CLN - Ask The Expert

The Role of Clinical Laboratories in Home-based, Acute-Level Healthcare

Ask the Expert: August

Michelle Parker, PhD

How do home-based, acute-level healthcare models work?

Home-based, acute-level healthcare provides services in a patient’s residence that would otherwise require an emergency department (ED) visit or hospital admission. For example, a collaboration between the regional point-of-care office at the University of Alberta Hospital and emergency medical services (EMS) in Edmonton, Alberta, Canada, delivers acute-level care to palliative patients in continuing care facilities, avoiding transport to the ED. Coordination among home-based care providers and the individual’s regular healthcare team ensures a fluid continuum of care.

Alternatively, programs modeled after the Hospital at Home program (pioneered by Johns Hopkins University School of Medicine and Bloomberg School of Public Health in Baltimore, Maryland) identify patients in the ED to be sent home with a team of health professionals. The team consists minimally of a physician and a nurse who develop a personalized care plan to resolve the acute episode. In the Hospital at Home model, common conditions that often can be treated at home effectively include community-acquired pneumonia and acute exacerbations of heart failure or chronic obstructive pulmonary disease. Other conditions, such as cellulitis or pulmonary embolism, may be included based on the needs of the community.

What is driving expansion of home-based, acute-level healthcare?

The aging population, limited hospital resources, and a focus on patient-centric healthcare approaches are key drivers for these models, which have successfully reduced hospital admissions and lowered overall costs of care. Importantly, these programs may achieve similar or even improved clinical outcomes in comparison to hospitalizations, such as reduced morbidity and mortality and fewer medical complications. Home-based care also increases caregiver and patient satisfaction because many patients, especially the frail, elderly, and those with cognitive deficiencies, prefer home treatment over ED visits or hospital admissions that can be stressful, disruptive, and potentially harmful.

How can clinical laboratories support home-based healthcare initiatives?

Different models of home-based healthcare will require and benefit from different types of interactions with clinical laboratories. Programs such as the Mobile Acute Care Team at Mount Sinai Icahn School of Medicine in New York City do not include any in-home point-of-care testing (POCT). In this type of program, a central laboratory performs testing and advises on pre-analytical factors, such as appropriate specimen collection and transport conditions, ensuring that turnaround times meet the needs of the mobile teams.

At the other end of the spectrum, programs may offer considerable in-home testing. For example, the EMS team at the University of Alberta Hospital offers POCT for cardiac markers (troponin and B-type natriuretic peptide) and basic chemistry (blood gases, electrolytes, and metabolites). In this type of program, core laboratories and POCT teams are essential for choosing and validating the appropriate devices, certifying operators, managing information technology connectivity, guiding integration of results into the electronic medical record, maintaining appropriate quality control and quality assurance procedures, and performing regular reviews of standard operating procedures.

Looking forward, clinical laboratories should maintain a flexible approach and engage with the innovative culture of home-based care as these programs grow and encounter new opportunities and challenges, such as remote assessment of continuous monitoring devices and patient-administered POCT.

For more information on this topic, see my Q&A in Clinical Chemistry (2018; doi: 10.1373/clinchem.2017.283093).

Michelle Parker, PhD, is a senior clinical chemistry fellow at the University of Toronto in Toronto, Canada.E-mail: parker.michellelorine[at]gmail.com

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