Hospital Care at Home

Podcast Transcript

Carol Pehotsky: In our day-to-day work as nurses sometimes we might find ourselves wondering, am I making a difference to this patient in front of me, but am I making a difference to the larger patient population, to others, maybe not directly within my reach. How often as nurses do we get to be part of innovations that truly change the face of nursing and healthcare?

I'm so thrilled to be joined today by Danielle Crow, nurse manager of hospital care at home that is in the process of changing the way we deliver care.

Hi, and welcome to Nurse Essentials, a Cleveland Clinic podcast where we discuss all things nursing from patient care to advancing your career, to navigating tough on the job issues. We're so glad you're here. I'm your host, Carol Pehotsky, associate chief nursing officer of Surgical Services Nursing.

Welcome back, everyone. We're recording today in August of 2025, and I don't always throw that date in, but I, I'm throwing it in specifically for the fact that we're five years plus out from the beginning of the COVID-19 pandemic and sometimes people will bring up what has gone well, what have we learned.

Obviously there was a lot of challenge and heartbreak and tragedy, and you know, as I look back on those five years. You know, one of my silver linings is the fact that our guest today is joining us via teleconference, which while we had video calling pre 2020, we really weren't using it to this advanced level. So that's one of my silver linings.

Another one that we're going to spend great amounts of time talking about today is having to get creative with the care of patients. You know, when our hospitals were bursting at the seams and really that challenge of giving many different people with many different needs, what they needed in terms of care, a lot of interesting and innovative things came out of that.

In terms of my area, in surgery, we started looking differently at who needs to spend the night post-surgery and how do we really ensure that they can safely go home as soon as possible. Well folks, I'm delighted to be joined today by Danielle Crow. Danielle is the nurse manager of hospital care at home for Cleveland Clinic, and she's going to be enlightening us.

I can't wait to learn all about the innovative team that she leads and the practice that she leads to give hospital level care at home. Danielle, thank you so much for joining us today.

Danielle Crow: Thank you for having me. I'm so excited to be able to share more about this care model and what we're creating here.

Carol Pehotsky: Yes. It's so cool. So first, if you don't mind, give us a little bit about your nursing background, your journey, what, uh, led you up to this role and this opportunity that you're sharing with us today.

Danielle Crow: Sure. Yeah. So, I actually am an ER nurse by background. So, I've spent 20 plus years working in emergency departments in different states and small and big.

After 20 plus years started to get a little burned out, right? I mean, especially the pandemic really exacerbated some of the same challenges we were seeing over the years get worse. But then it was exacerbated by the pandemic. And so, for me, I just started feeling like I needed to do something else, you know, where I could find some hope.

And like you said, the glimmer of light out of the darkness. And I've always said this has kind of been my light at the end of the tunnel in my career. because you know, now I'm at almost 30 years of my career and it's just so exciting to be doing something where I feel like I'm actually making a positive effect on healthcare overall.

Being able to, you know, do things differently, innovate, and really, I hope to change things for patients as well as nurses, right? One of my big passions is nurses who, you know, get to that point where they're burned out and what are other options for those nurses? So, this was a great opportunity for me to feel like I was helping patients and nurses all at the same time.

Carol Pehotsky: You've been there from the beginning with us, so tell us a little bit about how you got connected to us and really, if you don't mind the birth of this program and, and what it really means to be delivering hospital care at home.

Danielle Crow: Yeah. I didn't know what I was getting into. I found the job posting close to my house and I was like, sounds interesting.

I mean, I'd heard a little bit about you know, hospital at home, but didn't know a lot about it. So anyway, I jumped in. I thought this is a great way to be able to start something, you know, just being able to create something from the ground up and that excited me. So, when I talked to the team about what their plans were and about what their vision was, I just felt like it was a really great fit. You know, I have a lot of flexibility and resilience from my time working in the ER, and so I was like, you know what? I'm going to take this on. I want to build something. So yeah, I didn't really know what I was in for but here we are and it's going really well. It's just a lot of work.

