These health systems take big steps to provide care at home

Despite the growing body of evidence that supports the efficacy of at-home care for patients with chronic or acute conditions, including those who need hospital-level care, innovative health systems pursuing these care models do have to make up for some wild cards when caring for folks at home. Each patient presents a particular set of circumstances, needs, treatments and follow-ups that make standardizing at-home care challenging. 

But even with myriad obstructions in making home-care effective, innovative health systems are making it work well for their patients.

Here is a list of how members of the AMA Health System Program—which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine—are solving these problems to bring care to where patients live, especially for those who are homebound. 

1. Atlantic Health examines medicine cabinets at home 

   1. Whatever else one might say about the good and bad of hospital rooms, there is rarely a polyglot assemblage of prescription medicines lying around that, if taken, could pose a risk to the patient. Yet that is precisely the reality in the homes of patients, especially those who are 65 or older. That is why in its primary care at-home program, New Jersey-Based Atlantic Health System conducts a “medicine-cabinet autopsy,” in the words of Brenda Matti-Orozco, MD, an internist and hospice and palliative medicine physician at Atlantic Health System. Learn more about Atlantic Health System’s comprehensive at-home care approaches. 

2. Bayhealth brings the clinic to the community with an RV

   1. Medical literature has shown that if you are able to go to communities, you'll improve their health. With that in mind, Bayhealth was looking for a way to bring care to the underserved and to those with mobility issues. Their solution: Turn a 38-foot recreational vehicle (RV) into a mobile health clinic with a private exam room and two screening booths. Read more about this innovative method to offer care where patients live. 

3. Geisinger taps Geek Squad to elevate chronic care at home

   1. For patients with chronic conditions who are coming home from the hospital, it can be overwhelming trying to follow discharge instructions. After a trying hospital stay, the last thing they may want to worry about is how to install remote patient monitoring equipment to monitor patients’ health at home and transmit data back to their care team at Geisinger. But what if there were a way to take the guesswork out of technology installation and use? Officials at the Geisinger integrated health system believe they have found a way, and it involves partnering with Best Buy’s Geek Squad. Find out how the Geek Squad makes a difference for Geisinger’s patients at home. 

4. Marshfield sees a 44% drop in readmissions with home-recovery program

   1. There are 358 hospitals affiliated with 137 health systems in 39 states that have been approved by the Centers for Medicare & Medicaid Services (CMS) to participate in its Acute Hospital Care at Home program. But unless Congress takes action, come Jan. 1 the number of “hospital-at-home” programs will fall dramatically. While most of these programs were started during the COVID-19 public health emergency, the Marshfield Clinic Health System in rural Wisconsin was an early adopter. Learn more about how Marshfield Clinic’s hospital-at-home care system operates. 
   2. Marshfield Clinic joined the AMA and more than 60 other hospitals, health systems and medical associations in a letter to congressional leaders urging them to extend the Acute Hospital Care at Home waiver program for at least five more years. The Acute Hospital Care at Home waiver “is the keystone to the future of home-based care delivery for Medicare patients and beyond,” says the letter (PDF).

5. Ochsner’s digital health program cuts pre-term births by 20%

   1. Not all telehealth programs began during the COVID-19 pandemic. Ochsner Health started connecting pregnant patients with its digital medicine obstetric program in 2016 and has since achieved success across six key performance metrics including improved clinical outcomes, access to care and health equity. Ochsner Health’s Connected MOM (Maternity Online Monitoring) initiative uses digital health tools to offer expectant mothers a convenient way to safely manage their pregnancy in collaboration with their physicians at some 20 clinical sites in Louisiana and Mississippi. Discover how Ochsner’s program has progressed and evolved. 

6. Sanford Health is texting patients directly to stay connected

   1. A single mother of three young children who was working hard just to make ends meet was a frequent visitor to a local emergency department in the Sanford Health system for depression. The care team enrolled her in a low-tech, text-based remote patient-monitoring program at Sanford Health. It saved her life. Find out how Sanford Health physicians and teams used a simple method to provide better care. 

7. The Permanente Medical Group's virtual program makes patients feel right at home 

   1. The Kaiser Permanente Advanced Care at Home program combines home visits, telehealth encounters and remote patient monitoring connected to specialized command centers that coordinate services to help achieve a 30-day readmission rate for acute care patients that is lower than the national average. And importantly, the program also keeps patients connected to their homes and everything inside them that is conducive to their healing. Discover how The Permanente Medical Group’s program solves unique problems for patients. 

8. The Southeast Permanente Medical Group boosts postpartum BP control by 43%

   1. Within the intricate web of maternal care, The Southeast Permanente Medical Group took a technology-based approach to solve an all-too-common health problem in pregnant and postpartum patients: hypertension. Wielding the power of remote patient monitoring like a beacon of hope against the formidable foe of hypertension, the medical group aims to rewrite the narrative of maternal health. Learn more about how The Southeast Permanente Medical Group developed their unique remote-monitoring system. 

Learn more about monitoring chronic conditions outside of the traditional health care environment with the “AMA Remote Patient Monitoring Implementation Playbook.”

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