It’s possible for patients to receive hospital-level care inside their homes. HealthPartners Hospital@Home director Tia Radant and medical director Dr. Chrisanne Timpe talk about the program’s evolution as “the virtual unit,” which types of patients are ideal candidates for getting acute care at home, and the role community paramedics and other care team members play in treating patients.
It’s possible for patients to receive hospital-level care inside their homes. HealthPartners Hospital@Home director Tia Radant and medical director Dr. Chrisanne Timpe talk about the program’s evolution as “the virtual unit,” which types of patients are ideal candidates for getting acute care at home, and the role community paramedics and other care team members play in treating patients.
Producer's note: In this episode, Dr. Chrisanne Timpe says, "The Center for Medicare & Medicaid Services collected data for about three years on how these programs were doing nationally. And in that data with tens of thousands of patients, when they compared Hospital@Home groups to equally matched in brick and mortar treated groups, they showed that, for several diagnoses, there were reduced readmissions. But most importantly for somebody like me, there is a 20% chance of ending up needing a skilled nursing facility after hospitalization for frail elders for people who are in the brick and mortar, compared to 2.5%." The correct number is even lower: 1.2% for people in Hospital@Home, according to the Centers for Medicare & Medicaid Services.
Hosts: Kari Haley, MD, and Steven Jackson, MD
Guests: Tia Radant and Dr. Chrisanne Timpe
HealthPartners website: Off the Charts podcast
Got an idea? Have thoughts to share? We want to hear from you. Email us at offthecharts@healthpartners.com.
Kari Haley:
He is a rehab doctor from Chicago.
Steven Jackson:
She's an emergency medicine doctor from the Twin Cities.
Kari Haley:
Together we're examining the health equity emergency.
Steven Jackson:
Inviting voices for change without the cue cards.
Kari Haley:
I'm Dr. Kari Haley.
Steven Jackson:
I'm Dr. Steven Jackson.
Both, together:
And this is "Off the Charts."
Steven Jackson:
Welcome to our show. We're very excited to have our two guests, which I will sort of introduce in a minute. But just to kind of tee it up, medical care can be difficult, it can be scary, and when you're in an unfamiliar environment, it can make it all the more stressful. And we're really thankful for the Hospital@Home program, where one can receive medical care at home, and we're going to learn more about that. So today we have Dr. Chrisanne Timpe, who's the medical director of Hospital@Home, and we have Tia Radant, who is the director of Hospital@Home. Welcome, and thank you for being here.
Tia Radant:
Thank you.
Chrisanne Timpe:
Thank you for having us.
Steven Jackson:
So starting right off, tell us about the history of Hospital@Home. How did you guys come up with this? And tell us a little bit about it.
Chrisanne Timpe:
Great question. So here at HealthPartners, we had a couple of programs going on already where we were in patient homes. One of them was a program I was directing, which was a clinician in the home program called Home-Based Medicine, where we were seeing frail or chronically ill patients in their home because they couldn't or wouldn't go to clinic, and we found meeting them in their home was the best way to care for them. At that same time, Tia was directing her community paramedicine program, which she can talk about, and her program had the skill set that my program needed to deliver acute care. So we met in 2016 and put our heads together to create the Hospital@Home program, which was designed to treat people who were in need of a hospital bed at home in lieu of a hospital. Did you want to add to that?
Tia Radant:
Sure. So we have a team of community paramedics that work for Regions Hospital across HealthPartners, and a community paramedic is the expanded scope of practice from your standard 911 EMS paramedic. They have additional training on things like chronic-disease management, needs assessment, social determinants, navigating care. I like to think of our community paramedics as really good at life triage. They're able to come into a home and see what the priorities are from the patient's viewpoint and help access resources, whether that be clinical, maybe it's a physician's visit, maybe it's a tele visit, maybe it's getting a new sofa, maybe it is finding adult daycare for a parent. And that level of expertise is paired with the acute care expertise of a paramedic, so a community paramedic can still do all of the things a paramedic can do in terms of medications, monitoring, assessment, but brings this other life triage and disease management experience and lens to the scene.
And so when I heard about a team of people trying to pilot providing acute care in the home, I was at a meeting and where I met Chrisanne, someone said, "Well, who do we have in our system who can give IV Lasix?" which is a medication for congestive heart failure. And I rose my hand and said, "Oh, we have this team of paramedics doing this program. I think we would be a great fit." And so really that was sort of the beginning of this pretty awesome combination of skillsets from around HealthPartners. We have the paramedics, we have physicians, we have nurse practitioners, nurse clinicians, we have this whole team. And it really came from the idea of, we already have some folks at HealthPartners doing in-home care. And if we want to raise that up to hospital level care, who could we tap to do that?