Carol Pehotsky: What an amazing opportunity that not all of us get to really take something from the ground up.

Danielle Crow: Exactly. Yeah. I felt like I was lucky.

Carol Pehotsky: Well, we're lucky too. So, this is certainly not home care, right? So, I think people will hear hospital care at home and equate that with home care, which we also have a podcast episode if anyone's interested in learning more about that, and it's very important nursing. This is different. So, tell us what this is. Who, who are we serving? How are we serving them? What? What's it like to deliver hospital care at home?

Danielle Crow: Yeah, so I mean, I think the biggest point is, is absolutely that these patients are inpatients, right? Meaning they're not observation level; they're not discharged patients. They're actually admitted to the hospital, meet that inpatient criteria, and we're able to care for them in their home.

Now, of course there are clinical criteria and social criteria that we have to take into account that your, you know, your med-surg level patient, so patients who maybe, you know, need antibiotics two or three times a day for an infection.

You know, we've taken some post-surgical cases as well and hope to do more of that in the future. Lots of diabetic patients, lots of CHF patients, just a lot of patients that you would find on a typical med surg unit, we just move them home and we're able to provide the same services honestly, in their home.

You know, from mobile radiology to therapy to home health aides in the home to assist. And then our nurses are able to virtually, within our command center in Vero Beach, stay connected with those patients 24/7 and really oversee that full plan of care.

Inside of our command center, I mean, we have the nurses, we have hospitalists, we have pharmacists who are dedicated to our model. So, we have, it's almost like a small miniature hospital versus a nursing unit inside of the hospital.

Carol Pehotsky: And so, what kind of equipment is being set up in the patient's home so that they can be delivering this care virtually?

Danielle Crow: Yeah, there's a lot of tech equipment that goes into that.

Yeah, it's a, there's a tablet, very easy to use tablet. I think, you know, a lot of times, especially in Florida, we serve a more elderly population and there was concern around like, are the, they going to be able to manage this high-tech kind of house call situation? And the tablets are so easy to use, you know, there's just a button and that connects them to us.

One big green button on the front of the iPad. They touch it. Normally we answer within 30 seconds, so they do get a very quick response rate. So, we teach them about that. They wear an emergency bracelet, so that also is something that they can just push. They don't have to be near their tech equipment for that to alert us that they're having an issue.

We bring in vital sign equipment right across to our system. There's a backup battery, there's a router, and they have a phone as well. So, we bring in multiple different pieces of technology to enable us to care for them, and then also redundancy, backup ways for them to connect to us as well.

Carol Pehotsky: And so, do you have eyes on these? Like are they on a webcam? How are you assessing if a patient needs something and isn't the one calling for assistance through that iPad?

Danielle Crow: Good question. We do not monitor them 24/7. So, it is a little bit of a shift of mindset, right, from a nursing perspective. I think we've been so used to doing something the same way for many, many years.

This is how we take care of hospitalized patients. Nurses sometimes really want to control. But the patients, you know, we educate them so much and we're also on and off with them all day. The nurses are on video calls with their patients. Anybody that's coming in and out of the house providing care, which there are primary clinicians that go into the house every day. So those are the nurses or the paramedics that we work closely with on video to help guide what they're doing in the home.

So the 24 7 is there, but it's not continual. We're not watching a patient sleep. We're not watching them, you know, go to the bathroom if they need assistance, we can provide that in the home, but we really rely on them to contact us if they need something outside of the times when they have somebody coming into the home.

Carol Pehotsky: So, there's a lot of trust between that nurse and the command center and the clinicians that are going into that home that all the criteria being met and the protocols are being followed. So, you mentioned patient and social criteria. Can you talk through us a little bit about sort of the criteria and or the right, so to speak, patient for this level of care?

Danielle Crow: Yeah, so clinically, you know, we look at a couple of things. Obviously, we can't take care of anybody who needs any sort of continuous monitoring like we just talked about, whether that be telemetry or pulse oximetry, anything like that.

