The challenge

When leaders at Parkland Health & Hospital System in Dallas launched a novel program for administering long-term antibiotics to Parkland Memorial Hospital patients, they were seeking to address two problems that vex many provider organizations: disparities in the delivery of health care services and the inappropriate use of health care resources.

Kavita Bhavan, M.D., medical director of the Infectious Diseases Outpatient Parenteral Antimicrobial Therapy [OPAT] Clinic at Parkland, says the clinic treats many patients who need intravenous antimicrobial therapy for several weeks to recover from serious infections stemming from illness or injury.

Providers can administer long-term IV antimicrobial therapy to insured patients within a number of locations: an infusion center, a physician’s office, a skilled nursing facility or, most frequently, at home with support from home health services. Uninsured patients, however, have no access to home health nurses or other options, so they traditionally have been treated as inpatients at Parkland, the only provider organization that provides free care.

“It wasn’t unheard of to be here 42 days getting IV antibiotics,” says Bhavan, who also serves as associate professor of internal medicine at the University of Texas Southwestern Medical Center. “And they were doing fine — the only reason they were there was to get the antibiotics.”

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That meant inpatient beds were being tied up by patients who could be treated at home, while Parkland struggled to find beds for acutely ill patients coming through the emergency department.

At the same time, the patients receiving long-term antibiotics did not want to be in the hospital unnecessarily. “Many of our patients are the working poor,” Bhavan says. “They would like to get home to be able to pay their bills on time, and take care of their loved ones. It’s burdensome for them to be tied up in a hospital.”

Furthermore, spending weeks as a hospital inpatient comes with the risk of nosocomial infections, so Bhavan recognized a disparity in the quality of care being provided to uninsured patients versus their insured peers who were being treated at home.

The solution

Seeking a funding source that would allow those patients to receive home health support during the course of their treatment might be a logical solution, but it is not one that Bhavan considered. 

“Instead of asking for more resources, I wanted to find a way to maximum the potential we have in front of us,” she says.

That potential: the ability of patients to perform care traditionally provided by medical professionals.

Bhavan and her colleagues developed a program to train those patients to self-administer IV antibiotics at home, which frees up nearly 6,000 bed days and saves Parkland more than $7.5 million in unreimbursed care in a single year.

Now in its eighth year, Parkland’s self-administered OPAT, program, or S-OPAT, has shown that low-income patients, including non-English speakers and those with low literacy levels, can provide self-care that is equal to or, in some cases, better than that provided by medical professionals.

“You don’t have to have formal education to be able to perform these tasks because there’s no direct correlation between formal literacy and health literacy,” Bhavan says. “These patients do a beautiful job, and we are just trusting and empowering them to engage in their own care.”

How it works

The S-OPAT program is appropriate for patients who meet several criteria, including: being medically stable; not homeless; no history of IV drug use; access to a refrigerator and a telephone; able to go to Parkland weekly; and willing to self-administer drugs or work with a caregiver who is willing to administer them.

Eligible patients are referred to a pharmacist to determine whether an appropriate antibiotic can be safely administered at home. Some antibiotics require a level of monitoring that requires inpatient administration. The pharmacist determines the dose, frequency and duration of treatment.

A case manager then assesses whether a patient meets the program’s criteria. If so, a transitional care nurse trains the patient to administer the drug and care for the peripherally inserted central catheter line at home. Training is provided in English or Spanish, depending on the patient’s preference, or by using telephone-based translation services for other languages when necessary. Regardless of the language, the teach-back method is used to make sure the patient understands all steps associated with the procedure.

“We have them teach back to us on three separate occasions, going through the entire bundle of things that we think are important core elements,” Bhavan says. “If they can do all of those things, we send them home with their first week’s supply of antibiotics.”

Along with the drugs, the patients get a box of supplies — gloves, IV tubing, alcohol pads, saline flushes — and a card that reminds them of their next appointment and whom to call if a problem arises. The back of each IV bag includes a QR code. “Patients can scan that bar code with their phone to upload a YouTube video,” she says, in case they become confused. "You can stop, pause, rewind and learn at your own pace and in real time.”

The patient returns to the clinic each week for blood work and so that a nurse can change the PICC line dressing and address any potential problems.

Outcomes to date

Parkland conducted a four-year study from January 2009 through October 2013, to compare the outcomes of uninsured patients enrolled in the S-OPAT program with those of insured patients who received health care-administered therapy, or H-OPAT, in which their drugs were delivered at an infusion center, in a nursing home or at home with skilled nursing assistance.

Of the 1,168 patients discharged from Parkland to receive antimicrobial treatments as outpatients, 944 participated in the S-OPAT program and 224 received H-OPAT services.

  • The 30-day, all-cause readmission rate was 17 percent for S-OPAT patients and 24 percent for H-OPAT patients.
  • The one-year, all-cause mortality rate for the S-OPAT group was 5.4 percent, which was not significantly different from that of the H-OPAT group.
  • The S-OPAT patients avoided a median of 26 days of inpatient care. This means that, over the 46-month program, Parkland avoided 27,666 inpatient days that would have been needed to care for these patients had they been treated in the hospital.

More recent results show the program’s return on investment. In Parkland’s fiscal 2015, the direct costs associated with the S-OPAT program were $957,933, or $3,574 per patient. During that year, the program freed up 5,893 inpatient bed days, translating into direct cost avoidance of $7,561,130, according to the research brief, “Teaching Uninsured Patients to Self-Administer IV Antibiotics at Home,” by NEJM Catalyst.

Bhavan attributes the patients’ self-care performance to their personal motivation. While most provider organizations fall short of 100 percent hand-hygiene compliance, an individual patient striving to recover from a life-threatening infection is highly motivated.

“For health care providers, hand hygiene is an essential part of our job and we should be doing it because it is the right thing to do,” Bhavan says. “But patients don’t think of it that way. It’s not a job — it’s their body.”

Lessons learned

Initially, Parkland’s floor nurses were assigned to educate patients about the self-care protocol, which meant the training was not always consistent.

“They are going to naturally look at this as one more thing to do, and you’re going to have some who are highly motivated and some who aren’t,” Bhavan says.

That challenge was addressed by creating a transitional care nurse team dedicated to training the patients. That was the hospital’s single biggest investment in the S-OPAT program, and one that has proved well worth the expense, she says.

For those nurses, the top priority is spending enough time to make sure the patients know how to succeed at home and developing a relationship that gives patients confidence that they have the support they need.

“What’s wonderful is that there is a much more standardized, consistent process of training, and our nurses are motivated to teach the tricks of their trade to a patient,” Bhavan says. “It is empowering, and they are enthusiastic.”

Next steps

Bhavan plans to publish at least two more articles examining data from the pilot study. One will report on the high levels of satisfaction expressed by patients in the S-OPAT program; the other will examine the collateral benefits of activating a patient in this type of self-care.

“If you engage a patient to take ownership in one process effectively, and they feel good about it because they are doing a great job, what does that mean for their other health conditions?” she says. “We have shown that these patients who have successfully completed the program don’t come back into the hospital.”

Most of her patients have one or more chronic comorbidities, such as high blood pressure or diabetes. Because the program collects data on patients over time, Bhavan can examine whether their health metrics — blood sugar levels, blood pressure, smoking status and others — change during their course of antibiotic therapy.

Those findings may help health system leaders think about the return on investment of self-care initiatives in terms of their population health management goals.

“If you’re going to come up with interventions, how do you get the maximum return on those investments in ways where you are not just solving one problem, but perhaps getting collateral benefits in other areas as well?” she says.