Home From Hospital
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As hospitals reconsider how and where they deliver care to patients, many are seeing the hospital-at-home model as a promising approach to improve value. Hospital-at-home enable some patients who need acute-level care to receive care in their homes, rather than in a hospital. This care delivery model has been shown to reduce costs, improve outcomes and enhance the patient experience.
Members In Action: Atrium HealthIn response to the COVID-19 pandemic, Atrium launched a two-unit virtual hospital to free up hospital beds for the most complex patients and allow for some COVID-19 patients to recover in their homes, thus limiting community spread and stretching their capacity.
Members In Action: Brigham HealthThrough its home hospital program, Brigham Health patients receive hospital-level care in the comfort of their own homes. Patients in the program experienced fewer clinical interventions, more physical activity and comparable patient satisfaction scores as those being cared for in the hospital. The program has also helped lower costs and readmissions.
Interested in starting a hospital-at-home program? Get practical advice from HaH leaders in this webinar series that covers all aspects of implementing a HaH program. The webinars are part of our partnership with the Hospital at Home Users Group and the American Academy of Home Care Medicine. View the archives or register for upcoming webinars here.
Instituting this type of substitution in the U.S. could produce dramatic savings for the Medicare program and private payers, chiefly by eliminating the fixed costs associated with operating a brick-and-mortar hospital. Indeed, pilots of the model have already achieved savings of 30 percent and more per admission, while delivering equivalent outcomes and fewer complications than traditional hospital care.3 In addition to such savings, at-home care may also help avoid shortages of beds in U.S. hospitals.
The Johns Hopkins Model Johns Hopkins developed its hospital at home program as a means of treating elderly patients who either refused to go the hospital or were at such risk of hospital-acquired infections and other adverse events that physicians kept them at home out of concern for their safety. Early trials of its model (described in the box above) found the total cost of at-home care was 32 percent less than traditional hospital care ($5,081 vs. $7,480), the mean length of stay for patients was shorter by one-third (3.2 days vs. 4.9 days), and the incidence of delirium (among other complications) was dramatically lower (9% vs. 24%).4 One study of the program also found no difference in rates of subsequent use of medical services or readmissions. And patients and family members' satisfaction was higher in the home setting than among those offered usual hospital care, reflecting the convenience of the model.
Payment a Significant Barrier Despite these dramatic results and the refinement of portable imaging equipment and drug delivery systems that facilitate home-based care, the dissemination of the model in the U.S. has been slowed by lack of payer acceptance. By contrast, the state government in Victoria, Australia, reimburses for at-home care at the same rate it reimburses for inpatient care. Without that "hospitals would not be engaged enough to bother," says Michael Montalto, M.D., Ph.D., director of the "Hospital in the Home" program at both Royal Melbourne Hospital and Epworth Hospital. (In Australia, the state derives a financial benefit from reducing or eliminating the need to build new hospitals as demand for acute care increases.)
The Clinically Home model was designed in collaboration with Johns Hopkins (Leff serves as chair of the company's clinical advisory board and the health system has an institutional consulting agreement with the company.) Both the Clinically Home and Johns Hopkins models supply the equipment and staff necessary to manage intravenous lines, perform diagnostic tests, and provide other services in the home and rely heavily on physicians and nurses to manage care. But in the Clinically Home model, physicians do not make house calls. Instead, they engage with patients, as well as nurses and nurse practitioners making home visits, using two-way biometrically enhanced video that enables physicians to see, but not touch, their patients.
This approach introduces some complications. It requires using providers who are comfortable treating patients without face-to-face contact, as well as consistent and continuous communication among team members who operate in a virtual manner. Montalto also points out the lack of a physician presence in the home may inhibit patient confidence. The patients "stay at home through the acute episode because they are confident to do so. I think with no face-to-face [contact with physicians] at all, there are going to be some circumstances in which patients will bail," he says.
Another significant difference between the two models is that in the Clinically Home version, the admission eligibility criteria and protocols that physicians and other caregivers use to ensure care is standardized and safe include approximately 100 diagnostic-related groups (DRGs). Among them are asthma exacerbation, early sepsis, seizure disorders, and gastrointestinal conditions or diseases. Its founders believe that with the expanded list of DRGs, the model has the potential to vastly increase the number of patients treated at home and deliver care at half of traditional hospital costs. The larger savings ensue from eliminating physician house calls. "You really start to leverage economies of scale when you have a doctor who is covering a hospital at home program across wide swathes of geography," Leff says.
Clinically Home has been testing its approach at Advocate Health Care, an integrated delivery system in Oakbrook Terrace, Ill., that participated in a clinical trial of the program at its own expense. That trial focused on a single hospital that was at capacity and whose emergency department frequently had to turn away ambulances. The patients in the program and in the control group suffered from DVT, asthma, pneumonia, CHF, and COPD, among other conditions.
Time constraints are another barrier. Physicians who refer patients to the program must screen them carefully and make arrangements to introduce them to the concept of at-home hospital care. For many, it's simply easier to admit patients. "One of the biggest lessons learned is [that] the engagement of the emergency department physicians is critical because they are the ones who actually have to make the biggest adjustment in their decision making," Powder says.
Montalto still finds this to be a problem, even after 17 years of practice with at-home care. "We still get a lot of people who won't refer patients to us [because they] feel that we are an inferior choice to coming into the hospital." Presenting the program as a seamless hospital unit helps. "It gives them confidence to at least try us," he says. Having 24-hour coverage, presenting details of the program at meetings, and writing papers that demonstrate the effectiveness of the program are also essential, he says.
The chief financial officers (CFOs) of hospitals may also present a challenge, especially those who remain unconvinced that the beds freed by treating patients at home will be filled with patients needing more complex and intensive services. "When you don't have backfill opportunities, it is a little bit harder sell to the CFO of the hospital [that] you are going to walk away from a $10,000 or $12,000 admission," Powder says.
And finally, there are concerns about patient safety and gaming, the latter of which occurred in Australia when some hospitals began referring patients who only needed subacute care to the at-home program. Auditing programs, establishing accreditation programs, and reinforcing inclusion criteria may address these concerns. And with rigorous quality assurance and improvement programs, more providers may consider the model. ""I think it could be an adjuvant to what we are already doing in health care to produce higher value," says John Combes, M.D., senior vice president of the American Hospital Association. Gaining the full support of payers may take more time. Michael Montijo, M.D., president and COO of Clinically Home, says payers will want additional evidence of improvement in quality, reductions in readmission rates and costs, and improved safety. He's confident that will come with additional testing. "Once they feel comfortable with that and put it into their underwriting, the game changes," he says.
Your care team consists of physicians, nurse practitioners, physician assistants, registered nurses, and may include other healthcare professionals such as physical and occupational therapists. We treat and monitor your health. The length of your stay with Home Hospital is determined by your care team. Once you have achieved your care goals and wellness, you are discharged from the program.
Once you enter this program, we will work with your primary care physician and other care members to create a personalized plan and safely transport you out of the hospital setting back at home. Our care team will then work with you to meet your specific needs. That may include lab tests, mobile imagining like X-rays or IV therapy.
During your care, regular check-ups can be done in person at your home or through telehealth. When you are ready to be discharged from the program, we will work with your primary care physician to ensure a smooth transition. If at any time you decide that the program is not the right fit, we can help find a safe alternative. 2b1af7f3a8