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GIM Practice

Bringing Acute General Internal Medicine Outside of Hospital Walls

Michelle Grinman1*, Ryan Kozicky1, Michele Smith1, Kirsten Proceviat1, Laura Bettcher1, Shy Amlani1, Vivian Ewa1, Mary Jane Shankel2, Jason Goertzen1, Lindsay Wodinski1, Azadeh Motehayerarani1, Ghazwan Altabbaa1, Jolene Haws1, Colin DelCastilho1, Leanne Reimche1, Bhavini Gohel1

1Alberta Health Services; Calgary, Alberta, Canada;

2University of Calgary, Calgary, Alberta, Canada

Abstract

International Home Hospital (HH) programs have been shown to be safe and cost-effective. They are associated with lower risk of morbidity and mortality than conventional hospitalization for patients requiring lower acuity hospital-level care. However, there is a paucity of Canadian HH examples in the medical literature. To address this, the Complex Care Hub (CCH) program was created in Calgary, Canada. CCH is an adaptation of international HH models within the Canadian context. This program is unique because of its collaboration between General Internal Medicine physicians, Nurse Navigators, and Community Paramedics, while leveraging a robust technological infrastructure. While the preliminary data suggested that CCH is a viable Canadian HH model for a general medical population, this evaluation did not have a control group. Therefore, further studies are planned to evaluate the program’s quality and cost-effectiveness with control groups to enable direct comparison between CCH and conventional hospitalization.

Résumé

Les programmes internationaux d’hospitalisation à domicile (HAD) se sont révélés sécuritaires et rentables. Ils sont associés à un risque de morbidité et de mortalité plus faible que l’hospitalisation traditionnelle chez les patients nécessitant des soins hospitaliers de faible acuité. Toutefois, on trouve peu d’exemples canadiens de programmes d’HAD dans la documentation médicale. Pour remédier à cette situation, le programme Complex Care Hub (CCH) a été créé à Calgary (Canada). Ce programme est une adaptation de modèles internationaux d’HAD dans le contexte canadien. Ce programme est unique, car il s’agit d’une collaboration entre les internistes généralistes, les infirmières pivots et les ambulanciers paramédicaux communautaires, tout en tirant parti d’une infrastructure technologique robuste. Bien que les données préliminaires semblent indiquer que le programme CCH est un modèle canadien viable d’HAD pour une population médicale générale, cette évaluation ne comporte aucun groupe témoin. Par conséquent, d’autres études sont prévues pour évaluer la qualité et le rapport coût/efficacité du programme en utilisant des groupes témoins pour permettre une comparaison directe entre le programme CCH et l’hospitalisation traditionnelle.

Corresponding Author: Michelle Grinman: michelle.grinman@ahs.ca

Submitted: 8 April 2021; Accepted: 13 September 2021; Published: 14 March 2022

DOI: 10.22374/cjgim.v17i1.548

All articles published in DPG Open Access journals
This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)(https://creativecommons.org/licenses/by-nc/4.0/).

Introduction

One in five Canadians live with multiple chronic diseases, and are among the highest users of the healthcare system, with the poorest outcomes.1 In particular, while older adults (over age 65) constitute 17.5% of the population,2 they account for approximately 30% of healthcare spending.3 Furthermore, hospitalization is associated with a higher risk of morbidity, functional decline, and mortality when compared with those that receive comparable acute care services in their homes. Hospitalized older adults have a six-fold increased risk of discharge to long-term care 4,5 and 34.3-fold increased chance of dying in the hospital.6

Home Hospital (HH) programs provide acute care in patients’ homes for conditions that would otherwise require hospitalization. At minimum, this care is expected to be for 7 days, or at least 25% of the expected length of stay.7 Internationally, HH programs have demonstrated safety, excellent patient and caregiver experience, as well as reduced demands on hospitals.7-22 In HH, one life is saved for every 50 patients treated, versus a conventional in-patient ward.7 HH is also associated with lower risk of functional decline and admission to long-term care at 1 year post-discharge.911 Furthermore, this model reduces acute care utilization contributing to overall system cost savings of 17–62%.911,1722

