Telehealth visits with a physician and on-site nurse are one part of the home-hospitalization model. Another part is twice-daily nurse visits. In this image, Ariadne Labs, a joint project of Brigham and Women's Hospital and the Harvard public health school, simulate a home checkup and physician exam in Utah during an earlier phase of project development. (Ariadne Labs image)

For rural residents, just getting to the hospital during an illness can be a struggle.

A new trial of home-based hospital care may be a solution to that, officials think.

Called the Rural Home Hospital, Ariadne Labs developed the system to deliver home hospital principles to rural communities. 

Mary Frances Barthel, M.D., chief quality and safety officer at Blessing Health System in Quincy, Illinois, runs the Rural Home Hospital program there. Covering a three-state area (Illinois, Missouri and Iowa), Blessing Health includes three hospitals, two physician groups, an accredited college of nursing and health sciences, and a network of medical specialty businesses. Barthel said the healthcare system provides services for about 100,000 people.

Mary Frances Barthel

In February, Blessing Health started a three-year study of the home-based system. Based on a successful urban home hospital program at Brigham and Women’s Hospital in Boston, this trial will determine whether or not it can be applied to rural settings, Barthel said.

Just three patients have entered into the randomized study so far. Two of those patients were selected to stay in the hospital. One was selected to receive at-home care.

To enter into the program, a patient has to be admitted to the emergency department and then diagnosed with something that would normally require hospitalization to treat – like heart failure, chronic obstructive pulmonary disease, asthma, gout, chronic kidney disease, or diverticulitis. Once a patient has agreed to participate, they’re randomly selected to either stay in the hospital or be treated at home.

Those that are selected to be treated at home are discharged with a nurse who goes with them and sets up the necessary equipment in their house.

“They’re put on a monitor that gives us their vital statistics like blood pressure, blood oxygen… that information is available to me 24 hours a day, seven days a week,” Barthel said.

Patients are also connected to the doctor through telehealth visits. The nurse visits the patient in person twice a day, and Barthel checks in on them once a day via telehealth. Patients can also contact the nurse or doctor for telehealth visits if they have questions or concerns. In some cases, the monitor will connect with the doctor to alert them if things aren’t right.

“If there’s a change in their vital statistics, an alert will come across an app on my phone,” she said.

The system also alerts her if the monitoring equipment goes offline.

“We had an incident where the patient’s tablet went to sleep,” she said. “I got a notification on my phone and worked the patient through making sure the device didn’t turn off.”

The program frees up beds for more critically ill patients and ensures the patient can access the care.

“Transportation (to the hospital) is such an issue in rural areas, especially for our elderly patients,” Barthel said.

Research shows that home hospital programs tend to have higher patient satisfaction, lower readmission rates, and a reduced risk of getting hospital-acquired complications. Barthel said so far patients have reported that the program is beneficial.

“Patients reported getting up more and moving around more,” she said. “We also noticed they were more compliant with their medications and that they slept better.”

The program is not without its challenges, however. Barthel said some patients who were approached to join the study declined.

“They had an expectation that when they felt sick, that they were going to have people take care of them, and that they would be better when they left the hospital,” she said. “We are very careful about which patients we’re including. These patients did not want to go home to treat themselves.”

Another issue, she said, is internet access. The hospital has developed several strategies to ensure patients have a fast enough connection for a telehealth visit, including installing a new connection.

Another obstacle is staffing. Two in-home visits a day requires a significant amount of nursing capacity.

But advocates see the program as a way to reduce healthcare disparities for rural residents.

David Levine

“Access to high-value acute care services in rural communities is a growing national problem,” David Levine, M.D., leader of Ariadne Lab’s RHH team, said. “A randomized controlled trial will help us examine how we can provide a high quality and safe patient experience affordably in a rural context.”

Blessing is one of only two American rural hospital systems to run the trial. The other, Appalachian Regional Healthcare (ARH), provides services for rural Eastern Kentucky and southern West Virginia.

Between now and the end of the study in 2025, Barthel said she hopes to sustain an average patient population of four, with new patients entering the program and ones who have recovered being released.

“Past the trial stage, we hope to be able to replicate the program with staff deployed in each of our hospitals,” she said. “Our goal is to have these services available from each of our facilities.”

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