Covid-19 fundamentally changed the way Americans interact with the health care system, including an increase in patients' interest in at-home care. Kirk Tucker, CMO of Adena Health System, spoke with Advisory Board's Susan McDonald about how Adena implemented its Adena at Home program amid the Covid-19 pandemic and the lessons the health system has learned.
Question: Tell me about Adena at home, what it is, how it began and how has it evolved because of Covid-19?
Kirk Tucker: Adena had already been having conversations about the idea of Adena at Home prior to the outset of Covid-19. There was a lot of interest in the idea of hospital at home and in conversations with our Chief of Inpatient Operations, Jashanpreet Singh. Singh was committed to this hospital-at-home idea because he truly believed that there will be a time when everything that can be transitioned to home will be transitioned to home-based care.
Shortly after this communication and commitment, Covid-19 hit. While southern Ohio was not hit hard in the first wave, Covid-19 still had a major impact and the home-based care idea highlighted our commitment to deliver care via this virtual modality, which was the only way at the time we could.
We continued establishing our Adena at Home program, reaching out to staff and getting buy-in for this idea to deliver care virtual, and it was gaining traction. Then comes Fall, and we experienced a massive surge of Covid-19 inpatient census, first going up to 30 and then to 60.
We have only three hospitals and needed support. So we reached out to big health systems, but they said they couldn't take any patients. We had so many patients. We were too nervous to send them home, but they were also well enough to not need much inpatient support. Singh asked me if we had a way to monitor them just as closely, but at home, and if I would be comfortable with this approach. I knew it was an option we needed to peruse so we did.
Adena at Home was implemented in 10 days—we pulled in the population health division (mostly former inpatient RNs) together, and I became the attending physician. We also included NPs and primary care physicians.
We acquired 60 iPads, created smart sheets, educated the hospital on who would qualify, and called this a "pilot." We began by sending 10 patients home in the first week with an iPad, educated the patient on how to use it and how we would treat them at home, and met with the population health education team before discharge. We provided 24/7 call assistance, where the patient could immediately talk to an RN, and we deployed durable medical equipment in their home health onboarding, if needed to dispatch resources to home.
Within the first week of this trail, a patient, who had previously not qualified for oxygen, needed it immediately and they got it to their house within 40 minutes. Every 12 hours, we input all the patients' vitals into the smart sheet and that would go out to Adena at Home team (blood pressure, temperature, persistent symptoms, etc.).
The day after discharge, the population health RN would have a phone call asking how the patients are doing, if they have new symptoms, and ensure all their needs were met. We used Facetime to interact with our patients and documented everything in the EHR and billed as a telehealth visit.
Rapidly, as we decompressed the units, we became comfortable and it freed up beds—in part by shortening stay length by 3.4 days—for other Covid-19 patients who could not be treated at home.
The results: We enrolled and cared for 165 cases, and we're now averaging 15 inpatients a day, as opposed to as high as 60 previously. We have only a 13% readmission rate for Covid-19 patients after launching this program. It's been a tremendous success.
Q: How engaged was your leadership and board, particularly your CEO Jeff Graham? Was it important to have him intimately engaged?
Tucker: We got no pushback whatsoever. There was support for this approach at all levels, including our board. That's partly because our primary care doctors did not have time to address these issues right away and this approach gave nurses immediate access to a provider.
However, we initially had a hard time getting staff signed up to deliver this care. So I agreed to become the attending physician. I was on call 24/7 for the first two months. However, this commitment was infectious, and doctors and nurses alike soon wanted to support treating our patients at home.
Q: Tell me more about the technology and staffing. Did you partner with a vendor? What role did telehealth play?
Tucker: No, we used our EHR to do all the documentation, and we bought blood pressure cuffs and thermometers. I believe we even bought the thermometers off Amazon.
As we all know, this pandemic lit a fire in the use of telehealth. We took full advantage of loosening regulations and restrictions to expand care using this modality. While the future is uncertain, we are still expanding the use of telehealth.
For example, we extended telehealth to urgent care. Patients can choose to come in person or be seen virtually. Of course, that all depends on the care that is needed and when a telehealth visit makes sense and when the physician believes they need to see the patient in person.
