Skip to main content

Advertisement

Springer Nature Link
Log in

Effectiveness of a Multifaceted Implementation Strategy to Increase Equitable Hospital at Home Utilization: An Interrupted Time Series Analysis

  • Original Research: Qualitative Research
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Background

The number of Hospital-at-Home (HaH) programs rapidly increased during the COVID-19 pandemic and after issuance of Centers for Medicare and Medicaid Services’ (CMS) Acute Hospital Care at Home (AHCaH) waiver. However, there remains little evidence on effective strategies to equitably expand HaH utilization.

Objective

Evaluate the effects of a multifaceted implementation strategy on HaH utilization over time.

Design

Before and after implementation evaluation using electronic health record (EHR) data and interrupted time series analysis, complemented by qualitative interviews with key stakeholders.

Participants

Between December 2021 and December 2022, we identified adults hospitalized at six hospitals in North Carolina approved by CMS to participate in the AHCaH waiver program. Eligible adults met criteria for HaH transfer (HaH-eligible clinical condition, qualifying home environment). We conducted semi-structured interviews with 12 HaH patients and 10 referring clinicians.

Interventions

Two strategies were studied. The discrete implementation strategy (weeks 1–12) included clinician-directed educational outreach. The multifaceted implementation strategy (weeks 13–54) included ongoing clinician-directed educational outreach, local HaH assistance via nurse navigators, involvement of clinical service line executives, and individualized audit and feedback.

Measures

We assessed weekly averaged HaH capacity utilization, weekly counts of unique referring providers, and patient characteristics. We analyzed themes from qualitative data to determine barriers and facilitators to HaH use.

Results

Our evaluation showed week-to-week increases in HaH capacity utilization during the multifaceted implementation strategy period, compared to discrete-period trends (slope-change odds ratio—1.02, 1.01–1.04). Counts of referring providers also increased week to week, compared to discrete-period trends (slope-change means ratio—1.05, 1.03–1.07). The increase in HaH utilization was largest among rural residents (11 to 34%). Barriers included HaH-related information gaps and referral challenges; facilitators included patient-centeredness of HaH care.

Conclusions

A multifaceted implementation strategy was associated with increased HaH capacity utilization, provider adoption, and patient diversity. Health systems may consider similar, contextually relevant multicomponent approaches to equitably expand HaH.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
€32.70 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price includes VAT (Finland)

Instant access to the full article PDF.

Institutional subscriptions

Figure 1

Similar content being viewed by others

Data Availability:

De-identified datasets generated and analyzed during the study, codebook, and data collection tools may be available from the corresponding author on reasonable request.

References

  1. Kadakia KT, Balatbat CA, Siu AL, et al. Hospital-at-Home: Multistakeholder Considerations for Program Dissemination and Scale. Milbank Q. 2022;100(3):673-701.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039-2046.

    Article  PubMed  Google Scholar 

  3. Marcantonio ER, Solomon CG. Delirium in Hospitalized Older Adults. N Eng J Med 2017;377(15):1456-1466.

    Article  Google Scholar 

  4. Stewart NH, Arora VM. Sleep in Hospitalized Older Adults. Sleep Med Clin. 2022;17(2):223-232.

    Article  PubMed  Google Scholar 

  5. Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-Associated Disability: “She Was Probably Able to Ambulate, but I’m Not Sure”. JAMA. 2011;306(16):1782–1793. https://doi.org/10.1001/jama.2011.1556.

  6. Loyd C, Markland AD, Zhang Y, et al. Prevalence of Hospital-Associated Disability in Older Adults: A Meta-analysis. J Am Med Dir Assoc. 2020;21(4):455-461.e455.

    Article  PubMed  Google Scholar 

  7. Leff B. Defining and disseminating the hospital-at-home model. CMAJ. 2009;180(2):156-157.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Leff B, Montalto M. Home Hospital—toward a Tighter Definition. J Am Geriatr Soc. 2004;52(12):2141-2141.