To date, there is limited evidence on HH’s efficacy in Canada, particularly for an acute general medical population. The recent emergence of home-based acute care has been mostly for single system health issues21,22 or for programs that focus on post-hospital discharge.23 To our knowledge, only one Canadian HH program has been published for a general medical population, and was mainly staffed by Nurse Practitioners with consultative support from family medicine hospital physicians. This program was in operation in the early 2000s, and demonstrated improved levels of patient and caregiver satisfaction.24 While there was no cost difference between HH and conventional hospitalization (coefficient −$501, P = 0.11), the authors postulated that this was due to the program being early in its tenure with inadequately matched controls.25

In order to address the care gap described above, the Complex Care Hub program (CCH) was developed in Calgary, Alberta, Canada. Below described is the process of creating the CCH, from conceptualization to its adaptation during the COVID-19 pandemic and the lessons learned.

Program Design, Implementation, and Evaluation

The CCH team employed a quality improvement approach to develop and evaluate the program based on the Quadruple Aim Framework.26 This conceptual framework considers the impact of new models of care on patient outcomes, patient and provider experience, healthcare utilization, and cost. A parallel research study approved by the Conjoint Human Research Ethics Board at the University of Calgary is also currently being conducted and will be reported in the future.

An environmental scan revealed a local need for a HH model with intensive case management for a general medical population of older adults and patients with complex comorbidities. Calgary already had out-patient models of care for the provision of IV antibiotics and palliative and end-of-life care. So, the gap that remained was of the complex medical population, as they entered the various stages of their disease trajectory. As such, the CCH model was conceptualized by adapting the Bowtie Model of Palliative Care27 and a model presented by Dr. Sid Feldman for the University of Manitoba CPD Medicine Program (used with permission), regarding the stages of chronic disease management (Figure 1). Furthermore, an intensive literature review was conducted, as well as consultation with leaders of existing North American HH programs, and referral to Dhalla et al.’s Virtual Ward model in Toronto. This informed the design of CCH, including the importance of integration with patients’ family doctors, home care and community services.23

Figure 1. Schematic representation of the complex care hub within the continuum of care as patients develop increasing frailty and medical complexity.

A small inter-professional group consisting of a General Internal Medicine (GIM) physician, the Director for the Community Paramedic (CP) program, and two community elder care physicians, subsequently developed a process map. They followed a hypothetical HH patient’s journey from the hospital, through the program, and back to their medical home. The resulting diagram was simplified and presented to over 40 community stakeholders over the subsequent 8 months, including Palliative Care, Primary Care, Home Care, Transition Services, Geriatrics, the group of GIM physicians that would work on the program in the future, and the patient advisors. The stakeholders were asked to critique the proposed model and suggest changes to inclusion/exclusion criteria to improve safety and access to care.

Patient Selection

With an initial focus on reducing avoidable admissions, patients were recruited from the Emergency Department (ED). Primary Care Providers (PCPs) were also able to refer CCH patients back to the program after discharge to prevent readmissions. Eventually, the processes for transferring patients from in-patient wards were developed (see case finding below).

Admission criteria

Patients were eligible if they were 18 years of age or older, with an acute issue or level of acuity that would otherwise require in-patient admission. Eligible patients were required to be hemodynamically stable with appropriate social and functional supports to be treated at home. Patients and/or their substitute decision-makers (SDMs) were required to provide informed consent for receiving CCH care and to participate in the management plan.

Exclusion criteria

Patients or SDMs that did not provide informed consent were excluded. Patients were ineligible if they had acute surgical conditions, or required close monitoring for medical conditions (e.g. myocardial infarction, stroke, severe delirium, and injurious or frequent falls). They were also excluded if the home environment was unsafe or they posed a risk to themselves or others.

