Local Adaptations of Hospital in Home: Variations in Structure and Implementation Across Six VA Programs

The VA Hospital in Home (HIH) model of care delivers acute-level hospital care to Veterans at home across the country. We aim to examine the similarities and differences in the structure and implementation of existing HIH programs across sites to identify best practices that optimize resources, ensure high-quality care, and enhance sustainability and scalability of the program.

A total of 6 out of 11 existing VA HIH programs reported on their program through structured presentations at Community-of-Practice meetings in 2022. Additional site-level characteristics were retrieved from the VA Corporate Data Warehouse to describe context at each program and to identify HIH encounters, types of stays, and numbers of HIH patients for each site.

All sites offered transfer (from hospital-based inpatient service) and substitutive (from other than inpatient) HIH stays, though the proportion of patients for each varied (transfer patients ranging from 6% to 85%). Referral sources for substitutive stays varied across sites including Home-Based Primary Care (HBPC) (67%), outpatient primary care (83%), specialty care clinics (67%), and emergency departments (83%). Each program had interdisciplinary teams, though composition and staff size varied (4-7 full-time equivalent [FTE] RNs; 1.0-2.0 FTE physicians). Programs varied in the number of unique patients served per program (63-146 unique HIH Veterans annually). Programs reported similar procedures in clinical evaluation, informed consent, and maintaining 24/7 access to the HIH team. Outcome metrics tracked include readmission (67%), cost avoidance (50%), and length of stay (50%). Additionally, 50% of sites reported integrating ancillary services and introducing program adaptations during the COVID-19 pandemic period such as virtual follow-up visits.

Our study identified similarities and differences across the existing HIH programs, adapting to local contexts while maintaining quality of care. These characteristics may reflect differences in population and site characteristics, patient needs, and program goals.