Staff Successes and Challenges with Telecommunications-Facilitated Patient Care in Hybrid Hospital-at-Home during the COVID-19 Pandemic

Round 1

Reviewer 1 Report

This is a well-written article on hybrid at home model of care delivery. I just have a few comments and suggestions.

 

Methods

 

Please provide rationale on why a “group” interview method was chosen. In this case, it might be more appropriate to call them focus groups as interviews typically imply to the reader individual interviews.

 

The authors state that exploratory questions were asked directly either addressing the staff members or the larger group. Please clarify whether the participants asked the staff members individually first followed by the group or vice versa. Additionally, how did the authors decide when to ask the individual staff members vs the larger group? More details on the design and procedures involved in the interview would help clarify these details.

 

Analysis

Please provide a bit more detail on the reconciliation and consensus process – my understanding is that these authors were not involved in the original coding. What criteria or process was used to reach consensus?

 

Results

How are the codes used in the analysis related to the headers/themes? Presented in the results section? It would be helpful to clearly identify how these are related. If the results are organized by themes, then please clarify how the codes you used are integrated within these themes.

 

Line 251 – should this be figure 1?

 

It is not clear why the description about the “younger, easier patient” is part of the complexities. I think it might be helpful to relate it to why it is a challenge.

 

Similarly, the first set of direct quotes for SES related description does not seem to directly fit the description. 

 

Many of the quotes are very insightful and interesting to read through. 

 

My major suggestion for the results section is to better organize the themes and the content within the themes. The description is at times long and it is difficult to follow the theme/header and at times, the description seems to jump between related themes. 

Author Response

This is a well-written article on hybrid at home model of care delivery. I just have a few comments and suggestions.

--We thank our reviewer for this careful review of our manuscript to improve its impact.

 

Methods

 

Please provide rationale on why a “group” interview method was chosen. In this case, it might be more appropriate to call them focus groups as interviews typically imply to the reader individual interview.

--Thank you for this comment and suggestion. The group interview method was chosen due to time and staffing constraints in the H@H program at Mayo Clinic. We had a max of 45 staff coordinating and delivering care in 3 states and 3 time zones. This was to ensure staffing capacity for care delivery and patient needs. This protocol was also approved under our internal IRB application, ensuring high-quality safety standards for Mayo Clinic patients.

 

We agree that calling our group interviews “focus groups” is appropriate. We have updated and revised this terminology throughout the manuscript. Thank you for pointing this out. We believe this enhances the clarity of our methods section.

 

We also revised and updated section 2.3 with new information to thoroughly address your concerns:

“2.3 Focus Group Interviews

In selecting an interview method, the small size of the ACH program, with an average of 45 staff members running the inpatient-level program 24/7, was a critical limitation for scheduling interviews. Given the highly collaborative nature of the program and its reliance on virtual communication, including videoconferencing, the focus group interview method was used to tap into the day-to-day interaction among staff and to encourage staff participation from those who might be reluctant to be interviewed on their own or who might feel they have little to say [16].

Limited by the total number of staff-on-the-floor needed to deliver care, the maximum session time was set at 90 minutes to complete the interview, although interview length could be extended by the interviewers to ensure that all questions could be answered thoroughly by the staff.

Participating staff were informed that the interviews were confidential and that their responses would be deidentified. The interviews conducted for this study included open-ended question prompts (Appendix 1), allowing staff to raise issues of importance and use their own terminology to discuss these issues with colleagues [16].

Six interviews were conducted by qualitative researchers unaffiliated with the ACH program (SKZ and JS). To facilitate staff discussion, interviewers asked questions to each participating staff individually, followed by restating the question to the group at-large to obtain consensus. If participating staff joined late or left early, the question was only presented to staff in attendance. When participants elected to share an experience or theme independent of question prompts, an interviewer asked probing questions to obtain additional relevant information. Interviews were conducted virtually using the Zoom or Microsoft Teams software platform.”

