Advanced Care at Home

Mayo Clinic Advanced Care at Home is an innovative hospital-at-home program offering acute-level, inpatient-quality care to people in the comfort of their own homes. Health and safety are at the center of our care. The care combines both virtual and in-home services to meet each person's needs.

Many of the healthcare services you receive in a hospital can be provided in the safety and privacy of your home. For example, hospital-at-home care may include meals, imaging services, blood draws, physical therapy, wound care, medicine management and social work.

Hospital-at-home care provides you with:

• A computer tablet for video visits with your Mayo Clinic care team.
• A phone that connects directly to your care team.
• A personal emergency response bracelet.
• Vital sign monitoring devices.
• A router for internet access.
• A backup power supply.

Hospital-quality services such as lab tests, mobile ultrasounds and X-rays, and IV therapies also can be done in your home.

Advanced Care at Home is offered at Mayo Clinic in Jacksonville, Florida, and Phoenix, Arizona; and at Mayo Clinic Health System in Eau Claire, Wisconsin. You can learn more about the Eau Claire program at the website for the Mayo Clinic Health System.

Mayo Clinic has treated more than 2,000 people with this care model. Studies show that hospital-quality care at home reduced infections and falls, improved outcomes, and increased patient satisfaction while lowering hospital readmission rates.

Who might benefit from Advanced Care at Home?

Advanced Care at Home is a program for people who are sick enough to be in a hospital setting but not so sick that they need surgery, invasive procedures or advanced imaging. People who enter the program might have an acute-level condition that needs inpatient-quality care. Examples include heart failure, pneumonia, a bloodstream infection or bronchitis.

If you have a condition that might qualify for hospital-quality care at home, consider these questions:

• Are you interested in shortening your hospital stay?
• Are you interested in receiving hospital-quality care in the comfort and safety of your own home?
• Would you prefer to have services such as infusions or physical therapy on your schedule, not the hospital's?
• Can you commit to scheduling appointments with people who would come to your home to deliver services?
• Can you commit to being trained in how to use a computer tablet to connect with your care team for virtual visits?

Let your nurse know if you're interested in learning more about the Advanced Care at Home program. If you're eligible for hospital-at-home care, you decide whether to enter the program.

Other factors to consider

Your doctor or other healthcare professional talks with you about whether this service would be a good fit for you. Things to consider include your diagnosis, your health status, your home support, your insurance coverage and how near you are to your Mayo Clinic hospital.

Not all treatments, tests and services are available at all Mayo Clinic locations. Check with your healthcare team at your preferred location.

Services available at home

Through the hospital-at-home program, you receive these services:

• 24/7 virtual care.
  • Technology that allows for virtual care.
  • Remote vital signs monitoring.
  • Ability to connect with your virtual care team.
• In-person advanced practice provider, nursing and community paramedic care.
• A care plan and schedule designed around your needs.
• Pharmacy and medicine management.
• Targeted individualized patient education.

You receive these services as needed:

• Physical, occupational and speech therapy.
• IV infusion services.
• Laboratory testing.
• Meals and nutrition.
• Mobile imaging and ultrasounds.
• Behavioral health.
• Social work.
• Specialty consultations.

A team approach to personalized care

Your care team is led by Mayo Clinic doctors and includes nurse practitioners, physician assistants, nurses and other health care and service professionals. You have access to your team in the Advanced Care at Home command center anytime day or night. Your care may also include in-home visits by a nurse practitioner, a physician assistant or other health care professionals, depending on your needs.

Staff members in the command center direct each episode of care in the home and coordinate with a healthcare professional who is in your home. Each episode of care is detailed in your electronic health record.

A phased approach

You may be enrolled into the program from the hospital, from the emergency department or from a doctor's office. Once you're enrolled, you're transferred home, usually in an ambulance.

• Acute phase. Depending on your diagnosis, this phase could last up to six days. Your care team coordinates the appointments in your home to suit your schedule. The first appointment is with a paramedic team that conducts a home safety assessment to ensure that you have a setting suitable for this type of care. This includes things such as a stable internet connection, running water and space that limits the risk of falling.

  The paramedics also set up equipment you need and coach you in how to use it. Examples are a computer tablet on which you will hold video meetings with your care team, a router to provide internet service, various remote vital signs monitoring devices, a personal emergency response system (PERS) device for rapid response and any needed durable medical equipment. This visit lasts about an hour.

  After this first visit, your came team visits your home each day to address your care needs. Examples are infection control, respiratory therapy and infusions.

• Restorative phase. During the next 25 to 30 days, you may be enrolled in remote patient monitoring. Your vitals are remotely monitored through connected devices and you'll have access to your care team by video.

  You'll be ready to leave the program when you've met your goals. Examples include walking on your own, cooking, managing your medicine and making appointments.

• Return to primary care. When you are discharged from the Advanced Care at Home program, your follow-up care will be with your usual primary care team. The equipment you used during the program is returned to Mayo Clinic.

Depending on your needs, your care at home may include daily video visits with your healthcare team, in-person visits in your home with a physical therapist or daily visits from a nurse who delivers your medicine by way of infusion.

This phased approach ensures a continuity of comprehensive, restorative healthcare services for as long as you need them. This collaboration is a tightly integrated, multispecialty partnership in home-based care.

Hospitalists are experts in evaluating medical risks, enhancing the continuity of care, and facilitating communication between patients, their families and the rest of the care team. Their goal is to combine the latest evidence-based medicine with thoughtful consideration of each person's needs to foster wellness and healing.

Supplies are provided to people in their homes through a partnership with Medically Home. Medically Home is a Boston-based technology-enabled services company partnering with Mayo Clinic to deliver care. The company offers an integrated technology platform and network of services that allow Mayo Clinic health professionals to care for people at home.

Costs and insurance

Mayo Clinic works with your insurer on coverage for care provided. Insurance copayments, coinsurance and deductibles may apply.

Appointments

People who are in the hospital may be offered an opportunity to sign up for Advanced Care at Home. Doing so allows them to leave the hospital sooner than usual, because continued care is provided in their homes. Studies show that people receiving hospital-quality care at home may have improved clinical outcomes. Ask your hospital care team whether this might be an option for you.