PATH

A practical alternative to hospitalization

Opportunity

Emergency clinicians must make quick decisions on whether patients are stable to be discharged or require hospitalization. They weigh the benefits of hospital services against the risk of sending patients home. Often, patients are admitted to the hospital because safe outpatient care plans cannot be coordinated or supported.

Unfortunately, these potentially avoidable admissions strain hospital capacity. In 2018, 25 percent of patients admitted from the emergency department (ED) at Penn Presbyterian Medical Center (PPMC) were discharged within 48 hours - suggesting an opportunity to care for patients entirely outside the hospital walls.

Through conversations when this work began, we found that patients would often prefer to recover from acute illness at home if deemed safe and effective to do so by their provider.

Intervention

PATH provides a new model for delivering care to ED patients.

The program deploys a customized Agent dashboard to identify patients with potential hospital admissions or observation stays who may qualify for home treatment. 

Upon identification, the PATH team collaborates with ED physicians, primary care providers, families, and the patient to develop a personalized outpatient plan. Upon discharge, patients are closely monitored at home, with coordination of care to arrange outpatient appointments and testing, home health services for eligible patients, home infusion and laboratory services, and identification of health-related social needs. From the time they leave the ED to when they achieve a recovered state of health, patients and families can directly contact the PATH team via text message or call with questions or concerns.

Impact

Through a series of rapid pilots at PPMC, we demonstrated that PATH could provide patients with the right care in the right place at the right time. In the most recent pilot with 30 patients, the ED boarding time for PATH patients was reduced by an average of eight hours, and hospital occupancy decreased by two bed-days. The vast majority of patients were able to recover at home without returning to the hospital, and patients and providers expressed satisfaction with the program.

PATH is currently embarking on an extended trial at PPMC and exploring additional pilot interventions at other Penn Medicine hospitals. The team is also working on automating many of the program's services and integrating the model with routine clinical care.

COVID-19

PATH established a timely pathway for enrolling ED patients with COVID-19 in home health programs, making more hospital beds available for patients who truly need inpatient services.

Phase 2: It does work
Collaborators

Austin Kilaru, MD, MSHP
Danielle Flynn, MSN, RN
Penn Medicine at Home

Innovation leads

David Resnick, MS.Ed, MPH
Krisda Chaiyachati, MD, MPH, MSHP
Kat Lee, MD
Avanti Rangnekar
David Asch, MD, MBA

Platforms
Funding

Independence Blue Cross

Innovation Methods

Problem octopus

When working on problem definition you will uncover multiple interconnected root causes. To manage this complexity, gain consensus on the problem space, and ultimately scope your project you can use this framework to visually organize the problem space. The basic concept is that you start with the head of the octopus, “What is the high-level problem we are trying to solve?”. From there you can use the “5 whys” to drill down to the next level root causes of that problem definition, building the start of different tentacles. Continuing to ask “Why?” will allow you to build out each tentacle to get to the most granular root causes driving the problem space.

Problem octopus
Initially, we knew that we wanted to move acute illness care away from the hospital for appropriate patients. Still, we struggled to define a specific problem definition.
 
We leveraged the problem octopus to drill down to specific root causes of the problem space we were working in, which gave us the insight to focus our intervention specifically on patients in the ED.
A day in the life

One of the best ways to understand an experience or problem in context is to experience it yourself. Immerse yourself in the physical environment of your target user. Do the things they are required to do to gain first-hand experience into the challenges they face. Completing a day in the life exercise will also help you build empathy for target users.

A day in the life
We spent considerable time conducting contextual inquiry in multiple settings.
 
We shadowed nurses visiting patients at home to understand the types of interventions that could be delivered in that setting. We spent time following ED physicians to understand the responsibilities and time-pressures of their work. And we spent time speaking to and observing patients at home after discharge to understand their recovery process and needs.
Fake back end

It is essential to validate feasibility and understand user needs before investing in the design and development of a product or service. A fake back end is a temporary, usually unsustainable, structure that presents as a real service to users, but is not fully developed on the back end. Fake back ends can help you answer the question, “What happens if people use this?” “Does this move the needle?”

Fake back end

We used a fake back end to enroll patients in a home discharge program that did not exist yet. We provided services to patients and communicated information back to providers during the pilot period.

This process enabled us to identify what worked in practice and what didn't, allowing us to iterate quickly and at a low cost. It also helped us generate early evidence that a program like PATH could reduce unnecessary admissions.

Design for delight

Delight is a great concept to utilize when solving for user satisfaction. Here the idea is to ask “what work can we remove for the user?” “what would they not expect in this service?”. Some examples of this are things like surprise discounts or free shipping on your first order, or a hotel creating an itinerary for you based on previously identified interests.

Design for delight
We sought to help patients and their families experience delight amidst an admittedly frightening visit to the hospital for an acute and uncertain illness.
 
We provided care packages to patients going home to remind them that the PATH team would be there to guide them in the days ahead. We also designed our intervention to alleviate the workload from busy ED physicians to increase the uptake of our services.