Strategies used to implement Hospital at Home: a description of an approach to scaling a complex healthcare intervention

Abstract

Background Advances have been made in recent years to characterize facilitators and barriers to implementation of complex health care intervention and to classify the implementation strategies available to address these determinants. We study the implementation of a Hospital at Home (HaH) intervention in a multi-hospital health system to understand the selection and use of implementation strategies in its launch, sustainment, and scaling. Methods We report on the implementation portion of an effectiveness-implementation study of the hybrid type 1 design. First, we retrospectively identified determinants of practice most relevant to the HaH intervention using of the Integrated Checklist of Determinants (TICD) assisted by review of archived documents. We also identified implementation strategies using the listing created by the Expert Recommendations for Implementing Change (ERIC) that could potentially address each determinant. Second, we then identified which of the ERIC strategies were actually employed using a modified Delphi process to obtain consensus among HaH program leaders involved in the program implementation. Program leaders also rated the importance and effort expended on each strategy on 1-9 Likert scales. The most relevant implementation strategies identified through these steps were detailed with respect to actors, targets, dosing and justification, and associated with prospectively collected implementation outcomes. Results The majority of ERIC implementation strategies (57 of 73, 78%) were utilized; 7 strategies (10%) were not used. On the remaining 9 strategies (12%), program leaders did not reach consensus regarding utilization. For used strategies, mean importance was 6.87 and mean effort expended was 6.22. Implementation strategies rated most important by program leaders had a broad target of actions that included clinical staff, patients, leadership, external vendors, health plans, and government officials. The strategies varied in temporality and dosing. Over the course of the implementation, adoption, acceptance, and penetration increased over time, while measures of fidelity remained stable. Conclusions Considerable effort and multiple strategies were required to implement Hospital at Home. While potentially daunting, use of existing implementation frameworks can help focus limited efforts and resources by targeting strategies that address the key barriers and enablers to implementation of complex healthcare interventions.

Association of Costs and Days at Home With Transfer Hospital in Home

“…The greater number of community days among T-HIH patients is an important finding for Accountable Care Organizations and Direct Contracting entities, for whom this is to be a future quality measure. The significantly reduced use of nursing homes after hospitalization 16 meets a frequent, recent desire by patients, especially at a time when 36% of COVID-19–related deaths are among nursing home residents. 17…”

“…15 The greater number of community days among T-HIH patients is an important finding for Accountable Care Organizations and Direct Contracting entities, for whom this is to be a future quality measure. The significantly reduced use of nursing homes after hospitalization 16 a For community stays and nursing home stays, the observational window was within 90 d discharge of the index hospitalization. The HIH period was considered as community days.…”