With increasing complexity of hospitalized patients and the overall longer survival of cardiac patients, the care of patients beyond the acute phase of illness is challenging. Factors such as frailty, advanced age and lack of social support require many patients to be kept in the hospital beyond the time frame when inpatient care is mandatory. Lack of resources to safely continue care at home or as an outpatient frequently leads to unplanned readmissions to the hospital. Acute exacerbation of heart failure is a prime example of this dilemma in cardiovascular care. Much to the chagrin of cardiologists and hospitals, readmission for heart failure has been tracked by payers and hospital systems as a quality measure, and even penalized financially. While skilled nursing facilities and home health are available, access to these resources is often limited. As a result, innovative methods for caring for patients at home post-discharge are worth exploring.

A recent ACC webinar, "Hospital at Home: Rethinking Acute and Chronic Care Management," is an excellent starting point for anyone interested in this area. This panelists describe two models of care delivery using intensive oversight of patients considered high risk for readmissions post-hospital discharge:

• The Mayo Rochester model uses 'community paramedics' to visit patients with heart failure post hospitalization, and provide IV infusions, physical examination and blood testing under the supervision of the advanced practice providers in the heart failure care team.
• The model followed by Tampa General Hospital employs greater level of technology monitoring at home and uses hospital staff to make the home calls.

Both models offer an up-close opportunity to observe patients in their daily surroundings and intervene as appropriate. These models are very popular with patients since it saves them from repeated trips to hospital or clinic through bringing services directly home. The safety of the care providers making home visits was determined prior to the use of both models.

There are several unknowns with the 'Home at Hospital' approach. The existing capacity for this approach in various communities is unknown. Some of the services hospitals provide such as round-the-clock nursing help for a convalescing patient is now shifted to the family who may not be adequate to carry out this task. The added value of this model over skilled nursing facilities and home health needs to be validated. It is also unclear whether this service would be equally available for disadvantaged communities.

Read more about the 'Hospital at Home' concept in the cover story article in the October issue of Cardiology Magazine and download the home-based care workbook.

This article was authored by Chittur A. Sivaram, MBBS, FACC, professor and vice chief of the CV Section at the University of Oklahoma.