Leadership Perspectives on Hospital at Home and Equity: Broadening Access, Removing Enrollment Barriers, and Adding Value by Addressing Disparities.

BACKGROUND

Hospital at home (HaH) delivers safe and high-quality acute hospital-level care in patients' homes as an alternative to traditional hospital care. As HaH expands across the USA, there remains uncertainty in how HaH program leaders conceptualize equity and how they approach operational challenges affecting equitable delivery of HaH. Our objective was to explore how equity is defined, as well as barriers and strategies to achieving equity in HaH.

METHODS

We purposively sampled HaH programs diverse in size, geography, and safety-net status. We conducted semi-structured interviews and used rapid analysis with debrief templates and summaries, and applied targeted coding to develop themes, organized into a frame analysis.

RESULTS

We conducted 18 interviews with 28 leaders representing 15 hospital-based and three commercial HaH programs; approximately half represented safety-net hospitals. Participants articulated three distinct frames to conceptualize HaH equity, with associated themes incorporating challenges, and strategies to overcome them. Frame 1, Broaden HaH Access, focuses on factors limiting and enabling program establishment (e.g., in rural areas) to reach the broadest population. Frame 2, Remove Barriers to HaH Enrollment, focuses on socio-demographic factors (payer, geography, home safety, patient/caregiver preferences) affecting program enrolment. Leaders described specific strategies to overcome each factor (e.g., expanding payer mix). Frame 3, Add Value by Addressing Disparities, describes how HaH actively seeks to mitigate pre-existing health and social challenges and improve longer-term outcomes.

DISCUSSION: These three complementary and non-mutually exclusive frames reveal different HaH equity-related foci. Within each frame, HaH program leaders demonstrated an understanding of equity-related issues, barriers, and targeted strategies enhancing the equitable provision of HaH care and, in turn, HaH's value to health system goals.

CONCLUSION

Clarifying and aligning HaH equity frames and matching targeted improvements within and across frames can enhance the ability to deliver comprehensive, equitable care as the model continues to grow.