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Table 3 Coding of Adaptations of HaH

From: The effect of adapting Hospital at Home to facilitate implementation and sustainment on program drift or voltage drop

Wiltsey-Stirman’s Coding of Modifications and Adaptations of Evidence-based Interventions a
Adaptation What was modified For whom/what are modifications made Nature of the modification
Addition of 30-day post-acute transition component to the HaH model Content (30-day transition services) Cohort (done for all excepting patients with one payer) Adding element (appending new transition services to the end of a HaH episode)
Expansion of original target diagnoses and reduce exclusions (e.g., HIV exclusion) to reflect current medical practice Content (new diagnostic categories targeted) Population (expanded patient population) and Organization and Network (added throughout the program) Adding element (adding diagnoses not previously in most HaH programs thereby expanding the pool of eligible patients)
Implementation of Palliative Care Unit at Home Content (new service) and population (format for identifying patients with palliative care needs) Population (new patient population that would not have previously qualified for HaH) Adding an element, and integrating the intervention into another approach (adding new modules to HaH incorporating palliative care principles and approach to better meet needs of new population)
Collaborated with community paramedicine program to consult with HaH physicians by video for patients needing urgent visits in the home Format (how urgent visits managed) and personnel (how community paramedicine staff were used) Organization/Network (done throughout the program) Substituting an element (community paramedicine visits substituted for urgent clinician home visits or transport to the emergency department in certain cases)
Contracting for infusion services Personnel (format for inclusion of vendor for infusion services) Organization/Network (done throughout the program) Integrating another approach (contracted infusion nursing that did not do other aspects of nursing added to supplement existing staff for additional visits involving only infusion)
Dedicated nurses hired Personnel (format for registered nurse staffing) Organization/Network (done throughout the program) Substituting an element (pool of nurses also involved in other duties substituted with nurses dedicated to HaH)
Implementation of Observation at Home Content (new service) and setting (how patients otherwise admitted to hospital observation unit identified and managed) Cohort (new group of patients with observation needs) Tailoring, integrating the intervention into another approach, and departing from the intervention (tweaking of intake procedure to admit observation unit candidates, incorporating observation service procedures, and earlier discharge of observation patients after one day with the option of converting patients to longer stay HaH, if indicated)
Implementation of Rehabilitation at Home Content (new service) and setting and population (format for identifying and caring for patients needing subacute care) Cohort/Population (new group of patients from inpatient hospital units and slated to be referred to skilled nursing facilities for subacute care) Adding an element and integrating the intervention into another approach (new intake procedure to admit subacute care candidates and incorporating subacute care practices into HaH)
Expansion to new sites for enrollment along with developing new intake procedures customized for each site Setting and personnel (how new sites identified and managed patients and how personnel roles were modified accordingly) Hospital/ Organization (expansion to different hospitals within the organization) Adding an element and substituting elements (adding new hospitals and substituting different procedures and different type of personnel, as well as roles, depending on existing procedures and resources at the new site)
Adaptation of intake procedure for patients identified to need HaH services late at night by holding the patients overnight in the emergency department and transferring home in the morning Format (how intake and care procedures modified for after hours), setting and personnel (different staffing for overnight services in the hospital) Organization/Network (done throughout the program) Adding an element, substituting elements, and loosening structure (substituting services in the hospital overnight for services HaH would otherwise provide at home)
Launch of telehealth visits to supplement home visits Format (how video telehealth visits were conducted) and personnel (staffing to assist patient with telehealth at home and clinician staffing for video telehealth visits) Organization/Network (done throughout the program) Substituting elements and loosening structure (allowed substitutions of some clinician home visits with video telehealth visits)
Internalized major portions of pharmacy and lab services Format (how pharmacy and lab requests managed) Organization/Network (done throughout the program) Substituting an element (supplemented vendor services with option to use internal resources)
Implemented new version of electronic health record (EHR) Format (how care was communicated and documented for HaH) Hospital/ Organization (done throughout the program but with hospital-specific processes depending on EHR used) Substituting an element (new version of HaH EHR with improved functionalities replacing previous version)
Dedicated physical therapist hired Personnel (format for providing physical therapy services) Organization/Network (done throughout the program) Substituting an element (substituted full time dedicated physical therapist for pool of physical therapists also serving patients in other programs)
Role created for nurse care coordinator Format (how HaH care coordinated) and personnel (new role for existing staff) Organization/Network (done throughout the program) Tailoring (nurse care coordinator to manage active patient cases and coordinate staff and services)
Piloted weekend admissions Format and personnel (separate procedures, as well as personnel roles, for weekend admissions) Organization/Network (done throughout the program) Adding an element and loosening structure (new processes instituted for weekend admissions due to reduced weekend staff on duty)
  1. aWiltsey-Stirman’s coding also includes coding of by whom modifications are made. All adaptations were made by the program team [1]