Where to Start: Building Your Care at Home Program

Health care is moving into the home: patients demand it; pandemic preparedness demands it; the future of healthcare demands it. After decades focused on facility-based care, health systems are asking, “Where do we start?” 

Whether your organization is looking to launch an Hospital at Home program or deliver home-based care to patients with chronic disease, here are the primary things to think about when standing up your program. 

Project Team

The right team is key to the success of any project. Ensure you have cross-functional stakeholders from:

  • Clinical leadership
  • Clinical data
  • IT
  • Contracting and Revenue Cycle Management
  • Operations
  • Clinical stakeholders

Technology and Data

The basis of any home-based care program is the transmission of patient data to their care team in a meaningful format that they can easily act upon. A holistic monitoring and communication platform can prevent the need to configure multiple devices and integrations. At a minimum, you’ll need:

  • Remote Patient Monitoring device(s) and configurable alarms
  • HIPAA-compliant communication channels
  • Clinical dashboards with AI-driven alerts and risk stratification
  • Integration with your EHR system

Client Spotlight: UMass Memorial Health

UMass Memorial made integration with their Epic EHR system a priority for their Hospital at Home program. Learn from Dr. Eric Alper, CQO and CCIO at UMass about change management strategies for data and workflow integration.

Patient Populations and Success Metrics

Patient inclusion criteria that are either too broad or too narrow will lead to low program utilization. Use clinical and patient data—as well as engaged clinicians—to guide the initial scope for program enrollment.  

  • Consider starting your program with a patient population whose outcome metrics are already on your radar. For example, is your 30-day readmission rate for COPD patients above benchmark? Prioritizing these patients and the associated metric will help focus the first phase of your program and ensure you can easily track and measure success. 
  • Ensure that the clinicians currently involved in these patients’ care are engaged in the success of your home-based care program. 

Staffing Model and Responsibilities

While the staffing model of your program may be unique to your health system, most programs feature the same key roles.   

  • Key Roles: lead provider, nurse, social worker, physical therapist, program coordinator
  • Home Health teams, whether employed or contracted, help many health systems scale their home-based care 
  • MIH paramedics can help provide in-home care. Learn how South Shore built a program on this model. 
  • A Clinical Command Center, like Current Health provides, can help scale your program and ensure 24/7/365 response to patient alarms. 

Care Delivery and Ancillary Services

How will you deliver care to the patient in their home? Design a clinical pathway specific to the patient population your program is starting with. Ensure the plan includes a tailored approach for: 

  • Remote patient monitoring: devices, alarm thresholds, and triage protocol  
  • Virtual care visits: how often and with whom?
  • In-home care visits: how often and with whom?
  • In-home services (therapies, medication, labs)

Get in touch with our team to learn more about our proven Clinical Pathways.

Payer Contracting and Reimbursement

Payment policies for remote patient monitoring and telehealth currently vary across payers and insurance products, though many base their policies on the Medicare Payment Policy. Contracting factors could affect your target patient population. Consider: 

  • Whether your program qualifies for existing bundled payment arrangements
  • In which cases prior authorization will be required
  • A pilot program with a payer to demonstrate value

What should your team look for in a care at home platform? Download our buyer’s guide for 50 questions to help guide your search.