The 4 M model
Potential patient reported measures include a return to prior function, receiving enough support to perform self-care during the HaH stay, and effective transitional care education, over sight, and handoffs. Adding to this pragmatically collected patient-centered measures such as deprescribing and sim plifying medication regimens, documentation of an advance care planning or serious illness communication discussion, and emergent transfers could provide a multi layered PCC quality and safety approach all the while minimizing regulatory burdens and expense.
Providing flexibility in how programs provide skilled care while creating limits around the number, timing, amount, and in-person versus virtual care required by skilled clini cians needs balance and careful crafting in order to ensure efficiency, safety, and thus the viability of HaH programs.