We need to be able to get their care done and you know, two to three visits per day what they need. There are a lot of things we can assess via video too, but there are some things we can't do. So, the ideal patient is one that you can get out of those med surg beds in the hospital that also don't need the intense monitoring.

So we don't take anybody with the full monitoring. We don't take anybody with continuous fluids or continuous drips of any sort right now. So, all intermittent steroids, antibiotics, things like that, we can't take anybody who is on greater than 10 liters of oxygen. So, we do provide oxygen. So, there are some clinical criteria that the physician does prior to the patient even being referred to us.

Once they're referred to us and we've reviewed it, we also do that social, which we talk about like, do you have running water? Do you have a functioning toilet? Are you able to get to your refrigerator? So, we have to just make sure they have all the basic things that we need to be able to care for them safely in their home.

After all of that, they've passed. We talk about what's their plan of care going to look like. What do we need in the home from a supply perspective or an equipment perspective, and how many visits a day will this patient need? So, we talk about all of that before they ever get transferred into our unit.

Carol Pehotsky: What sort of skills and techniques does the nurse who's effective in these roles need that perhaps is different or you modified from that I'm in person doing the skills myself?

Danielle Crow: There are a lot of nurses that are very interested in this model. I hired 17 nurses since February. There's a lot of applicants; there's a lot of people that are interested.

I didn't know what was going to make a great virtual nurse, and I think anybody can do it. It's more about that learning curve. It's a very steep learning curve. I think people that are already kind of skilled at technology. You know, we work with three screens and we're bouncing around in all kinds of different systems that nurses aren't used to.

Right? We're in the radiology systems. We're involved in a lot more than what we would be in the brick and mortar, which is inside of the hospital. So, I think flexibility, you know, and being able to go back to that novice feeling. A lot of us haven't felt that for a long time, and I can tell you every single nurse that goes through this is like, oh my gosh I'm like, back at the beginning. I'm like, yeah, it's tough. You know?

It takes four to five weeks of orientation, even for the most experienced nurses, so honestly, it's a steep learning curve for everybody. I think that being able to prioritize, being able to mentally prioritize and the physical demand isn't there, but the mental demand is very high.

And then just, you know, the ability to look at things differently because if you really get stuck in how we've always done things it's difficult to transition into this role. There is a loss of control, but I always do like to point out the same thing you pointed out, which is that we didn't have eyes on them 24-7 in the hospital either.

And honestly, we're reacting to that call from them probably quicker, sometimes in a call, like could even be in the hospital. So, I feel really good about the care that we're providing and I think that any nurse can do it no matter.

We've got 39 years of experience and three years of experience on our team. All different backgrounds, from Cath Lab to ER, to observation units, to med surg units. Like it really is cool to see all those different people come together to provide care in this way as well.

Carol Pehotsky: Well, and so wonderful. You're all in the command center together, so just like you would in a nursing unit, hey, I'm not sure what's going on with my patient. There's still that ability to collaborate, I assume.

Danielle Crow: Absolutely. Or hey, I can't get my headphones to work.

Carol Pehotsky: Good point.

Danielle Crow: You know, it like works both ways.

Carol Pehotsky: How has it been for your physician colleagues, like how they're getting into this, again, different level of medicine and, and how the interaction is between the nurses and the physicians in the command center?

Danielle Crow: It is so cool for me because I do kind of liken it to my time in the ER where the physician's right here with us, right? I mean, during the day, obviously they're not here overnight, but during the day it's like, it's really collaborative all day. Lots of conversations because again we're all new to this, right?

So really practicing that high reliability that Cleveland Clinic is so like focused on, which is really important, is the only way we've been able to safely grow this. Right? Like having lots of conversations around, you know. What do you think about this patient? Do we have everything in place that we need?

