PATH

A practical alternative to hospitalization

Opportunity

Emergency clinicians make difficult decisions about whether patients require hospitalization or can be discharged home. Patients are often admitted or observed in the hospital because safe outpatient care plans cannot be coordinated or patients lack the support necessary to recover safely at home.

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. We have also 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 practical alternative to hospitalization for ED patients by expanding the point-of-care options available to physicians and deploying health system resources in the home setting.

First, the program leverages a customized Agent dashboard to identify ED patients under consideration for hospital admissions or observation stays who qualify for home treatment. Once identified, the PATH team collaborates with ED physicians, primary care providers, families, and the patient to develop a personalized outpatient plan.

After discharge, all patients receive a next-day scheduled phone call from the PATH team to monitor symptoms, adjust treatment plans, and address patient or family concerns. Additional PATH services include coordination support to arrange outpatient appointments and testing, home health services for eligible patients, home infusion and laboratory services, and identification of health-related social needs.

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 recovered safely at home without returning to the hospital, and patients and providers expressed satisfaction with the program.

PATH is currently completing 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 served as a model for the COVID Accelerated Care Pathway, a successful initiative led by CHCI, the Center for Connected Care, Penn Medicine at Home, and the Hospital of the University of Pennsylvania. This initiative created a pathway for moderate-severity patients with COVID-19 requiring hospitalization through specialized management in the ED observation unit and outpatient management through COVID Pulse Enhanced, a customized version of the CHCI COVID Watch program. The PATH team is working with these partners to explore new models that build upon the insights from these efforts.

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 many interconnected root causes.

To manage this complexity, gain consensus on the problem space, and ultimately scope the project, you can use the problem octopus to organize the problem space visually.

The basic concept is that you start with the head of the octopus, asking, "What is the high-level problem we are trying to solve?".

From there, you can use the five whys to drill down to the next level root causes of that problem definition, building out different tentacles. Continuing to ask "Why?" and "Why else?" will enable you to get to the most granular root causes of the problem.

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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 learn more about a problem area is to experience it yourself. Immerse yourself in the physical environment of your user.

Do the things they are required to do to gain a firsthand experience of the challenges they face. Completing a day in the life exercise will enable you to uncover actionable insights and build empathy for the people you're hoping to help.

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 questions, "What happens if people use this?" and "Does this move the needle?"
 
As opposed to fake front ends, fake back ends can produce a real outcome for target users on a small scale. For example, suppose you pretend to be the automated back end of a two-way texting service during a pilot. In that case, the user will receive answers from the service, just ones generated by you instead of automation.
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 you're striving to create a breakthrough user experience.
 
Delight expresses a situation in which you've created an experience so compelling and emotionally resonant that people tell others about it, generating active word of mouth. 
 
Key drivers of delight include positive surprises, including the elimination of work and effort. So, key questions to ask include "What would users not expect in this service?" "How do we want users to feel when using this service?" and "What work can we remove or do on behalf of users?"
 
Examples of designing for delight include Zappos surprising customers with free overnight shipping on their first order or an Airbnb host 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.