The concept of hospital at home may have flourished during the COVID-19 pandemic, but it also will be a possible post-pandemic model for care.
“Hospital at home offers the ability to be much more agile and deliver the care patients need,” says David M. Levine, MD, MPH, MA, assistant professor of medicine at Harvard Medical School and medical director for strategy and innovation for Brigham and Women’s Home Hospital. “I think, in the next five to 10 years, we’ll see a major shift toward the home. The genie is out of the bottle — inpatient care has massive costs.”
The program is especially useful at night, when it can be difficult for hospitals to maintain staffing. “Hospital at home does not require the same staffing levels as the hospital for monitoring patients,” Levine says. “It works with wireless systems and response teams that could be at the home if needed.”
Before the pandemic, there was little appetite or institutional readiness for managing patients at home, says Alyssa Millan, MPH, senior manager of health innovation at Southern California Permanente Medical Group.
“The pandemic immediately pushed our providers and clinical care team to learn and become comfortable with managing patients in the home,” Millan says.
As hospital at home programs evolve, different models will emerge. “What the chronic patient needs is different from what an acute, post-episodic hospital patient needs,” Millan explains. “The way we design the home programs will look different, but the infrastructures and systems will need to be the same.”
Expanding the program during the pandemic helped build trust in the technology and clinical accuracy of remotely received data. One early issue was integrating technology in patients’ homes. Sometimes, the hardware and software did not connect well with one another, says Earl Quijada, MD, FACP, a physician in geriatric, palliative, and continuing care at Southern California Permanente Medical Group.
“We took off the Bluetooth-enabled devices and made it manual,” Quijada explains.
Eliminating Bluetooth technology made it simpler. Also, program leaders decided to not clean and inventory returned equipment, as had happened with home hospital devices before the pandemic. (See story on how hospital at home worked in the pandemic in this issue.)
As the healthcare economy evolves in the United States, hospitals must be creative, particularly when faced with economic and staffing constraints. For example, CMS issued a hospital waiver to make hospital at home and telemedicine programs economically sustainable. This is temporary, but may become permanent.
“If the waiver ends, it will be a huge blow to hospitals if they can’t continue the hospital at home program,” Levine says.
For health systems operating under value-based, capitated financial arrangements, hospital at home is efficient and economically sensible. If made permanent, Medicare could enable hospitals to develop long-term hospital at home programs.
Before the pandemic, few health systems used these programs for acute care patients. “This home hospital program has enabled us to create an alternative setting of care for our patients,” says Dan Huynh, MD, regional assistant medical director and regional hospitalist for the Southern California Permanente Medical Group. “For Southern California, we have eight medical centers with hospital at home.”
Monitoring vital signs of at-home patients enhances care delivery, making it possible to manage patient care in their home setting. “Remote monitoring will enable management of heart failure and diabetes and glucose levels, and it sets the foundation that we’ll continue to build in KP Care at Home, from very high acuity to disease management,” Huynh explains.
In the past, remote monitoring was used more sparingly. “Remote monitoring prior to the pandemic was used for chronic conditions, like high blood pressure and diabetes,” Quijada notes. “What we’re learning from the pandemic is remote monitoring can be used for acute conditions like COPD, congestive heart failure, and COVID.”
Patients can be remotely monitored for their vital signs, glucose levels, and receive help with chronic disease management.
“Technology is going to expand the potential to take care of patients at home instead of a hospital or nursing home,” Quijada says. “Technology will help us with care coordination, which will be huge.”
To achieve a true hospital in the home experience, care coordination must occur between physicians, nurses, pharmacy, durable medical equipment, physical therapy, social workers, diagnostics, and case managers.
“The traditional settings we are used to thinking about are the hospital and skilled nursing facility [SNF] or subacute care,” Huynh says. “But when you survey patients, they’d much rather be at home. We want to bring care to where the patient is.”
Over the past five years, the program has brought a 50% decrease in the census of patients sent from the hospital to SNFs. “We have the ability to send a physician to the home, if need be,” Huynh adds. “We have nurses who can come to the home daily, and we have the ability to draw blood or do imaging in the home.”
Many patients prefer to be home, eating their own food, sleeping in their own beds, and walking around in their own houses. “They walk more and have more mobility when they’re in their home,” Huynh says. There also is less risk of infections from patients or healthcare professionals.
Shifting patients to the home setting worked well during the COVID-19 pandemic. “Across the country, hospitals were overwhelmed, and given the numbers and volume we had in Southern California, there’s no question we would have been completely overwhelmed and out of beds without this program,” Huynh says. “At the peak of the third surge, we were managing 1,600 patients across Southern California, per day. If we had kept them in a hospital, we wouldn’t have had enough hospital beds, so the program showed its value with improving bed capacity and reducing COVID-19 exposure of patients and staff.”
The integrated model pulled together staff quickly as the need increased for remote monitoring and sending patients home.
“For us, it was very seamless,” Huynh says. “We pulled teams together from nurses in the ambulatory setting to hospital staff to physicians to specialists.”
A central command center connects patients to the clinician they need across various hospitals.
“As we shift more and more care to the home, we’re leveraging technology and our ability to build this program to provide an alternative setting for patients,” Huynh says. “Soon, we’ll see there will be more and more patients shifted to the home, including more acute care patients sent to the home, and more disease management in the home.”
REFERENCE
- Huynh DN, Millan A, Quijada E, et al. Description and early results of the Kaiser Permanente Southern California COVID-19 Home Monitoring Program. Perm J 2021;25:20.281.
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