Kari Haley:
And I think maybe if you guys don't mind describing the program a little bit just because I think it does get a little confusing for people and for even people who are listeners within our organization and then people who aren't. This is a really cool program. There's others ones across the country, but I think we do it really, really well here. So just so we know, what is Hospital@Home? Who are you caring for? Who are the patients? What are you doing? What are their criteria? That sort of stuff.
Chrisanne Timpe:
So patients who receive care through Hospital@Home are people who would otherwise be sitting in a hospital bed in a brick and mortar hospital to receive that same care. So that is the criteria for admission is that you need hospital-level care, but rather than sitting in the hospital to receive that care, you can receive it in the home. So we bring the medications, the durable medical equipment, the clinicians, the expertise to the patient in their home. So it really is designed to be exactly what it is called, Hospital@Home. So it receiving hospital level care, but in the comfort of someone's home. Tia always says that it's, we call it the virtual unit. It's like an extra floor of the hospital, and every room in that floor looks like someone's living room. And so that really, I think, is the best way to describe it. What would you add?
Tia Radant:
Yeah, I think it's really important to realize that hospital-level care can mean a lot of things. And when people hear that, it seems like, "How could you possibly do that in my home?" So we don't bring an intensive care unit into your home. We don't bring a surgical suite into your home, but a lot of patients who spend time in a physical brick and mortar hospital are in a bed being cared for by a team and having a physician make daily medical decisions for that care. And that part can be replicated in the home.
Steven Jackson:
Who is Hospital@Home for? And I do understand it's for people that need, or at least you have to need hospital-level care. But who is Hospital@Home for versus who is it not for?
Chrisanne Timpe:
Hospital@Home is for patients who want to be home, prefer to be home rather than in the brick and mortar, and are comfortable caring for themselves in the home. So it's not for people who really need 24/7 custodial care, which is why we don't, for example, do this in nursing homes. In some parts of the country, this is done in homeless shelters and hotel rooms. We typically are doing this in people's homes or their assisted living facility, assuming that they are independent.
Who does it benefit most? I would say there are certain populations who benefit most from this program. People with any sort of sensory deficit, so dementia, blindness, hearing loss, physical disability. People who have learned to adapt to those challenges in their community and thrive in their homes tend to do really well in this program because they can receive their acute care and not be denied the freedoms of living their life the way that they'd like to. Versus if they're in a brick and mortar hospital, and they oftentimes are staying in our beds, they have our lighting, they have people coming and going, and they don't have the control or the power to do things the way that they're used to doing them.
So that is one population. Another population that tends to do well are non-English-speaking patients and communities of color. Sometimes people who don't feel comfortable in a hospital setting for some reason would prefer to receive their care in their home space. So we've seen that it works well for people who otherwise might feel unwelcome in the hospital setting.
Kari Haley:
Yeah, I can say based on just personal experience working in the emergency department where we do refer quite a few patients or try to refer quite a few patients to the Hospital@Home program, I feel like the biggest piece truly is that they can take care of themselves at home and that they are motivated to get their care at home. Because sometimes that's one of our limiting factors of being able to enroll people is that they require two people to assist them to get to the bathroom, or they really just want to feel the love of a hospital bed and that inpatient stay when they could do it at home. But when you have that disconnect, sometimes it's harder to motivate someone to potentially be a good candidate for this program.
Tia Radant:
Some of the things that help conceive of, what condition would I have that would make me eligible for Hospital@Home where there would be a safe choice between inpatient in the hospital or inpatient at home, might be an infection on your arm or leg that requires your labs to be drawn every day, your blood samples to be drawn to monitor, and some IV medications. It might be that you have influenza or another type of pneumonia, where you need oxygen that you didn't previously need. You need someone to monitor that for you. But at the same time, you're well enough at home to get up and use the restroom on your own. You're well enough to get up and make yourself something to eat. We do provide meals if patients want them, but they would need to be able to get up and prepare them.
So it's the person who otherwise could get up and care for themselves in the hospital room but still needs hospital-level care. That's the sweet spot today across the country for Hospital@Home. There are programs that have more support in the home, more care providers, more time during the day with a care team at the patient's side and can take a more complex situation. But for us right now, what we're focused on are patients who want to be at home, who are safe to be at home, and who can have a safe plan of care, but would otherwise be in the physical brick and mortar hospital.
