Rural Home Hospital: Proof of Concept

Study Overview
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Brief Summary
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This study examines the implications of providing hospital-level care in rural homes.

Detailed Description
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Home hospital care is hospital-level care at home for acutely ill patients. In multiple publications mostly in urban environments, home hospital care delivered cost-effective, high-quality, excellent experience care with similar quality and safety as traditional hospital care. Most home hospital models deliver care in urban environments, not in rural environments. To further improve the model, the investigators propose to determine the feasibility of home hospital care in a rural home setting through a proof-of-concept approach.

Official Title
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Hospital-Level Care at Home for Acutely Ill Adults in Rural and Ultra-Rural Settings: Proof of Concept

Conditions
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Infection, Heart Failure, Chronic Obstructive Pulmonary Disease, Asthma, Gout Flare, Chronic Kidney Diseases, Hypertensive Urgency, Atrial Fibrillation Rapid, Anticoagulants; Increased

Intervention / Treatment
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* Other: Home hospital care


Participation Criteria
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Eligibility Criteria
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Patient clinical inclusion Criteria: >=18 years old Any infectious process (e.g., pneumonia, diverticulitis, cellulitis, complicated urinary tract infection) Heart failure exacerbation Asthma and chronic obstructive pulmonary disease exacerbation Atrial fibrillation with rapid ventricular response Diabetes and its complications Venous thromboembolism: This includes a patient who requires therapeutic anticoagulation and concomitant monitoring (thus requiring inpatient status) Gout exacerbation Chronic kidney disease with volume overload Hypertensive urgency End of life / desires only medical management: Regarding a patient who desires only medical management, this includes a patient who requires acute care for symptom management but declines any surgical intervention. This may include a patient who is about to transition to hospice care, for example, but still has the functional capacity to meet our criteria below. Under these circumstances, we would make sure that various contingencies, including possible transition to hospice care or hospital readmission, are completely understood by patients and caregivers as applicable. Patient social inclusion criteria: Lives in rural or ultra-rural area (see definitions in Appendix) that can be served by one of our RHH clinicians. Has capacity to consent to study Can identify a potential caregiver who agrees to stay with patient for first 24 hours of admission. Caregiver must be competent to call care team if a problem is evident to her/him. After 24 hours, this caregiver should be available for as-needed spot checks on the patient: This criterion maybe waived for highly competent patients at the patient and clinician's discretion. Patient caregiver inclusion criteria: (not required for patient participation): Age >= 18 years old Has capacity to consent to study Lives with or nearby to patient Clinician inclusion criteria: Any member of the rural home hospital (RHH) clinical team (MD, RN, paramedic, NP) who will be participating in the screening and recruitment of patients for the rural home hospital intervention and/or providing care to rural patients that enroll in the intervention. Patient Clinical Exclusion Criteria: Acute delirium, as determined by the Confusion Assessment Method Cannot establish peripheral access (or access requires ultrasound guidance, unless ultrasound guidance is available) Secondary condition: active non-melanoma/prostate cancer, end-stage renal disease, acute myocardial infarction, acute cerebral vascular accident, acute hemorrhage Primary diagnosis requires controlled substances Cannot independently ambulate to bedside commode As deemed by on-call MD, patient likely to require any of the following procedures that have not already occurred: computed tomography, magnetic resonance imaging, endoscopic procedure, blood transfusion, cardiac stress test, or surgery For pneumonia: Most recent CURB65 > 3: new confusion, BUN > 19mg/dL, respiratory rate>=30/min, systolic blood pressure<90mmHg, Age>=65 (<14% 30-day mortality); Most recent SMRTCO > 2: systolic blood pressure < 90mmHg (2pts), multilobar CXR involvement (1pt), respiratory rate >= 30/min, heart rate >= 125, new confusion, oxygen saturation <= 90% (<10% chance of intensive respiratory or vasopressor support); Absence of clear infiltrate on imaging; Cavitary lesion on imaging; Pulmonary effusion of unknown etiology; O2 saturation < 90% despite 5L O2 For heart failure: Has a left ventricular assist device; GWTG-HF17 (>10% in-hospital mortality) or ADHERE18 (high risk or intermediate risk 1)*; Severe pulmonary hypertension For complicated urinary tract infection: Absence of pyuria; Most recent qSOFA > 1 (SBP≤100 mmHg, RR≥22, GCS<15 [any AMS]) (if sepsis, >10% mortality) For other infection: Most recent qSOFA > 1 (SBP≤100 mmHg, RR≥22, GCS<15 [any AMS]) (if sepsis, >10% mortality) For COPD: BAP-65 score > 3 (BUN>25, altered mental status, HR>109, age>65) (<13% chance in-hospital mortality): exercise caution For asthma: Peak expiratory flow < 50% of normal: exercise caution For diabetes and its complications: Requires IV insulin For hypertensive urgency: Systolic blood pressure > 190 mmHg; Evidence of end-organ damage; for example, acute kidney injury, focal neurologic deficits, myocardial infarction For atrial fibrillation with rapid ventricular response: Likely to require cardioversion; New atrial fibrillation with rapid ventricular response; Unstable blood pressure, respiratory rate, or oxygenation; Despite IV beta and/or calcium channel blockade in the emergency department, HR remains > 125 and SBP remains different than baseline; Less than 1 hour of time has elapsed with HR < 125 and SBP similar or higher than baseline For patients with end-stage renal disease on peritoneal dialysis: Peritoneal catheter malfunction; Requires temporary hemodialysis Home hospital census is full (maximum 3 patients at any time) GWTG-HF: AHA Get with the Guidelines: SBP, BUN, Na, Age, HR, Black race, COPD ADHERE: Acute decompensated heart failure national registry: BUN, creatinine, SBP Patient social exclusion criteria: Non-english speaking Undomiciled No working heat (October-April), no working air conditioning if forecast > 80°F (June-September), or no running water On methadone requiring daily pickup of medication in police custody Resides in facility that provides on-site medical care (e.g., skilled nursing facility) Domestic violence screen positive

