Giving the Hospital at Home Strategy a Pediatric Spin

Atrium Health’s Levine Children's Hospital has launched the first Hospital at Home program in the country that focuses on children and their families. 

Few would argue that the hospital is no place for a child. But can the Hospital at Home strategy work for children who would otherwise be stuck in a hospital bed?

Levine Children’s Hospital, part of the Atrium Health network, is putting that theory to the test. The 247-bed hospital in Charlotte, North Carolina, launched the nation’s first program to deliver acute-care services to children at home earlier this year.

Stefanie Reed, medical director of the Pediatric Hospital at Home Program, says the program is modeled after Atrium’s Health’s Hospital at Home program, one of hundreds across the country following the Centers for Medicare & Medicaid Services’ (CMS) Acute Hospital Care at Home (AHCAH) model. That model establishes protocols for home treatment of patients who would otherwise be admitted to a hospital, with a mixture of daily in-person and telehealth visits and remote patient monitoring.

But where those programs focus on adult patients, Levine is targeting a very different population.

“We do things a little bit differently,” Reed says, pointing out that whereas adult-level care focuses on the patient, pediatric care often envelops the whole family. The program aims to bring “wrap-around care” to the patient and family, bringing in a much larger mix of care providers, including pediatric hospitalists, certified nurses and pharmacists as well as specially trained paramedics, child life case management and discharge managers and other specialists.

That’s a different dynamic, she says, focusing on team-based care rather than individual visits or services.

Stephanie Reed, medical director of the Pediatric Hospital at Home Program at Atrium's Health's Levine's Children's Hospital. Photo courtesy Levine Children's Hospital.

“It’s important for us to make sure that we really support families and team members throughout the hospitalization by being really, really available to them in ways that probably you don't need to be on the adult side,” Reed says.

A unique program with unique protocols

In many ways, providing home-based care for pediatric patients is more complex. Aside from the use of specialists, Reed says they’re tracking more metrics. Alongside the basic data on care quality, readmission rates, hospital flow and patient safety, they’re taking a closer look at patient experience with care teams and technology. Among the questions being asked: Is this an easier and better way of doing things than in the hospital?

They’ve also built in some “extra checks and balances,” Reed says. Clinicians are asked to visit more than once a day with families. And a clinician--doctor, nurse or paramedic--is online or at the home every time a medication is administered or the child is interacting with technology.

“Even in these early days there are some really positive things,” she says. “We are definitely seeing a lower readmission rate and revisit to the ED rate. We are certainly seeing our patient satisfaction rates off the charts. I've yet to have a family that that said, ‘You know this was no fun.’ Every single family has said, ‘Thank goodness we could do this.’”

Since the program was launched in February, Reed says 40-50 kids have received care at home, and those numbers are growing.

An effective Hospital at Home program, of course, begins in the hospital. Pediatric patients and their network of caregivers need to be screened well in advance of moving care into the home. Reed says the program runs on an “inclusion/exclusion basis,” meaning anyone from infancy up to age 17 can be eligible. That said, the range is currently limited to the Charlotte area, and children in intensive care or with complex care needs aren’t eligible at this point in time.

Reed says they’ve treated everyone from newborns with jaundice to teens dealing with flu or dehydration—and, most importantly, their families.

“We always start with family-centered care,” she points out. “Families should feel engaged and [be able to] participate in the care of the child from the moment that they come into our care.”

“I joke all the time,” she adds. “I've met more aunties and grandmas and pets because I'm in the house and I can really talk to them about the support that this mom needs.”

Assessing the home environment

They also take a close look at the home, assessing social determinants of health (SDOH) like food, transportation and family dynamics. Social workers and case managers play a role in this evaluation.

“We really want to elevate that environment,” she adds. “We know if we can do a good job, whether they're with us in a brick and mortar [setting] or they're discharging from hospital at home, if we've set that groundwork, then you have a healthier child and the likelihood of them needing to come back to an emergency room drops dramatically.”

Even then, when all the boxes are checked, things crop up, and the care team sometimes has to react on the fly. Reed says one family assured them that they had transportation, but when a paramedic visited the home he found that the car battery was dead. So he stayed around to recharge the battery and make sure the care was working.

The program is entirely voluntary, Reed says. And there are times when the hospital is a better place for care than the home.

“If a family is not ready, if the home environment is not ready, if they need our support in a different way, that's OK,” she says. “We will be there and we can reapproach it [later if necessary].”

Reed says the program can be an important bridge from the hospital to the home for both children and their families.

“It’s hard to leave the hospital and go home, even when you’re ready to go home,” she says. “Having someone there, holding your hand, so to speak, making sure you really, truly have what you need, someone that you can call anytime of the day or night is a value in a support system in itself.”