What do we need to do with their plan of care? Is there anything that we're missing that, you know, there's a lot of conversations all day between physicians, nurses, and the pharmacists, so that's a really exciting thing to see as well.

I would say the physicians need training as well. They can't come over and jump right into this model either without a little bit of education around the model.

Carol Pehotsky: You know, in a hospital, physicians making rounds, they might be in the OR, there's other places that physician is the, the level of access everyone has to each other is amazing.

Danielle Crow: Yeah. I really enjoy it.

Carol Pehotsky: Yeah. You think about building trust and rapport with a patient, and as nurses sometimes we do that through touch. We do that through talking. We do that through meeting patient's needs. Your nurses are doing that in a different way. Talk to me about how to build trust and rapport with a patient through a video call, essentially. And, and what are some techniques that you've taught your nurses over this time to help enhance that?

Danielle Crow: I don't know how to explain it, but one of the first things that I was very surprised about in this model was that all of us were like, we feel like we can get a deeper connection with the patient this way. And you know, after thinking about it, it makes sense. The patients are more comfortable, they're more open, they're surrounded by the things that they love.

We are actually in their home. You know, seeing art behind them on the wall and asking them about it or getting to know their pet and you know, talking to their pet on the video. And, you know, just, I feel like you get to know more about the patient as a person quicker and more intimately honestly, by seeing that little window into their life and their home.

And that has just created a place where nurses are, they just usually asking like, oh, hey, I see this behind you. Or you know, where's Pepper the dog?

Carol Pehotsky: I'm going to have to see the dog. Yep.

Danielle Crow: Yeah. It's like, and, and the conversation, you know, it is more conversation, right? There's a lot more education because the patients are fully participating in their care. Right. We're not bringing a cup of pills in and saying, oh, you know, this is this, this, and this. The patient actually pulls out the meds, shows us the label, opens it up, you know?

So there's a lot of like education and there's a lot of just collaboration in the care and participation that I, I think we strive for sometimes in the hospital, but it's just more challenging to be able to achieve it.

Carol Pehotsky: All great points. I hadn't really thought of it that way. What are the biggest challenges that you and your nursing team face in delivering this type of care, and how do you get through that and mitigate that because you can't just pop on over and figure things out physically.

Danielle Crow: There are so many challenges, whether it be just overall changing healthcare and what people think about how we care for a patient acutely ill in the hospital.

Right. Education of those teams in all the hospitals that we're admitting their patients. You know, we're in five hospitals in Florida. We have a unit in each hospital there, and then we are now shortly going to have two more hospitals in Ohio. So really just getting that awareness and that education.

And people were a little bit nervous about it too, right? Like that's why I was so excited to come on here because it's like I can share more about what we're doing and how we're safely providing care and what it looks like in our world.

Challenges inside the home are things just the orchestration. One of our nurses called our nurses Nurse Mastros, and a very nice thing that she wrote about us, and I was like, yes, they're orchestrating everything right? And there's so much pre-planning down to how many syringes do I need in the home. It's very in depth.

So I just think like those challenges come just because of the logistics. Right, like you're trying to get radiology into the house, lab into the house, and the primary in-home clinicians into the house and making sure all the supplies are there and that things are happening on time and according to the patient's plan of care.

So those challenges are there. Those are innate to the program, and we work through those all the time. We're in a constant state of improvement. How can we make this, you know, more efficient and better? But overall, I would say the biggest challenge is just overcoming kind of the, this is the way we do healthcare and getting that out to people.

Carol Pehotsky: What does a typical day look like for one of your nurses?

Danielle Crow: They are coming in and they're, they have five to six patients just like you would on a typical med-surg unit, and they have a computer with three screens. They are multitasking, like I said, everything about the patient's plan of care.

So where in the hospital, you know, a patient might get an x-ray. You of course know they're going to get that x-ray, but you're not really involved in the actual x-ray, you know, but we're involved in checking the rad tech in, ensuring the images, crossover to our system, making sure that the labs are labeled appropriately by somebody else before they're couriered to the lab.

