INNOVATION AND CUSTOMER EXPERIENCE

Acute, In-Home Care Partnership Satisfies Patients, Eases Overcrowding

In the spring of 2021, Inova Health System (Inova), the largest not-for-profit health care system in the Washington, D.C. metropolitan area, was doing something it had never done before.  

“We have a ‘greenlight’ policy,” recalls Tanveer Gaibi, MD, chief of the Emergency Medicine Division at Inova. “We take any transfer from anywhere in the country. But for the first time ever, we paused that policy. We weren’t sure we could take them.” 

More than a year into the COVID-19 pandemic, Inova was at a breaking point. It had more capacity than many systems, with more than 1,000 licensed beds and 20,000 team members, and it was accustomed to about 415,000 emergency department (ED) visits and 100,000 inpatient admissions annually.  

“But after a year of an influx of high volumes and high-acuity patients, along with the ‘Great Resignation’ of many health care professionals, we had major capacity management issues,” explains Michael Barkema, MHA, the senior director of Inova’s medicine service line. “We were turning away external transfers and we had boarders sitting in the ED for 10 to 12 hours at a time. We realized that we needed to start thinking differently about care. How could we develop a different cost structure to increase value and generate more inpatient capacity?” 

One of the system’s executives had previously worked with Carlton Stadler, MD, an emergency physician and regional medical director of DispatchHealth, an innovative, high-acuity, in-home health care delivery provider founded in 2013. Barkema, Dr. Gaibi and other Inova leaders began discussions with Dr. Stadler, and beginning in late 2021, the health system officially began a partnership with DispatchHealth to provide in-home care for a subset of its patients. 

All three spoke about the partnership during a session on innovation through collaboration at the SHSMD Connections conference last September, and the resulting in-home care approach falls into two categories: 

1. Urgent medical care in the home: This includes same-day treatment for serious health concerns. “Our Acute Care service treats 95% of common ED diagnoses and includes diagnostics and IV medications, with the ability to care for a higher-acuity patient than an urgent care center or home health agency,” Dr. Stadler says.  
2. Recovery care at home: This includes follow-up care after discharge from the ED, hospital or skilled nursing facility.   

Within these two categories are multiple services, including the following: 

• Bridge Care services: “This type of care involves hospitalized patients who could be cared for at home with a little more support or greater understanding of social determinants of health,” Dr. Stadler notes. “For example, a patient with mild to moderate congestive heart failure could have DispatchHealth take them home in a much shorter time, and then provide a follow-up visit within 24 to 72 hours that includes focused physical examination, medication reconciliation and acute interventions, if needed.”  
• COVID-to-home services: “This is something we created with Inova,” Dr. Stadler says. “We have the ability to discharge patients with new oxygen requirements home with acute care medicine support, including a visit within 24 hours and 14-day virtual care with a registered nurse.” 
• ED-to-home services: “We have patients who take up beds in the hospital for observation admissions because we don’t feel comfortable sending them home,” Dr. Gaibi says. “For example, think of a patient seen in the ED for a common condition like diverticulitis. They usually are admitted for treatment with IV antibiotics, but if someone can come to your home the next day and give you the IV antibiotics there, avoiding the need for admission, that’s more comfortable and less costly for the patient, and frees up a bed in the system.” 

The care team for these services includes a physician associate or nurse practitioner and/or a medical technician, supported by an emergency medicine physician if necessary. Their capabilities include high-acuity diagnostic and treatment equipment, including a hospital-grade 12-lead electrocardiogram machine; mobile x-ray and mobile ultrasound; moderately complex bedside lab testing such as urinalysis and rapid infectious disease point-of-care testing; equipment for procedures such as splinting and catheter changes; and options for pharmaceutical management such as IV, intramuscular and oral antibiotics and anti-emetics, steroids, nebulizers and IV fluids. 

DispatchHealth is available from 8:00 a.m. to 10:00 p.m., 365 days a year (including weekends and holidays). Common clinical scenarios managed through the program have included dehydration, mild to moderate congestive heart failure exacerbation, cellulitis, diverticulitis, influenza, chronic obstructive pulmonary disease or asthma exacerbation, pneumonia, uncomplicated fractures or sprains, corneal abrasions, vertigo, and urinary tract infection.  

As of late August 2022, the program had completed 2,155 total visits. In the ED-to-home component of the program alone, 43 patients avoided admission at Inova, with close to $1 million in cost savings accrued. On average, only about 6% to 8% of patients have had to return to the hospital.  

“Our directive from the system CEO when we adopted this partnership was that it needs to be seamless and that patients must be satisfied,” says Dr. Gaibi. “The patient experience is no longer the icing on the cake—it’s part of the cake. It’s what we do.” 

If the program’s net promoter score (NPS) is anything to go on, they’ve achieved the CEO’s goal. Health care organizations typically receive lower than 30 on this minus-100 to plus-100 scale, with popular companies like Amazon rating in the 50s and Apple in the 60s. DispatchHealths’ overall NPS with Inova patients is 97.  

“Nobody sits at [the] bedside of a patient for 45 to 90 minutes in [the] primary care office or hospital,” Dr. Gaibi notes. “But in this program, they do. Our patients have really found value in that.”