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Bringing the Hospital Home

Michelle and Steve Lengle
Michelle and Steve Lengle

Since his 2020 diagnosis with multiple sclerosis, Steve Lengle has had good and bad days. The bad days are becoming more frequent as his condition continues to decline, causing debilitating pain, weakness, and fatigue, and affecting everything from his memory to his ability to walk. 

Even on his worst days, Steve, 64 and a military veteran, generally remains stoic and fiercely independent. But one morning last October, his wife Michelle, a nurse, could tell that something wasn’t right with her husband of 25 years. Steve had become noticeably weaker, and he was falling more often. He began to perspire heavily, and his body shook with uncontrollable chills. It was clear to his wife that he needed help, whether or not he would admit it.

“He had recently spent time in the hospital for a sepsis infection, and I was afraid it was happening again,” Michelle said. “That last hospital stay was stressful for both of us, and he was determined that he wasn’t going back.” 

The Lengles found the help they needed through Penn Medicine Advanced Home Health (PMAHH), a new program that aims to prevent hospitalizations by providing a higher level of in-home care to patients who are experiencing an acute medical concern. 

Home is where the care is

Dr. Leon Kraybill and nurse practitioner Jessica Mendez visit a patient in her home. Kraybill talks with the patient at her kitchen table, as Mendez takes the patient’s blood pressure.
When patients are experiencing a health crisis, the Penn Medicine Advanced Home Health team, including Leon S. Kraybill, MD (left) and nurse practitioner Jessica Mendez, CRNP (right), establishes a plan to provide all necessary care safely at home.

The innovative approach is part of the health care industry’s continued shift away from traditional settings, such as hospitals and doctors’ offices, to a place that offers unrivaled comfort and convenience: the home. More and more patientseven those facing a serious health issueprefer to remain at home to receive care whenever it can be delivered there both safely and effectively.

PMAHH addresses patients’ acute needs through in-home medical provider visits, testing, and treatment, rather than sending them to the hospital for emergency care or an admission. The program is available to Lancaster County patients who already receive traditional home health services, such as nursing visits or infusion therapy, through Penn Medicine Home Health.

PMAHH Medical Director Leon S. Kraybill, MD, said that although a significant number of home health patients will experience an acute medical need each month, many want to avoid a hospital stay for a variety of reasons, including schedule disruptions, financial concerns, and the possibility of acquiring an infection. 

“While these patients might need quick medical attention, in many cases they don’t necessarily need to be hospitalized,” he said. “With close daily supervision by a medical provider, many of these conditions can be safely managed at home.”

A team approach to avoiding hospital stays

PMAHH is one of a growing number of Penn Medicine programs designed to deliver safe and effective clinical care within patients’ homes. Kris Armitage, agency director for Penn Medicine Home Health Lancaster General Health, said the COVID-19 pandemic only accelerated existing efforts to meet patient demand for more in-home care options.

“Home care offers many benefits for patients and their families,” she said. “In addition to providing high-quality care in a familiar location, those benefits include increased patient satisfaction, lower risk of complications, less stress for caregivers, and significant cost savings.”

PMAHH arose from a collaboration between Lancaster’s home health and Innovation teams. While they are separate entities within the health system, the physician-led PMAHH team works closely with Lancaster’s home health team to deliver this service.

At any time, about 400 Lancaster County patients are receiving home health services through Penn Medicine. In a given month, Kraybill said, about 20 percent of those patients will experience an acute medical need that could require emergency care or hospitalization. 

The PMAHH team’s involvement begins when, during a routine visit, a home health clinician notices a concerning symptom, such as a low oxygen level, fever, or weight gain. These symptoms could signal that the patient is experiencing a potentially serious condition, such as congestive heart failure, chronic obstructive pulmonary disease, pneumonia, or an infection. 

The team, which includes Kraybill and two nurse practitioners, temporarily assumes primary care of the patient, including daily home visits. On the first visit, the team assesses the patient with a physical examination and a thorough review of medical history, medications, and both acute and chronic health concerns. They establish a plan to provide all necessary medical care at home, which could include performing lab tests and X-rays, and administering intravenous medications.

During this time, the patient continues to receive traditional home health services, such as nurse visits and remote monitoring of vital signs, as needed. The PMAHH team further coordinates the patient’s care through communication with their regular primary-care provider and other medical specialists.

“A wide range of people are involved in caring for patients during their time of acute need,” said PMAHH lead advanced practice provider Jessica Mendez, CRNP. “We work together as a team to ensure that all of our patients’ needs are met, not just addressing the initial symptoms.” 

Serving a growing need

Members of the Penn Medicine Advanced Home Health leadership team include, from left, Jessica Mendez, CRNP; Michael Killinger, MSN, RN; Kris Armitage; and Leon S. Kraybill, MD.   Alt text: Jessica Mendez, Michael Killinger, Kris Armitage, and Dr. Leon Kraybill
Members of the Penn Medicine Advanced Home Health leadership team include, from left, Jessica Mendez, CRNP; Michael Killinger, MSN, RN; Kris Armitage; and Leon S. Kraybill, MD.

The acute concern may be just one of a patient’s many health conditions, Kraybill said. In addition to treating the immediate issue, the PMAHH team assesses each patient’s entire medical picture, which is often quite complex. 

For example, the team might address fall risks in the home or discuss advance care plans with patients and their families. They also work to mitigate any social factors that may affect overall health, such as untreated mental health conditions, or food or housing insecurity. 

Once the patient is stable, they return to the care of their primary care provider. Patients continue to receive traditional home health services for as long as necessary.

Despite the PMAHH team’s best efforts, it’s not possible to care for all patients safely at home. For those patients, hospitalization remains an option. And in the case of some gravely ill patients, the team might make a referral to hospice care. 

In its first five months, PMAHH has served 40 patients. Kraybill expects PMAHH will continue to grow as the program adds more staff and expands its referral sources, admission criteria, scope of services, and the number of patients who can be served. 

“We are committed to providing top-notch care to more patients at home, which is where they want to be,” he said. “Our goal is to care for our patients whenever and wherever they need us.”

A ‘godsend’ for patients and families 

The Lengles are grateful recipients of that care, which came at the suggestion of Steve’s home health physical therapist. The PMAHH team arrived at the family’s home to find him with several alarming symptoms, including an irregular heart rate and low blood-oxygen levels. Although he was seriously uncomfortable, he would not consider going to the hospital. 

Blood tests and a chest X-ray showed that Steve had another sepsis infection. The PMAHH team worked through his fear of needles and dislike for medical procedures to treat him with IV antibiotics and fluids in the comfort of his home. After a week of daily visits, Steve recovered and returned to the care of his regular medical team, without returning to the hospital.

“The whole Penn Medicine Advanced Home Health team was fantastic,” Michelle said. “It was a godsend, not just for my husband, but for me.”

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