    Article  PubMed  Google Scholar 

  9. Conley J, O'Brien CW, Leff BA, Bolen S, Zulman D. Alternative Strategies to Inpatient Hospitalization for Acute Medical Conditions: A Systematic Review. JAMA Intern Med. 2016;176(11):1693-1702.

    Article  PubMed  Google Scholar 

  10. Goncalves-Bradley DC, Iliffe S, Doll HA, et al. Early discharge hospital at home. Cochrane Database Syst Rev. 2017;6(6):CD000356.

  11. Shepperd S, Iliffe S, Doll HA, et al. Admission avoidance hospital at home. Cochrane Database Syst Rev. 2016;9(9):CD007491.

  12. Arsenault-Lapierre G, Henein M, Gaid D, Le Berre M, Gore G, Vedel I. Hospital-at-home interventions vs in-hospital stay for patients with chronic disease who present to the emergency department: a systematic review and meta-analysis. JAMA Netw Open. 2021;4(6):e2111568. https://doi.org/10.1001/jamanetworkopen.2021.11568.

  13. Nogues X, Sanchez-Martinez F, Castells X, et al. Hospital-at-Home Expands Hospital Capacity During COVID-19 Pandemic. J Am Med Dir Assoc. 2021;22(5):939-942.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Clarke DV, Newsam J, Olson DP, Adams D, Wolfe AJ, Fleisher LA. Acute hospital care at home: the CMS waiver experience. NEJM Catalyst. 2021;2(6). https://doi.org/10.1056/CAT.21.0338.

  15. Adams D, Wolfe AJ, Warren J, et al. Initial findings from an acute hospital care at home waiver initiative. JAMA Health Forum. 2023;4(11):e233667. https://doi.org/10.1001/jamahealthforum.2023.3667.

  16. Levine DM, Souza J, Schnipper JL, Tsai TC, Leff B, Landon BE. Acute Hospital Care at Home in the United States: The Early National Experience. Ann Intern Med. 2024;177(1):109-110.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Levine DM, DeCherrie LV, Siu AL, Leff B. Early Uptake of the Acute Hospital Care at Home Waiver. Ann Intern Med. 2021;174(12):1772-1774.

    Article  PubMed  Google Scholar 

  18. Sitammagari K, Murphy S, Kowalkowski M, et al. Insights From Rapid Deployment of a "Virtual Hospital" as Standard Care During the COVID-19 Pandemic. Ann Intern Med. 2021;174(2):192-199.

    Article  PubMed  Google Scholar 

  19. S. 4350 — 118th Congress: A bill to amend title XVIII of the Social Security Act to extend acute hospital care at home waiver flexibilities. 2024; https://www.govtrack.us/congress/bills/118/s4350. Accessed June 17, 2024.

  20. Leff B, DeCherrie LV, Montalto M, Levine DM. A research agenda for hospital at home. J Am Geriatr Soc. 2022;70(4):1060-1069.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Vandenbroucke JP, von Elm E, Altman DG, et al; for the STROBE initiative. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Ann Intern Med. 2007;147:W-163-W-194. https://doi.org/10.7326/0003-4819-147-8-200710160-00010-w1.

  22. Okoli C, Pawlowski SD. The Delphi method as a research tool: an example, design considerations and applications. Inf Manag. 2004;42(1):15-29.

    Article  Google Scholar 

  23. Malterud K, Siersma VD, Guassora AD. Sample Size in Qualitative Interview Studies. Qual Health Res. 2016;26(13):1753-1760.

    Article  PubMed  Google Scholar 

  24. Auriemma CL, Taylor SP, Harhay MO, Courtright KR, Halpern SD. Hospital-Free Days: A Pragmatic and Patient-centered Outcome for Trials among Critically and Seriously Ill Patients. Am J Respir Crit Care Med. 2021;204(8):902-909.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Jakobsen JC, Gluud C, Wetterslev J, Winkel P. When and how should multiple imputation be used for handling missing data in randomised clinical trials – a practical guide with flowcharts. BMC Med Res Methodol. 2017;17(1):162. https://doi.org/10.1186/s12874-017-0442-1.

