Huntsman Cancer Institute program offers hospital-level care in patient’s own home

Karen Titchener, MS, APRN
Karen Titchener

Huntsman Cancer Institute at University of Utah launched a program designed to bring hospital-level care into the homes of patients with cancer.

The Huntsman at Home program is run by community visiting advanced nurse practitioners, with physician oversight and traditional home health services provided by Community Nursing Services, a community home health agency.

Patients are provided with acute, supportive and palliative care services at home, with continuity of care assured due to coordination with the patient’s attending oncologist at Huntsman Cancer Hospital. The program also provides ongoing support and input to manage symptoms associated with treatment.

HemOnc Today spoke with Karen Titchener, MS, APRN, director of the Huntsman at Home program at Huntsman Cancer Institute and adjunct assistant professor in the College of Nursing at University of Utah, about how this program works, the benefits it offers, and what other cancer centers consider if they want to implement a similar initiative.

Question: How did this initiative come about?

Answer: University of Utah Huntsman Cancer Hospital had been looking into a hospital-at-home model for its patient population. They knew there were gaps in care when transitioning patients from acute care to the community, particularly the home. There was also overuse of EDs to deal with poorly controlled symptoms, and continuing pressure to free up hospital beds in a timely way. In 2017, two members of Huntsman Cancer Institute visited me and the hospital-at-home program I had developed and was directing in London. After consulting with them in Salt Lake City, they offered me a position to lead the development and implementation of a hospital-at-home program for their population of patients with cancer.

For the first year, we scoped the unmet needs of patients and their families, how services could be designed to address them, what would and would not be reimbursed given current reimbursement models, and the current palliative care and hospice models in the U.S. health care system. I also spent time with home health and hospice agencies to understand their level of care. With key stakeholders, we designed the Huntsman at Home program to address the identified care gaps.

Q: What challenges did you encounter while trying to start the program?

A: For me, coming from a socialized health system, the biggest barrier was learning how care was designed around the fee-for-service reimbursement model rather than having the ability to design a program based on need and have the services covered. Many of the necessary services to implement a community-based program are not adequately addressed in the fee-for-service model, which is designed around hospital- or clinic-based care. Because we engaged the key stakeholders early on in the design and there was a known need, there were few challenges with getting the program up and running. Huntsman Cancer Institute was willing to underwrite the program knowing much of it was not reimbursable in the current payment models, choosing to develop an improved care model and then seek new reimbursement models. To do this, we proposed a 3-year demonstration project to explore the value of such a program.

Q: How does the program work?

A: The Huntsman at Home program is a 24-7, 365-days-of-the-year program that is predominately led by a nurse practitioner with physician backup and consultation to oversee care. Referrals are received from the acute cancer hospital inpatients, clinics or the community. Patients can also self-refer if they previously have been on the program. The team provides support for early discharge after an acute hospital admission for patients who need continued intense monitoring, medication titration, and continuing monitoring and management of symptoms. The team also provides step-up care from the community or from outpatient clinics for patients with acute worsening symptoms.

Q: How have things gone since the launch in December?

A: In general, we are seeing a reduction in ED admissions, hospital readmissions and deaths in the hospital for patients being cared for by the Huntsman at Home program. Patients, family caregivers, and physician and nurse referrers are extremely positive about our service. Hospital administrators credit our program for relieving some of the bed pressure for the hospital. We believe we are achieving other benefits, including more goal-concordant care and less futile chemotherapy at the end of life. We are committed to a comprehensive evaluation of the program, outcomes and cost and will have sufficient data for evaluation within the next year.

Q: How is this benefiting patients in terms of comfort, outcomes and time spent in the hospital?

A: The big thing we are providing is continuity of care. We are only 7 months into the program and we are already seeing evidence that suggest improved outcomes for patients and benefits to the health care system with demand management. Right now, we offer both acute response and palliative care. We also transition patients to hospice and we remain the lead provider for those hospice patients. This ensures that the Huntsman Cancer Hospital can look after these patients from diagnosis to recovery or death. For example, patients who are experiencing adverse events from treatment can call us and we will provide acute interventions that will prevent them from using the ED for symptom care or requiring an unplanned hospital admission. We have a 2-hour response commitment for patients who experience symptom fluctuations, which is key for families to feel we will support them.

Q: What advice would you give to other institutions that might want to implement a similar program?

A: Institutions should scope their needs, determine the outcomes they want, identify which key stakeholders to involve in the service design, and build a sense of ownership to help make the program successful. This program is not for the faint-hearted. It is very demanding and intense for the care team. It takes commitment and flexibility. The training, integration, communication and partnership must be aligned.

Q: Is it likely that this approach will become more mainstream in cancer care?

A: Having established several hospital-at-home programs in the U.K. that had a much wider patient profile, I have been pleasantly surprised by how well the hospital-at-home model works for patients with cancer. This is due to the sometimes-unpredictable and rapidly changing trajectory of needs related to disease or treatment side effects. The responsiveness of the hospital-at-home program allows the team to manage these rapid changes in the patient’s own home. We are conducting extensive evaluation research of the program to ensure programs like this become mainstream in cancer care with appropriate payment models. – by Jennifer Southall

For more information:

Karen Titchener MS, APRN, can be reached at University of Utah, 2000 Circle of Hope, Salt Lake City, UT 84112; email: karen.titchener@hci.utah.edu.

Disclosure: Titchener reports no relevant financial disclosures.

