OBJECTIVES To describe the evolution of a hospital at home (HaH) program to a HaH with a 30‐day posthospitalization transition period (HaH‐Plus) and results of a retrospective review of cases. DESIGN After launching HaH‐Plus, we used the same interdisciplinary clinical team to provide acute home‐based care for a broader range of home‐based acute‐level services than originally conceived in the Hospital at Home model. These included a palliative care unit at home (PCUaH), an observation unit at home (OUaH), a post‐acute care rehabilitation at home (RaH), and a program for the hospital averse – those patients needing to be in the hospital but who refuse. SETTING Urban health system. PARTICIPANTS Individuals 18 years or older residing in specified catchment area with Medicare fee‐for‐service or accepted Medicare/Medicaid Advantage plans requiring facility‐based care. INTERVENTION Provision of facility‐based acute‐level care at home to 685 participants. MEASUREMENTS Length of stay, readmission, and mortality. RESULTS HaH‐Plus cared for 685 individuals. The PCUaH had the oldest participants (mean age 87), and all groups were predominantly female and dually eligible for Medicare and Medicaid. Diagnoses and length of stay were similar in all groups except that those in RaH had a larger group of diagnoses, than those accepted in to HaH‐Plus and those in OUaH had a shorter stay. Rate of readmission was highest for RaH (19%). Mortality during the active treatment episode was highest for PCUaH and hospital averse as compared to HaH‐Plus, OUaH and RaH. CONCLUSION Providing a broader range of facility‐based care in the home has significant advantages for patients and increases the scalability of HaH. Developing a spectrum of services was possible by leveraging a robust, 24‐hour HaH team. Community‐ and home‐based care could become a greater part of the U.S. healthcare system if a platform of HaH services along with advances in technology and payment models were developed. J Am Geriatr Soc 67:596–602, 2019.

Prior to being referred to the emergency department (ED), patients such as the frail elderly often call their primary care physician. However, the on‐call primary care physician or covering provider does not always have the tools to make an accurate and safe assessment over the phone or to treat patients remotely. This often results in preventable transport to an ED, avoidable admissions and iatrogenic events. An opportunity exists to reduce unnecessary ED referrals by enhancing the capabilities of the on‐call primary care physician. In this communication, we describe the development of a community paramedicine programme that supports on‐call primary care providers managing a high‐risk patient population with the goal of reducing avoidable ED referrals.

Selection, standardization, and implementation of instrumentation and reagents throughout a health care facility network can often be a difficult process. However, in today's ever-changing health care setting, it is often mandated. The Veteran's Integrated Systems Network 16 (VISN 16) was faced with such a task early in 1999, with the targeted area being its coagulation laboratories. The plan outlined in this paper was drafted to help facilitate the selection, standardization and implementation of coagulation systems for 17 health care facilities that make up the VISN 16 network. The VISN, encompassing 170,000 square miles, has 10 tertiary care hospitals, six of which have close relationships with affiliate universities. There are 299,733 patients enrolled in this health delivery system. The facilities range from large institutions performing both tertiary and outpatient care to small outpatient clinics. Because of the plan's detailed, comprehensive content, which included analyses of a large number of performance parameters as well as cost-efficiency, the selection process was carried out using a checklist that could be helpful to other organizations selecting equipment and reagents for coagulation studies. An implementation process was devised, resulting in coagulation standardization across the Integrated Health Network.

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