Leadership, Stakeholder Engagement, and Funding

The team sought executive sponsorship within Alberta Health Services (AHS) Calgary Zone (metro Calgary and surrounding rural areas). Based on international literature, the potential benefits of HH in the Calgary Zone were rationalized with a theoretical model. This model estimated the ability to reduce the days in the hospital, and the potential cost savings based on the average cost of physician billings for a 7 day admission, and cost of nursing for conventional versus HH patients. The cost of CP visits and hoteling costs were included for CCH and conventional in-patients respectively. The team expected that as patient volume increased, the care days out of hospital and potentially reduced readmissions would outweigh the program’s fixed costs. A formal business case was requested and approved by executive leaders, eventually resulting in operational funding.

A steering committee was assembled to bring together the decision-makers from hospital and community (CPs, Home Care, Primary Care Networks). Several sub-committees addressing operational, evaluation, and community integration issues were developed. In 2018, a parallel steering committee was established at a second Calgary hospital to begin planning for spread to a second site.

A major barrier to the program’s development was physician remuneration, particularly due to lack of billing codes for virtual care prior to the COVID-19 pandemic, and the expected low patient volumes at the beginning of the program’s implementation. This was a concern for fee-for-service physicians, and thus a daily stipend was obtained from the operational funding. Eventually, CCH succeeded in obtaining a Clinical Alternative Relationship Plan (cARP) from the Ministry of Health that would remunerate participating GIM physicians on an hourly basis rather than by patient volumes. This funding allocation is reviewed annually to adjust the amount required by the program, and the contract is renewed every 3 years. In exchange, the program must report basic healthcare utilization metrics, patient outcomes, and patient/provider experience quarterly and annually.

Infrastructure Development

A robust technological infrastructure was required to facilitate patient-to-provider and provider-to-provider communication, information sharing, and documentation. The CCH team worked with AHS’ Information Technology team to create a virtual in-patient module within the hospital’s electronic medical record (EMR) (see Figure 5). Patients were “admitted” to CCH, appearing as an in-patient allocated to a virtual bed. This modality was chosen because of its integration with the hospital system, familiarity for the physicians and nurses, and the ability to have one source of information for the entire acute care team, as the patients flowed from the hospital to home and vice-versa. The CPs were trained and given remote access to the hospital EMR to facilitate co-documentation and the ability to remotely complete medical orders.

Figure 2. Patient journey from hospital to community via the CCH program.

*Admission to CCH includes obtaining informed consent from patient/SDM.

Figure 3. Algorithm for patient selection

Abbreviations: IM: Internal Medicine; ICU: Intensive Care Unit; ED: Emergency Department; CCH: Complex Care Hub; OT: Occupational Therapy.

Figure 4. Stakeholder map

Figure 5. Virtual in-patient module screenshots from electronic health record (A) Screenshot of orders tab and custom order for Community Paramedic visits with free text enabling the physician or nurse navigator to specify the assessment, labs and interventions required. (B) Screenshot of document list

Being a virtual in-patient unit enabled the CCH team to access hospital services with the same priority as for other in-patients, which was essential in actively managing acute issues. This virtual in-patient module served as a platform for documentation, order entry, and viewing of diagnostic testing and laboratory results, with the benefit of being familiar to the nurses and physicians. The order entry function was crucial in facilitating access to acute investigations and procedures (e.g. biopsies, scopes, and bronchoscopies). It also enabled physicians to enter an order for the CPs to carry out in patients’ homes, including phlebotomy and medication administration, which would otherwise have required faxing and maintenance of a separate health record in the absence of the module within the hospital EMR. To facilitate the use of this technology, the CCH team acquired laptops for all care providers and a cell phone for the CCH physician.

Prior to the COVID-19 pandemic, the program leveraged the existing encrypted video-conferencing technology available within AHS, customized in collaboration with the provincial Virtual Health team. During the pandemic, CCH was part of a provincial team that obtained federal funding to acquire a virtual care platform, including digital remote patient monitoring (dRPM) patient-provider video-conferencing, and text messaging. This addition enabled the optimization of the use of CPs only for visits that required in-person assessments, bloodwork, or IV therapies.

