BC project manages acute-care patients in their own homes

VICTORIA, BC – British Columbia has rolled out its Hospital at Home pilot in three different communities – two at Island Health and one with Northern Health. The project is already demonstrating that acute-care patients can often be managed as effectively in their own homes as in hospitals.

The project was announced last fall by the BC government with an investment of $42 million. The plan is to test the concept to see if it can be expanded throughout the province as a way of reducing pressure on “brick-and-mortar” hospital facilities.

Under the Hospital at Home program, patients with a variety of ailments such as pneumonia, heart failure, and COPD are managed at home with daily visits from a nurse, physician, and/or clinical pharmacist. They’re also outfitted with instruments for taking vital signs and medical equipment for treating their illnesses; the equipment includes oxygen and IV-pump-delivered and balloon-driven medication systems.

Participation in the program is voluntary, and patients are only enrolled if they’re keen to try it. Patients are checked into a particular hospital – the Victoria General or Royal Jubilee, both of which are on Vancouver Island, or the University Hospital of Northern British Columbia, in Prince George. They are cared for, however, in their own homes.

Since last fall, clinicians at the Victoria General Hospital and the Royal Jubilee Hospital, each of which has nine “virtual beds”, have together cared for over 175 patients.

Each of the nine-bed units is staffed by one physician, three nurses and a clinical pharmacist during the day. Both a nurse and a physician are scheduled to be available to patients at any time of the day or night.

“We’re not limited to a certain patient population or disease state,” said Dr. Sean Spina, the research leader of the project. “We’re open to all patients who can be safely cared for in their homes.”

Dr. Spina, PharmD, is also the Coordinator of Clinical Pharmacy Services at Royal Jubilee Hospital.

Quite unusually, and to its credit, the BC Hospital at Home pilot has already achieved a 100 percent approval rating from patients who have received treatment at home through the program.

“100 percent of the patients we’ve interviewed have told us that if the opportunity to go through the program came up again, they would do it,” said Dr. Spina. “They loved the independence of being at home and in their own beds. They also benefited from the help and presence of their loved ones, something they don’t always have at the hospital, especially during the pandemic.”

Each patient is admitted to hospital, but their “beds” remain in their own homes.

Dr. Spina noted that based on early evaluation results, the bed turnover, or length-of-stay, for patients at home is similar to that of hospitals, with an average stay of about five days.

In addition to taking pressure off hospitals, there are other advantages to caring for patients in their own homes.

Of course, during the pandemic, it has promoted infection control for both the patients and hospital staff, as it’s important to reduce patient traffic through large institutions.

Even when the pandemic is over, it’s believed that home-based care can reduce infection rates, as patients are less exposed to hospital-borne pathogens, such as MRSA and C. difficile.

Moreover, many patients prefer staying in their own homes, when possible, rather than going to a hospital.

Dr. Spina commented that patients in hospital tend to stay in bed and do less each day. In contrast, “At home, people get up in the morning, they get dressed and go on with their day. They’re much more mobilized.”

That mobility can lead to better mental and physical health, and results in a person who is still productive, even though he or she is technically in a “hospital bed”.

The BC Hospital at Home project was launched in conjunction with a public engagement strategy led by Dr. Spina’s team. The engagement included interviews with a variety of key stakeholders, a survey open to patients, family caregivers, clinicians, and health system decision makers. It was feedback from the patients who suggested an important component of the technological platform, the “virtual call bell”.

“The call bell hadn’t been on our radar,” said Dr. Spina. “It was only because of patient involvement that we discovered it.”

When asked whether they would participate, patients answered that in order to have confidence in the project, and to feel safe while being cared for at home, they’d like to have a device that could alert a clinician if immediate attention was needed.

Dr. Spina explained that this is much like the bedside call-bell that a hospital patient uses to alert a nurse.

The project found a wireless device that can be used at home; when the button is pressed by the patient, a clinician is immediately alerted by an operator and the two parties are connected.

“Now, even if the patient is in the garden or the shower, they can contact someone for help,” he said.

Using this system, patient and clinician can be quickly connected by voice. If the patient needs an ambulance, the operator can immediately connect to 911.

The device also has the capability to detect falls, but the teams haven’t activated that feature yet.

Since the start of the project last fall, the Hospital at Home program has developed a whole technological platform that is used to connect caregivers and patients.

The backbone is the Vocera network, which provides a secure and private communication system linking clinicians to one another. It can be used by nurses visiting patients at home, where it connects to the cell-phone system. When used in hospital, it connects to the local Wi-Fi network.

The Vocera system can be used by clinicians to send quick messages to each other, or to groups of peers. Each of the participating clinicians is using an iPhone, which has been integrated into the technology platform.

In the home, patients are outfitted with a tablet computer and several devices that are used for taking vital signs, such as blood pressure, heart rate, temperature, blood oxygen levels, and weight.

In many cases, it’s the visiting nurse who helps take these measurements and loads them into the tablet, where they can be transmitted back to the central server. Some patients, however, are able to take their own vital signs and send them in.

The program is using video-visits between the patients and care team, and integrated video is part of the IT platform. There are also electronic records for the patients, just as in the hospital.

Dr. Spina noted that the program is still in the early stages, and that its organizers want to refine it further. In particular, they’d like the equipment to become even more “patient friendly”, so that it’s more intuitive for the patients and nurses to use.

For example, he said, one of the goals is to further integrate the vital signs equipment so that it loads automatically into the tablet computer and into the central server.

The team is also looking into better ways of alerting patients that their doctor, nurse, or pharmacist wants to talk to them by video. This could be done first by a phone call, but Dr. Spina believes there might be more streamlined methods, where a patient sees a flashing red light on the tablet, for example. Just by pushing a button, he or she would then be online with a clinician.

Something being bandied about, as well, is the idea of continuous monitoring of vital signs. A patient might only need to wear a patch or bracelet that automatically takes measurements and feeds them into the system.

Dr. Spina said it would also be useful to know if patients were taking their medications as directed. A device might be introduced that lets clinicians know if daily medications were dispensed.

Overall, however, he asserted that “technology does not provide the care, technology allows us to be more efficient.” Ultimately, patients need to know they are in the hands of caring nurses, doctors, and clinical pharmacists, and that these clinicians are actively managing their diagnoses and treatments.

To expand the Hospital at Home program, the managers of the project also want to answer important questions. They are actively conducting research, said Dr. Spina, to find out:

• How patient friendly is the technology, and what needs to be improved?
• How safe is the care? How do the outcomes and length-of-stay compare with in-hospital care?
• What are the hospital readmission rates? How do they compare with conventional care?
• How do the costs of acute care at home compare with those in the hospital?

Dr. Spina said all of this has been made more urgent by the COVID-19 pandemic, as hospitals and health regions continue to care for patients during the global crisis. “There has been a lot of development going on, and a lot of new solutions are being tested,” he said.

This accelerated pace of technological change and modernization, he said, has been something of a silver lining in the midst of the COVID-19 crisis.

To follow BC’s Hospital-to-Home journey or to learn more, please see the website at https://www.islandhealth.ca/our-services/hospital-home-services/hospital-home.