You know, checking in with home health aides who come in and explaining to them the plan of care. The calls are constant. At certain times of the day, we're having like 80 to 90 calls per hour coming into our command center. So, there's a lot of ringing, there's a lot. We've even had to work to develop some changes in the software that we use to help our nurses be able to more effectively like triage their calls that are coming in.

So any person that goes into the house, whether it be a delivery of supplies or a food delivery or a courier drop off, the nurse is involved in that and checking that. So that's their day. They've got five or six patients that they're doing this with and they're awesome. Like I said, they're doing their med passes.

With a nurse or a paramedic in the home if it requires their assistance like an IV or checking to make sure they're giving it all right and the right rate and the right dose and all those things. Or whether we're sitting down with a patient and saying, okay, we need you to check your blood sugar going over the sliding scale, making sure they've got the right amount of insulin pulled up.

So there is a lot, like I said, of real collaboration going on with the patient all day.

Carol Pehotsky: Wow. That's fantastic. So, you mentioned patient experience and, and yeah, how much better it is to be at home. The program is relatively young, but have you seen any patient outcome changes or patient experience, like what sort of outcomes have you been able to measure with the patients in this program?

Danielle Crow: This is what I'm so passionate and excited about. There's not enough research out there, right? So, I'm so excited that we're starting to be able to contribute to some of that literature and that, you know, we don't have benchmarks. We don't have a lot of things that you would have. So, what I'm most excited about that we've seen is decreased readmission rates both 7-day and 30-day, which makes complete sense.

Again, we are setting patients up to be able to care for themselves in their home, being participants in their care while they are hospitalized, as well as obviously no hospital acquired infections. I mean, technically we do have lines, and we do have Foleys in the home, but we've had none and we've had no hospital acquired wounds either.

So really, we've got a really high quality of care going on. Definitely decreased readmission rates. And then other things that I think, and I, you know, don't have any data to support it, but I want to study are like sleep. Patients are definitely reporting that they're getting better sleep, which is obviously very important to healing.

As well as functional status. Patients are up moving around in our program, right? They're doing more, they're moving more than they would sometimes in a hospital bed, or actually all the time in a hospital bed. So, I think those are two things I'm really interested in studying - sleep and functional status.

Carol Pehotsky: Yeah. Their cortisol levels have to be way better, you know, just think about the, the stress that they're, yes, it's still stressful to be ill and to be healing and having people coming in outta your house, but yes, it, to have covered the dog with you is a good thing.

Danielle Crow: Yeah, it's busy and you know patients also, they like, you know, they like being at home. They feel more comfortable. Like I said, they're more open. Most of them like it. There are some that it feels like too much for and we always check in with them about, you know if they're coping well, if their family is coping well, if they're helping us with the care, do we need to get a home health aide if we don't already have one? because it is a lot of answering the door and you know, answering phone calls.

And so we always try to stay in tune to that as well. It's like, how is the patient and how is the family doing with this model of care?

Carol Pehotsky: Very good. So, we've spent a lot of time talking about how great this has been largely for our patients and our nurses. What is the benefit for the hospital?

Danielle Crow: The biggest one I think is overcrowding. You know, the number of times and hours that people wait in the ER for a bed or even wait to come into one of our hospitals in Cleveland. Taking those patients that really, I think, honestly do better in the home and moving them into the home as a spot for them to be hospitalized, and that way those beds in the hospital are kept for the patients that need the continuous telemetry, the continuous medication.

So overall as system-wide, I think it helps with decompression of the hospital and that's what we're hopeful for, and that that will continue to grow and be able to bring meaningful change there, as well as those decreased readmission rates, decreased hospital acquired infection rates, right? Like all of those things also benefit the healthcare system as a whole.

Carol Pehotsky: And so, this has been so fantastic, and I can't thank you enough for joining us today. We do have listeners from outside the organization and so hope, I am confident you've inspired everybody, including those nurses, and so maybe they work in an organization that doesn't yet have something like this. So, what advice would you give them?

