Design a workforce model that blends virtual and in-home roles to provide continuous, acute-level care in the home environment.

• Establish adaptable staffing structures
  • Combine mobile care teams (registered nurses, paramedics, ancillary staff) with virtual roles in command centers or remote clinical support.
  • Leverage shared resources across departments/facilities, and use per diem pools or cross-coverage arrangements, to address workforce constraints.
• Ensure credentialing, licensure, and liability compliance
  • Verify licensure for clinicians practicing across state lines in virtual settings.
  • Address liability coverage for in-home services and inter-facility workforce sharing.
  • Explore systemwide credentialing to support flexible staffing across locations.
• Clearly define roles and responsibilities
  • Identify expectations for each team member (in-home nurse, remote provider, dispatch coordinator, etc.) using standard, role-based workflows.
  • Define care team structure, decision-making authority, and escalation responsibilities to ensure accountability.
  • Clarify distinctions between HaH and BAM care teams, specifying their respective roles in patient assessment, history and physical (H&P) exam performance, and care planning.
  • Refer to Mount Sinai’s Staffing the Hospital at Home Program guide.

Develop operational systems that support real-time care delivery, communication, and supply coordination across dispersed settings.

• Select a command and coordination model
  • Select between centralized command centers, lean hubs, or distributed coordination structures, depending on the program’s scale and geography.
• Support mobile care teams
  • Equip clinical teams with EHR access to document notes, log vitals, and communicate securely while in the field for in-home visits, assessments, and interventions.
• Coordinate transportation and field operations
  • Provide access to reliable vehicles and scheduling systems for mobile visits.
  • Establish patient transport protocols for urgent escalations, community appointments, or facility transfers.
• Streamline delivery of medications, equipment, and services
  • Develop logistics systems for timely delivery of meds, oxygen, durable medical equipment (DME), lab kits, and meals.
    • Refer to HaH Users Group guidance relevant to pharmacy.
  • Enable secure, temperature-controlled deliveries with GPS tracking and escalation protocols supported by AI triage for 24/7 response.
  • Establish vendor service-level agreements (SLAs) for delivery accuracy, timeframe, and quality assurance.

Build comprehensive care pathways that mirror inpatient processes and meet regulatory and quality standards in the home.

• Map home-based workflows from intake through discharge
  • Define tasks within each phase of the patient journey, including triage, monitoring, escalation, and wraparound support.
    • Refer to Section 1: Patient Journey Map.
  •  Confirm the timing, location, and responsible provider for the first in-person patient exam to determine when admission orders and care plans are written and when remote provider consultations begin.
• Create standardized protocols and escalation pathways
  • Use evidence-based care plans for high-volume or high-risk conditions.
  • Define response time expectations with ecosystem partners (e.g., logistics, DME, mobile care teams) within SLAs to coordinate efficient escalation management.
  • Set clear thresholds for when to escalate care or transfer patients back to the hospital.
• Coordinate with brick-and-mortar (BAM) facilities
  • Define joint admission and transfer or discharge criteria with emergency departments (EDs) and inpatient units.
  • Use shared communication workflows and documentation protocols for warm handoffs.
  • Recognize patient movement rate, including all transitions and planned care outside the home, as an operational complexity requiring continuous monitoring and coordination to minimize disruptions.
• Ensure documentation meets CMS Conditions of Participation (CoPs) as needed
  • All clinical records must comply with hospital-level CoPs, even in the home, to participate in Medicare and Medicaid programs.
  • Implement real-time charting, audit trail capture, and compliance with medical necessity and billing standards.

Select patients who are appropriate and match care intensity to their clinical and social risk factors to ensure safety and success.

• Define clear eligibility and screening criteria
  • Screen for diagnosis, clinical stability, home safety, and care partner support.
    • Refer to CMS example inclusion/exclusion criteria.
    • Refer to CMS clinical, diagnostic, and social/environmental criteria. 
    • Refer to HaH Users Group example eligibility forms and processes.
  • Leverage AI to enhance patient identification and eligibility determination with rules-based algorithms.
  • Develop pathways for both direct admission to HaH and timely transition from inpatient care, with referrals facilitated by electronic flags and appropriate checkpoints in the admission process.
• Implement a robust risk stratification model
  • Tailor RPM frequency and visit cadence to patient acuity.
  • Reassess risk regularly and adjust care plans and escalation protocols as needed.
• Incorporate social determinants of health (SDOH), area deprivation index (ADI) and care partner insights
  • Use standardized screening tools from CMS or PRAPARE to identify and action non-clinical risk factors, including SDOH, that may impact patient safety or success at home.
  • Evaluate ADI to inform risk stratification and program expansion to address the unmet needs of additional patients (e.g., meals services, caregiver support).
    • Refer to the ADI Neighborhood Atlas.

Use data to drive continuous improvement, track return on investment (ROI), and support reimbursement conversations. Refer to Section 3: Program evaluation & reimbursement pathways.

• Align measurement strategies with business priorities
  • Compare HaH to traditional inpatient care by measuring program performance, ROI, and cost.
  • Drive payor adoption and promote value-based care integration by demonstrating HaH’s value proposition and alignment with other home-based care models (e.g., SNF-, hospice-, and ED-at-home).
• Monitor key measures to evaluate program value and impact
  • Track clinical, quality, & safety outcomes, access, equity, & experience, cost & resource utilization, and operational performance & efficiency.
  • Use dashboards and conduct weekly reviews to spot trends, resolve delays, and translate impact into value propositions for key stakeholders.
• Build systems for feedback and iteration
  • Engage frontline teams in identifying process gaps and co-developing data-driven solutions.
  • Use root cause analysis for adverse events and escalations to refine clinical workflows and training.

Prepare all team members, including care partners, to deliver safe, high-quality care in the home.

• Implement comprehensive training programs
  • Cover clinical and social assessments, in-home care, DHT usage, documentation workflows, and safety protocols in training programs for staff and care partners.
    • Refer to HaH Users Group guidance relevant to staffing/training.
    • Refer to HaH Users Group guidance on caregiver support.
  • Use simulation-based education for high-risk scenarios like equipment failure or patient deterioration.
• Establish and train staff on service level agreements (SLAs)
  • Collaborate with home health agencies, diagnostics vendors, logistics partners, and meal providers to guarantee consistent quality.
• Enhance cultural competency and communication
  • Provide training focused on respectful, effective communication strategies for diverse patient populations and perspectives.
• Promote ongoing education and skill developmen
  • Set up continuous professional development opportunities for staff focused on emerging technologies, regulations, and evidence-based best practices.
  • Explore continuing education resources for your team, such as AMA Ed Hub.