With hospitals and EDs overwhelmed with patients in many communities, there is growing interest in a concept that provides hospital-level care in the home for certain patients. Such candidates present to the ED and meet criteria for hospitalization with general medicine issues such as exacerbations of chronic conditions or infections.
Through this home care approach, advocates note that patients can avoid healthcare-associated infections and other adverse consequences that have been associated with inpatient care. Meanwhile, facilities can preserve hospital beds and other resources for patients who require intensive care or other services that must be delivered in the hospital. Further, when carried out on a large enough scale, advocates note that such an approach should be able to relieve ED boarding or crowding related to a lack of inpatient beds.
While the hospital-at-home concept comes with numerous challenges, particularly regarding reimbursement, several health systems are demonstrating that the approach can save significant dollars without jeopardizing care quality or safety. Studies show that along with equal or superior outcomes to similar hospitalized patients, such a model can deliver improved patient satisfaction. Now, some health systems with years of experience working with the concept are crafting new ways to leverage the approach.
Foster Collaboration
Emergency clinicians are an integral part of the home hospital program at Brigham and Women’s Hospital in Boston, according to David Levine, MD, MA, an internist and clinical investigator who is leading the program. “This requires very close collaboration with emergency providers because they are the admitting team,” he says.
Given that all appropriate patients are identified for the program in the ED, emergency staff played a significant role in development, particularly enrollment process designs, Levine observes. “We made sure we would be incredibly fast in approaching patients so that we wouldn’t slow down [the ED] workflow and end up creating bottlenecks,” he says. “We also then involved key ED stakeholders in the entire process so that there would be a feeling of collaboration the entire time.”
The program, in effect for about two years, generally targets patients who otherwise would be hospitalized on a general medicine ward. “These are patients who require acute care, but they are not going to crash,” Levine notes. “They are not going to need intensive care and end up in the ICU.”
For instance, patients with pneumonia, heart failure, or complications related to chronic conditions such as diabetes or COPD might be good candidates for the home hospital program. “It’s really the bread and butter of internal medicine,” Levine adds.
Emergency providers triage and examine all patients as usual, Levine observes. First, a resident or physician assistant sees the patient. Then, an attending physician visits the patient. However, the case-finding process begins as soon as patients present to the ED. Nonclinical staff members who have been trained by the home hospital team rely on inclusion and exclusion criteria to identify which patients might be appropriate for the program.
Further, eligible patients must live within a specific geographic area surrounding Brigham and Women’s main campus or Brigham and Women’s Faulkner Hospital, a community facility in Boston that also is participating in the home care program, Levine says. Also, while there are no age requirements, the median age of patients in the program is around 82 years, Levine says.
“We are trying to take care of acutely hospitalized Americans,” Levine says. “We have built a lot of important processes around older adults ... [however], we have 20-year-olds in our program sometimes.”
With the list of potential candidates for the program, a member of the home hospital team will consult with ED team members to hear their opinions on which patients would be a good fit for the program.
“Sometimes, [the emergency clinicians] will call us [with a potential candidate for the program] because we have signs everywhere, including the conditions we treat,” Levine notes. “However, we will often come to them, and our team will facilitate a conversation.”
Following this discussion, both the ED team and the home hospital team will approach patients who both teams have mutually agreed are good candidates for the program. Team members will describe the program to patients and offer the home care option as an alternative to inpatient hospitalization. The option appeals to some patients more than others, some of whom may be hesitant or concerned about receiving acute care at home.
“It is an interesting struggle sometimes to get patients to enroll in the program,” Levine acknowledges. “It really runs the gamut from patients who are cheering with joy after they learn of this opportunity to [patients from whom] we get very much the opposite response, who feel they never could go back home [in their condition].”
Patients who select the home hospital approach are returned to their residences via professional transport in a manner that is tailored to their needs, Levine explains. “Often, a team member will ride with [patients] or meet them at their home,” he says. “The core of the team is a nurse and a physician who will see the patient. Then, we can ratchet up or down the needs of the team based on what the patient needs.”
For instance, the team can bring in a social worker, physical therapist, occupational therapist, home health aide, or other assistant, as needed, during the acute episode, Levine notes. Everyone who goes home is monitored continuously through technology.
“We monitor heart rate, respiratory rate, and telemetry on patients,” Levine says. “We have a set of machine algorithms that are monitoring the data, and when there is a problem in the data, it alarms ... whoever is on call in the home hospital team.”
Further, the home hospital team can visit with patients via video. Patients are always free to communicate with providers via phone and text messaging. “We provide a tablet to patients and a platform for them to communicate with us while they are at home,” Levine adds.
While the program generally serves only about four patients receiving acute care in the home at one time, results from the approach thus far show promise, Levine reports.
