Quality Measures and the Success of Hospital-at-Home Programs
It’s no secret that hospital-at-home programs are a rising trend in the healthcare industry. Their lasting success, however, will depend on quality data and the hospital quality departments responsible for documenting, collecting and reporting on it.
Here’s what to know as a quality manager about hospital-at-home programs and where your clinical documentation, data collection and reporting, quality measure, and performance metrics responsibilities will fall along the execution and evaluation of those programs.
Extending acute care into the home
Hospital-at-home programs are care delivery models that offer patients the opportunity to safely receive acute-care services typically provided by hospitals on an inpatient basis in their homes. There’s an important distinction to make: it’s not traditional home care, it’s acute care in the home.
Some forward-looking hospitals and health systems have been experimenting with hospital-at-home programs for several years as part of the industry’s overall transition to value-based care models from fee-for-service care models. The idea is hospital-at-home programs can provide clinically eligible patients safe and effective acute-care services at home at a lower cost and do so in a more convenient setting preferred by most patients. Several studies have shown that these hospital-at-home programs accomplish both of these objectives.
But, thanks to the COVID-19 pandemic, the days of a handful of innovative hospitals and health systems tinkering with hospital-at-home models are over. Hospitals and health systems across the country need two things: space in their facilities to treat COVID patients (even those who don’t need intensive care) and the ability to treat non-COVID patients safely at home.
In late November, the Centers for Medicare and Medicaid Services responded to that pressing need by creating its Acute Hospital Care at Home, or AHCAH, waiver program. Essentially, CMS lifted regulatory restrictions that prevented hospitals from providing acute care to patients in their homes. Under the waiver program, hospitals and health systems can now do so if they meet certain conditions.
That’s where quality managers and quality departments come in. It will be their job to ensure hospitals or health systems are meeting AHCAH waiver conditions and consequently proving it with the quality data that is collected and reported to CMS.
Let’s break down clinical documentation requirements and the quality data that needs to be collected and documented in three phases: before, during and after a patient’s hospital-at-home episode of care.
Just to be clear before we begin, this is a voluntary program and all requirements we review below are not part of your hospital IQR, OQR or any other value-based care program.
Before a hospital-at-home stay
The information that needs to be documented in the patient’s medical record falls into four domains:
- Social determinants of health. CMS is requiring participating hospitals to have screening tools in place to assess SDOH factors present in the patient’s home. These would include determining whether the home has working utilities, any physical barriers that would prevent optimum care or signs of domestic violence.
- Source of admission. Hospitals can only admit acute care patients to their homes from two places: the emergency department or an inpatient hospital bed. In other words, patients must go to the hospital first to assess their medical condition before they can go home.
- In-person physician evaluation. Before a patient transfers from the ED or hospital bed to their home, a physician must evaluate the patient in person to determine if the patient’s diagnosis and medical status allow them to be care for at home. CMS says more than 60 different acute conditions, including asthma, congestive heart failure and pneumonia, can be treated at home.
- Patient consent. Participation in a hospital-at-home program is voluntary for patients. Hospitals can’t force a transfer to home-based care, and patients who don’t want acute care at home are not required to accept it.
The documentation of the above criteria likely will be done by physicians, nurses and other licensed care professionals. These are not traditional quality reporting requirements that would require chart abstraction or eCQM data submissions. That said, some of the data in that documentation may be used for quality improvement or performance measures purposes at a later point.
During a hospital-at-home stay
Now this is where it gets interesting—and challenging.
How do you replicate inpatient care in the home in terms of monitoring by doctors, nurses and other clinicians? CMS’ answer is this: A registered nurse must evaluate a patient at home once a day (either in person or remotely). An RN or paramedic must also physically visit an at-home patient at least twice a day.
That means the RNs and the paramedics must document those at-home evaluations and visits in the patient’s medical record. This can be done on-site using mobile devices or shortly afterwards in an EHR system. Per CMS, EHR clinical documentation “should be consistent with existing hospital policies for inpatient admissions.”
That’s critical because the data from those patients’ medical records is needed to assemble the hospital-at-home quality measures that are reported to CMS. Those measures fall into five domains:
- Patient volume. How many patients you discharged from your hospital-at-home program.
- Unanticipated mortality during an acute episode of care. How many of your hospital-at-home patients died either at home or after being transferred back to the hospital.
- Escalation rate. How many hospital-at-home discharges resulted in patients back to the hospital.
- AHCAH safety committee review. Whether your patient safety committee reviewed your measures and looked into cases that needed further investigation.
- Patient identifiers. How many at-home patients were Medicare beneficiaries, Medicaid recipients or dual-eligibles, meaning they qualified for Medicare and Medicaid coverage.
Oh, and one other thing: If a hospital is what CMS calls an “inexperienced hospital,” or one that’s treated fewer than 25 acute-care patients at home, quality measures must be reported weekly. If a hospital is categorized as an “experienced hospital,” or one that’s treated 25 or more acute-care patient at home, quality measures can be reported on a monthly basis.
And, of course, the data that qualifies your hospital as inexperienced or experienced must also be reported.
After a hospital-at-home stay
The clinical documentation and quality data elements extracted from that documentation will give a quality manager and quality department the capability to determine how well a hospital-at-home program is working in terms of costs and outcomes.
For now, CMS hasn’t determined what hospital-at-home performance measures to track. But, several hospital-at-home case studies and peer-reviewed pieces of published research suggest a few to consider if participating in the AHCAH waiver program.
In this case study of the hospital-at-home program operated by Presbyterian Healthcare Services in Albuquerque, N.M., published by The Commonwealth Fund, the health system used the following performance measures to compare its hospital-at-home outcomes with its inpatient care outcomes:
- Patient and family satisfaction
- Illness-specific clinical quality measures
- Hospital readmission rates
- Total cost of care
In this original research published in the Annals of Internal Medicine, researchers evaluated the hospital-at-home program operated by Brigham and Women's Hospital in Boston using these metrics:
- Total direct cost of acute-care episode
- Healthcare utilization (laboratory orders, imaging studies and consultations)
- Level of physical activity
And in this study published in JAMA Internal Medicine, researchers used the following metrics to evaluate the hospital-at-home program operated by the Mount Sinai Health System in New York:
- Length of stay
- Hospital readmissions
- ED visits
- Admissions to skilled nursing facilities
- Referrals to home health agencies
- Patient experience with care
Whatever measures your hospital decides to use to monitor the performance of your hospital-at-home program and use for quality-improvement purposes, the task will fall on quality managers to collect the data to build those measures and report them internally and, at some point, externally to payers like Medicare.
The transition to value-based care accelerated by the COVID-19 pandemic has pushed the idea of hospital-at-home programs to the front of the line in new care models. These new programs will be fueled by data and the ability of you and your quality department to collect and report it. The time to prepare for an expanded role beyond the four walls of your hospital is now.
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Brian Hill is the Vice President of Quality Measures at Medisolv, Inc.