 

The authors state that exploratory questions were asked directly either addressing the staff members or the larger group. Please clarify whether the participants asked the staff members individually first followed by the group or vice versa. Additionally, how did the authors decide when to ask the individual staff members vs the larger group? More details on the design and procedures involved in the interview would help clarify these details.

--Thank you for highlighting this issue for us. Our first draft lacked clarity regarding this approach. We presented each question to individual staff first, and then opened the question to the whole group together to achieve a consensus answer. We revised this section of the manuscript to address your concerns:

 

“Six interviews were conducted by qualitative researchers unaffiliated with the ACH program (SKZ and JS). To facilitate staff discussion, interviewers asked questions to each participating staff individually, followed by restating the question to the group at-large to obtain consensus. If participating staff joined late or left early, the question was only presented to staff in attendance. When participants elected to share an experience or theme independent of question prompts, an interviewer asked probing questions to obtain additional relevant information. Interviews were conducted virtually using the Zoom or Microsoft Teams software platform.”

 

Analysis

Please provide a bit more detail on the reconciliation and consensus process – my understanding is that these authors were not involved in the original coding. What criteria or process was used to reach consensus?

--2.4 Data Analysis

 

Interviews were transcribed by Mayo Clinic external partners. Two study investigators (SKZ and JS) qualitatively analyzed interview transcripts, guided by grounded theory’s iterative methods [17]. With grounded theory, investigators used an inductive approach to develop theories based on evidence from data collection and analysis. Given the unprecedented situation in which the hybrid H@H program was deployed, namely the COVID-19 pandemic, the use of deductive methods to analyze interview data was unsuitable. In contrast, a grounded theory approach was appropriate to study novel experiences unique to this program during the pandemic. 

After n = 3 transcripts (21%), which were representative of our sample and included staff from multiple sites, were coded to consensus using an open coding process by two investigators (SKZ and JS), one investigator (SKZ) used an axial coding process to generate a codebook of inductively identified categories (Appendix 2). After a review of the codebook by two study investigators (MJM and MP), NVivo 12 was used to individually code each transcript (n=14). All investigators were involved in the review of coding and analysis to ensure accuracy and consistency across study sites for the program. Through coding, themes were identified from participant stories and examined through the lens of the study’s goals: to explore staff experiences in implementing a new hybrid care delivery model and in using new technologies to deliver care. Quoted statements were edited for readability when necessary. Here, we present themes related to the experiences of hybrid H@H staff at rural, urban, and desert medical centers during the COVID-19 pandemic.

 

 

Results

How are the codes used in the analysis related to the headers/themes? Presented in the results section? It would be helpful to clearly identify how these are related. If the results are organized by themes, then please clarify how the codes you used are integrated within these themes.

--Thank you for this helpful suggestion. We agree that clarifying how the study aims were investigated can improve the results section of this manuscript. The results section is separated into two sections, one for each of the study’s two goals; however, we added subheaders for each of the codes used to understand the study’s goals. The subheaders offer clarity regarding what the quotes are describing.

 

Line 251 – should this be figure 1?

--Thank you for pointing this error out. This should be labeled figure 2. Thank you for your time and careful review.

 

It is not clear why the description about the “younger, easier patient” is part of the complexities. I think it might be helpful to relate it to why it is a challenge.

--We agree that this finding could be addressed more robustly. Thank you for this comment. We revised the corresponding paragraph as below:

“Another staff member reflected that, in the early days of the program, the eligible patient population was more challenging to deliver ACH services to, as the inclusion criteria for ACH excluded healthier and younger patients due to the scope of the AHCaH waiver. Over time, however, private insurance payers reimbursed for ACH services for a wider range of eligible patients. Compared to younger patients with fewer comorbidities, older patients, are, on average, less mobile and less comfortable with technology, thereby complicating the delivery of a new hybrid H@H program during the pandemic [22-23].”

 

Similarly, the first set of direct quotes for SES related description does not seem to directly fit the description. 

