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Unplanned acute care is inevitable in seniors with multiple chronic conditions. Episodes of exacerbations of heart failure, chronic obstructive pulmonary disease (COPD), hyper/hypoglycemia and other illnesses arise and need medical attention.
Given these vulnerable seniors are at highest risk for severe disease and death from COVID-19, it is critical to keep them out of any environment where they could be exposed to the coronavirus. Based on our experiences with teams in our Home-Based Acute Care Learning and Action Network (HomeLAN), we have outlined key steps to help keep older adults out of the hospital for non-COVID-19 conditions while caring for them safely at home.
Focus on the five most common chronic conditions: heart failure, COPD, cellulitis, urinary tract infection, and pneumonia.
Adapt existing health system order sets for these conditions for home-based delivery, understanding there may be conditions present for which you do not have an order set, but still have capability to treat at home.
Use virtual visits as often as possible when safe to do so.
Gather key stakeholders. Along with the core team of clinicians, care managers, representatives from emergency medical services, home health, infusion pharmacies, and supply chain, consider including risk management and legal/compliance team members as part of your planning and implementation efforts.
Identify your population of focus. Determine the group of patients most likely to benefit. Start with non-COVID-19 patients with straightforward care needs (e.g., cellulitis patients who need IV antibiotics). Many HomeLAN teams are focused on discharging non-COVID seniors from the hospital and finishing their treatment at home or keeping seniors out of the emergency department if they can be safely treated at home.
Create process maps
. Document each step of how you think the process will work.
Start simulations as soon as possible. Begin with tabletop simulations, first by talking through the process, then by walking through it with all the stakeholders. Finish by conducting a simulation with a real patient who is in good health.
Test your process using rapid cycle testing
). Start small. Only move forward if the process works on a small scale (e.g., one patient at a time, then five, then 25, etc.). Revise process flow maps as you learn.
Always maintain evidence-based practice. Adapt institutional policies and procedures for use at home.
Create redundancy and back-up plans. Consider the worst-case scenario and have a plan (e.g., backup physicians or nurses, escalation protocols, and communication channels). Remember 911 is always available.
Work upstream. Consider a pre-engagement strategy for your population of focus. Reach out to patients proactively, let patients and families know what to do, who to call, and when. Teach them not to wait until symptoms are severe.
Communicate. Debrief each case. Have daily virtual multidisciplinary team
Standardize. Consider creating checklists and visit templates for reliability and fidelity.
Create a measurement and evaluation strategy. Track some key quality and outcome measures:
We understand the need to move fast and implement processes that in normal situations would have gone more slowly and methodically. As much as possible, be mindful of these learnings and opportunities, and weigh the risks and benefits of moving forward.
Avoid doing too much all at once. This can hamper a team’s progress and their ability to gain traction.
Try not to move too fast. Test and adapt necessary processes until they prove to be successful before advancing to a larger scale or greater complexity.
Remember to collect data on small tests of change. Think carefully about what you are trying to accomplish. What do you want to try? What did you predict will happen? How did the test go? What needs to happen or be adjusted next?
Ask patients and families what matters most to them.
Create a plan to help prevent transmission of the coronavirus between health care workers coming to the home and patients. Even though the total number and duration of interactions with health care providers may be lower in the home versus in a facility, this is still an important concern.
Amy R. Stuck, PhD, RN, is Senior Director, Value-Based Acute Care at the West Health Institute. Christopher Crowley, PhD, is Program Manager, Successful Aging at the West Health Institute. Mary Pisciotta, MPH, is a Director at the Institute for Healthcare Improvement. Cory Sevin, RN, MSN, is a Senior Director at the Institute for Healthcare Improvement.
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The Keys to Effective Telemedicine for Older Adults
How to Limit the Exposure of Older Adults to COVID-19 and Provide Age-Friendly Care
More COVID-19 Guidance and Resources