Sunkara Padageshwar, Nagaraj Raghava, Nguyen Hieu, Murphy Stephanie, Goslen Kevin, Barot Harsh, Hetherington Timothy, Stephens Casey, Isreal McKenzie, Kowalkowski Marc
Department of Internal Medicine, Section of Hospital Medicine, Wake Forest University School of Medicine, Winston Salem, North Carolina, USA.
Center for Health System Sciences, Atrium Health, Charlotte, North Carolina, USA.
J Hosp Med. 2025 Apr;20(4):344-351. doi: 10.1002/jhm.13525. Epub 2024 Oct 8.
Early-supported discharge (ESD) hospital-at-home (HaH) programs facilitate hospitalized patients to receive ongoing acute-level care at home, thereby promoting patient-centeredness while improving hospital throughput.
The current study aimed to test multiple implementation strategies to increase and sustain HaH ESD utilization.
We conducted interrupted time series analyses to evaluate the effectiveness of implementation strategies on weekly HaH ESD referrals and capacity utilization at five hospitals. Intervention 1 included provider-focused education and HaH nurse navigator support (July 2021 to May 2022). Intervention 2 added provider-level referral performance feedback and daily electronic health record-based eligibility reports (May 2022 to December 2022). During postintervention (January 2023 to June 2023), implementation strategies were no longer supported by the study team. Clinical outcomes were assessed over time and between patient subgroups.
There were 5951 HaH ESD patients overall. After Intervention 2, we observed immediate increases in weekly HaH ESD referrals (level change mean difference [MD, 95% confidence interval]: 14.8, 5.9-23.6) and capacity utilization (level change MD: 13.9%, 6.2%-21.5%) and additional week-to-week increases in capacity utilization (slope change MD: 0.6%, 0.2%-0.9%), compared to Intervention 1 trends. HaH ESD referrals and capacity utilization were sustained postintervention. The proportion of provider-initiated referrals increased over time (Intervention 1: 79.4%, Intervention 2: 90.9%, postintervention: 95.2%). As HaH ESD utilization increased, we observed shorter inpatient length of stay and fewer HaH ESD encounters per visit (p < 0.01). There were small, statistically significant differences in 30-day mortality and readmission for residents of rural and socioeconomically disadvantaged areas.
Applying referral-focused provider feedback and daily eligibility reports were effective within a multicomponent approach to increase and sustain HaH ESD utilization.
早期支持出院（ESD）居家医院（HaH）项目有助于住院患者在家中接受持续的急性水平护理，从而在提高医院效率的同时促进以患者为中心的医疗服务。
本研究旨在测试多种实施策略，以提高并维持HaH ESD的利用率。
我们进行了中断时间序列分析，以评估实施策略对五家医院每周HaH ESD转诊和床位利用率的有效性。干预1包括针对医护人员的教育和HaH护士导航支持（2021年7月至2022年5月）。干预2增加了医护人员层面的转诊绩效反馈和基于每日电子健康记录的资格报告（2022年5月至2022年12月）。在干预后阶段（2023年1月至2023年6月），研究团队不再提供实施策略支持。对临床结果进行长期评估，并在患者亚组之间进行比较。
总共有5951名HaH ESD患者。干预2实施后，我们观察到每周HaH ESD转诊量（水平变化均值差[MD，95%置信区间]：14.8，5.9 - 23.6）和床位利用率（水平变化MD：13.9%，6.2% - 21.5%）立即增加，与干预1阶段相比，床位利用率还出现了逐周额外增加（斜率变化MD：0.6%，0.2% - 0.9%）。干预后，HaH ESD转诊和床位利用率得以维持。医护人员发起的转诊比例随时间增加（干预1：79.4%，干预2：90.9%，干预后：95.2%）。随着HaH ESD利用率的提高，我们观察到住院时间缩短，每次就诊的HaH ESD接触次数减少（p < 0.01）。农村和社会经济弱势地区居民的30天死亡率和再入院率存在微小但具有统计学意义的差异。
在多组分方法中应用以转诊为重点的医护人员反馈和每日资格报告，对于提高并维持HaH ESD利用率是有效的。