Preparing for Implementation

When the funding was confirmed in fall 2017, a go-live date was chosen by the hospital steering committee, and efforts intensified to reach this milestone, requiring the following activities in parallel:

Clinical process development, staff hiring, and scheduling

CCH clinicians were organized into two teams: The hospital-based team, comprised of GIM physicians to oversee the care plan, and Nurse Navigators (NNs) to provide intensive case management. The home-visiting team consisted of CPs with advanced skills in respiratory and cardiopulmonary assessments, gerontology, and public health, as well as being able to administer over 50 medications, draw bloodwork, and perform ECGs. CPs served as CCH physicians’ “eyes and ears,” reporting their assessments and care planning suggestions. This was unique compared to other HH programs that utilize CPs for episodic interventions — CCH empowered CPs to participate actively in assessment, decision-making, and management with the physicians. The ability to leverage CPs in this capacity adds to the types of practitioners that can be safely deployed to perform daily rounding. While the practitioners may vary, the most important aspect of care is the relationship and trust between providers working on both ends of the virtual consultation, and whenever possible, to ensure continuity of care.

The GIM physician group organized a new line on their call schedule and a plan for future recruitment to ensure adequate workforce. An NN was hired with expertise in Emergency Medicine, GIM, and Home Care. The NN role was created within the Transition Services portfolio to ensure integration with home care through dual access to the Hospital and separate Home Care EMRs. Therefore, the NN was able to document and complete orders within both EMRs, providing a direct bridge between acute and community services. New CPs were recruited, a schedule for CP’s dedicated to CCH was created, and a new role within the CP dispatch office was created.

Lastly, CCH clinician leaders developed patient screening algorithms and checklists based on best practices, and documentation templates (admission, progress notes, discharge summaries and complex care plans).

Table top exercises

A series of clinical scenarios were created to test the processes, protocols, and technology in the months prior to the go-live date with a broad group of stakeholders. This enabled refinement of IT, patient flow, patient safety, and care escalation processes. Protocols to address potential patient death at home, and unexpected EMR downtimes were also created.

Clinician education and onboarding

Several initiatives were undertaken to educate and onboard CCH’s frontline staff.

Clinical training for CPs

CPs already had extra training in the treatment of vulnerable populations (geriatrics, palliative, no fixed address) at home, and have been working in a variety of settings (supportive living, long-term care, group homes and community shelters) since 2012. As such, their strong knowledge base was augmented with a series of educational opportunities to support their new role in performing daily rounds on patients with a higher level of acuity via several modalities:

Medical teaching unit rotations: CPs were paired with GIM physicians providing in-patient care for 3–4 days, enabling relationship-building and mutual learning opportunities.

Group learning sessions: Two GIM physicians led training days that combined physical examination teaching (abdominal, volume status, and causes of edema), cardiac physical exam simulation, didactic lectures on basic laboratory test interpretation and communication of clinical findings with physicians.

Self-learning: CPs were given access to the University of Calgary’s Medical School physical examination textbook to consolidate their learning and provide a common language between CPs and physicians when describing clinical findings.

Technology training sessions: All physicians, nurses, and CPs were trained to use the hospital EMR’s virtual in-patient module and AHS’ encrypted video-conferencing technology. This occurred prior to simulation scenarios (see below) followed by real-time refreshers and mentoring after the program’s launch.

High fidelity simulation: Two clinical scenarios were developed for physicians and CPs to practice working together with the program’s technology infrastructure. CPs at the simulation mannequin’s bedside obtained information about the patient from the EMR and conducted an initial assessment. They then consulted the physician (accessing the same information in real-time in a separate room) via AHS’ encrypted video-conferencing technology. These sessions were conducted in the month prior to go-live, and over the subsequent 6 months, to onboard clinicians before their first CCH rotation.

Program Promotion

In-services were conducted in the month leading up to go-live and periodically throughout the first year to educate frontline staff and physicians in ED and medical wards regarding CCH’s inclusion/exclusion criteria, and tasks required for a smooth transition for patients onto the program. Multiple sessions were held to reach casual staff, and account for staff turnover.

A logo was created for all program materials, making them easily identifiable for patients and providers. Posters and stickers for computer terminals were placed throughout ED to remind physicians to refer patients. One-page information sheets were also emailed to various departments and stakeholders.

