A new service piloted at Penn Medicine allowed a proportion of patients to avoid hospitalization by providing them with greater support after visiting the emergency department. The vast majority of the patients enrolled in the service - nearly 9 out of 10 - did not need to return to the hospital for care in the month that followed their initial visit. The study was published in Healthcare.
"The culture is shifting where we realize that hospitalization is not always the best option for patients - particularly patients with chronic illness," said one of the study's lead authors, Austin Kilaru, MD, an emergency physician at Penn Medicine. "We need to find better ways of helping patients not just get healthy in a hospital, but stay healthy at home - whenever they are ready to be there."
Increasingly, emergency departments care for greater shares of patients with acute symptoms and illnesses. Increased visits can lead to strain on hospitals, so Kilaru, co-author David Resnick, a senior innovation manager at Penn Medicine's Center for Health Care Innovation, and their team devised a method to open capacity in emergency departments and hospitals - by sending patients home with the right resources and support to help them recover safely.
The project, which began in 2018 within the Center for Health Care Innovation's annual Innovation Accelerator, was named Practical Alternative to Hospitalization (PATH). It contained two important elements.
First, the PATH team deployed an advanced practice provider (APP) to screen hospital bed requests to determine which patients met criteria for discharge to home. They considered the reasons for the patient's visit, their vital signs, medical history, and social support systems. If the patient's emergency physician agreed with enrolling in PATH, the APP developed a comprehensive plan in partnership with that physician and the patient's care team.
Patients enrolled in the program received personalized support at home. This included phone calls or text messages to assess their status, coordination of outpatient appointments, and additional diagnostic testing. This tailored plan might also include home nursing visits, physical or occupational therapy, or transportation assistance.
"We were concerned that emergency physicians would be reluctant to discharge patients who they would have normally hospitalized, but it turns out that they liked having the option of choosing our services," Kilaru said. "It's a new alternative to staying in the hospital or going home completely on their own. We were seen as an added support, acting in the best interests of patients and medical providers alike."
In this study's 14-day trial period set in a single hospital during December 2019, 52 patients met PATH's eligibility requirements (of 199 possible patients). More than half of them, 30, enrolled in the program, with most of the remainder still requiring hospitalization at the discretion of the treating emergency physician.
Many of the patients enrolled in the program for common conditions, such as chest pain, high blood sugar, and congestive heart failure. The study authors estimate that patients would have spent more than two days, on average, in the hospital and eight additional hours waiting in the emergency department. Only four patients needed to return to the hospital within 30 days of their initial visit, when the PATH team recognized that patients again required hospital-level care.
"Another concern in this pilot was that patients might have worsening illness at home and need to return to the emergency department," Kilaru said. "Fortunately, our patients did well and had good outcomes - even 30 days later. We created careful safeguards to select the right patients, so while a few patients did need to return, it was not unexpected, and we could help communicate key medical and social issues to the emergency department and hospital teams."
The study took place just a few months before the COVID-19 pandemic swept the East Coast. While the service was paused as a result, the pandemic created a surge of interest in shifting care from hospitals to home, like Penn Medicine's Cancer Care at Home. In addition, lessons from this study have been applied to efforts to manage COVID at Penn Medicine, including an "accelerated care pathway," where patients who only needed short hospital stays were identified in the emergency department, efficiently treated in the hospital, and followed closely at home.
"This could be promising for payers, health systems, and patients alike," Resnick said. "Payers benefit by having their members avoid costly inpatient stays. Patients benefit by having more safe days at home. And hospitals with busy emergency departments and full beds benefit by freeing up resources that can be utilized by the most sick and complex patients."
Other authors on this study include Danielle Flynn, Avanti Rangnekar, Madeline Snyder, Kehinde Oyekanmi, Denise Fitzpatrick, Zachary Meisel, David Asch, and Krisda Chaiyachati.