Kari Haley:
Right, and I feel like maybe we're making it sound like it's a very small amount of people, but it's actually quite a large population that is very much a candidate for this program, I think. And what I'd love to hear is maybe some success stories that you guys have had because there are many, many successes with this program. And just instead of hearing, it's kind of easy to focus on what doesn't work with it, but it really does work for a very large population of patients. And who is doing super well with it?
Tia Radant:
Well, I think of the patient who was completely blind that Chrisanne sort of mentioned earlier. He had an infection, he needed IV medications, he needed his labs to be monitored every day. And he lives in an apartment with his spouse and at home can navigate around to make his own meals, use the restroom when he wants to, sit on his chair, find what he needs to find. But when that same patient is being cared for in our hospital, he's really essentially trapped in his hospital bed unless a staff member comes to his side and helps him walk around.
And one of the biggest risks that we find in recovery is often how mobile you can be during your recovery. So if you can't get up and stretch your legs, if you can't get up and use the restroom at your leisure, that adds some risks to your recovery and really a complete loss of control and autonomy for that patient who's now completely at the systems, needs everything to be done for them rather than being able to be engaged in their own care at home. And so that patient, you can imagine, was very ecstatic to be home, felt safer at home, felt like they had the ability to make good decisions for their own care at home, and loved Hospital@Home. So that's a quick and easy success story.
Chrisanne Timpe:
We've had several cases, and I'll give you an example of one, of patients with dementia who are well cared for by their families. But in the past, when they've been hospitalized, the outcomes have been pretty dire. So people will become deconditioned because they're not allowed to move around as much. They get delirious. They get into a cycle where the sleep-wake cycle gets off. They end up being medicated at night for their agitation. And what turns into what should have been a 48-hour stay for an infection turns into a week long, where you're trying to unravel a delirium that is really detrimental to a patient's overall.
So we've had a few cases now where there are patients with dementia who come in with an infection, really need hospital care, but the family will advocate and say, "What can we do to make sure we can keep mom or dad at home with us?" And in all of those cases, the family has been excellent at helping to be an advocate in the home, communicating with the team. The team shows up, delivers the hospital care, the patient does well. None of them become delirious, none of them fall, and the hospital stay ends up being the 48 hours that it should have been to begin with. So that I think is one, and as sort of a geriatric-minded person, I think it's a really great example of how to use the program.
The other major category for success is congestive heart failure. Congestive heart failure continues to challenge us in health care.
Steven Jackson:
Readmissions. Oh, yeah.
Chrisanne Timpe:
People end up being readmitted very frequently despite our best efforts. When you are in a patient's home diuresing them, and you see that they're going to drink a liter of Mountain Dew and have a bag of tater tots for dinner, you can adjust the plan of care to meet their financial needs and their preferences. And so I do think that what we're seeing, and I also practice as a hospitalist, so what I see in a hospital ward where somebody orders a meal from a menu that's tailored to their 2000-milogram sodium diet and sitting in our bed where we can help them to the bathroom and back, and we bring them all of their pills, they do great until they leave. And then they go home, and they open their freezer, and they pull out their freezer meals and their low-cost food, which tends to be higher in sodium, and they have to somehow keep track of which medications to take when. There's a major voltage drop there in the support that those people are getting.
So what we found is that if we can manage the acute illness in the home and incorporate social determinants into the plan of care, people tend to do better and have a better understanding of their own health care issues than they did when we did it in the hospital. Now, that's not to disparage hospital care. I am a hospitalist, and I think we do our best. But there is a missing piece that we cannot receive when somebody is in our hospital, and that's that entire social spectrum.
Kari Haley:
Are there data points that show how patients who do Hospital@Home differ from those who receive their care in the hospital?
Chrisanne Timpe:
Yes. So after the waiver was put out in 2020, CMS, the Center for Medicare & Medicaid Services, collected data for about three years on how these programs were doing nationally. And in that data with tens of thousands of patients, when they compared Hospital@Home groups to equally matched in brick and mortar treated groups, they showed that, for several diagnoses, there were reduced readmissions. But most importantly for somebody like me, there is a 20% chance of ending up needing a skilled nursing facility after hospitalization for frail elders for people who are in the brick and mortar, compared to 2.5% [Update: The actual number is 1.2%] for people in Hospital@Home.
Kari Haley:
That's crazy.
Steven Jackson:
It's unbelievable.
Chrisanne Timpe:
It is.
Kari Haley:
But also believable at the same time.
Tia Radant:
None of our Hospital@Home patients have acquired a hospital-acquired infection while at Hospital@Home.
