HOSPITAL-AT-HOME CARE

To affirm that patients treated in the hospital-at-home (HAH) setting are entitled to the same level of care as those treated in an inpatient hospital setting; further,

To support HAH care models that provide high-quality, patient-centered pharmacist care, including but not limited to: (1) clinical pharmacy services that are fully integrated with the care team; (2) a medication distribution model that is fully integrated with the providing organization’s distribution model and in which the organization’s pharmacy leader retains authority over the medication-use process; (3) information technology (IT) systems that are integrated or interoperable with the organization’s IT systems and that allow patient access to pharmacy services, optimize medication management, and promote patient safety; and (4) ensuring the safety of the pharmacy workforce throughout the HAH care delivery process; further,

To advocate that pharmacists be included in the planning, implementation, and maintenance of HAH programs; further,

To advocate for legislation and regulations that would promote safe and effective medication use in the HAH care setting, and for adequate reimbursement for pharmacy services, including clinical pharmacy services, provided in the HAH care setting; further,

To provide education, training, and resources to empower the pharmacy workforce to care for patients in HAH care settings and to support the organizations providing that care; further,

To encourage research on HAH care models.

Rationale

Hospital-at-home (HAH) care is a patient care model that provides acute-level care to patients in their own homes. The first described HAH program was originally developed by the Johns Hopkins Schools of Medicine and Public Health over 25 years ago, and the HAH care model has seen broader adoption by other hospitals and health systems in recent years. HAH care models have been shown to improve clinical outcomes, reduce length of stay, provide higher patient satisfaction, and reduce costs and medical complications.

The COVID-19 pandemic forced hospitals and health systems to explore new and innovative care models, with a heightened focus on remote care. In March 2020, the Centers for Medicare & Medicaid Services (CMS) announced its Hospitals Without Walls program, which resulted in broader regulatory flexibility in providing services beyond hospital walls. This program was expanded in November 2020 to include the Acute Hospital Care at Home program, which allows eligible patients to be treated for acute illnesses in the comfort of their homes. CMS has outlined more than 60 acute conditions such as heart failure, asthma, pneumonia, and chronic obstructive pulmonary disease (COPD) that can be safely managed from a patient’s home with proper monitoring and treatment protocols. As of June 4, 2021, there were 59 health systems and 133 hospitals in 32 different states participating in the Acute Hospital Care at Home program.

Medication management is a mainstay for most, if not all, of the conditions treated under HAH programs. Pharmacy practice leadership and expertise is therefore needed to ensure patient safety and quality outcomes. Patients treated in HAH programs are entitled to the same level of high-quality, patient-centered pharmacist care as those treated in an inpatient hospital setting. ASHP supports HAH care models that provide high-quality, patient-centered pharmacist care. Patients receiving HAH care should have access to clinical pharmacy services that are fully integrated with the services provided by rest of the patient’s care team. To ensure optimal medication use, the HAH program should use a medication distribution model that is fully integrated with the providing organization’s distribution model, and the organization’s pharmacy leader should retain authority over the entire HAH medication-use process to promote integration with the organization’s pharmacy enterprise. The HAH program should use information technology (IT) systems that are integrated or interoperable with the organization’s IT systems to allow patients to access pharmacy services, the pharmacy workforce to optimize medication management, and the organization to promote patient safety. Finally, HAH programs should ensure the safety of the healthcare workers delivering care, including members of the pharmacy workforce.

The pharmacy workforce needs to be included in the planning, implementation, and maintenance of HAH programs. Early in the planning process, pharmacy departments can evaluate and determine (1) the in-person, virtual, and electronic patient assessment role for pharmacists in the HAH program to determine staffing requirements; (2) how medications will be provided and stored for patients, especially controlled substances and medications with strict storage requirements (e.g., temperature-sensitive medications); (3) formulary considerations and payer design; (4) state and federal regulations and licensure interpretations to support the practice and supply chain model requirements necessary for HAH programs; (5) how medication administration will be documented (e.g., through bar-code-enabled medication administration), including waste management; (6) electronic healthcare record platform capabilities required to support the HAH program, including an assessment of ancillary information systems or platforms that will need to be integrated with the organization’s IT systems to support medication-use documentation and pharmacist consultations; and (8) differences between HAH and home infusion models, and when to deploy the appropriate model.

Pharmacy departments should proactively assess the pharmacy clinical services needed to care for patients in the HAH program and determine the competencies and training to meet expected demands. Examples would include determining how drug information questions will be channeled and how care transitions will be managed (e.g., follow-up appointments for chronic care management, transitions to palliative care). The pharmacy department will need to develop processes to integrate telehealth services for patients to receive pharmacist care (e.g., education). Other considerations include patient choice and healthcare disparities, which may impact the ability to meet the criteria to receive HAH care.

Changes in law, regulations, and standards will be required to support HAH care models, particularly because some elements of the HAH care model were supported by temporary regulatory flexibilities granted to address the COVID-19 public health emergency. Specifically, the continued adoption and expansion of the HAH model will require the creation of sustainable reimbursement models for pharmacist-provided HAH services. Additionally, regulatory changes, particularly from CMS may be needed to ensure that pharmacists can administer medications in the home setting.

To prepare the pharmacy workforce to meet the needs of patients in HAH programs and the organizations managing them, ASHP will need to provide education, training, and resources to prepare the pharmacy workforce for these new and evolving roles, including the development of best practices, residency standards, and workforce competencies. To achieve these goals, ASHP will need to collaborate with interprofessional organizations such as the Hospital at Home Users Group (HAHUsersgroup.org), a collaborative of HAH programs around the U.S. and Canada that fosters the development and dissemination of resources and best practices to expand the reach of HAH programs, drive practice advancement, and inform regulatory and reimbursement policies to spread the HAH model of care. To provide a basis for these efforts, ASHP will also need to encourage research on the HAH model of care.