Danielle Crow: Yeah, I would say just try to get in, linked up with the community. There is a hospital-at-home users’ group online that is available to join and that, you know, there are some conferences now focused on hospital care at home, including an international conference. I would say just start talking to the people that make the decisions around what you're doing.

Like are you looking to add buildings and beds? I think this is a real opportunity for us to start to shift things across the country. I know there's lots of hospitals that are starting up new programs as we speak, and then I would just say reach out and, and make that community because it helps me to be able to reach out to managers or directors of other programs across the country and say, Hey, we're all in this together, right? What are your best practices? How are you staffing? Like we we're leaning on each other in that way.

So I would just encourage you to get kind of involved in the hospital at home community, and then also just try to pitch some of the benefits that I've even just talked about in this podcast because there is more research coming out. So, there will be the proof, I think, that we need to say like the quality is there in this type of model of care, and it also can be beneficial for the health system as a whole.

Carol Pehotsky: Yeah, you guys are changing model of care, not just for our organization, but really for the country. That's, it's incredible.

Danielle Crow: Yeah. And you know, other countries have been doing this a lot longer than us. Oh yeah. Decades. So that's why they have this international conference as well, where we go over and learn from other countries that have been doing this.

Carol Pehotsky: Oh, that's fantastic.

Danielle Crow: You know longer too, so, yeah.

Carol Pehotsky: Excellent. Well, Daniel, I can't thank you enough. You shared such really powerful information with us today. I'm hoping you'll spend a few minutes with me to wrap up. Uh, we like to ask guests some fun questions, so our audience will learn more about you as an amazing human being, as well as an amazing nurse. So first off, if you weren't a nurse, what would your passion career be and why?

Danielle Crow: Uh, well, there's a couple things I would love, but I think the thing that I always go back to is like a lawyer, you know, I just really enjoy that. I really enjoy listening to legal podcasts and listening to, you know, things like that. Really educating myself around those things. And I just, yeah, I think if I could do it all over again, I might do that.

But then again, I really love where I am in my nursing career because it's so exciting that like this far into a nursing career, I'm doing something that inspires me, brings me hope for the future of healthcare in our country, and really allows me to create change for nurses. Yeah, so I think a lawyer would be what I would go with.

Carol Pehotsky: You're clearly exactly where you were meant to be right now. So probably related to that we've spent a lot of time as an organization this year talking about the power of purpose, so I'm hoping you're, you'll share with us what's your why.

Danielle Crow: I really feel like this is my purpose right now. Right. You know, it feels good to have found that spot because in the ER I felt like ugh, am I creating any change? Yeah, I'm making change for patients individually, you know, from time to time, of course.

But like overall, looking at where we are as a country and our healthcare and really as a nursing profession, I just feel so strongly about nurses having options where, again, we didn't even touch on this, but like even the workplace violence. Right? And like, not having to always feel like you're, you know, you're worried about somebody doing something in that way.

We have a real safe environment here and, and I feel really happy that nurses feel safe. They feel happy, they feel hope, they feel inspired that they have the power to change things. So, I really do feel like that is my purpose and my why, besides raising two amazing boys.

Carol Pehotsky: Well, Daniel, thank you so much for joining us today. We're so glad to have had you share all this great information with our audience.

Danielle Crow: Oh, thank you so much for having me.

Carol Pehotsky: As always, thanks so much for joining us for today's discussion. Don't miss out. Subscribe to hear new episodes wherever you get your podcasts. And remember, we want to hear from you. Do you have ideas for future podcasts or want to share your stories? Email us at Nurseessentials@ccf.org. To learn more about nursing at Cleveland Clinic, please check us out  at clevelandclinic.org/nursing.

Until next time, take care of yourselves and take care of each other.

The information in this podcast is for educational and entertainment purposes only and does not constitute medical or legal advice. Consult your local state boards of nursing for any specific practice questions.