--Thank you for this comment. We agree with our reviewer and believe that the results section could be reorganized to offer enhanced clarity. As such, we reorganized the placement of quotes in the results section by code according to the two study goals. We believe that this modification addresses your concern and greatly enhances the reliability of the manuscript. We addressed SES issues as a component of care coordination and provided references to support this.

 

Many of the quotes are very insightful and interesting to read through. 

--Thank you for this comment! We agree, and we were inspired to write this manuscript based on the robust, intricate, and unique insights offered by our interviewed staff. We believe these quotes will impact research in hybrid H@H for years to come.

 

My major suggestion for the results section is to better organize the themes and the content within the themes. The description is at times long and it is difficult to follow the theme/header and at times, the description seems to jump between related themes. 

--Thank you for this comment. We agree with our reviewer that the results section could be reorganized around codes and by study aims to improve the manuscript and have completed this in our new draft. To highlight this change, we also updated the abstract, as below:

“Technology-enhanced hospital-at-home (H@H), commonly referred to as hybrid H@H, became more widely adopted during the COVID-19 pandemic. We conducted focus group interviews with Mayo Clinic staff members (n = 14) delivering hybrid H@H in three separate locations - a rural community health system (Northwest Wisconsin), the nation’s largest-city-by-area (Jacksonville, FL), and a desert metropolitan area (Scottsdale, AZ) - to understand staff experiences with implementing a new care delivery model and using new technology to deliver care during the pandemic. Using a grounded theory lens, transcripts were analyzed to identify themes. Staff reported that hybrid H@H is a complex care coordination and communication initiative; that hybrid H@H faces site-specific challenges modulated by population density and state policies; and that many patients are receiving uniquely high-quality care through hybrid H@H, partly enabled by advances in technology. Participant responses amplify the need for additional qualitative research with hybrid H@H staff to identify areas for improvement in the deployment of new models of care enabled by modern technology.”

Additionally, we reviewed each of the quotes included in the manuscript and slightly edited any that required additional clarification, as noted in the methods section.

Reviewer 2 Report

Thank you for the opportunity to review this manuscript.  This is an interesting study of a renewed model of care from the pandemic with ongoing implications.  Issues of layered and siloed health systems are highlighted by the multi-state delivery.  

The manuscript is well-written and the study well-executed.  I have only a few minor suggestions for the authors:

1. As this journal, Healthcare, is applicable to many disciplines, consider including "EMS" or "paramedic" -related keyword since the addition of this member was instrumental to the study and discussed at length.  

2. Page 3; paragraph, lines 111-118 - I recommend writing this in past tense, as this describes the practice settings and model during the study processes.

3. Consider discussing the Conditions of Participation waiver earlier in the manuscript and provide a primary citation for this waiver.  It would seem this waiver is key to the overall success of this project implementation; however, it is first mentioned on page 10.

 

Author Response

Thank you for the opportunity to review this manuscript.  This is an interesting study of a renewed model of care from the pandemic with ongoing implications.  Issues of layered and siloed health systems are highlighted by the multi-state delivery.  

--Thank you for this helpful feedback! We agree that there is a critical need for research in this area and hope that our paper serves as a starting point to encourage more clinicians and scientists to conduct studies in this area.

The manuscript is well-written and the study well-executed.  I have only a few minor suggestions for the authors:

1. As this journal, Healthcare, is applicable to many disciplines, consider including "EMS" or "paramedic" -related keyword since the addition of this member was instrumental to the study and discussed at length.  

--We agree with our reviewer that one of the gaps in the literature filled by this manuscript is that it considers allied health professionals and community members who make hybrid H@H possible – not just the clinical nursing and physician staff members. By including a “paramedic” keyword, we believe that this manuscript will reach a broader audience and, in turn, encourage more researchers to investigate the roles and experiences of allied health professionals and community members in optimizing hybrid H@H programs.