“In general, we have shown large reductions in the direct cost of care compared to a control group of patients who stayed in the hospital,” he explains. “We have shown no appreciable differences in the quality of care or the safety of care between patients who go home in our program versus those who stay in the hospital. We have shown improvements in the patient experience [in the home hospital program].”
Levine adds that in one recent study, investigators found that patients in the home hospital program logged fewer readmissions at 30 days than similar patients who were cared for in the hospital.1 However, it is still unclear how public and private payers will handle home hospital approaches, as the concept does not fit neatly into traditional payment models.
Currently, care provided through Brigham and Women’s home hospital program is funded mostly through grants and support from the Partners HealthCare Center for Population Health, which is a group affiliated with Brigham Health. Some insurance reimbursement is available for physician house calls. Nonetheless, buoyed by performance outcomes, Levine notes that the program is in expansion mode. “We are adding lots of new diagnoses and some new technological capabilities,” he says. “We are also working to increase the geography in which we operate.”
While the home hospital program remains a research enterprise, it has evolved into a service line, Levine observes. “A lot of people think of research and operations as two completely separate entities. I would argue that is a very old-fashioned view,” he offers. “I try to position our home hospital work in between both research and operations ... it is definitely both.”
The Mount Sinai Health System in New York City started its own hospital-at-home program in 2014. Since then, the program’s shape and focus have evolved significantly. For instance, the program initially was limited to patients with six conditions clinical leaders determined could be managed safely in the home: community-acquired pneumonia, cellulitis, congestive heart failure, high and low blood sugars for diabetes, deep vein thrombosis, and COPD. However, those parameters have widened in recent years.
“We have definitely increased the number of medical diagnoses that we look for in our EDs,” notes Linda DeCherrie, MD, clinical director of Mount Sinai’s hospital-at-home program and a professor of geriatrics and palliative medicine. “Retrospectively, we have coded in over 59 different DRGs [diagnostic-related groups]. We really look at every patient who comes through our ED at this point in time who meets our insurance and geography criteria to see why they are being admitted and [whether] it is something we could take care of in the home.”
For example, if someone requires care in the ICU or cardiac monitoring, that patient is ruled out from the hospital-at-home approach immediately, DeCherrie notes. “But if they are going to go to a general medicine floor, we are really looking at their case to see if it is something we could offer to them.”
Another change from the early days: Patients referred to observation used to be prime candidates for hospital at home. “Observation is still a source, but I would say we try to go more upstream now and focus much more on our EDs,” DeCherrie notes. “We used to wait to even review charts until after the ED physician had determined the patients required admission. We still absolutely need to make sure the patient meets criteria to be admitted. Now, we follow patients [electronically] from the moment they arrive in the ED.”
Administrative assistants monitor the ED board continuously to see which patients meet insurance and geographic criteria. “Then, from that point, every potentially eligible patient is followed electronically by a clinical person,” DeCherrie says. “One of our nurses, nurse practitioners, or physicians will follow them in the ED if there are reasons they seem appropriate for the program or definitely not appropriate.”
Program developers have found that if one waits until after an emergency physician tells a patient he or she needs to be admitted, it is much harder for patients to conceptualize the idea of receiving care at home, DeCherrie explains. Patients already may have told family that they are going to be admitted and made arrangements for pets or other issues, she says.
Instead, what works better for the program is if the hospital-at-home concept is introduced to patients well before the emergency physician has made a decision on disposition. Typically, program staff will tell appropriate patients that if the emergency physician determines they require admission, they likely will meet the criteria for hospital at home. “Then, patients are generally more interested in doing the program,” DeCherrie says.
DeCherrie adds that as soon as program administrators think a patient is appropriate for receiving acute care in the home, a hospital-at-home physician will visit the ED and talk with the emergency physician. “The emergency physicians are not the ones clinically deciding if someone might be appropriate, but they all have to know about the program,” she says. “We are also making sure that primary care providers [PCPs] in our community know about us. People who are connected to PCPs are going to call [patients] from the ED to tell them they are being admitted [to hospital at home] and ask what they think about it.”
However, training every single emergency physician who works at Mount Sinai’s main campus hospital about the nuances of determining which patients are appropriate for hospital at home is practically impossible, DeCherrie notes. “We have a large group of faculty and a large group of residents,” she says. “Plus, we have residents from multiple other services like medicine and psychiatry, and all sorts of services who all rotate through the ED.”
At some smaller hospitals participating in the program, emergency physicians may play a role in identifying patients who are appropriate for the program. DeCherrie explains that because these providers are part of a much smaller faculty, training them about eligibility criteria and the other intricacies of the program is easier.
