Sentara To Home: Build a Lightweight Ambulatory Acute Care-at-Home Model in Two Weeks
Guest: Dr. Colin Findlay, Associate Chief Medical Officer, Sentara Norfolk General Hospital; Clinical Leader, Sentara To Home Program
Sentara To Home Summary:
Sentara To Home is an ambulatory acute care program originally created as part of the COVID-19 response to rapidly expand hospital capacity using existing system resources. Built in just two weeks, the program combines virtual hospitalist oversight, home health nursing, remote monitoring, and home oxygen to safely transition medically complex patients home earlier in their hospital stay.
Over four years, the model evolved into an acute transition of care program designed to improve clinical outcomes, reduce length of stay, support safer discharges, and lower readmissions. Rather than functioning as a true inpatient substitution hospital-at-home alternative, Sentara To Home emphasizes “hospital-style management” for patients with medical complexity who still need close follow-up after discharge.
The program is lighter-weight and less costly than traditional inpatient-at-home models, enabled by home health billing, ambulatory telehealth visits, flexible visit scheduling, and targeted clinical criteria. It delivers approximately four virtual physician visits over a two-week episode, supported by home health nurses who provide hands-on care and serve as the primary in-home presence.
Sentara To Home has demonstrated meaningful value: earlier discharge, improved transitions, modest reductions in readmissions, and enhanced system capacity without requiring 24/7 command-center infrastructure. As federal Hospital at Home policy remains uncertain, Sentara views its ambulatory strategy as a durable, lower-risk approach that supports ongoing acute care at home.
How did the Sentara To Home program start, and what problem were you trying to solve?
(Timestamp: 00:01:41)
Sentara Health is a 12-hospital system across Virginia and northeast North Carolina. Sentara to Home was born during early COVID as a rapid response to projected bed shortages.
Leadership was modeling a 200% shortfall in hospital beds and realized they had only about two weeks to create additional “hospital-level” capacity without building new physical infrastructure. (00:02:20)
They combined three existing strengths: hospitalists with a growth mindset, an integrated home health division experienced in caring for patients in the home, and remote monitoring plus home oxygen.
The core insight: if they could get a doctor (virtually), a nurse at the bedside, remote monitoring, and oxygen into the home, they could safely manage many COVID patients there instead of inpatient beds.
“We built it and deployed it in two weeks, and enrolled our first patient at the end of April 2020.” (00:04:33)
How did COVID modeling influence the urgency and design of the program?
(Timestamp: 00:02:20)Early projections showed a “really bad” mathematical model for COVID’s impact, with a projected 200% bed shortfall. (00:02:39)
Even though demand never ultimately exceeded capacity, those early projections forced the team to think creatively about redeploying resources instead of building new facilities.
What existing resources did you leverage instead of building new infrastructure?
(Timestamp: 00:03:22)Strong hospitalist teams willing to innovate, an integrated home health division adept at in-home care, partnerships with remote monitoring solutions, and the ability to deliver home oxygen. (00:03:50–00:04:25)
These pieces formed the “foundation of Sentara To Home.” (00:04:25)
Why did you keep Sentara to Home as an ambulatory transition program instead of fully building to the CMS Acute Hospital Care at Home waiver?
(Timestamp: 00:05:00)
By the time CMS released the Acute Hospital Care at Home waiver (late November 2020), Sentara to Home had already been operating for about five months. (00:05:56–00:06:10)
Sentara applied and one hospital became one of the first waiver-approved sites outside the pilot. (00:06:30–00:06:38)
However, the feared COVID surge never materialized as projected, so Sentara didn’t deploy it as a full inpatient-at-home program. Instead, they used it as a transition program: patients were admitted in the hospital and later stepped down to home with oxygen and ongoing monitoring several days earlier than usual. (00:06:54–00:07:26)
The transition experience at home proved powerful: patients could leave an isolating hospital stay 4–7 days earlier, recover at home, and have ongoing communication and reinforcement of discharge instructions. (00:07:26–00:08:15)
A hospital president who herself transitioned home through the program told Colin: “I want every one of my patients to have a transition experience like this.” (00:08:08–00:08:16)
What did you learn about transitions of care from operating as a transition program?
