To deliver hospital-level care at home, practice makes perfect
Years of planning come to fruition as Hospital at Home teams test run a new era of patient care devoted to better outcomes and fewer readmissions.
Mr. Three was lying in a bed, his face contorted in frustration. He had come to the Emergency Department at the Hospital of the University of Pennsylvania (HUP) after passing out in his attic, and now the doctor just told him he had cellulitis and he would need to be admitted for 2-3 days. Mr. Three didn’t want to be away from his dogs that long. A nurse approached his bed.
“Hi, Mr. Three, my name is Lakenia. I’m one of the nurses with Hospital at Home. It’s basically a program—a creative and innovative program,” Lakenia Miller, BSN, RN, said. Then she paused. “I’m sorry, I’m really nervous!”
A chorus of “that’s OK, you’re doing great!” came from the nurses standing behind her. Miller caught her breath and continued, not missing another beat as she introduced the patient to a new program that would allow him to receive hospital-level care from the comfort of his home.
Moments later, she reflected: “I was a little nervous doing that, but in the real world it will be easier for me to help the patient understand,” Miller said.
Practice and readiness for the real world was exactly the point. Miller’s conversation with Mr. Three (not a real patient) was part of a simulation exercise that stretched over four days in early April 2026, just a week before Penn Medicine officially launched its Hospital at Home program at HUP and Penn Presbyterian Medical Center. The rehearsal served as a low-stakes way for clinical teams to test run the process, work out bugs, and shake off nerves ahead of the enrollment of real patients in this newest mode of acute care in patients’ homes.
“We’ve done a lot of work over the past year trying to plan how to build a virtual hospital, and that’s a complicated process,” said Hospital at Home Medical Director Robert Burke, MD. “It’s really important for us to be able to do high-fidelity simulations before we enroll patients.”
Now, patients like Mr. Three can get the same quality of care as they would in the hospital, but still have their pets at their side and sleep in their own beds.
Practice makes perfect
It’s a bit like learning a dance routine; once everyone knows the steps, it’s a remarkable effort to watch. Enrolling Mr. Three into the program during his ED visit was just one of a handful of scenarios simulated to nail down the steps.
On the first day of the simulation, before Mr. Three arrived, nurses and staff filled an ED exam room at Penn Presbyterian. Laptops were open on every flat surface in the room. The group ran through the basic steps of a Hospital at Home admission with fits and starts as they reviewed the technology, processes, and new terminology: For example, when a patient is enrolled in Hospital at Home, they are not discharged. Although they are going home, they remain a patient of the hospital, using medications and infusions from the inpatient hospital pharmacy.
The simulation also involved oxygen and durable medical equipment vendors to test both the delivery process and the Hospital at Home nurse’s role in helping patients set up and run the equipment.
“Until you get the actual team that’s delivering this program in the room, it’s hard to tell what will resonate with them from a training and onboarding perspective, so they will feel comfortable and confident,” said Head of Digital and Emerging Care Transformation Christina O’Malley, MHA. “We had to learn in real time what the best approach was.”
Planning for the simulation started in September, and more than 50 people ultimately took part in the four-day event across four different sites, including a real apartment that served as a simulated patient’s home. Running the simulation in real-life settings mattered, because it’s one thing to draw up a dance on paper, and it’s another thing to get everyone in sync on a dance floor that might have some warping, or a loose floorboard, or an expected wire strung along the ground.
“You would never walk out onto a Broadway stage without practicing over and over again,” said Sebastian Ramagnano, the clinical director of Penn Medicine at Home, and the interim clinical director of Hospital at Home. “The simulations are a perfect time to actually test your adaptability, your flexibility, your ability to manage ambiguity.”
What is Hospital at Home?
Modern hospital at home programs were born of the COVID-19 pandemic. Hospitals needed more space to handle the wave of sick patients, and innovations in remote technologies were making it easier for patients to be monitored from a distance. Near the end of 2020, the Centers for Medicare and Medicaid Services (CMS) started issuing waivers allowing for health care systems to take care of patients in need of less acute care in their homes. It was a win for hospitals to free up more bed space, and a win for patients who preferred to be treated at home. Many private insurers followed CMS’ lead and covered their own enrollees who received this acute care at home from hospitals that had the Hospital at Home waiver.
Even as the pandemic ebbed, the usefulness of these programs remained clear. Patient outcomes were better, with fewer readmissions, and the cost of care was lower, compared with traditional inpatient care. Congress extended the waivers through 2030, providing Penn Medicine with enough certainty to start a program of its own.
“We know from other programs that patients really like it. It's a huge patient satisfier, and the other perspective is it allows us to build more capacity,” said Penn Medicine at Home Chief Operating Officer Sarah Johnson.
Building Hospital at Home from concept to reality at Penn Medicine has taken nearly three years, a successful pilot of a similar initiative, and upwards of a thousand meetings. The effort tapped into Penn Medicine at Home’s expertise in providing decentralized care and ideas propelled by the Center for Healthcare Transformation and Innovation.
Patients who meet specific criteria are invited to enroll, either when they would have otherwise been admitted to the hospital from an emergency department visit, or during a hospital stay. If they agree, then the logistical wheels start turning. They receive two daily in-home visits from nurses and a daily virtual check-in from a doctor.