Kari Haley:
They don't have the same deconditioning that they do in the hospital either.
Steven Jackson:
You mean since it started?
Tia Radant:
Since our program started.
Steven Jackson:
Wow.
Tia Radant:
We've had over 900 admissions. I can tell you we have had no infections. We've had two falls. One required a bandaid for a skinned knee, and one which was assisted by a family member to the floor came back to the hospital just because of their level of weakness with no other bad outcomes.
Chrisanne Timpe:
We've also similarly had no pressure ulcer development and no C. diff or other acquired infections from Hospital@Home.
Steven Jackson:
I think I want Hospital@Home.
Tia Radant:
There's another recipe or another ingredient in our secret sauce, and that is, all of the patients in our Hospital@Home program continue to see those community paramedics for up to 30 days after discharge. And so when we first started our community paramedicine program here, we studied whether or not we had any impact on readmissions and return trips to the ED. And what we found for patients with congestive heart failure and other cardiopulmonary conditions is not only do we see a reduction in ED visits and readmissions in the 30 days while we're seeing the patient post discharge, but all the way out to six months after discharge, meaning we're able to help patients navigate the longitudinal care that they need. I always say it's like getting that train on the right track and not quite as wobbly. So food access, medication access, access to the right specialty care, talking to patients' families about understanding what the disease process is.
And I had one of our very first community paramedics say to me, "Tia, I told a patient that they could feel better. And she'd never heard that before, that she'd never heard that, yes, you have a chronic disease, but you can feel better." And so a lot of it is about, the acute care in the home is great. It reduces risk, it gives patient power, but it allows us to see what might really be going on that isn't as obvious when you're reading a chart in Epic or you're sitting at the clinic. And I don't know about you, but we tell our doctors what we think they want to hear, which may not always be 100% true all the time.
Steven Jackson:
Does that really happen?
Tia Radant:
So we're able to just sort of level set with patients and say, "Hey, I see what's going on. How can I help you from where you are?"
Steven Jackson:
What an awesome program. I know we've met, and I think you were on that same meeting when we were talking about Hospital@Home, and I didn't know much about it at that time. And I feel like I'm a little slow, so maybe I forgot everything we talked about, but this has been awesome just to hear about the program. And some of the things that stand out to me, some overriding themes, number one, I've heard power. We're empowering patients and families. We talk often on this podcast about power dynamics. When our patients are admitted, they're likely half-dressed, they're likely lying down, not sitting up, they're likely in pain, and they have to stay there. We get to go home as care providers. How can we change the power dynamics? Well, this is one way to do that.
The other thing that I'm hearing also is equity, meeting people where they are, not giving them the cookie cutter treatment plan or treatment approach. If you're not comfortable in the hospital for whatever reason, well, we have a program that might mitigate some of that. Or if you have a chronic illness or if you have blindness as an example, well, we don't want you to just get in line and deal with it because this is what we have in place, but we have something for you that's going to benefit you. So I think this is great, and it just falls in line with our values as an organization as well. So kudos to you guys. I would clap, but I don't know how it would sound on the recording.
Kari Haley:
May not sound so good, right. Maybe too loud. What about the people who are providing the care? What are our community paramedics thinking? What are you as a hospitalist thinking about this? And how has this changed how you view patients in the hospital and/or has it brought any other fulfillment to the career in how you feel about caring for patients?
Chrisanne Timpe:
Yeah, absolutely. So my partner and I did a mini study with our hospitalist group. We asked them questions about job satisfaction, the greater group, which is about a hundred clinicians, and then the 12 of us who do Hospital@Home. And the scores for that subset of people who do Hospital@Home for job satisfaction, joy in your work, just day-to-day satisfaction and self-wellness were leaps and bounds better than the greater group. And when we talk about it as a group, a lot of them will say things like, "It just feels like practicing holistic medicine." "It's a window into the humanity of my patients," is a quote by Dr. Ankit Mehta, and it's true. I mean, really there's something about the hospital. We enjoy working here. It's fulfilling work, but the pace is a little different, and the connection with the patient is a little bit different. There's something about seeing their homes and learning about their cat or their ailing mother-in-law that gives you a new perspective on how to meet them where they are. So I think that it without a doubt has been a satisfier for hospitalists.
