Research over the past 15 years has explored the concept of providing a large amount of what is currently hospital based care in the home setting. This has been validated in numerous studies showing cost savings from 30 to 50%. The history of the concept and validation is below.
1995 Dr. John Burton, of Johns Hopkins School of Medicine, and Dr. Donna Regenstreif of The John A Hartford Foundation conceived a new program to provide safe and effective hospital-level care in the home. A geriatric study team led by Dr. Bruce Leff developed medical eligibility criteria and the basic clinical model and designed the study and measurement methodology.
1996-1998 A 17-patient pilot trial showed the Hospital at Home® was feasible, safe, and cost effective.
2000-2002 A National Demonstration and Evaluation Study tested Hospital at Home® in three Medicare managed care organizations and one Veterans Affairs medical center. Hospital at Home® met disease-specific quality standards at rates similar to the acute hospital. The average patient length of stay was shorter, and overall costs were a third lower than an inpatient stay. Patients also had a lower chance of developing delirium, requiring sedatives, or needing chemical restraints. In addition, both patients and family members were more satisfied with care compared to those treated in the hospital, and family member stress was lower. Patients also regained their ability to do usual tasks more quickly.
2002-Present Hospital at Home® is in practice or is being developed at numerous sites throughout the country, including:
Presbyterian Health Services, Albuquerque, NM
Centura Health Systems, Colorado Springs, CO
Cedars Sinai Medical Center, Los Angeles, CA
Veterans Affairs Medical Center, Boise, ID
Veterans Affairs Medical Center, Honolulu, HI
Veterans Affairs Medical Center, New Orleans, LA
Veterans Affairs Medical Center, Philadelphia, PA
Veterans Affairs Medical Center, Portland, OR
Veterans Affairs Medical Center,Cincinnati, OH
2010 A public/private partnership tested a modified model of Hospital at Home®, in which home-based care is provided by nurses, with physician consult via biometrically enhanced two-way telemedicine-video. The new model is also managed by a physician group, instead of a hospital.
2014 Mount Sinai Medical Center, New York, is awarded an Innovation Challenge Grant from the Center for Medicare and Medicaid Innovation (CMMI) at the Center for Medicare and Medicaid Services (CMS) to develop HaH in a fee-for-service Medicare setting and to develop data to inform the future development of a 30-day bundled payment for HaH care.
Using evolving technologies over the past decade, makes the case for hospital care at home even more compelling. The ability to reduce costs 30 to 50% over performing the same services as an inpatient could radically alter the delivery of healthcare. Telemedicine and the technologies for active monitoring of patients has dramatically changed. The ability to monitor blood pressure, heart rate, oxygen saturation, temperature respiratory rate and weight is quite easy. Video communication also allows direct oversight and monitoring of the patient.
The literature dates back to some original work at Johns Hopkins where they termed the process hospital at home care. Annals of Internal Medicine recently published studying the work at partners healthcare at Faulkner Hospital how effective and reasonable this change in healthcare delivery can be. Abstract of the article is below
Ann Intern Med 2019 Dec 17
Patients receiving hospital-level care at home had lower healthcare costs and fewer readmissions than did similar inpatients.
Providing hospital-level acute care for select patients at their homes — hospital-at-home (HaH) — has not been studied in randomized, controlled trials. Investigators at Boston's Brigham and Women's Hospital and Faulkner Hospital (a smaller community hospital in the same healthcare system) randomized 91 emergency department (ED) patients slated for non–intensive care unit hospital admission to receive either traditional inpatient hospital care or acute care at home, which included daily nurse and physician visits, intravenous medications, point-of-care testing, remote monitoring, and video communication. Patients at high risk for clinical deterioration based on validated algorithms were excluded. Approximately 80% of included patients were admitted for infections, heart failure, or chronic obstructive pulmonary disease or asthma exacerbations.
Patients cared for in HaH spent significantly less of their care time sedentary (12% vs. 23%) or lying down (32% vs. 66%), used significantly fewer healthcare resources (e.g., lab orders, radiologic studies, specialty consultations); and were significantly less likely to require readmissions within 30 days (7% vs. 23%). Adjusted cost of HaH — and HaH plus 30-day post–acute care — was about two thirds the cost of traditional hospital care and remained significantly lower even when physician labor costs were incorporated. Length of stay, patient quality and safety measures, and patient satisfaction were similar between the two groups. No HaH patients were transferred back to an acute care hospital.
There is a long list of advantages of hospital care at home and many diagnoses which are amenable to Treatment at home. Bruce Leff, MD one of the founding proponents of this novel approach has stated
“ 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,"
Some of the easiest diagnosis to care for include Conditions with defined treatment protocols, such as congestive heart failure (CHF),
chronic obstructive pulmonary disease (COPD),
community-acquired pneumonia,
asthma and
cellulitis
seizures
deep venous thrombosis
Real-time interaction and visits including obtaining diagnostic lab test and even imaging studies can be performed relatively easily using mobile technology. Additional advantages include the comfort of the patient who buy most patient centered measures would strongly prefer to be in a home setting. In addition reducing the large number of iatrogenic errors in hospital settings is desirable. Medicare attempts to eliminate hospital acquired conditions such as infection, falls, skin breakdown. Home based care will be dramatically reduce these complications.
