Nemours Moves Beyond the Hospital at Home Concept

The pediatric health system has launched Advanced Care at Home, which aims to support parents in caring for their children and reduce hospital stays and ED visits.

The Hospital at Home model may not be everybody's cup of tea, and several health systems and hospitals are finding value in less complex programs that focus on reducing hospital length of stay and improving home-based care.

The latest to jump into the water is Nemours Children's Health, which unveiled its Advanced Care at Home program last year. An early pilot of the program, officials say, prevented 27 hospitalizations and 91 ER visits and reduced length of stay by 177 days.

The program, says Jane Mericle, DNP, MHS-CL, BSN, RN, CENP, Nemours' EVP, Chief Nursing Executive and Patient Operations Officer, isn't part of the CMS Acute Hospital Care at Home (AHCaH) model. And that's deliberate.

"We're really innovating around … advanced care models," says Mericle, who calls the program a bridge between the health system's hospitals in Delaware and Orlando and the home. As such, it's not meant to turn the patient's bedroom into a hospital room, but create a virtual link between parents and the patient's care team.

"What happens … is this baby can go home much earlier because we're able to see the baby, talk to the parents, get information about the feeding and do a lot of the care at home," she says. "We really believe, and there's evidence, that children do better in their home. So we think that if there's a way for us to care for a child in the home, that's what we want to do."

"There are times when we can help either allay a fear or do an assessment, or maybe help wean oxygen or things like that for those kids so that they don't have to keep coming in and out of the hospital," she adds.

A Focus on Simplicity

Hospital at Home programs have been criticized for their complexity, and Mericle says Nemours is focused on simplicity, and putting the family and caregivers at the center of care and support. This program is designed to give parents the resources they need – including 24/7 virtual access to a care team and home visits when needed – to care for their child.

Jane Mericle, DNP, MHS-CL, BSN, RN, CENP, EVP, Chief Nursing Executive and Patient Operations Officer at Nemours Children's Health. Photo courtesy Nemours Children's Health.

‘What we've seen is that there's a lot we can do with simplicity," she says, adding that technology can sometimes "overcomplicate" care. "Sometimes it's just a matter of helping our families have confidence, or being able to say, ‘Hey, I'm going to sit here with you while you do that and then, if you still need extra help, we'll see where to go.' And a lot of times we can help our families troubleshoot."

The program is run through Nemours' 24/7 clinical logistics center, which was already up and running for the health system's inpatient monitoring and virtual nursing programs. It's primarily a virtual model, with scheduled and on-demand telehealth visits and protocols in place when an in-person visit or return to the hospital is required.

Sometimes, Merical says, the care team decides to bring the child back to the hospital for 3-4 days for more intensive monitoring and care. When that decision is made as part of the care plan, it's a more coordinated transition leading to better outcomes, rather than a hurried trip to the ER or readmission.

Tailoring the Care to the Child

The program also uses digital health devices for remote patient monitoring. Mericle says there are plenty of FDA-approved devices on the market to choose from, and the health system looks for ease of use and reliable data collection. She says Nemours is always looking to partner with device makers to create new tools or platforms that simplify the remote collection of data and transfer to the medical record, as well as creating a pathway for real-time RPM.

And while the program selects patients on a case-by-case method, Mericle says Nemours clinicians see value in this for some of their more complex patients.

"About 70% of our children [at Nemours] are children with complex health needs," she points out. "And if you know about that population, they are high utilizers of hospital and healthcare resources, and we have found that we have been able to do a lot with them at home."

"We had our orthopedic surgeons in our Orlando hospital say, ‘Hey, if we could get some of these kids with spinal surgery out earlier, we think we can prevent some of the complications just by having them at home, getting the right mobility,'" she says. "And then we can monitor their incision. So we've been doing that kind of model."

Reducing Length of Stay

The key benchmark in that regard is length of stay. Mericle says the program was launched on the idea that Nemours could carve off a few days at the end of a patient's hospital stay, which would not only bring children home earlier and improve outcomes but give the health system more hospital capacity.

Oftentimes, and in hospitals of all sizes and specialties, those last one to three days before discharge are comprised of tasks that could be done at home under virtual supervision. That's where programs like Nemours may be able to find that sweet spot, if they can find the right formula that also appeals to payers.

"Payers also want quality of care for these kids and the families, and they really understand the burden, especially with the kids with complex care needs," Mericle says, noting that early conversations with payers have been "optimistic."

"We have audacious goals," she adds, adding that they're talking to pediatric hospitals across the country about how to make the program better. "We have this concept of whole-child health. … We want kids not in a hospital and we want kids in their home. And we want to pay for health. We don't want to pay for sick."