Hospital at Home (HaH)

MITIGATION STRATEGIES

• Perform failure mode and effects analysis (FMEA) or use other proactive risk assessment tools to identify key risks and develop proactive mitigation strategies. These can be leveraged to set clear expectations for selecting, managing, and negotiating with vendors
• Ensure HaH staff have the requisite knowledge and competencies for care of patients in a HaH setting
• Develop system-based redundancy with associated contingency planning
• Establish policies that outline an escalation process for each vendor
• Define structures, processes, and measures for ongoing and continuous improvement

MITIGATION STRATEGIES

EARLY STAGES

Programmatic Fundamentals:

• Develop programmatic foundation that recognizes key goals, patient populations, conditions to be included in services, and available resources

Delivery of Clinical Care:

• Implement a pilot phase to evaluate the feasibility of service delivery
• Establish clear measures to evaluate feasibility, patient safety, and programmatic success
• Develop infrastructure for preparing and engaging a competent workforce
• Identify opportunities for automation, e.g., integration with electronic health records (EHR) to identify appropriate patients
• Implement intentional review of clinical processes and pathways for HaH

Equitable Care:

• Establish a data stratification plan to monitor potential biases and inequities

• Review data with a perspective that considers significant differences between HaH and brick-and-mortar clinical care locations

Safety & Emergency Planning:

• Keep as many systems as possible consistent with brick-and-mortar workflows, e.g., same safety reporting system
• Ensure a senior sponsor for safety and the dedication of resources to allow for patient and workforce safety
• Establish safety management processes for review and assessment of safety metrics
• Identify community support and resources, such as local police or ambulance services
• Early review of emergency plans

Expansion Considerations

• Build trust with senior leaders when considering expansion.
• Use existing data and metrics, such as CMS required reporting and readmissions data, to compare with hospital measures to help guide the safety of expanding a program*

MITIGATION STRATEGIES

ORDERING:

• Establish medication ordering and subsequent dispensing workflows that meet HaH regulatory standards
• Clear adherence to the medication reconciliation process

ADMINISTERING:

• Ensure standardized medication dispensing, e.g., batch filled for 24 hours
• Always double-check packaging
• Use tamper-evident packaging
• Consider redundant kits for clinically urgent medications
• Dispense medications in a way that reduces bedside medication preparation
• When needed, dispense medications in a form that allows for the use of reconstitution devices to ensure safe bedside medication preparation and handling
• Use temperature indicators for temperature-sensitive medications
• Employ point-of-care barcode scanning

Self-administration screening

• Screening should include assessments of the patient’s ability to self-administer medications safely. Considerations include the patient’s capacity to self-administer medications, level of support needed or provided by caregivers, etc.
• Technology may be deployed to support self-administration practices by patients with some limitations in self-medication administration adherence

Personal Protective Equipment:

• To limit PPE use, package medication so that minimal medication preparation is needed in the home setting
• Ensure PPE is available for clinical team members who need to handle or administer hazardous substances

STORING:

• Evaluate best options, such as lock boxes and using two-colored pill boxes: one color for patient-administered medications and a different color for clinician-administered medications

CONTROLLED SUBSTANCES
(DISPENSING, SECURING, AND DOCUMENTING):

• Ensure process reflects all steps in the chain of medication custody
• Limit visibility of controlled substances and ensure tamper-proof packaging for couriers
• Consider engaging a virtual nurse for self-administration of medications
  
  

OTHER CONSIDERATIONS

The list below represents other important areas of consideration for HaH, though they were not discussed in detail with the task force.

• patient consent and setting clear expectations
• emerging technology solutions, e.g., automatic dispensing machines
• standardized use of safety event reporting system and event review process with the respective hospital to ensure all team members, including patients, caregivers, and HaH staff can participate
• patient and family experience and feedback, e.g., might not be the same “quiet at night” metrics, but “how are you sleeping?” is important
• evolving regulatory requirements