For-profit entities have entered the marketplace to provide just this type of service and there have been explorations of this type of healthcare delivery across the world including research done In Australia
The data actually further supports improved both patient satisfaction and outcome and the return on investment is substantial for those willing to transition to this model of delivery. The current expenditures out of the Healthcare budget include 30 to 40% spent on hospital based care and savings of up to half $1 trillion could be achieved. With relative facility certain health systems within the United States of actively explored this model of care including the icon school of medicine at Mount Sinai and under alternative payment models this type of care would be highly advantageous A joint venture between Marshfield Health system in Wisconsin and Contessa health in Nashville has also explored this type of alternate delivery system. The three-year study at Mount Sinai demonstrated many benefits
Shorter length of stay (3.2 days vs. 5.5 days
Lower rates of hospital readmissions (8.6% vs. 15.6%)
Lower rates of emergency department visits (5.8% vs. 11.7%)
Fewer transfers to skilled nursing facilities (1.7% vs. 10.4%)
More likely to rate their medical care highly (67.8% vs. 45.6%)
Operationalizing the program is quite straightforward and can be instituted at both an outpatient setting or emergency room. Patients are identified based on diagnosis and strict eligibility criteria. They have their services coordinated with daily clinical visits through nursing, advanced clinical providers or physicians and are provided with monitoring needed for their particular clinical condition Evidence-based clinical care pathways and illness specific care maps and evaluations are used to establish when hospital care at home can be discontinued. Creating the network of mobile or virtual services is easy and can include oxygen, intravenous fluids and medications such as antibiotics, respiratory services and skilled nursing services (PT, OT etc) are all coordinated in the program Even the use of advanced diagnostic imaging such as CT US or MRI can be arranged through transport to an imaging center.
A task list to assess eligibility and care management typically includes the following:
An emergency department or community physician identifies a patient who is sick enough to be hospitalized but stable enough to be treated at home. Narrowly defined eligibility criteria help distinguish patients who need intensive services and/or multiple visits from specialists—and therefore should be treated in hospital settings—from those whose needs may be met at home by visiting physicians, nurses, and other clinical staff. Conditions with defined treatment protocols, such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), community-acquired pneumonia, and cellulitis, are a natural fit.
The suitability of the home is assessed to confirm it has air conditioning, heat, and running water.
Responsibility for care is assigned to a physician.
A greeter meets the patient in the emergency department or elsewhere to discuss the program, arrange transportation, and deliver the biometric and communication devices that will be needed to oversee care.
A caregiver meets the patient at home and a physician—either in person or via video—explains the treatment protocol. Orders are written and clinical staff, including respiratory therapists, physical therapists, and other caregivers arrive as needed to administer intravenous medications and fluids, provide nebulizer treatments, and conduct tests, including ultrasounds, X-rays, and electrocardiograms. Meals are arranged if necessary. The patient's vital signs are monitored electronically.
The physician visits the patient daily, or in some models, communicates with the patient via telemedicine equipment. To capture any decline in the patient's condition when clinicians are off site, providers monitor patient using telemedicine equipment.
Once the patient is stabilized and well enough to return to activities of daily living, he or she is handed off to his or her primary care physician. In one model, providers maintain oversight of the patient for at least 30 days, to ensure he or she is keeping appointments and is not suffering any adverse consequences. During this period, the physician provides updates to the patient's primary care physician.
Creating direct pathways to the patient’s primary care physician oversight and or other dedicated hospitalist equivalent services is straightforward. This setting creates much less stress for the patient and satisfaction surveys uniformly show that it is well received. While those representing the hospital industry may oppose these changes, the higher quality safer more efficient care with better outcomes and satisfaction will prevail especially when adopted by self insured employers.
The late Clayton Christensen espoused the need for disruptive innovation to alter an industry. We see it here and now. Some have pointed to technology as the ultimate solution but the combination of high tech (telemedicine), evidence based protocols, seamless integration and patient centered care all through hospital care at home is very exciting.
For further information see references below or
Please email me at nargy@nicolasargy.com
References:
https://www.commonwealthfund.org/publications/newsletter-article/hospital-home-programs-improve-outcomes-lower-costs-face-resistance
http://www.hospitalathome.org/
https://www.johnshopkinssolutions.com/employers/
https://www.fhi.no/en/publ/2018/Hospital-at-home-as-an-alternative-to-hospital-treatment-Systematic-reference-list/
Copyright NicolasArgy 2020