Care Redesign
Relentless Reinvention

Why I Believe in Hospital at Home

Article · February 5, 2017

As a medical resident in the late 1980s, I made house calls to homebound older adults in Baltimore. I loved seeing patients and their families in their own space, thinking about their medical issues in that context, relying a bit more on my physical exam than I did in the hospital, and developing care plans consistent with patients’ preferences. I was a trusted guest in patients’ homes — being on their turf gave them power over their care.

When these homebound elderly patients got sick, some flat out refused to go into the hospital — patients with pneumonia or exacerbations of chronic illness, even heart attack or stroke. As one amiable Baltimorean told me, “Doc, you guys are wonderful, but you run a crappy hotel.”

I witnessed that reality when I was on inpatient service: terrible food, schedules driven by providers’ (not patients’) needs, the impossibility of sleep, and maladies galore related to being in the hospital — delirium, falls, functional decline, and so on. In my own practice, I sometimes wonder if hospitalizing a particular patient will confer more harm than benefit.

These experiences prompted us at Johns Hopkins to ask, 20 years ago, “Could acute medical illness that normally requires hospital admission be well managed in a patient’s home instead?” The result was Hospital at Home (HaH) — an option for some patients with community-acquired pneumonia, exacerbations of heart failure or chronic obstructive pulmonary disease, cellulitis, and (recently) other conditions. And HaH is still going strong today.

How Hospital at Home Works

A candidate for HaH is usually identified in the emergency department, where an ED physician deems the patient sick enough to warrant inpatient admission (if HaH were not available). The patient must meet validated clinical-appropriateness criteria for HaH and have housing where care can be provided safely. Common reasons to deem a patient inappropriate for HaH are uncorrectable hypoxemia (low blood concentrations of oxygen) and ischemic chest pain (pain caused by inadequate blood supply to the heart). However, having multiple chronic conditions and living alone are not obstacles to eligibility. Consider this case:

A frail 82-year-old woman who lives with her daughter presents to the ED with increasing shortness of breath. She has a history of dementia, chronic kidney disease, and chronic obstructive pulmonary disease. On examination, she is found to have worsening COPD related to pneumonia.

The ED physician determines that the patient requires hospital admission. She is deemed eligible for HaH, and she and her daughter opt for it. The patient receives her initial dose of intravenous antibiotics and corticosteroids in the ED. The HaH physician in the ED evaluates the patient and mobilizes HaH services — oxygen, respiratory, and infusion therapies, as well as nursing staff. (Resources for these services may come from the hospital, health-system sponsor, or partner vendors.)

The patient is transported home with oxygen by ambulance. An HaH nurse meets the patient at home, provides initial care, and educates the patient and her daughter about the daily routines of HaH. The nurse stays for three to four hours to ensure that all needed services are in place, that the patient is clinically stable, and that she and her family are comfortable with the care. The nurse then communicates the patient’s status to the HaH physician, who acts as a home hospitalist, and a care plan is developed collaboratively.

For the next three days, home visits occur twice daily by the nurse and once daily by the same physician (more often if clinically indicated). The HaH care team is available 24/7 for urgent issues. If needed, blood tests, X-rays, echocardiography, ultrasound, EKGs, and skilled therapies are provided at home. If the patient requires a diagnostic test that cannot be done in the home (a rare occurrence), she is transported to the hospital for the test and returned home. After treatment (which averages 3 days), the patient is “discharged” from HaH, with subsequent care-transition services as needed.

The Data on Hospital at Home

My colleagues and I conducted our earliest pilot study of HaH in 1997, and we subsequently did a multisite demonstration study in several Medicare Advantage plans and a Veterans Affairs medical center. Early experiences showed that, compared with usual hospital care, HaH resulted in fewer complications (e.g., drastic reductions in delirium), greater satisfaction with care for patients and family members, less caregiver stress, better functional outcomes, and lower costs.

Since then, HaH has been one of the most studied innovations in health care. A 2012 meta-analysis of randomized controlled trials of HaH showed a 38% lower 6-month mortality rate for HaH patients than hospitalized patients. Clearly, if HaH were a drug, it would be a blockbuster!

Hospital at Home has been adopted most successfully by systems that have visionary leaders and the will to align the Great Triumvirate of the hospital, the providers (including ED personnel), and the payer. Examples include Presbyterian Health Services in Albuquerque, New Mexico, which has implemented HaH for its Medicare Advantage patients; the VA, which offers HaH at 11 sites; Cedars Sinai Medical Center, in Los Angeles, which uses HaH in its accountable care organization and in managed care; and Geisinger Health System, which will soon launch HaH.

Obstacles and Opportunities

Traditional, hospital-centric clinical workflows can make HaH challenging to implement. For example:

  • Opportunities to activate an HaH admission may be missed if provider partners and associated vendors fail to make their services available in a timely manner.
  • Patients who have waited for a long time in a crowded ED may not be in the mood to opt for HaH when it is offered.
  • Although a patient already admitted to HaH gets 24/7 coverage, no HaH program is yet equipped to first admit a patient at any time of day or night.

Perhaps the greatest barrier to widespread implementation of HaH is the lack of payment mechanism for HaH in fee-for-service Medicare. But there is hope: New York’s Icahn School of Medicine at Mount Sinai is testing HaH, under a CMS Innovation Center challenge grant, to inform a possible 30-day bundled payment model for HaH in fee-for-service Medicare. And the John A. Hartford Foundation is funding a research evaluation.

As the health system shifts to value-based care, HaH will challenge the traditional, facility-based model.  In addition to providing a “virtual hospital unit” for acute admission, it allows hospitals to link HaH to disease-management programs and to hospice- and home-based primary- and palliative-care programs. Along with other home-based care models, HaH can be a versatile platform for creating an alternative to skilled-nursing-facility care after hospital discharge, a complement to early-discharge programs, and an option for post-surgical care. And technological advances, such as biometrically enhanced telehealth modalities, will make HaH more viable.

If you doubt that HaH can be scaled effectively, look to Victoria, Australia. The health authority there decided, in the mid-1990s, to pay for an HaH admission at the same rate as an inpatient admission. HaH blossomed. By 2009, nearly 33,000 annual HaH admissions accounted for 5% of all acute bed days, obviating the need to build a 500-bed hospital. Considering that a hospital bed in the U.S. costs about $2 million to capitalize, HaH can yield a substantial return on investment.

***

As a boy in the late 1960s, I visited an aunt after her cataract surgery at a major New York hospital, where she lay in bed blindfolded for a week. We now take for granted that nearly all cataract surgery is done on an ambulatory basis. Care can move out of the hospital. It’s time to open our eyes, get up, and get moving.

 

This article originally appeared in NEJM Catalyst on December 21, 2015.

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