(Timestamp: 00:08:42)Sentara discovered they were not doing transitions as well as they thought. (00:09:02)
Repeated communication over several days at home dramatically improved understanding and adherence.
The program created new value streams: early discharge (1–5 days sooner), better transitions, and improved readmission outcomes due to the ability to escalate care quickly if needed. (00:09:15–00:09:38)
How do you tell the value story of Sentara to Home to the C-suite and other leaders?
(Timestamp: 00:09:44)
Colin emphasizes first understanding the value proposition you’re trying to drive - capacity, outcomes, financial margin, or some combination. (00:10:25–00:10:45)
He distinguishes between inpatient and outpatient/ambulatory models:
Outpatient program value: clinical outcomes, reduced length of stay, improved transitions, lower readmissions, and lighter infrastructure costs. (00:10:45–00:11:22)
It manages a less acutely ill population without 24/7 deployable resources, which makes it cheaper and easier to implement while still creating significant value. (00:11:22–00:11:52)
They also highlight the financial structure: home health bills for nursing, and hospitalists bill telehealth visits, creating revenue rather than pure cost for nursing at home. (00:12:47–00:13:24)
How do outpatient and inpatient care-at-home models differ financially and operationally?
(Timestamp: 00:10:42)Outpatient/ambulatory: lower infrastructure cost, less acute population, easier to implement; value revolves around outcomes and transitions rather than hospital replacement. (00:11:22–00:12:07)
Inpatient: higher fixed cost (command center, 24/7 resources), but potentially greater margin when replacing entire hospital episodes.
“The infrastructure cost for a program like this is substantially smaller… and that makes it… really attractive financially.” (00:11:55–00:12:08)
How have volumes and break-even economics played out?
(Timestamp: 00:12:09)The program ran break-even for several years. Volumes haven’t grown enough recently to maintain that trajectory, but Colin believes systems already running inpatient programs could shift some patients into ambulatory models and achieve good efficiency. (00:12:09–00:12:36; 00:12:78–00:13:18)
Which patients are you targeting, and how does a patient get into Sentara to Home?
(Timestamp: 00:14:04)
The program is focused on transition outcomes. Colin frames transition risk as driven by two factors: medical complexity and social complexity. Sentara To Home primarily targets medical complexity (e.g., complex chronic disease needing “hospital-style management” after discharge). (00:14:29–00:15:11)
Sentara first expanded from COVID to heart failure - discharging once patients transitioned to oral diuretics and continuing daily labs and monitoring at home. (00:15:17–00:15:41; 00:15:58–00:16:10)
Then they extended to respiratory disease and sepsis transitions, seeing particularly strong outcomes for sepsis (shorter length of stay and lower readmissions). (00:16:10–00:16:22)
Today, they focus less on specific diagnoses and more on any patient with medical complexity where a hospitalist-led transition at home could be helpful. (00:16:23–00:17:01)
They actively try not to enroll patients whose primary risk is social complexity, because they don’t yet have the community resources to manage those needs, though many patients do have both medical and social complexity. (00:17:01–00:17:13; 00:17:89–00:17:99)
How do hospitalists feel about discharging patients earlier into this program?
(Timestamp: 00:17:14)Reactions have been mixed, as with any change: some enthusiastic, some reluctant. (00:17:59–00:18:14)
Framing matters: presenting Sentara To Home as “additional resources for your patient to help them be successful” resonates strongly. (00:18:14–00:18:23)
Comfort grew as hospitalists who worked Sentara to Home shifts shared positive experiences with colleagues; most referrals historically come from the hospital where those physicians practice. (00:18:24–00:19:16)
Who else helps identify appropriate patients and drive referrals?
(Timestamp: 00:20:10)Experimented with algorithms based on distance from hospital, primary diagnosis, and payer, but found it “a lot of work for a little reward.” (00:21:03–00:21:27)
Currently, a home health care liaison at Norfolk General is the main entry point: she receives referrals from regional hospitals, evaluates clinical and payer appropriateness, and passes candidates to Sentara To Home physicians for final review and enrollment. (00:21:36–00:22:18)
Transition conversations often surface during multidisciplinary rounds, where ICM/case management or clinical leaders suggest: “Have you thought about Sentara To Home for this patient?” (00:19:51–00:20:09; 00:20:59–00:21:04)
Is enrollment optional for patients, and when would you not add a physician to a home health episode?