Tia Radant:
I'm a paramedic, and I worked 911 in the suburban area around the Twin Cities for about 14 years. And I remember hearing about community paramedicine and alternative ways of caring for patients towards the end of my time on the ambulance. And I remember a 911 call for a woman who simply just didn't have the energy to stand all the way up out of her recliner, so she had slipped to the floor, and her husband couldn't lift her up. And so we all went. We made sure she was OK. It turns out she really did need to go to the hospital that day. But in the moment, in talking with her, this was her third call for that same thing. And I thought, "Boy, if the first time she called, we had another resource other than a fire truck, a police car, and an ambulance to send to her house to help her recognize her increasing weakness, figure out a plan, we would've avoided an injury and a trip to the emergency department."
I think that the paramedics who are drawn to this work, it's really hard to describe it. I will tell anybody who's interested, I would love for them to come just spend a half day with our team. Because once you've done a few of these visits, it really does click why you need the acute care skills of a paramedic but you need the humanity of someone who's really used to working in the community. So you're used to opening the door and greeting people wherever they're at and whatever shape their home might be and whatever location home is with whomever is inside the home and working within the resources that are already there.
I think our paramedics would tell you this is the most rewarding of the work that they've done. We all probably started as green paramedics thinking lights and sirens and trauma. As an instructor, I have once said, "Chest trauma is the sexy part of EMS." But in the end, it really isn't because you don't really get to solve the problem, and the people who are drawn to this are really problem solvers and want to be able to see the success of the patient throughout a timeline.
But today, the team is small, and I anticipate that community paramedicine will continue to grow, and the role within Hospital@Home will grow. Something else worth pointing out is, during the pandemic, a public health emergency waiver was put in place. It's the Hospital@Home waiver we talk about. And really what that meant was hospitals were allowed to waive their condition of participation of having a nurse available 24 hours a day, and that's what allowed Hospital@Home to be a billable admission. That's how our program really was able to thrive, and many around the country were created from this. It's currently extended until March 31st of 2025, which we all recognize is awfully soon. And so we are looking and hopeful that there'll be some longer-term extensions of that.
But one of the most fascinating things is that Medicare specifically states in this waiver that the acute care at home can be delivered by either a nurse or a mobile integrated health paramedic. And it's the first time Medicare has ever acknowledged paramedics providing care apart from an ambulance, that the transportation and the ambulance itself is not a part of that acute care. And so we partner with nurses and can deliver even better care because we have both nurses and paramedics involved, and I think the relationship of our paramedics with those nurses and with the hospitalists have brought a lot of professional growth and professional satisfaction. I can tell you, five years ago, I'm not sure how many hospitalists knew what a paramedic really was, much less a community paramedic. And certainly you didn't have paramedics chatting and calling and sidebarring with hospitalists on a regular basis.
So we have this really neat dynamic where the EMS medical director still provides medical direction to the paramedics, but the daily care decision making is a partnership between the paramedic and the hospitalist. So the long version is, there's a lot of great professional development that comes from this, and I fully expect to see it grow.
Kari Haley:
As a EMS person who has been very tuned with your guys' program, I think that it's just like another avenue for paramedics to get involved in the system of health care because for so long they've been outside that. We bring people to the hospital. The way it's reimbursed is we bring people places, not necessarily we're part of the clinician team. And having this program and having this elevation of paramedicine, I think, will only bring better results to health care in general, and I think it just brings that street cred in a little bit. Paramedics work in the street, they thrive in the street, they thrive outside the hospital walls, and that's where we maybe are looking towards to providing more care. So I think your program's awesome. I'm incredibly biased by that though, so thank you so much for being here and talking about it. I don't know, Steve, do you have any other good closing thoughts? You always do.
Steven Jackson:
As the non-EMS person at the table, I'd just like to say that I'm very impressed. What this program does, it meets people exactly where they are. Again, it's not just a good idea, and this is kind of cool, but this is needed. The one thing that I can't really get out of my head, when you go to all the conference rooms across campus and across the system, you'll always see relationships built on trust and service to all. This is the epitome of that. People need this, and I can't help but to think about the family that doesn't want to go into the hospital. I mean, how great is that for the hospital? I mean, literally, the hospital comes to them, and they can thrive in their own environment and get the same if not better outcomes in those that go to the hospital. That's called leveling the playing field. That's equity at its finest. So thank you guys for what you do, and on behalf of all the people that you have affected, thank you.
Chrisanne Timpe:
Thank you for having us.
Tia Radant:
Thank you.
Steven Jackson:
"Off the Charts" is a production of HealthPartners and Park Nicollet.
Kari Haley:
It is recorded by Jimmy Bellamy, with creative by Peggy Arnson, Tina Long, Tim Myers and Jeff Jondahl.
Steven Jackson:
Production service is provided by Matriarch Digital Media.
Kari Haley:
Our theme music is by Ryan Ike.