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Home hospital care<br>Patients receive hospital-level care in their home, as a substitute to traditional hospital care. | Other: Home hospital care<br>* Patients receive hospital-level care in their home.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rural home hospitalization accomplished | Completion of rural home hospitalization using a checklist to assess process completion on a scale of excellent, very good, good, fair, poor or does not apply. | Day of admission to day of discharge, estimated 10 days later | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 3-item Care Transition Measure | This is a hospital level measure of performance that reports the average patient reported quality of preparation for self-care response among adult patients discharged from general acute care hospitals. Data will be collected by a Research Assistant via patient | Day of discharge to 7 days later | 
| Picker Experience Questionnaire | The Picker Patient Experience Questionnaire is a fifteen item questionnaire covering eight domains including information & education and coordination of care. The questionnaire is used to measure patient experience with in-patient care. The questions have two (yes or no) to four response options (yes, no, I did not need to, or yes, to some extent). Neutral answers, such as I did not need to, and the most positive answer are coded as a non-problem (score = 0). The remaining responses are coded as problems (score = 1). A problem is defined as any aspect of health care that could be improved upon. Data will be collected by a research assistant via patient | Day of discharge to 7 days later | 
| Global satisfaction: scale | Measure of patient experience and satisfaction with care using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible. Data will be collected by a Research Assistant via patient | Day of discharge to 7 days later | 
| Perceived acceptability of RHH care | Perceived acceptability will be assessed qualitatively through post-discharge semi-structured interviews with clinicians, patients, and caregivers. | Day of discharge to 30 days later | 
| Perceived safety, quality of care, caregiver burden | Perceived safety, quality of care, caregiver burden will be assessed qualitatively through one post-discharge semi-structured interview with each participating clinician, patient, and caregiver. | Day of discharge to 30 days later | 
| Escalation of care to hospital | If enrolled patient must be discharged from rural home hospital and taken to an acute-care hospital for care. Data to be collected daily by a research assistant via the Registered Nurse or Paramedic | Day of admission to day of discharge, estimated 10 days later | 
| Adverse event | Adverse events include Fall, Delirium, Potentially preventable VTE, New pressure ulcer, Thrombophlebitis at peripheral IV site. Data to be collected daily by a research assistant via the Registered Nurse or Paramedic | Day of admission to day of discharge, estimated 10 days later | 
| Unplanned mortality during admission | Any case of unplanned death among enrolled rural home hospital patient.Data to be collected daily by a research assistant via the Registered Nurse or Paramedic | Day of admission to day of discharge, estimated 10 days later | 
| Lab Orders, number | Number of clinical lab orders. Data to be collected daily by a research assistant via rural home hospital records | Day of admission to day of discharge, estimated 10 days later | 
| Length of stay | The number of days enrolled patient is admitted to rural home hospital.Data to be collected daily by a research assistant via rural home hospital records | Day of admission to day of discharge, estimated 10 days later | 
| Unplanned readmission(s) after index, number and yes or no | Unplanned readmission of patient to hospital 30 days post discharge from rural home hospital. Data to be collected by a research assistant via the patient. | 30-days post-discharge | 
| ED visit(s) after index, number and yes or no | Any ED visits 30 days post-discharge from rural home hospital. Data to be collected by a research assistant via the patient | 30-days post-discharge | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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home hospital, hospital at home, hospital in the home