Hospital to Home Program: A Unified Team Response to COVID-19

The genesis of our Hospital to Home (H2H) Program began at the peak of the COVID-19 pandemic in Texas, due to critical hospital bed shortages. Our teams implemented the project to ensure a timely and safe discharge of our patients from the hospital/SNF/ER settings to the patient’s home. The H2H Program expedited patient throughput and increased hospital bed availability in three specific market locations with assigned Hospitalists. A specific referral process was developed for early identification of acute patients, including their individual and home medical equipment needs prior to their facility discharge and transition into home healthcare within the first 48 hours.
The interprofessional approach of the H2H Program significantly improved cross-functional, proactive communication of the patient’s status and disposition for designated team members from the Case Management, Home Health, Patient Transportation, Home Medical Equipment, Supportive/Palliative Care, physicians, and senior leadership. To achieve positive patient outcomes, any existing communication silos between teams were ended. The consistent, active participation of each team representative developed into mutual, professional group rapport, leading to honest and open communication. The interprofessional patient reporting huddles, directed by a lead physician, resulted in early nursing and therapy interventions, improved patient outcomes, reduced ER visits, and decreased hospital re-admissions from 12.9% to 5%.
Other new technologies evolved from the project, including the utilization of secure text messaging communication, virtual patient reporting, a monitored group mailbox, and remote patient monitoring via tablets with Bluetooth periphery equipment for telehealth capability. Based on the consistent, positive outcomes from the H2H Program, the future operations of home healthcare in collaboration with interprofessional teams will support these best practices in parallel with evidenced-based research. Our lessons learned will promote other interprofessional teams to facilitate the delivery of safe, quality patient care for the most acute, high-risk patient populations.