(Timestamp: 00:22:52)Enrollment is opt-in; all participants also receive home health, so the program is “home health plus” with a physician in the loop. (00:22:52–00:23:16)
Physician time is a limited resource, so they prioritize the highest-risk, most complex patients; if they don’t believe they can meaningfully help the patient and nurse, they try not to add a physician. (00:23:22–00:23:39)
Nurses can later enroll patients after discharge if they feel they need physician support: “They can also enroll the patient after discharge… and get that support if needed.” (00:23:39–00:23:59)
What does care look like once the patient is home - visit cadence, roles, and episode length?
(Timestamp: 00:24:00)
Visit schedules are flexible and clinician-driven. When COVID volumes were high, patients were often seen daily with same-day starts; now most transitions target a 48-hour start after discharge. (00:24:45–00:25:23)
If a patient is particularly acute, hospitalists can request more aggressive timing (e.g., next-day visits). (00:25:16–00:25:23; 00:25:46–00:25:52)
Not every nursing visit includes a physician; the nurse, patient, and physician jointly decide when both should be present. (00:25:52–00:26:02)
Typical episode: about four physician visits over roughly two weeks, providing a “really nice, protracted transition.” (00:26:02–00:26:18)
All physician visits are virtual; nurses are in the home. (00:26:19–00:26:29)
How do you handle medications, orders, and practical issues once patients are home?
(Timestamp: 00:26:30)The ambulatory model is far less regulated and operationally complex than inpatient hospital-at-home pharmacy workflows.
If doses need to change, they simply send an outpatient prescription to the hospital’s outpatient pharmacy, courier meds to the patient, and bill insurance like any other outpatient script. (00:27:18–00:27:54)
Colin contrasts this with the multi-step, label-heavy inpatient pharmacy workflow and notes, “This is so much less complicated, because it’s so much less regulated.” (00:27:31–00:27:50; 00:28:06–00:28:13)
Why didn’t you build a 24/7 command center, and how do you think about overnight support, scale, and acuity?
(Timestamp: 00:28:19)
The program does provide overnight clinical support, but not via a fully staffed 24/7 command center.
Patients can reach a home health nurse at any hour, and nurses can reach a Sentara to Home hospitalist overnight if they need physician input. (00:29:02–00:29:25)
What they intentionally avoided is the expensive command-center infrastructure that drives much of the cost in inpatient hospital-at-home models. (00:29:25–00:29:36)
Regarding scale, the real question is: how sick a patient are you willing to enroll? With robust inpatient-at-home infrastructure, a system could discharge quite high-acuity patients home once advanced imaging is done and manage much of their stay at home. (00:29:39–00:30:22)
Colin believes an integrated strategy—pairing an ambulatory transition model with an inpatient-at-home program—could aggressively shorten length of stay and get “the best of both” in terms of capacity and safety. (00:30:22–00:30:34; 00:30:45–00:30:48)
What technology and remote monitoring do you use to support an ambulatory acute-care-at-home model?
(Timestamp: 00:31:07)
Colin describes the goal as replicating a med-surg level of care at home. (00:31:26–00:31:31)
Patients receive three-times-daily vital signs. If they don’t enter vitals themselves, nurses call to remind them and ensure data gets into the system via a tablet and connected devices. (00:31:35–00:31:47)
Continuous pulse oximetry is used when clinically indicated; that data streams continuously to the team. (00:31:47–00:31:53)
Monitoring intensity is matched to clinical need—more for higher-risk patients, less for stable ones. (00:31:53–00:31:57; 00:32:15–00:32:16, implied in context)
How does the reimbursement and financial model work for Sentara to Home?
(Timestamp: 00:32:16)
There are two main revenue streams:
Home health billing for nursing and home-based services. (00:32:16–00:32:29)
Telehealth billing for ambulatory physician visits. (00:33:28–00:33:40)
Limitation: Sentara Home Health has contracting gaps with some commercial payers, so not every clinically appropriate patient can be enrolled. (00:32:30–00:33:00)
Hospitalists are paid like for a hospital shift (primarily shift-based pay) and largely payer-agnostic—similar to inpatient work. (00:32:43–00:33:00)
The program depends on continued telehealth waivers, which Colin currently views as more secure than the Hospital at Home waiver but still subject to Congressional decisions. (00:33:40–00:33:48)
What is your staffing model, and how do synchronous vs asynchronous visits affect capacity?