Q: How did you evaluate the need in your market? What was your business case and what operational resources were needed?
Tucker: We did a financial analysis and business plan to make it a system-wide clinical plan, and it's been very successful from a financial standpoint. We plan to make future capital investment to build out Adena at Home.
Q: What was the reaction from your patients who were treated at home?
Tucker: Fantastic! Our patients and family members could join my check-in calls with the patient, stressed that being in the hospital was terribly lonely, and said they felt cared for because they had access to a nurse and provider 24/7 if needed.
We know that Covid-19 takes a tremendous psychological toll on patients and they would much rather be at home with their family. One of our inpatient nurses' fathers was admitted for Covid-19, so we saw firsthand how difficult it is for both the patient and their family to go through this isolating experience.
Q: How has this pandemic accelerated the future for Adena at Home?
Tucker: We had plans for the Adena at Home model before the pandemic. Our experience with moving Covid-19 patients to the home allowed us to prove how this could work. From the patient to the care givers, it was a positive experience for all. Now, in phase 2 we are building clinical operations and support treating other chronic diseases that require hospital admission to be relocated to the home as soon as it is safe to do so, following the model we used for Covid-19 patients. We are already starting this for heart failure. Then we will be looking at treating COPD, pneumonia, and heart attacks—all cared for in the patient's home.
Q: How did you determine what services should or could shift to home?
Tucker: All these conditions are on the CMS readmission reduction and are very expensive to treat in the hospital. They need to be managed effectively, and we know from our experience with Covid-19 that patients would rather be in the home.
One of our own doctors experienced this firsthand with his father. Singh's parents live in India, and when his father went into heart failure, Singh was thankfully able to travel to India and care for his father. But the experience begged the question, "how do regular folks manage this?"
Q: What were your biggest challenges?
Tucker: The Adena at Home program touched many divisions within our health system, i.e. home care, population health, inpatient, primary care, DME (oxygen supply). We would not have been able to progress unless everybody was aware and on board. We had to scale this across the system needed to loop everyone in, coordinate communication, and ensure we received input from our staff and leaders.
Q: Did you find advantages in being a smaller system?
Tucker: I like to think of the difference in a British warship and a Corvette. When Spain was an empire, the British would build these massive battleships that kept losing. Spain was the Corvette and taking down the massive warships because the Spanish Corvette was extremely nimble and able to shift course quickly to find the best path to victory. That is how I see Adena and our ability to do the same; we took advantage of our size and our ability to be nimble.
Q: If you were to share your top "must need to consider" when developing a Hospital at Home program, what would they be?
Tucker: If you ask yourself, where will patients best recover from illness? Where do you get better the quickest? Hospital at home is where patients recover the best.
We know that the American health care system is broken and it's too expensive. This is a much cheaper solution to providing care, so it just makes sense and systems should be open to this type of care setting.
We know America is aging, more people who are falling ill and who are going to need inpatient beds—in fact, the acuity average for inpatient is double from a few years ago. Care needs to be delivered where it best fits the patient's need, and in turn, the hospital-at-home approach frees up beds for patients who require hospital-based care.
Patients would rather recover at home than in the hospital; they want to be with family and loved ones rather than isolated in the hospital. This approach improves satisfaction scores, patients want this, they don't want to be surrounded by weird people, sounds, places. They would rather be in the comfort of their own home.
The best advice I would give to a health care system working to stand up a hospital-at-home program—the "secret sauce to success"—is having someone who sees the vision, is clinically passionate, and is a leader.
Adena had that in Singh, originated from caring for his father's condition and working as a hospitalist. His passion for this cause was the reason that this was able to be stand this up so quickly.
Also keep in mind that people fear change. To get people past fear, demonstrate a trial first with yourself. I told my staff, "I won't do anything to you that I would not do to myself." Leaders must show the vision and be willing to fully participate. Once the team saw I was fully committed—serving as the doctor on call 24/7—there was a chain reaction. People were reaching out and wanting to help.
There is a scene in "Full Metal Jacket" where the field general is being interviewed on an active battle ground, he is out there on the front lines when he could have been commanding from safety. This is how you lead.