Implementation

In the first week of CCH’s launch, a team of IT analysts and a Virtual Health implementation lead were available to support the clinical team to troubleshoot problems. As expected, the first admission was challenging and required some minor adjustments to the IT processes. While the steering committee’s work had laid the foundation for a successful program launch, each new case brought a new patient need or challenge in integrating care with the community. The CCH team had to be proactive in identifying potential barriers and patient safety issues to quickly find solutions. As these issues arose, the IT team provided expedited support to the CCH team, until the program’s needs became less over time. This lasted for approximately the first 6 months of the program’s implementation at each site.

Program Evaluation and Modification

An evaluation framework based on the Quadruple Aim was developed in parallel with a research study that was approved by the University of Calgary’s Conjoint Health Research Ethics Board. Both the preliminary evaluation and study collected data on patient outcomes (mortality and health-related quality of life at baseline, discharge and 30 days), patient, informal caregiver and healthcare provider experience (surveys and semi-structured interviews), as well as healthcare utilization and cost. CCH patients were asked to consider providing informed consent to participate in the research study and a waiver of consent was obtained to collect administrative data.

Additionally, a Developmental Evaluation (DE) approach was employed by AHS’ Health Systems Evaluation and Evidence (HSEE) team that supported the program’s evaluation.28 This approach exceled at capturing the evolution of this complex and rapidly changing program within a dynamic environment involving multiple systems and stakeholders.29 HSEE team members observed and recorded program developments in real-time, as well as performing unstructured developmental interviews with clinical program staff and leaders. This provided information on CCH’s current state, as well as key challenges and opportunities. Gathered observations and interview data were collated and presented back to participants to help inform rapid decision-making and program modifications.

Changes during the COVID-19 Pandemic

The COVID-19 pandemic popularized virtual care, propelling the concept of HH to the forefront. CCH leaders collaborated with a post-discharge home-based acute care program in Edmonton to begin the development of a provincial approach to virtual hospital care. This resulted in AHS obtaining a federal grant to procure a virtual care platform that included digital remote patient monitoring and patient-provider communication tools (secure video-conferencing and texting). A hybrid model of acute in-person and virtual care resulted. Patients were able to measure their vital signs, participate more effectively in self-management of their conditions, and communicate directly with CCH physicians.

The virtual care platform was implemented within a very short window of time and was facilitated by the assembly of a large provincial inter-professional team from AHS. New protocols, processes, and training were developed and implemented within 2 months. HSEE evaluated the virtual care platform by collecting early implementation data from CCH and EZVH program and hospital databases, a developmental log derived from meeting notes, observations, and documentation, patient, caregiver, and provider surveys, patient safety reports (AHS Reporting and Learning System for Patient Safety), as well as interviews and focus groups with AHS leadership and staff.

CCH deployed 115 virtual care packages to 109 patients from May 29 to December 31, 2020. The average and median age of patients who used the technology was 67.8 and 71.0 years, respectively, and 52.3% were male. CCH patient enrollment increased 30.9% from June 1 to September 30, 2019 (before the virtual care platform was implemented) to June 1 to September 30, 2020 (after the virtual care platform was implemented). However, clinical program growth may be attributed to other operational changes happening alongside virtual care platform adoption.

Most CCH patients, caregivers, and providers surveyed (92%, n = 37) were satisfied with the virtual care platform. Initially, some CCH physicians expressed some anxiety over the new technology at program meetings. But overall, clinician experience surveys suggested that they welcomed the increased ability to communicate with patients directly, and to optimize the use of CPs for visits that required in-person assessments, bloodwork and IV therapies. The CP program reported a lower demand for their services and an increased capacity to see more patients. CCH submitted 7 patient safety reports relating to technology failure or malfunction from May 29 to December 30, 2020. The team successfully mitigated all reported concerns with no resulting impact to patient safety.