  26. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117. https://doi.org/10.1186/1471-2288-13-117.

  27. Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nurs Health Sci. 2013;15(3):398-405.

    Article  PubMed  Google Scholar 

  28. Jaklevic MC. Pandemic boosts an old idea-bringing acute care to the patient. JAMA. 2021. https://doi.org/10.1001/jama.2021.0127.

  29. Powell BJ, Fernandez ME, Williams NJ, Aarons GA, Beidas RS, Lewis CC, McHugh SM, Weiner BJ. Enhancing the impact of implementation strategies in healthcare: a research agenda. Front Public Health. 2019;7:3. https://doi.org/10.3389/fpubh.2019.00003.

  30. Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, Proctor EK, Kirchner JE. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci. 2015;10:21. https://doi.org/10.1186/s13012-015-0209-1.

  31. Li S-A, Jeffs L, Barwick M, Stevens B. Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review. Syst Rev. 2018;7(1):72. https://doi.org/10.1186/s13643-018-0734-5.

  32. Gorbenko K, Baim‐Lance A, Franzosa E, et al. A national qualitative study of Hospital‐at‐Home implementation under the CMS Acute Hospital Care at Home waiver. J Am Geriatr Soc. 2022;71(1):245-258.

    Article  PubMed  Google Scholar 

  33. Lewis CC, Klasnja P, Powell BJ, Lyon AR, Tuzzio L, Jones S, Walsh-Bailey C, Weiner B. From classification to causality: advancing understanding of mechanisms of change in implementation science. Front Public Health. 2018;6:136. https://doi.org/10.3389/fpubh.2018.00136.

  34. Fernandez ME, Ten Hoor GA, van Lieshout S, Rodriguez SA, Beidas RS, Parcel G, Ruiter RAC, Markham CM, Kok G. Implementation mapping: using intervention mapping to develop implementation strategies. Front Public Health. 2019;7:158. https://doi.org/10.3389/fpubh.2019.00158.

  35. Virgili G, Weiss D, Rydland HT, Øversveen E, Jensen MR, Solhaug S, Krokstad S. Innovative technologies and social inequalities in health: a scoping review of the literature. Plos One. 2018;13(4):e0195447. https://doi.org/10.1371/journal.pone.0195447.

  36. Leong MQ, Lim CW, Lai YF. Comparison of Hospital-at-Home models: a systematic review of reviews. BMJ Open. 2021;11(1):e043285.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Leff B, Burton L, Mader S, et al. Satisfaction with Hospital at Home Care. J Am Geriatr Soc. 2006;54(9):1355-1363.

    Article  PubMed  Google Scholar 

  38. Chua CMS, Ko SQ, Lai YF, Lim YW, Shorey S. Perceptions of Hospital-at-Home Among Stakeholders: a Meta-synthesis. J Gen Intern Med. 2022;37(3):637-650.

    Article  PubMed  Google Scholar 

  39. Leff B, Ritchie C, Ciemins E, Dunning S. Prevalence of use and characteristics of users of home-based medical care in Medicare Advantage. J Am Geriatr Soc. 2023;71(2):455-462.

    Article  PubMed  Google Scholar 

  40. Probst J, Eberth JM, Crouch E. Structural Urbanism Contributes To Poorer Health Outcomes For Rural America. Health Affairs. 2019;38(12):1976-1984.

    Article  PubMed  Google Scholar 

  41. Callaghan T, Kassabian M, Johnson N, et al. Rural healthy people 2030: new decade, new challenges. Prev Med Rep. 2023;33:102176. https://doi.org/10.1016/j.pmedr.2023.102176.

  42. Brownson RC, Kumanyika SK, Kreuter MW, Haire-Joshu D. Implementation science should give higher priority to health equity. Implement Sci. 2021;16(1):28. https://doi.org/10.1186/s13012-021-01097-0.