A key component is the remote monitoring, made possible with a patch applied to the patient’s chest just below the collarbone. The patch, about as thick as two credit cards and the length of a cell phone, monitors vitals and transmits them continuously to a nearby tablet, which then sends the data back to the team overseeing the patient’s care.
All of the data runs through an FDA-rated algorithm that learns a patient’s baseline vitals and then constantly monitors for any signs that a patient’s condition starts to worsen. If that happens, an alert is triggered so the care team can intervene.
Patients are also sent home with a scale, a blood pressure cuff, and a pulse oxygen monitor. All of the equipment is connected by Bluetooth to the tablet.
In the home
On the second day of the simulation, a team of nurses walked into a third-floor apartment in West Philadelphia, where the patient, “Mr. Kelly,” sat in a chair at a desk opposite a big bed. The home had been volunteered for the simulation by a member of the Patient Family Advisory Council.
“We'll be caring for several patients throughout the week and practicing all of our workflows and actually acting everything out with all of our vendors,” said Laura Makin, MPH, who was managing the simulation.
Afternoon sunlight and fresh spring air filtered through the half-opened window. It was a comfortable setting for the patient, but new and challenging for the nurses.
“When we’re in the hospital, that’s more of my environment,” said Latakia Fowler, BSN, RN. “You’re not in control when you go to someone else’s home.”
As one nurse managed the equipment, another nurse started to run down a checklist: Smoke alarms functioning, windows that could open, no signs of pests, rodents, or unhygienic pets. The inspection is a matter of safety, but also a moment to become familiar with the home and better understand the patient as a whole. And if there is a health or safety concern, the Hospital at Home team works with the patient to solve the problem.
“It gives you a wonderful opportunity to meet the patient where they are and where they’re going to be caring for themselves after you discharge them,” Ramagnano said.
A nurse pulled out a silver lock box for the medications needed as part of the patient’s treatment, but also the ones the patient was already taking. Though the patient was at home, hospital rules applied for the duration of his Hospital at Home admission, and he needed approval before taking any medications. It was another of the wrinkles the simulation helped clarify for the nurses.
It’s critical for the nurses to document all medications taken by a patient, "because what happens if you take a pill for blood pressure, and we gave you pills for blood pressure? You’re double doing it and that’s way too much,” said Julie Ann Arthington, RN, BSN, CEN, CNMP.
The nurses then paired the patient’s remote monitoring equipment via Bluetooth with a tablet, which took some time as they solved connection issues and called for remote instruction when the fix wasn’t apparent. Each solution helped prepare them for the moment they would soon go through this process with real patients.
The nurses walked Mr. Kelly through how to use the devices, checking his vitals along the way. They wrapped up the visit by practicing a handoff to the virtual nurse.
“We are checking out,” Karmen Hatton, RN, said to applause in the room as the simulation visit finished.
Lessons learned
The hub of the Hospital at Home is an office building in Bala Cynwyd, where field nurses start their shifts and gather supplies to take to patients’ homes. It’s also where nurses are stationed to discuss care remotely with patients.
And as the week of simulations closed, this was a place for celebration. Smiles replaced the furrowed brows of concentration that marked the first day of the simulation. People felt more comfortable with each other, and with the process.
Even after the program’s launch, the learning continues. Penn Medicine’s Hospital at Home program will spend the first year scaling up its operation, first at Penn Presbyterian and HUP, then Lancaster General Hospital this fall, and then to all other Penn Medicine acute-care hospitals: Chester County Hospital, Doylestown Hospital, Pennsylvania Hospital, and Princeton Medical Center.
“This is a living and growing program that’s going to be characterized by being very safe and very innovative,” Burke said.
Burke’s hand was one of those on a knife that sliced through the red-ribbon icing of a cake as everyone cheered, signifying a new era in Penn Medicine care. This was a virtual hospital opening, there was no tangible place for the ceremonial ribbon cutting. Instead, the ribbon was the icing on this entire enterprise.
From simulation to reality
Just a few days after the ceremonial cake was cut, Donald Peacock was sitting on his front porch with Shay Bryan, his sister. They were back to joking with one another after an eventful week.
Several days earlier, Peacock, who is diabetic, had had a sudden drop in blood pressure. Peacock is blind and Bryan is his caregiver; she called 911 and he was taken to Penn Presbyterian. Peacock had been taking too much insulin and was retaining fluid. He was admitted to the hospital where the condition proved stubborn.
“The nurse came in and said, ‘I want to introduce you to this program,’” Bryan said.
With that, Peacock became the first patient of Penn Medicine’s Hospital at Home program. He was given transportation home and set up with equipment.
“When he got here, his whole demeanor changed—he was in his comfort zone,” Bryan said. “We laughed, we joked like we normally do.”
The days were warmer than average, and so Peacock spent a bunch of time sitting out on the front porch with Bryan, enjoying the weather, a luxury not possible in the hospital. The nurses were also paying attention to the weather, and brought in fans to keep the inside of Peacock’s house cool. It was just one of several little touches that made the experience exceptional for Peacock.
“They even do labs, I was surprised. The nurse definitely kept me up to par with the medicine and the insulin,” said Peacock. “It was 24-hour care.”
He said those three days of Hospital at Home had him feeling better, faster than his time in the hospital had. Now Peacock says he’ll be telling other people about his experience.
“Just being around the people that you love, your own comfort zone ... It’s definitely better for them to be around people that they love.”