DHA 733 Week 7 Proposal for a New Administrative Model Example

The Hospital Comes Home: Proposing a Regional Rural Home Hospital Service for Four North Carolina Counties

[Student Name]

University of Phoenix

DHA/733: Contemporary Leadership Issues

Week 7 Assignment

[Instructor Name]

[Date]

The health network, the proposed service, staffing, costs, volumes and governance are composites written for a model paper; research findings come from the sources cited, and federal payment rules are described in general terms.

On a January night during a respiratory virus surge, every inpatient bed in the region's hospitals was full. Three patients waited in rural emergency departments for transfer, one for thirty hours. Among the patients occupying beds were older adults with pneumonia, heart failure and cellulitis who needed intravenous medications and monitoring but not the operating room or intensive care. The regional vice president asked whether some of them could have been treated at home. This paper proposes a model that would make that possible.

The Limits of the Bed-Based Model

The region's inpatient capacity is fixed by buildings and, more tightly, by nurse staffing. Adding beds is expensive and slow. A new medical-surgical unit at the regional hospital would cost more than $12 million and take three years, and the region could not staff it today. Each winter, respiratory surges push occupancy above 95%, and the rural hospitals, which send most of their sickest patients to the regional hospital, wait longest. Meanwhile, older patients often do poorly in the hospital: they lose strength lying in bed, become delirious in unfamiliar surroundings and acquire infections. For some patients, the hospital itself carries risk.

Evidence From a Randomized Trial

Levine and colleagues randomly assigned 91 adults admitted through the emergency department with selected acute conditions to home hospital or usual hospital care; the home arm brought clinicians to the house, delivered intravenous drugs, watched vital signs remotely, used video check-ins and ran bedside tests, After adjustment, an acute episode treated at home cost 38% less. Home patients also received far fewer lab tests, scans and specialist consultations, were up and moving for more of the day and returned to the hospital within a month less often, 7% of them against 23% of the comparison group (Levine et al., 2020).

Limits of the Trial

The trial was small, conducted at two urban sites and enrolled highly selected patients; 63% of eligible patients declined. Its results show what is possible, not what every program will achieve. Travel distances in Boston are measured in minutes; in the region, a nurse's visit to a farmhouse may take forty minutes each way, which changes staffing and cost.

Evidence From a Multisite Study

An earlier study broadens the picture. Leff and colleagues studied 455 older patients at three sites needing admission for pneumonia, heart failure, chronic lung disease or cellulitis and reported that care at home met quality standards about as often as care on the wards, with a shorter length of stay, 3.2 versus 4.9 days, some evidence of fewer complications and a lower mean cost, $5,081 versus $7,480 (Leff et al., 2005).

Evidence From a Rural Setting

Rural adaptation is less studied. Desai and colleagues described a rural home hospital in Utah in which a remote attending physician and a registered nurse deployed to the home cared for three acutely ill patients; admission, daily care and discharge were accomplished, patients and clinicians reported satisfactory experiences and success depended on team dynamics, technology, workflows and care coordination (Desai et al., 2024). The evidence for rural settings is promising but thin. In a rural region, the hardest part of home hospital care is not the medicine but the miles.

The Proposed Model

The regional home hospital service would operate from the regional hospital. Emergency physicians at any of the rural hospitals would identify eligible patients with conditions such as pneumonia, heart failure, cellulitis and chronic lung disease flares, who have a safe home, a caregiver or phone access and live within sixty minutes of a base.

Staffing

A remote hospitalist would oversee up to ten home patients by video and phone. Registered nurses would visit at least twice daily, and community paramedics, already trained in the region's post-discharge program, would respond to urgent needs around the clock. A pharmacist and a logistics coordinator would manage medications, equipment and supplies.

Technology and Logistics

Patients would receive a tablet, cellular hotspot, continuous monitoring devices and a pendant to call for help. Because broadband is unreliable in parts of the region, cellular connectivity would be tested before admission. Laboratory draws would be processed at the nearest rural hospital. Supplies would be stocked in kits at each rural hospital so that nurses begin from the closest base, and a courier would deliver medications within two hours of an order.

Payment and Regulation

A federal waiver has allowed hospitals to be paid by Medicare for acute care at home if they meet specific requirements, including in-person visits and remote monitoring, but its continuation depends on Congress. The region would also negotiate contracts with Medicaid managed care plans and commercial insurers and would not expand beyond a pilot until payment was secure. State licensing rules for home health and hospital services would be reviewed with counsel, and nurses crossing county lines would need clear protocols for supervision and documentation.

Governance

The service would be governed as a regional service line with a medical director, a nurse director, a quality committee reviewing every escalation and transfer and representation from each rural hospital, so that it strengthens rather than competes with local hospitals.

Safeguards

Every patient would have a clear escalation plan: paramedic response within thirty minutes and ambulance transfer to a hospital if needed. Patients could choose hospital care at any time. Criteria would exclude patients likely to need intensive care. Caregivers would be told plainly what the service expects of them and what it provides, since home hospital care can shift work onto families, particularly older spouses.

Costs

Start-up costs of about $900,000 cover equipment, technology, training and a vehicle fleet. Operating costs are expected to be lower per episode than inpatient care, and freeing beds allows the regional hospital to accept transfers it now declines. If the service treated two patients a day at home, it would free the equivalent of about eight beds during surges, enough to end most overnight waits for transfer.

Anticipated Resistance

Some physicians may doubt that patients can be safe at home, and some rural hospital leaders may fear losing inpatients to a regional service. The pilot will include rural hospital physicians in patient selection, count home admissions from each hospital's patients toward that hospital's volume and share every escalation openly.

Pilot and Evaluation

A twelve-month pilot would enroll about 150 patients, measuring escalations, transfers, deaths, readmissions, cost per episode, patient and caregiver experience and staff workload, compared with similar patients treated in the hospital.

Conclusion

The region's bed shortage and the harms hospitals pose to frail older patients call for a new model. Evidence from a randomized trial and a multisite study shows home hospital care can be safe, less costly and preferred by patients, and a rural pilot shows feasibility. With careful design, governance, safeguards and payment, a regional home hospital service could bring hospital care to patients' homes across four counties.

References

Desai, M. P., Ross, J. B., Blitzer, S., Como, N., Horton, D. J., Ostergar, J., Hernández, C., & Levine, D. M. (2024). Hospital-level care at home for acutely ill adults in rural settings. Home Healthcare Now, 42(1), 21-30. https://doi.org/10.1097/NHH.0000000000001227

Leff, B., Burton, L., Mader, S. L., Naughton, B., Burl, J., Inouye, S. K., Greenough, W. B., Guido, S., Langston, C., Frick, K. D., Steinwachs, D., & Burton, J. R. (2005). Hospital at home: Feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Annals of Internal Medicine, 143(11), 798-808. https://doi.org/10.7326/0003-4819-143-11-200512060-00008

Levine, D. M., Ouchi, K., Blanchfield, B., Saenz, A., Burke, K., Paz, M., Diamond, K., Pu, C. T., & Schnipper, J. L. (2020). Hospital-level care at home for acutely ill adults: A randomized controlled trial. Annals of Internal Medicine, 172(2), 77-85. https://doi.org/10.7326/M19-0600