acute problem. These are stable patients who would normally be referred to the emergency room for further work-up or treatment. About 80% of patients sent to the emergency department by home care are admitted for observation. OAH is now a home care option so their stable patients can be seen instead of having to send them to the emergency room. Patients with potentially dangerous cardiac, pulmonary, neurological or other potentially unstable complaints are still sent immediately to the emergency room via 911. Patients typically seen in OAH through home care referrals tend to have an early-onset COPD exacerbation, patients with CHF who have weight gain or increased shortness of breath but no breathing problems, or patients with an infection of the upper respiratory tract requiring further investigation. In these patients, staff can intervene early in an exacerbation and help prevent the patient from having to go to the emergency room. Patients referred to OAH are typically seen the same day as the referral.
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Primary care providers or convenient caregivers. PCP or Convenient Healthcare Providers can also refer patients to OAH where they will be seen the next day and provide assurance that their care plan is effective and that the patient is progressing, as well as to continue to provide care that they may not otherwise have received unless they go to be sent to a hospital. the First Aid. The top referrals PCP and Convenient Care staff see are COPD exacerbations and acute respiratory infections such as COVID19, influenza or pneumonia in at-risk populations.
MEETING THE CHALLENGE
‘We complete ours telemedicine video visits using the Epic EHR,” said Stephen Kapa, administrative director of telehealth services at FirstHealth of the Carolinas. “All information is passed on via that platform. For patients transitioning to the VCAH program, we use blood pressure cuffs and pulse oximeters from Health Recovery Solutions. The patients download an app from the supplier on their phone and can upload their measurements from their monitoring equipment via the app.
“A nurse monitors these daily and calls patients directly if anyone has vital signs out of range,” he continued. “Patients can also call the nurse directly if they have any concerns. Occasionally we may need to initiate a televideo visit where patients are re-enrolled in the OAH program or advised to go to the emergency room.”
FirstHealth has found that keeping things as simple as possible is the best strategy, and it has worked since the COVID-19 pandemic. Too often, the more complicated things are made, the more clumsy they become, resulting in more steps that are less likely to be used — keep things simple, he added.
RESULTS
“One of our biggest achievements in the past fourteen months has to be the average daily census in the program,” Kapa reported. “Our financial year runs from October to October. In the first week of October 2023, our average daily count was under two. We’ve had highs and lows throughout the year, but the trend line has always been positive. week of our financial year we had an average of 13 patients per day.
“This has had a significant impact and has contributed to increased patient access and bed capacity, as well as increased patient satisfaction and employee engagement,” he continued. “We expect the average daily count to continue to increase, especially with the normal increase in patients during the winter months.”
Another success that the staff is very happy with is their 30-day readmission rate for heart failure and all causes.
“The average national 30-day readmission rate for heart failure and all-cause readmissions is approximately 20% and 14.5%, respectively,” Kapa noted. “For patients enrolled in the OAH program, the rate for both heart failure and all-cause readmissions is below 10%. While this represents a cost savings, more importantly it demonstrates that we can safely and effectively care for patients with the OAH program.
“Finally, one subjective measure that we really can’t keep up with is the appreciation of patients and families who are grateful to receive their care safely at home rather than having to be hospitalized,” he added. “We have had so many words of thanks and gratitude for what this program has done to help them be where they feel most comfortable: at home.”
ADVICE FOR OTHERS
“My advice is twofold,” Kapa said. “Keep things as simple as possible and be persistent. As you can see from the growth of our average daily census, it did not grow overnight, nor on its own. You must be very persistent in conveying of your message about the program to all groups, especially providers and discharge planners.
“From a healthcare provider perspective, many have been practicing medicine for some time,” he continued. “They are used to doing things in a disciplined and traditional way. I am a physician assistant by training, so I understand this. Giving them the option of the OAH program gives them another option that traditionally wasn’t there . All It is necessary to be persistent and share the success stories, no matter how few they may be in the beginning.”
And go to all possible provider meetings, he added.
“Go to discharge planner meetings, go to interdisciplinary rounds and talk about the program wherever you can,” he concluded. “Once providers start to see the benefits of the program, see their patients being cared for safely and see readmission rates drop, this will take on a life of its own. I hope we are in this last case.” stage now.”
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