Karen Titchener, MS, APRN
Karen Titchener

Huntsman Cancer Institute at University of Utah launched a program designed to bring hospital-level care into the homes of patients with cancer.

The Huntsman at Home program is run by community visiting advanced nurse practitioners, with physician oversight and traditional home health services provided by Community Nursing Services, a community home health agency.

Patients are provided with acute, supportive and palliative care services at home, with continuity of care assured due to coordination with the patient’s attending oncologist at Huntsman Cancer Hospital. The program also provides ongoing support and input to manage symptoms associated with treatment.

HemOnc Today spoke with Karen Titchener, MS, APRN, director of the Huntsman at Home program at Huntsman Cancer Institute and adjunct assistant professor in the College of Nursing at University of Utah, about how this program works, the benefits it offers, and what other cancer centers consider if they want to implement a similar initiative.

Question: How did this initiative come about?

Answer: University of Utah Huntsman Cancer Hospital had been looking into a hospital-at-home model for its patient population. They knew there were gaps in care when transitioning patients from acute care to the community, particularly the home. There was also overuse of EDs to deal with poorly controlled symptoms, and continuing pressure to free up hospital beds in a timely way. In 2017, two members of Huntsman Cancer Institute visited me and the hospital-at-home program I had developed and was directing in London. After consulting with them in Salt Lake City, they offered me a position to lead the development and implementation of a hospital-at-home program for their population of patients with cancer.

For the first year, we scoped the unmet needs of patients and their families, how services could be designed to address them, what would and would not be reimbursed given current reimbursement models, and the current palliative care and hospice models in the U.S. health care system. I also spent time with home health and hospice agencies to understand their level of care. With key stakeholders, we designed the Huntsman at Home program to address the identified care gaps.

Q: What challenges did you encounter while trying to start the program?

A: For me, coming from a socialized health system, the biggest barrier was learning how care was designed around the fee-for-service reimbursement model rather than having the ability to design a program based on need and have the services covered. Many of the necessary services to implement a community-based program are not adequately addressed in the fee-for-service model, which is designed around hospital- or clinic-based care. Because we engaged the key stakeholders early on in the design and there was a known need, there were few challenges with getting the program up and running. Huntsman Cancer Institute was willing to underwrite the program knowing much of it was not reimbursable in the current payment models, choosing to develop an improved care model and then seek new reimbursement models. To do this, we proposed a 3-year demonstration project to explore the value of such a program.

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Q: How does the program work?

A: The Huntsman at Home program is a 24-7, 365-days-of-the-year program that is predominately led by a nurse practitioner with physician backup and consultation to oversee care. Referrals are received from the acute cancer hospital inpatients, clinics or the community. Patients can also self-refer if they previously have been on the program. The team provides support for early discharge after an acute hospital admission for patients who need continued intense monitoring, medication titration, and continuing monitoring and management of symptoms. The team also provides step-up care from the community or from outpatient clinics for patients with acute worsening symptoms.

Q: How have things gone since the launch in December?

A: In general, we are seeing a reduction in ED admissions, hospital readmissions and deaths in the hospital for patients being cared for by the Huntsman at Home program. Patients, family caregivers, and physician and nurse referrers are extremely positive about our service. Hospital administrators credit our program for relieving some of the bed pressure for the hospital. We believe we are achieving other benefits, including more goal-concordant care and less futile chemotherapy at the end of life. We are committed to a comprehensive evaluation of the program, outcomes and cost and will have sufficient data for evaluation within the next year.

Q: How is this benefiting patients in terms of comfort, outcomes and time spent in the hospital?

A: The big thing we are providing is continuity of care. We are only 7 months into the program and we are already seeing evidence that suggest improved outcomes for patients and benefits to the health care system with demand management. Right now, we offer both acute response and palliative care. We also transition patients to hospice and we remain the lead provider for those hospice patients. This ensures that the Huntsman Cancer Hospital can look after these patients from diagnosis to recovery or death. For example, patients who are experiencing adverse events from treatment can call us and we will provide acute interventions that will prevent them from using the ED for symptom care or requiring an unplanned hospital admission. We have a 2-hour response commitment for patients who experience symptom fluctuations, which is key for families to feel we will support them.

Q: What advice would you give to other institutions that might want to implement a similar program?

PAGE BREAK

A: Institutions should scope their needs, determine the outcomes they want, identify which key stakeholders to involve in the service design, and build a sense of ownership to help make the program successful. This program is not for the faint-hearted. It is very demanding and intense for the care team. It takes commitment and flexibility. The training, integration, communication and partnership must be aligned.

Q: Is it likely that this approach will become more mainstream in cancer care?

A: Having established several hospital-at-home programs in the U.K. that had a much wider patient profile, I have been pleasantly surprised by how well the hospital-at-home model works for patients with cancer. This is due to the sometimes-unpredictable and rapidly changing trajectory of needs related to disease or treatment side effects. The responsiveness of the hospital-at-home program allows the team to manage these rapid changes in the patient’s own home. We are conducting extensive evaluation research of the program to ensure programs like this become mainstream in cancer care with appropriate payment models. – by Jennifer Southall

For more information:

Karen Titchener MS, APRN, can be reached at University of Utah, 2000 Circle of Hope, Salt Lake City, UT 84112; email: karen.titchener@hci.utah.edu.

Disclosure: Titchener reports no relevant financial disclosures.