Why U.S. Patients Declined Hospital-at-Home during the COVID-19 Public Health Emergency: An Exploratory Mixed Methods Study

Abstract

To understand why US patients refused participation in hospital-at-home (H@H) during the coronavirus disease 2019 Public Health Emergency, eligible adult patients seen at 2 Mayo Clinic sites, Mayo Clinic Health System—Northwest Wisconsin region (NWWI) and Mayo Clinic Florida (MCF), from August 2021 through March 2022, were invited to participate in a convergent-parallel study. Quantitative associations between H@H participation status and patient baseline data at hospital admission were investigated. H@H patients were more likely to have a Mayo Clinic patient portal at baseline ( P-value: .014), indicating a familiarity with telehealth. Patients who refused were more likely to be from NWWI ( P-value < .001) and have a higher Epic Deterioration Index score ( P-value: .004). The groups also had different quarters (in terms of fiscal calendar) of admission ( P-value: .040). Analyzing qualitative interviews (n = 13) about refusal reasons, 2 themes portraying the quantitative associations emerged: lack of clarity about H@H and perceived domestic challenges. To improve access to H@H and increase patient recruitment, improved education about the dynamics of H@H, for both hospital staff and patients, and inclusive strategies for navigating domestic barriers and diagnostic challenges are needed.

Early experience and lessons following the implementation of a Hospital‐at‐Home program

“…Interestingly, more than 70% of patients with an eligible ZIP code and payor failed to receive a documented clinical screening by a hospitalist and represented the largest leak in the patient acquisition funnel. Similar to the published experience of patients ( n = 13) who declined HaH admission during the COVID‐19 pandemic, we conducted an analysis of 84 patients who declined HaH admission and offer strategies to address these concerns in Figure 2b 14 . We identified variation in hospitalist screening practices, HaH communication, and interpretation of clinical appropriateness as key provider‐driven barriers to patient acquisition (Figure 2b).…”

“…Similar to the published experience of patients (n = 13) who declined HaH admission during the COVID-19 pandemic, we conducted an analysis of 84 patients who declined HaH admission and offer strategies to address these concerns in Figure 2b. 14 We identified variation in hospitalist screening practices, HaH communication, and interpretation of clinical appropriateness as key provider-driven barriers to patient acquisition (Figure 2b). To address these, we further standardized screening workflows, encouraged clinicians to introduce the program early, and coached hospitalists on how to make a clear recommendation when HaH was appropriate.…”

Towards a conceptual framework for addressing state-level barriers to decentralized clinical trials in the U.S.

“…To implement, evaluate, and refine the CARE-P 3 framework, DCT case studies characterized by a range of interventions and representative of various socioeconomic and diagnostic conditions are critical. While the pilot implementation of this framework has been trialed in both rural and urban settings, refining this approach will require multiple rounds of analysis and feedback to identify major gaps and arrive at a robust framework that can be used by researchers before, during, and after a DCT [22][23][24]. A chief challenge facing this work is limited research funding; however, evidence from the growing body of DCT research conducted during the pandemic may suggest that the economic impact of not addressing state-specific barriers will be more costly.…”