Note Benefits, Outcomes
Patients who are enrolled in hospital at home generally receive daily visits by a physician or nurse practitioner. If a patient needs IV medication management, a nurse might visit up to three times daily. “We do some visits via video in the home; that is a newer approach for us,” DeCherrie reports. “We may do the middle-of-the-hospital-course visit as a televisit. A nurse will set it up in the home so the physician can [interact via] video with the patient.”
At the program’s busiest point, when it could receive Medicare fee-for-service patients as part of a Center for Medicare & Medicaid Innovation grant, the hospital-at-home program was admitting 10 to 12 patients every week. There could be as many as 30 patients involved in the program at one time. However, that grant ended in August 2017. Now, the program works with just three payers: Healthfirst, EmblemHealth and Oxford-UnitedHealthcare.
The incentive for insurance participation? It could be that the approach has demonstrated consistently that it can deliver cost savings in the 19-38% range compared to similar patients who have been hospitalized. Further, one recent three-year study of the hospital-at-home model combined with a 30-day transitional care program demonstrated additional benefits. Those benefits included shorter lengths of stay, lower rates of hospital admissions, fewer follow-up ED visits, fewer transfers to skilled nursing facilities, and higher patient satisfaction scores.2
Monitor CMS Changes
Despite positive outcomes from the approach, numerous challenges to the hospital-at-home program remain. Certainly, coming up with a more consistent method of reimbursement is a big issue, although there has been some progress. DeCherrie notes that CMS has approved a proposal for a new payment model in which the government would provide 95% of the DRG to cover a 30-day episode of care, and shared savings based on quality metrics compared to similar hospitalized patients.
“It was approved for everyone in the country, not just for Mount Sinai,” DeCherrie explains. “It was a pretty major thing.”
However, with multiple leadership changes at the Department of Health and Human Services, implementation of the new payment approach has yet to occur, DeCherrie notes. “It was approved last September, and that is where it stands. No information has come to us since then,” she laments. “We think it will be at least another year, if not longer.”
In the meantime, for the insurers that have offered reimbursement for hospital-at-home programs, it has not been easy, DeCherrie notes. “[Insurers] have to fit a program that is providing inpatient care into outpatient rules and regulations,” she says. “They have to process [reimbursements] through an ambulatory, outpatient methodology, which requires insurance companies to make ... infrastructure changes in order to process this.”
Hospitals need to consider patient volume when thinking about starting their own hospital-at-home programs. Administrators have to justify the cost of employing a robust team providing 24-hour care in the home to acutely ill patients.
“Probably somewhere between 200 and 300 patients need to come through every year [to justify] appropriate minimal staffing,” DeCherrie says.
To meet this requirement, Mount Sinai has expanded the reach of the hospital-at-home service line to maintain adequate staffing. For example, the program offers observation care in the home for patients who are only with the program for 24 hours. Also, Mount Sinai provides palliative care at home for patients who otherwise would be hospitalized in the facility’s palliative care unit. In certain cases, Mount Sinai might even provide at-home services for patients who fear hospitals, even if clinicians believe those patients need to be in a medical facility.
“Also a very large, successful part of our program is something called subacute rehabilitation at home,” DeCherrie says. “People don’t want to go to a nursing home for three weeks [following an inpatient hospitalization]. We can provide six days a week of physical therapy, occupational therapy, nursing services, and oversight from a physician ... in their home.”
It is a much higher level of service than a visiting nurse would be able to provide, DeCherrie observes.
“We have diversified our services as one way that we are able to have more robust staffing for our program.”
Another barrier to consider with a hospital-at-home approach: the logistics of delivering the right supplies and equipment into the home at all hours. “Sometimes, I feel like we run a mini-Amazon here,” DeCherrie quips.
Reducing ED crowding was a key goal of Mount Sinai’s hospital-at-home approach. The idea might appeal to other large, academic medical centers that deal with volume-related congestion. However, the approach probably would not be a good fit for hospitals that rely heavily on inpatient admissions for revenue, DeCherrie says. She does note that if medical facilities use value-based contracts, then a hospital-at-home approach might be worth considering.
“One of the first things [interested hospitals] should do is talk to people who are already doing this, and get some help from the outset,” Levine recommends. “Someone who has been doing this can help you figure it out.”
REFERENCES
1. Levine DM, Ouchi K, Blanchfield B, et al. Hospital-level care at home for acutely ill adults: A pilot randomized controlled trial. J Gen Intern Med 2018;33:729-736.
2. Federman AD, Soones T, DeCherrie LV, et al. Association of a bundled hospital-at-home and 30-day postacute transitional care program with clinical outcomes and patient experiences. JAMA Intern Med 2018 Jun 25. doi: 10.1001/jamainternmed.2018.2562. [Epub ahead of print]
With hospitals and EDs overwhelmed with patients in many communities, there is growing interest in a concept that provides hospital-level care in the home for certain patients.
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