Hospital at Home: a Healthcare Revolution?
Providing hospital-level care to patients in their own home is a model that’s here today and advances the triple aim of improved patient experience, improved outcomes and lower costs.
"The sooner patients can be removed from the depressing influence of general hospital life the more rapid their convalescence."
– Charles Mayo
A Silver Lining
One of the few positives of the pandemic has been the rapid creation and acceptance of innovative healthcare technologies and care modalities.
Hospital at home (HaH) programs have been one of the beneficiaries of this, and they show the potential to have a lasting impact on the future of our healthcare system.
The Story So Far
While we may be hearing more about them recently, the first hospital at home program was created in 1994 by Johns Hopkins Medicine. Since then, adoption has been slow, primarily because of a lack of payment models and the unwillingness of CMS to reimburse such programs. Then came COVID-19.
Responding to overwhelmed hospital facilities, the Centers for Medicare & Medicaid Services (CMS) announced the Acute Hospital Care at Home waiver program in November 2020. This paved the way for Medicare to pay for hospital at home care. The initiative launched with six participating healthcare organizations, today there are 83 systems representing 187 hospitals in 34 states on board. There’s enthusiasm for the idea.
Why Do It?
“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm. It is quite necessary, nevertheless, to lay down such a principle.”
– Florence Nightingale
Beyond being depressing places that limit access to loved ones and serve unappealing food, hospitals are dangerous places. One night in a hospital carries a 17.6% risk of healthcare-associated infection (HAI), rising by 1.6% each additional night. In a 2015 CDC survey, about one in 31 inpatients had an HAI at any given time. That’s 687,000 people annually, about 72,000 of whom died. Hospital at home treatment essentially eliminates these risks.
Additionally, during the pandemic, home hospitalization limits exposure of non-COVID patients to those with the disease, and frees up hospital beds for those needing the most acute care.
How Does It Work?
When a patient presents to the Emergency Department (ED), an evaluation team determines if the at-home care would be a good option. Conditions with well-defined treatment plans such as dehydration, chronic obstructive pulmonary disease (COPD), pneumonia, diabetes, cellulitis or congestive heart failure are the best candidates for home admission.
Patients are either sent home from the ED or return home after a brief inpatient stay, usually along with equipment needed to administer treatment (IV infusion, oxygen etc), remotely monitor vital signs and receive telehealth visits.
Nurses—and doctors, either in person or remotely—visit once or more daily, and physical therapists, home health aides, occupational therapists and other staff are available as needed.
How Well Does It Work?
“The power of community to create health is far greater than any physician, clinic or hospital.”
– Mark Hyman, M.D.
Results are impressive.
A study was conducted by David Levine, M.D., MPH, MA, Assistant Professor of Medicine, Brigham and Women's Hospital. It found that home hospitalization yielded one-third as many readmissions and almost halved return ED visits within 30 days. Lab orders decreased on average from 15 to three. Patients at home received imaging in 14% of cases, versus 44% in the hospital. Physical activity is improved, with 32% versus 66% of the day spent lying down.
Presbyterian Healthcare Services (PHS) in New Mexico found HaH especially valuable for older patients. Their program found reduced onset of delirium and risk of falls and infection. They also report a cost reduction of 58% compared to inpatient admission. More than 92% of those offered at-home care take it, according to a 2016 case study.
Allowing patients to recover in their own home, surrounded by family, eating familiar food and sleeping in their own bed is obviously an improved care experience. The PHS program patient satisfaction score is 99%.
Where Do We Go From Here?
“A hospital is no place to be sick.”
– Samuel Goldwyn
While it’s early days since the pandemic gave the hospital at home concept a booster shot, there’s a lot of understandable excitement about it.
Analysts at Forrester predict that HaH providers will triple in 2022. Major health systems such as Mayo Clinic, Kaiser Permanente and UnityPoint Health have already expanded their programs.
One potential roadblock to be navigated is the payment model. The Acute Hospital Care at Home waiver has shown CMS support and allowed programs to flourish, but there are no guarantees post-pandemic. And while most insurers won’t pay for hospital at home, that could be changing. Humana has partnered with at-home services company DispatchHealth to offer acute care to 8.4 million Medicare patients nationally.
Essentially a single payer for their own population, the Veterans Administration has implemented programs without payment issues. Similarly, health systems running their own insurance plans can circumvent the payment problem
On the legislation side, there are powerful forces aligning to create change. Moving Health Home is an alliance formed to encourage state and federal legislation that would allow hospital at home programs to continue to thrive post-COVID. Members include Ascension, Amazon Care, and Intermountain Healthcare.
The future looks bright. With programs solidly advancing the triple aim, hospital at home is good for healthcare and good for patients.
As Dr. Gary Call, Chief Medical Officer at Gainwell Technologies said:
“These programs solve so many problems that it’s hard to imagine that they won’t be part of the caregiver’s toolkit going forward. An alignment of technology and need that lowers costs and improves both outcomes and patient experience is incredibly compelling.
I think we’re seeing the beginning of a shift that will fundamentally change the future of healthcare for the better.”