Acute Care at Home (ACH):  An ED-based Alternative to Admission

Acute Care at Home (ACH) addresses the problem that 70% of hospital admissions for older adults originate in the ED, despite a growing body of evidence that home-based alternatives for select conditions are lower in cost, preferred by patients and result in better outcomes.  The ACH innovation provides new, efficient disposition options for qualified patients to be treated in the comfort and safety of their home following evaluation in the ED.  From the beginning, our ACH innovation team adopted a performance improvement methodology that prioritized sustainability and scalability.  For this approach to succeed and have tangible impact we:

1) developed needed resources and processes for transitions from the ED to home-based acute care. 
2) embraced existing infrastructure and resources.  
3) used technology to overcome inevitable process barriers.
4) worked within existing reimbursement models, understanding that new payment models are emerging.

We did not want to simply add yet another study showing the well-established importance of home-based alternatives to hospitalization; we were already familiar with a body of compelling evidence of benefit, especially for our nation’s seniors, who face elevated risk for delirium, physical de-conditioning and hospital-acquired infections.  Rather, we wanted to confront the difficult process of making the ACH innovation sustainable, starting with what was available and then iteratively improving, using the foundations of quality improvement and implementation science.  We needed to reach beyond the ED, to enlist primary care affiliates, and to team up with a like-minded home health agency.  Although not directly affiliated with our hospital, our home health partners worked with us hand-in-hand as we jointly developed the order sets and then the communications and logistical infrastructure to tie everything together operationally.  Most of the care provided within this ACH innovation was directly reimbursed by patients’ insurance, including the skilled home health care.   Consistent with our focus on sustainability, the primary measure of effectiveness for ACH was cost savings, notwithstanding that the overall motivation was fundamentally to provide care better matched to the needs of seniors that visit the ED.

AcuteCare@Home Clinical Process

Process Flow

Barriers Diagram

Publication Date: 
2017
Hospital: 
University of California, San Diego: Department of Emergency Medicine
Toolkit Category: 
Clinician Initial Evaluation
Disposition Decision
Exit from ED
Clinical Areas Affected: 
Clinics
Emergency Department
Geriatric Emergency Department
Staff Involved: 
Administrators
Ancillary Departments
Case Management
ED Staff
IT Staff
Nurses
Pharmacists
Physicians
Registration Staff
Social Workers/Case Managers