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.
METHODS: Before and after implementation evaluation using electronic health record (EHR) data and interrupted time series analysis, complemented by qualitative interviews with key stakeholders.
METHODS: 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.
METHODS: 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.
METHODS: 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.
OBJECTIVE: Evaluate the effects of a multifaceted implementation strategy on HaH utilization over time.
METHODS: Before and after implementation evaluation using electronic health record (EHR) data and interrupted time series analysis, complemented by qualitative interviews with key stakeholders.
METHODS: 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.
METHODS: 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.
METHODS: 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.
摘要：
背景：在COVID-19大流行期间，以及在医疗保险和医疗补助服务中心(CMS)居家急性医院护理(AHCaH)豁免后，居家医院(HaH)项目的数量迅速增加。然而,关于公平扩大HaH利用率的有效策略的证据很少。
目的：评估多方面的实施策略对HaH利用的影响。
方法：使用电子健康记录（EHR）数据和中断时间序列分析进行实施评估前后，辅之以与关键利益相关者的定性访谈。
方法：在2021年12月至2022年12月之间，我们确定了在北卡罗来纳州六家医院住院的成年人，这些医院经CMS批准参加AHCaH豁免计划。符合条件的成年人符合HaH转移的标准(HaH符合条件的临床状况，合格的家庭环境)。我们对12名HaH患者和10名转诊临床医生进行了半结构化访谈。
方法：研究了两种策略。离散实施策略（第1-12周）包括临床医生指导的教育推广。多方面的实施策略（第13-54周）包括正在进行的临床医生指导的教育推广，通过护士导航员提供当地的HaH援助，临床服务部门高管的参与，以及个性化的审核和反馈。
方法：我们评估了每周平均HaH产能利用率，每周统计唯一转介提供者，和患者特征。我们从定性数据中分析了主题，以确定HaH使用的障碍和促进因素。
结果：我们的评估显示，在多方面的实施战略期间，HaH产能利用率每周都在增加，与离散周期趋势相比（斜率变化比值比-1.02，1.01-1.04）。转介提供者的数量也每周增加，与离散周期趋势相比（斜率变化均值比率-1.05，1.03-1.07）。农村居民中HaH利用率的增幅最大(11%至34%)。障碍包括与HaH相关的信息差距和转诊挑战；促进者包括以患者为中心的HaH护理。
结论：多方面的实施策略与提高HaH产能利用率有关，提供商采用，病人的多样性。卫生系统可能会考虑类似，与上下文相关的多组分方法，以公平地扩展HaH。
目的：评估多方面的实施策略对HaH利用的影响。
方法：使用电子健康记录（EHR）数据和中断时间序列分析进行实施评估前后，辅之以与关键利益相关者的定性访谈。
方法：在2021年12月至2022年12月之间，我们确定了在北卡罗来纳州六家医院住院的成年人，这些医院经CMS批准参加AHCaH豁免计划。符合条件的成年人符合HaH转移的标准(HaH符合条件的临床状况，合格的家庭环境)。我们对12名HaH患者和10名转诊临床医生进行了半结构化访谈。
方法：研究了两种策略。离散实施策略（第1-12周）包括临床医生指导的教育推广。多方面的实施策略（第13-54周）包括正在进行的临床医生指导的教育推广，通过护士导航员提供当地的HaH援助，临床服务部门高管的参与，以及个性化的审核和反馈。
方法：我们评估了每周平均HaH产能利用率，每周统计唯一转介提供者，和患者特征。我们从定性数据中分析了主题，以确定HaH使用的障碍和促进因素。
结果：我们的评估显示，在多方面的实施战略期间，HaH产能利用率每周都在增加，与离散周期趋势相比（斜率变化比值比-1.02，1.01-1.04）。转介提供者的数量也每周增加，与离散周期趋势相比（斜率变化均值比率-1.05，1.03-1.07）。农村居民中HaH利用率的增幅最大(11%至34%)。障碍包括与HaH相关的信息差距和转诊挑战；促进者包括以患者为中心的HaH护理。
结论：多方面的实施策略与提高HaH产能利用率有关，提供商采用，病人的多样性。卫生系统可能会考虑类似，与上下文相关的多组分方法，以公平地扩展HaH。