  43. Kerkhoff AD, Farrand E, Marquez C, Cattamanchi A, Handley MA. Addressing health disparities through implementation science—a need to integrate an equity lens from the outset. Implement Sci. 2022;17(1):13. https://doi.org/10.1186/s13012-022-01189-5.

Download references

Acknowledgements:

The authors gratefully acknowledge Jennifer Priem, PhD, for her contributions to initial planning and study oversight and Ryan Burns, MS, for his assistance in managing project milestones. Additionally, the authors would like to thank the clinical leaders and clinical teams from the participating hospitals and the Atrium Health Hospital at Home program. Finally, the authors extend their gratitude to all of the study participants for sharing their time and insights.

Funding

Research reported in this publication was supported by the Duke Endowment under award number 6993-SP. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Duke Endowment.

Author information

Authors and Affiliations

  1. Department of Internal Medicine, Section of Hospital Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA

    Marc Kowalkowski PhD, Padageshwar Sunkara MBBS & Raghava Nagaraj MBBS, MPH

  2. Center for Health System Sciences, Atrium Health, Charlotte, NC, USA

    Marc Kowalkowski PhD, Casey Stephens MPH, Hieu Nguyen MS & McKenzie Isreal MPH

  3. Information Technology, Data and Analytics, Atrium Health, Charlotte, NC, USA

    Timothy Hetherington MS

  4. Department of Anthropology, University of Kentucky, Lexington, KY, USA

    Henry Bundy PhD

  5. Population Health, Clinical Integration, Atrium Health, Charlotte, NC, USA

    Colleen Hole BSN, MHA

  6. Department of Internal Medicine, Division of Hospital Medicine, Atrium Health, Charlotte, NC, USA

    Kranthi Sitammagari MD, Andrew McWilliams MD, MPH & Stephanie Murphy DO

  7. Virtual Care, Atrium Health, Charlotte, NC, USA

    Marvin Knight MD

  8. Medical Group, Atrium Health, Charlotte, NC, USA

    Susan Marston BSN, MBA

  9. Division of Community and Social Impact, Atrium Health, Charlotte, NC, USA

    Pooja Palmer MS

  10. Information Technology, Medical Informatics, Atrium Health, Charlotte, NC, USA

    Andrew McWilliams MD, MPH

  11. Medically Home Group, Inc., Boston, MA, USA

    Stephanie Murphy DO

Authors
  1. Marc Kowalkowski PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Casey Stephens MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Timothy Hetherington MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hieu Nguyen MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Henry Bundy PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. McKenzie Isreal MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Colleen Hole BSN, MHA
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Padageshwar Sunkara MBBS
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Raghava Nagaraj MBBS, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Kranthi Sitammagari MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Marvin Knight MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Susan Marston BSN, MBA
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Pooja Palmer MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Andrew McWilliams MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Stephanie Murphy DO
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Marc Kowalkowski PhD.

Ethics declarations

Ethics Statement:

The study was approved by the Wake Forest University Health Sciences Institutional Review Board (IRB00082471) on September 27, 2021.

Conflict of Interest:

Dr. Kowalkowski reports receiving grant support from the National Institutes of Health, Agency for Healthcare Research and Quality, and Duke Endowment outside of the submitted work. Dr. McWilliams reports receiving grant support from the Duke Endowment outside of the submitted work. Dr. Murphy reports receiving salary support from Medically Home Group, Inc. All other authors have no conflicts to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 772 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kowalkowski, M., Stephens, C., Hetherington, T. et al. Effectiveness of a Multifaceted Implementation Strategy to Increase Equitable Hospital at Home Utilization: An Interrupted Time Series Analysis. J GEN INTERN MED 39, 2496–2504 (2024). https://doi.org/10.1007/s11606-024-08931-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-024-08931-3

KEY WORDS

Search

Navigation