NNU nurse sounds the alarm on 'hospital-at-home' programs

Some nurses are speaking up about what they see as the dangers of "hospital-at-home" programs, which they say can potentially harm patients, devalue the work of the nurse and can create inequalities amongst users.

Since the pandemic, hospitals and health systems have been expanding and creating hospital-at-home programs, in part aided by pandemic-era waivers. Various coalitions and advocacy groups are pushing for the extension of the acute hospital care-at-home waivers as well as increasing the number of programs there are. Hospitals and health systems tout the benefits of hospital at home, saying that it helps patients heal in a more comfortable setting, provides savings and frees up hospital beds. 

However, some nurses are concerned about such programs. Michelle Mahon, RN, is the assistant director of nursing practice at National Nurses United, where she advocates for higher standards of care for nurses. She spoke to Becker's about the various ways in which nurses and the NNU are worried about the proliferation of hospital at home programs and why she thinks the programs should be scrapped altogether. 

She mentioned that the programs can present issues for patient safety, given that the condition of patients can change quickly, regardless of setting. 

"When you consider the various types of situations that arise at the hospital, even in a very controlled environment, even with so-called stable patients, their conditions can change rapidly," she said.

Ms. Mahon argues that the NNU analysis of hospital-at-home programs indicates that the burden of care for patients who are sent home is shifted either to the family of the patient or to the patient themselves. This has the potential to affect safety, well-being and health of the patient as well as their family, as they take on more responsibility to care for their loved one, risking complications if their condition deteriorates or changes.

"This is not appropriate in our view. When you look at the types of complications, the types of evaluation, the types of monitoring that these patients need, the acute care hospital-at-home program does not provide any kind of safety net for them other than the 911 system," she said.

The technology used in hospital-at-home programs can also pose an issue, she says. For one, patients who participate in the hospital-at-home programs are required to be technologically literate enough to make use of the apps and hardware or have someone to help them, which excludes populations of people who do not have such support or understanding. Then there are issues with the technology itself, which even nurses who use it daily struggle to make work, presenting challenges for those who do not have as much experience as the nurses.

"We're constantly struggling with tech issues," Ms. Mahon said. "We saw during COVID-19, a very basic measuring tool, the pulse oximetry was never designed, tested, and doesn't really work on Black patients and we're going to put them at home and that's the sole lifeline we have to see if they're breathing properly? No."

Much of the monitoring technology has to be applied just right, and even in hospital settings often needs to be reapplied if a patient moves too much, she said. 

She also takes issue with the level of certification of the staff who are sent to care for these patients, arguing that only a combination of treatment from registered nurses, licensed practical nurses and nursing assistants is sufficient to provide the patient with the best care possible.

"​​Registered nurses have specialized skill, knowledge and education and thorough current scope of practice and are the only nursing members who are competent to provide assessments, meaning and interpret the data collected," she told Becker's. "So instead of having that complement, what [health systems] are doing, they're sending EMTs or unlicensed personnel or home health aides."

As an alternative to these programs, she argues that hospitals should invest in nursing as a sure way to improve patient outcomes.

"We are obligated to sound the alarm here, seeing the expansions of these programs and the continuation of really an untested, unproven model of care. It's largely a social experiment in our view and it does take away and devalues the work of registered nurses in our healthcare system," Ms. Mahon said. "This is an old adage in medicine and nursing — treat the patient, not the monitor. This entire system flips that narrative on the head, acting as though monitoring data is the same thing as providing care. And it isn't."

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