Remote Physician Care for Home Hospital Patients

Study Overview
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Brief Summary
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This study examines the implications of providing remote physician care to home hospitalized patients compared to usual home hospital care with in-person/in-home physician visits.

Detailed Description
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Home hospital care is hospital-level care at home for acutely ill patients. In multiple publications, home hospital care delivered cost-effective, high-quality, excellent experience care with similar quality and safety as traditional hospital care. Most home hospital models require a licensed independent practitioner to see their patients physically in their home. To further improve the efficiency and scalability of home hospital care, the investigators propose to test remote care, where the physician would provide care via a video interaction, instead of in-home/in-person care. The investigators propose a non-inferiority evaluation of this intervention.

Official Title
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Remote Physician Care for Home Hospital Patients: A Randomized Controlled Trial

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: Remote Visit


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Resides within either a 5-mile or 20 minute driving radius of emergency department Has capacity to consent to study OR can assent to study and has proxy who can consent >= 18 years-old 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 may be waived for highly competent patients at the patient and clinician's discretion. Primary or possible diagnosis of cellulitis, heart failure, complicated urinary tract infection, pneumonia, COPD/asthma, other infection, chronic kidney disease, malignant pain, diabetes and its complications, gout flare, hypertensive urgency, previously diagnosed atrial fibrillation with rapid ventricular response, anticoagulation needs, or a patient who desires only medical management that requires inpatient admission, as determined by the emergency room team. Exclusion Criteria: 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 Acute delirium, as determined by the Confusion Assessment Method2 Cannot establish peripheral access in emergency department (or access requires ultrasound guidance, unless point-of-care ultrasound is available) Secondary condition: end-stage renal disease on hemodialysis, acute myocardial infarction, acute cerebral vascular accident, acute hemorrhage Primary diagnosis requires multiple or routine administrations of intravenous narcotics for pain control Cannot independently ambulate to bedside commode, unless home-based aides are available As deemed by on-call MD, patient likely to require any of the following procedures: computed tomography, magnetic resonance imaging, endoscopic procedure, blood transfusion, cardiac stress test, or surgery High risk for clinical deterioration Home hospital census is full

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
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Remote Visit<br>After an initial physical in-home visit, the physician will see home hospitalized patients by facilitated video each day. | Other: Remote Visit<br>* After an initial in-home visit, the physician will see home hospitalized patients by facilitated video.<br>|
| No Intervention: In-Home Visit<br>The physician will see home hospitalized patients physically in their homes each day, as is usual care. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Adverse events, # | The per patient count of adverse events, including fall, delirium, potentially preventable venous thromboembolism, new pressure ulcer, thrombophlebitis at peripheral IV site, catheter-associated urinary tract infection, new Clostridium difficile, new methicillin-resistant Staphylococcus aureus, new arrhythmia, hypokalemia, acute kidney injury, transfer back to hospital, mortality (unplanned) during admission, mortality (unplanned) 30-day post-discharge. | From date of admission to date of discharge (except for 30-day mortality), an expected average of 4 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Unplanned readmission after index admission, y/n |  | Day of discharge to 30 days later | 
| Picker experience questionnaire, score | Score between 0 and 15, with higher scores signifying better experience | Day of discharge, an expected average of 4 days | 
| Global experience, score | Score between 0 and 10, with higher scores signifying better experience | Day of discharge, an expected average of 4 days | 

 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