Preliminary Results

The preliminary mixed methods evaluation of CCH’s first 2 years (February 2018–March 2020) with 262 patients (290 admissions), suggested a trend towards reduced days in conventional hospital care, as well as high patient and provider satisfaction. Over this time, 2117 days of care were provided on the Acute Care Arm (potentially replacing days in hospital) and over 1505 days were provided on the Subacute Care Arm (transitional care days aimed at reducing readmissions). The median length of stay on the program was 8 days. Average patient age was 70 years, (range 19–101) and 58% were female. Approximately two thirds (64%) of CCH patients had a Charlson Comorbidity Index score of 2 or more, suggesting high medical complexity.

Patient outcomes and experience suggested that the program provided safe care. CCH had no unexpected deaths in 2 years. The program’s mortality rate was 0.08% (n = 2). Both deaths were expected and received proactive palliative care. CCH patients reported high satisfaction (average 9.3/10; n = 169) and 77% felt that CCH helped them regain their independence and function (n = 168). Self-reported overall health status (EQ-5D-5L30) increased from time of admission to discharge (average 5.1 point difference), and further increased another 0.4 points at 30 days.

Similar experiences were reported by informal caregivers and healthcare providers. Caregivers’ (n = 34) mean Zarit Burden Interview31 scores represented a mild to moderate level of burden at baseline (mean = 10.2, SD = 7.4) and at discharge (mean = 9.9, SD = 7.8). The observed difference in burden between the two time periods was not significant (t-value 0.35 with 33 degrees of freedom, p = 0.73). This suggested no statistical evidence that CCH increased caregiver stress. However, further investigation over time or using a comparison group would elucidate impact on caregiver burden. Most surveyed healthcare providers felt that CCH helped patients regain their function and independence “quite a bit” or “completely” (88%, n = 117), and rated their experience with providing care to CCH patients as “good” or “excellent” (93%, n = 114).

CCH’s 30-day readmission rate was 9.2% versus 13.4% for patients from Calgary’s medical wards.32 Also, 11.4% of hospital readmissions were avoided by admitting patients directly to CCH, bypassing hospital completely. The cost analyses are currently being performed.

Lessons Learned

CCH’s implementation and evolution required a highly flexible approach, able to adapt to a dynamic environment with a multitude of acute and community stakeholders. While many issues were foreseen by extensive co-design, planning, and simulation prior to the go-live date, the program underwent continuous evaluation and adjustment to improve processes, ensure patient safety and better serve its patients. Below are some examples of the lessons learned and modifications made by the CCH team over the first 3 years of the program.

Care streams

It quickly became apparent that as patients stabilized on CCH, the intensity of their care needs varied. Less complex patients were discharged from the program when their acute issues were resolved. Patients with more complex medical or biopsychosocial issues, however, required more time on the program, but as their acute issues resolved, the team felt that the frequency of visits needed to be adjusted to reflect their acuity. Many of these patients required intermittent hospital-level interventions or monitoring a few times a week to ensure that they did not require an escalation in their care. In addition, the care team’s more comprehensive understanding of patients’ home environments and barriers (accessing healthcare or managing their issues) often revealed the root causes that required intensive case management, to develop a complex care plan that would be feasible in the patients’ medical home. As such, the CCH team developed a mechanism for stratifying patients to provide step-down care for the most vulnerable and complex patients, creating the ‘Acute Care’ and ‘Subacute Care Arms’. On the Acute Care Arm, patients receive daily check-ins and hospital-level interventions (e.g. intravenous medications, hydration, and supplemental oxygen) to address acute issues. The time spent on the acute arm was estimated to be an approximate replacement for in-patient days, and most aligned with HH. Daily care was most often provided through home visits by CPs (in consultation with CCH doctors), or in our hospital-based clinic. Occasionally, CCH doctors conducted home visits.

The subset of patients identified as requiring more time for case management, or follow-up of conditions not easily managed by a family doctor, were transferred to the Subacute Care Arm. Patients were seen less frequently, but involved in co-developing action plans for management of their chronic conditions. The CCH team liaised with patients’ primary care team, Home Care, and community services to assist with medical and social needs. Since patients would traditionally be discharged at this point in a conventional hospitalization, time on the Subacute Care Arm aimed at reducing the risk of readmission rather than replacing time in hospital on the index admission.