(Timestamp: 00:33:54)
Today, Sentara to Home uses 100% synchronous visits, meaning nurse and physician are virtually present during the same in-home visit. (00:34:05–00:34:15)
Coordinating nurse visit windows with physician Zoom slots is “extremely challenging” and significantly limits how many patients each provider can see. (00:34:15–00:34:41)
Colin believes shifting to asynchronous models—nurse and physician contacting the patient at different times—would safely increase physician capacity. Many inpatient programs already do this. (00:34:41–00:35:01)
He estimates a break-even point at around 15 physician visits per day, similar to inpatient hospitalist productivity. (00:35:01–00:35:21)
How do you coordinate care and prioritize acutely ill patients today?
(Timestamp: 00:35:22)The team uses daily huddles so nurses and physicians can align on priorities and ensure the sickest patients are seen first. (00:35:42–00:36:11)
When they roll out asynchronous visits, there will be mechanisms for clinicians to flag specific patients who still require synchronous, joint visits. (00:35:48–00:36:09)
What outcomes and KPIs do you track, and what have you seen so far?
(Timestamp: 00:36:13)
Operational metrics: Daily census is the primary operational KPI -“How many patients are you serving every day? Are you making sensible use of your investment?” (00:36:38–00:36:51)
Financial metrics: They currently maintain separate P&Ls for nursing and provider sides but plan to move the program into the home health division and unify P&L to better align priorities and growth. (00:37:03–00:37:25)
Clinical metrics: They track hospital length of stay and readmission rates. (00:37:26–00:37:39)
They also track outcomes for a control group of referred patients who did not enroll due to patient choice or payer mismatch. (00:37:39–00:37:56)
Follow-Up Question 1 (rewritten): What impact have you seen on readmissions and length of stay, and how do you present that to leadership?
(Timestamp: 00:38:07)Readmissions: a 3–5% absolute reduction compared with the control group, though Colin wishes it were higher and notes selection bias (referred patients are very high-risk). (00:38:21–00:38:39)
Length of stay: about one day shorter for enrolled patients; Colin believes integrating this with a robust inpatient-at-home program could easily achieve two days of length-of-stay reduction. (00:38:39–00:38:56)
These metrics (plus daily census and financials) are part of the story presented to the C-suite. (00:38:07–00:38:21)
How are you thinking about patient experience and patient-reported outcomes?
(Timestamp: 00:39:08)
Sentara To Home does not yet track patient experience at the program level. (00:39:27–00:39:33)
Their home health division collects patient-experience data as part of routine surveying, but they haven’t built a dedicated patient-experience measurement framework specifically for Sentara to Home. (00:39:32–00:39:47)
Colin agrees this is important and something they’ve discussed but not implemented yet.
What key lessons have you learned, and how do you see the future of ambulatory vs inpatient acute care at home - especially given waiver uncertainty?
(Timestamp: 00:39:54)
Colin’s central lesson: leaders must be crystal clear on the value proposition they’re trying to drive - margin, clinical outcomes, capacity, or some mix. (00:40:21–00:40:39)
He contrasts strategies:
Inpatient program: greatest advantage is financial margin - replacing the entire hospital episode with a lower-cost home-based episode. “If we can get that patient home from the ED and provide the entire episode of care at home, I can do it on a much less costly framework.” (00:40:56–00:41:10)
Ambulatory program: excels at length of stay reduction, improved transitions, and readmission reduction, with lighter infrastructure and lower cost. (00:41:18–00:41:57)
Capacity can be driven by both models, but ambulatory programs focus on the “actual space and the patient’s journey” after discharge. (00:41:18–00:42:03; 00:42:09–00:42:17)
Given the current climate of month-to-month Hospital at Home waiver extensions, Sentara chose to pause building out inpatient-at-home infrastructure until there’s a long-term federal commitment. (00:42:34–00:43:09)
In the meantime, an ambulatory strategy is a “great mechanism to continue providing acute care at home, regardless of the status of the waiver program.” (00:42:41–00:42:56)