NUR6003 Module 1 health care trend analysis example

The Acute Bed Moves Home: What Hospital-Level Care at Home Means for a Rural BSN Curriculum, and How Much of It the Program Should Change Now

Student Name

American College of Education

NUR6003: Influencing Forces in Nursing Education

Module 1 Assignment

Instructor Name

January 14, 2030

The Program and the Trend

I teach adult health in a composite BSN program at a regional public university in a rural part of the upper South. The program admits 96 pre-licensure students a year, and most graduates take jobs within a hundred miles of campus. Our largest clinical partner, a regional health system with a 280-bed hub hospital, has announced that it will open a hospital-at-home program next year, taking selected patients whose admitting problem is, for example, cellulitis, a heart failure exacerbation or community-acquired pneumonia, to acute care in their own homes. Several of our graduates are likely to work in it. This paper examines that trend, asks what it demands of new nurses and argues for the changes our curriculum should make in response, and for the changes it should not yet make.

What the Evidence Shows

Hospital at home is substitutive care: the patient would otherwise be admitted, and instead receives hospital-level treatment at home, including nurse and physician visits, intravenous medications, remote monitoring, video communication and point-of-care testing. In a randomized controlled trial at an academic medical center and a community hospital, Levine et al. (2020) found the home arm's acute episode cost 38% less after adjustment; those patients also needed fewer laboratory tests, scans and specialist consultations, were more physically active and returned to hospital less often within 30 days, 7% compared with 23%.

The evidence has limits that matter for a curriculum. The trial enrolled 91 patients at two sites, the patients were highly selected and 63% of those eligible declined to take part (Levine et al., 2020). The model's results in rural areas, where travel times are long and broadband is uneven, are less certain than in the city where the trial was run. The trend is real and growing, but it is still a small share of acute care, and a curriculum should respond to its direction without pretending it is already the norm.

Why the Trend Is Growing

The model's recent growth in the United States owes much to policy. In November 2020, the Centers for Medicare & Medicaid Services announced the Acute Hospital Care at Home waiver, which waived the requirement for round-the-clock on-site nursing and allowed hospitals to receive full inpatient payment for hospital-level care provided at home (Gorbenko et al., 2023). Interviews with clinical leaders of 14 programs found that launching one required building electronic records, vendor relationships, pharmacy and monitoring systems that extend the hospital into the home, and that uncertainty about the waiver's future slowed wider adoption (Gorbenko et al., 2023). For educators, that means the trend depends partly on decisions outside health care. Our partner's program may grow quickly or stall with a change in federal payment, and a curriculum built entirely around it would be exposed to that risk.

What Nurses in the Model Do Differently

Hospital-at-home nurses perform familiar acute care in an unfamiliar setting. From the model's components and my conversations with our partner's planning team, four differences stand out. First, assessment happens without the environment of a hospital: there is no colleague down the hall and no rapid response team on the unit, so the nurse must recognize deterioration early and escalate through a virtual command center or a physician on video. Second, the nurse interprets remote monitoring data, deciding which alerts reflect a change in the patient and which reflect a displaced sensor. Third, the home itself becomes part of the assessment: stairs, food, a caregiver's capacity and the safety of oxygen or intravenous lines in a house with small children. Fourth, teaching and coordination with the patient's family take a larger share of the work, because the family is present for more of the day than any clinician.

Mapping the Demands to the Essentials

None of these demands is outside the current competency framework for entry-level nursing education. The AACN Essentials organize competencies into ten domains (American Association of Colleges of Nursing [AACN], 2021), and the four differences map onto four of them. Early recognition and escalation without on-site backup belongs to Domain 5, Quality and Safety. Interpreting remote monitoring data belongs to Domain 8, Informatics and Healthcare Technologies. Assessing the home and family belongs to Domain 2, Person-Centered Care. Coordination with a virtual team and community services belongs to Domain 7, Systems-Based Practice. The mapping is reassuring: hospital at home does not require new outcomes, but it does ask for existing ones to be practiced in a setting our students rarely see in acute care courses, since almost all of our adult health clinical hours are spent on hospital units.

What the Program Should Not Change Yet

Weighing the trend also means deciding what not to do. Three responses have been suggested by colleagues, and I would decline each for now. The first is a stand-alone course in home-based acute care. A course takes a year or more to approve, displaces credit hours that are already contested, and would be built on a model whose national scale and payment are uncertain; if the waiver lapsed, the course would outlive its reason. The second is to move a large block of adult health clinical hours into the home program. Our partner's program will start with perhaps eight to twelve patients at a time, too few to host 48 students a semester without crowding the patients' homes and the nurses' days. The third is to add a certificate or elective aimed at graduates who want to work in the model. That may make sense in three or four years if the program grows and hires our graduates in numbers, but today it would market a job that barely exists locally. Declining these options is not a judgment that the trend is unimportant. It reflects the principle that a curriculum is a scarce resource, that every hour added displaces another, and that the size of a response should follow the size and certainty of the force behind it.

Three Proportionate Changes

Given the strength of the evidence, the uncertainty of the policy and the size of the gap, I propose three changes rather than a new course. First, in Adult Health II, one week of content will be rewritten around acute care at home, using a heart failure patient followed from emergency department decision to discharge from the home program, with emphasis on escalation criteria and caregiver teaching. Second, two of the course's existing simulation scenarios will be recast in a home setting: one in which a patient's remote monitoring shows a gradual rise in respiratory rate and a fall in oxygen saturation that the student must escalate by video, and one in which a caregiver's capacity to manage an intravenous antibiotic is in doubt. In the national simulation study run by the licensing boards' council, programs that swapped as much as 50 percent of their clinical time for well-designed simulation saw graduates perform no worse at the end of the program (Hayden et al., 2014), which supports teaching an unfamiliar setting through simulation when placements there are scarce. Third, if our partner agrees, ten students a semester will spend one eight-hour shift with a hospital-at-home nurse, both in the command center and on home visits, as a pilot to be evaluated before any expansion.

Each change can be undone if the model stalls, and each strengthens competencies that matter in any setting. That is the test I would apply to any trend: respond in proportion to the evidence and in ways that remain useful if the trend reverses. I will report back to the curriculum committee after one year with student performance in the recast simulations and feedback from the partner's program on the graduates it hires.

References

American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/essentials

Gorbenko, K., Baim-Lance, A., Franzosa, E., Wurtz, H., Schiller, G., Masse, S., Ornstein, K. A., Federman, A., Levine, D. M., DeCherrie, L. V., Leff, B., & Siu, A. (2023). A national qualitative study of Hospital-at-Home implementation under the CMS Acute Hospital Care at Home waiver. Journal of the American Geriatrics Society, 71(1), 245-258. https://doi.org/10.1111/jgs.18071

Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2), S3-S40. https://doi.org/10.1016/S2155-8256(15)30062-4

Levine, D. M., Ouchi, K., Blanchfield, B., Saenz, A., Burke, K., Paz, M., Diamond, K., Pu, C. T., & Schnipper, J. L. (2020). Hospital-level care at home for acutely ill adults: A randomized controlled trial. Annals of Internal Medicine, 172(2), 77-85. https://doi.org/10.7326/M19-0600