Medication management

The IT team initially adapted an out-patient clinic medication list within the hospital EMR to enable printing of prescriptions and medications lists with patient-friendly language. However, the out-patient list was more cumbersome to use and unfamiliar to the team. Furthermore, clinicians had to alternate between the out-patient list of patient-administered medications and the in-patient orders for medications delivered by CCH providers. This was flagged as a major risk to patient safety, and so the IT team worked quickly with CCH leaders to develop a modification to the in-patient order entry system that would serve the program better, without losing the functionality of pre-populating a prescription and patient-friendly medication list.

The CCH team also found that patients did not always understand their medication regimens despite extensive education. Furthermore, the medication list did not always match what patients were taking at home, as they often had over-the-counter medications or old prescriptions. This led to a policy of medication reconciliation and patient educations with every CP and clinic visit, including all other medications stored in patients’ homes with removal of all medications considered unnecessary or interacting with the medications on the CCH medical orders.

Blister packs posed challenges when patients required multiple medication adjustments. Over time, CCH developed a system of ordering medications from community pharmacies in two forms — medications likely to be modified would be delivered in vials and those not expected to change would be supplied in blister packs. Medications were prescribed for 7 days to enable frequent changes to the regimen. Medications not easily obtained from community pharmacies or only required for a few doses were dispensed from the hospital’s in-patient pharmacy.

Case Finding

Despite intensive promotion of CCH, patient volumes were low for much of the first year for multiple reasons. First, the program was new and referring physicians were still learning what was achievable outside of hospital walls. Second, the NN found it prohibitively time consuming to support case-finding while trying to care for patients already admitted to the program. Lastly, the time available for the CCH team to admit patients was found to be incongruent with the natural rhythm of ED consults. ED physicians tended to refer late in the day when the team did not have sufficient time to do the eligibility screening, care coordination, and organize the transport home. Often ED patients were too undifferentiated, or required a few more hours to stabilize sufficiently for HH care.

These learnings resulted in two major changes to improve case-finding and admissions —transfer of patients from in-patient wards and temporarily hiring a Clinical Assistant (CA). The ability to identify patients early in their admission enabled the CCH team to capture patients that were often more amenable for CCH, as their diagnosis and stability were already established. The CA worked for CCH for approximately 1.5 years, helping to screen for eligible patients, standardizing the physicians’ approach to assessing potential candidates, increasing awareness of CCH amongst hospital staff, and standardizing approaches among the physicians rotating on the program weekly.

Preparation for spread

After 7 months, GIM leaders from a second Calgary hospital requested that CCH spread to site. This required funding, which was acquired by the expansion built into the cARP application that provided physician remuneration and liberated operational funding to support NN’s and CP’s for the new site.

A steering committee was created for this hospital (Figure 4), leveraging the knowledge of leaders that worked at both sites, or through consultation from other leaders in the Calgary Zone (CCH Medical Director, Transition Services manager, IT and Virtual Health Implementation Leads). The technology infrastructure and processes from the first hospital were locally adapted, enabling program implementation within 7 months at the second hospital.

Evaluation

While preliminary data suggests that CCH is a viable Canadian HH model for a general medical population, showing a trend towards achieving the Quadruple Aim, the evaluation has several limitations. The initial evaluation was limited by the lack of a control group that would enable a direct comparison of patient and healthcare utilization outcomes. In addition, a thorough economic evaluation is needed to understand the cost-effectiveness of this model of care when compared to traditional hospitalization. As such further studies with comparator groups are currently underway to better assess the outcomes of this program both prior to and during the COVID-19 pandemic.

Conclusion

CCH is a viable Canadian HH and intensive case management model for a general medical population. Preliminary findings suggest improved quality of care for lower acuity hospital-level conditions outside of hospital walls. Further studies are planned to more rigorously to evaluate the program’s quality and cost-effectiveness with control groups that will enable direct comparison between CCH and conventional hospitalization.

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