We revised our list of keywords to be more reflective of this fact, including the following keywords: “paramedic, ancillary health professionals, allied health”.

2. Page 3; paragraph, lines 111-118 - I recommend writing this in past tense, as this describes the practice settings and model during the study processes.

--We agree with our reviewer that this specific paragraph should be rewritten for clarity and grammatical precision. We thank the reviewer for highlighting this flaw and have revised our manuscript with the following paragraph:

“While site license limitations at MCF and MCA required the use of an outsourced supplier model to facilitate at-home care, the NWWI community practice used an insourced supplier network to provide home health, nursing, pharmacy, and paramedicine services. Patients in ACH received a proprietary technology package, with the following wireless-enabled tools to record and transmit frequent biometric data for remote monitoring: a blood pressure cuff, a pulse oximeter, a thermometer, and a scale. Patients also received a Bluetooth-enabled mobile tablet for 24/7 access to the MCF Command Center via video or text-based chat.”

 

3. Consider discussing the Conditions of Participation waiver earlier in the manuscript and provide a primary citation for this waiver.  It would seem this waiver is key to the overall success of this project implementation; however, it is first mentioned on page 10.

--We agree with our reviewer that the CoP waiver is critical to the implementation of home hospital examined in this study. We agree that discussing the waiver should be done earlier in the manuscript. We included a primary citation for this waiver as well, with [8]. As such, we rewrote the following sentences in the introduction section:

“Widespread adoption of the program, however, was never realized in the U.S., in part due to limited payer reimbursement [7]. During the COVID-19 Public Health Emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) introduced a waiver, the Acute Hospital Care at Home (AHCaH) waiver, permitting hospitals participating in Medicare to temporarily forgo the federal standard for Conditions of Participation (CoPs) that stipulates 24/7 on-site nursing staff be available for inpatient care [8]. This waiver allowed eligible patients to receive hospital-level care at home and providers to receive reimbursement for home hospital services identical to those delivered in a brick-and-mortar setting, provided that 24/7 clinical monitoring was performed using remote monitoring and telehealth [9]. Thus, regulatory reforms implemented during the COVID-19 pandemic generated momentum to deploy H@H programs across the U.S. [10].”

To improve the readability of the manuscript, we removed the paragraph detailing the CoPs on page 10.

Reviewer 3 Report

The idea of hospital-at- home (H@H) is very valuable due to the benefits for the patient and the quality of hospital care at a similar level as in a traditional hospital. I rate the manuscript presented by the authors very highly and support its publication. The authors could briefly describe the differences between the H@H solution they used and the solutions presented by other authors in their publications.

Author Response

The idea of hospital-at- home (H@H) is very valuable due to the benefits for the patient and the quality of hospital care at a similar level as in a traditional hospital. I rate the manuscript presented by the authors very highly and support its publication.

--We agree with our reviewer that H@H care can be very valuable for patients. We are grateful for this encouraging feedback!

The authors could briefly describe the differences between the H@H solution they used and the solutions presented by other authors in their publications.

--We agree with our reviewer that the differences between Mayo Clinic’s model and other comparable models should be explained in closer detail. We added this clarification in the final introduction paragraph, from lines 83-89:

“To understand the experiences of hybrid H@H staff in diverse environments during the COVID-19 pandemic, we conducted a focus group interview study of staff members in the Mayo Clinic hybrid H@H program, which consists of comparable services delivered in other studied hybrid H@H programs, including at-home twice-daily nurse visits, intravenous medications, remote monitoring, video telehealth, and point-of-care testing, with the distinct structural difference being that while most hybrid H@H programs are limited geographically to a single state and its licensed providers, Mayo Clinic’s command center for H@H across states is located at Mayo Clinic Florida. We assess our findings in the context of broader healthcare staffing issues as it relates to experiences in implementing a new care delivery model and experiences with new technology to monitor patients at home to outline new areas for qualitative research in hybrid H@H programs and consideration by policymakers and payers.”