By Melinda Young
EXECUTIVE SUMMARY
A case management-style hospital-at-home program produced $6 million in savings and cut hospitalizations by 53% in one year.
- More hospitals have adopted hospital-at-home as a model for providing care efficiently and maintaining hospital bed capacity — even during crises.
- Primary care providers and case managers can do even more with this model by providing services that prevent ED visits.
- Instead of taking an ambulance to the ED each time there is a medication problem or symptom flare-up, patients can contact their primary care provider and case management team to receive help directly and quickly.
Hospital-at-home is a growing phenomenon. Case management leaders and programs are poised to take a big role.
Since the pandemic began, hospital-at-home programs have grown and expanded in health systems and communities across the United States. In 2023, more than 100 health systems actively provided hospital-at-home services, and more than 350 organizations were planning on implementing these services.1
The authors of a recent study found that patients who received care under the Acute Hospital Care at Home initiative, from November 2020 through March 2023, recorded a low mortality rate consistent with previous findings of hospital-at-home programs, says Alexx Pons, deputy director of the media relations group at the Centers for Medicare & Medicaid Services (CMS). The study authors also noted that patients experienced minimal complications in instances where they needed to return to the hospital to complete their course of care.
“Hospitals that have an approved waiver under the CMS Acute Hospital Care at Home initiative may continue to offer this care through Dec. 31, 2024,” Pons says. “CMS encourages all hospitals that provide hospital care in the home to continue to focus on patient safety and quality.”
“Hospital-at-home existed in some capacity before the pandemic, but after the pandemic, we saw reimbursement models changing,” says Pouya Afshar, MD, MBA, chief executive officer and co-founder of Presidium Health in San Diego.
Hospitals were attracted to hospital-at-home during the pandemic because of bed capacity issues. Health systems lobbied CMS to find another way to manage patients because they could not keep up with the pandemic surges. “We all saw tents and people waiting to come into the hospital,” Afshar says.
With hospital-at-home, hospitals could triage patients in the ED and then discharge them home if they were stable enough to be cared for in a non-ICU setting. At home, the hospital could provide them with the same services as those they would receive in the hospital.
“They found a way to get providers connected to patients and to send personnel, nurses, and other staff members to provide services at home,” Afshar adds. “This allowed them to create an outlet for the surge they were experiencing during the pandemic.”
It was so popular among patients and healthcare organizations that a grassroots movement formed after a payment model was created through payers’ diagnosis-related groups (DRGs).
“They were able to leverage that same payment model in the home setting, so when patients had the option of hospital at home, they could receive the same payment,” Afshar explains. “It created a lot of interest because it’s a financially viable model, and I would argue it has less overhead than a hospital would need.”
ED-at-Home Is Possible
The next phase could be the expansion of hospital-at-home beyond the ED-to-home model. The current model of hospital-at-home gives ED patients who meet inpatient criteria the option of receiving treatment at home — wherever that is. An alternative option is for a primary care physician (PCP) to bypass the ED, triage the patient, and provide inpatient-at-home services without the ED visit.1
“Say you have a patient who is not doing well at home, and their only option — because primary care providers don’t have the ability to handle acute events — is to land in the ER, where they’re subjected to tests and services in a high-cost and high-risk environment. Then, they’re sent to hospital at home,” Afshar says. “Why couldn’t someone intervene before they get to the hospital? Someone could call a triage line that could handle their call any time of the day or night.”
The providers on the triage line could obtain the patient’s vital signs and determine whether an ED visit is needed or another intervention is possible, such as sending a clinician to the patient’s home.
Fifty years ago, PCPs made home visits and handled nearly all their patients’ medical needs, following them into the hospital when needed. They were comfortable managing patients’ acute conditions. “Now, primary care is divided up into many silos,” Afshar says.
There are PCPs patients see for their annual wellness check, PCPs who handle their chronic diseases, PCPs who work with nursing home patients, and there are hospitalists who handle cases when patients are hospitalized. Because of the siloed nature of patient care, numerous redundancies and inefficiencies arise. For example, when a patient lands in the ED, and the health system has no medical record for that patient, the ED will conduct a big workup.
“If a patient calls their primary care provider, and the provider knows their baseline and common issues, then they have a much better chance of managing those symptoms without ordering all these tests,” Afshar explains.
Ideally, patients’ symptom flare-ups would be handled by the physician who knows them best — their PCP. It would be part of the value-based world that CMS and other health plans are trying to move physicians into.
“In a value-based world, the idea is to empower primary care providers to handle their patient 24 hours a day, seven days a week, with the right infrastructure,” Afshar says. “Those PCPs could participate in a hospital-at-home service with a patient panel. In that scenario, you wouldn’t need high DRG payments; there could be some type of funding that is appropriate and that doesn’t cover the overhead hospitals are trying to cover.”
Socially Complex Patients
In a pilot program with a local Medicaid plan, Presidium Health worked with 93 members with the highest risk and highest cost. Those 93 people had more than 530 hospitalizations and $17.9 million in care costs. The organization took over the 93 patients’ care, using a hospital-at-home model. When the positive results occurred, the organization would receive payment based on its success.1 This is challenging because it forces the provider to cover expenses for more than a year, and claims data are always lagging, Afshar explains.
Until value-based care takes root among payers and health systems, the innovators must foot the bill while waiting for payment after the expected outcomes are achieved. “We need to incentivize primary care providers with the value-based model,” Afshar says. “That takes risk.”
The patients’ issues were socially complex. Whenever they experienced medical issues, they visited the ED for help instead of seeking care at a primary care clinic.
“We were tasked with helping these members, many of whom were homeless, underhoused, dealing with financial issues, food issues, lots of insecurities, and battling medical complexity and social complexity together,” Afshar says. “Over the course of a year, we met with these members wherever they were at. We found them in their houses, homeless shelters, [or] on the streets.”
One patient was even living out of her car, parked in front of a friend’s home. (For more information, see the story in this issue on case studies of patients helped by hospital-at-home team.)
“We gave them 24-hour access to a physician-backed triage line that could answer the phone at any time they called,” Afshar says. “We had information about them — their diagnosis, medications, baseline.”
In some cases, providers gave patients a smartwatch that could check and report their vital signs. Providers could order labs and other services, and they provided hospital-at-home care with a concierge service that helped the top 1% of underserved patients. The result was a 53% reduction in hospitalizations, and the cost of care fell from $17.9 million to $11.9 million in just one year.
“If you invest in primary care providers to do it all — which they have the capability of doing — there’s a huge opportunity, and patients will be more satisfied and thrive better in society,” Afshar notes. “We were responsible for their functioning and provided them with help finding jobs, housing, [and more]. It was 100% case management.”
PCPs like Afshar go to great lengths to help their patients break the ED-to-hospital-to-home-and-repeat cycle. The team of case managers, social workers, legal aides, and social aides, as well as field providers (including PCPs, nurse practitioners, and physician assistants), worked to meet all the patients’ needs. They also coordinated with a behavioral health team, a psychiatrist, and a pain medicine physician who helped with substance use issues. This diverse team was employed to address all 93 patients’ medical, behavioral, and social needs.
“A financial consultant taught them how to save a little money for their future. Some helped them fill out their taxes and go back the last six to seven years to make sure their tax forms were completed,” Afshar says. “Anything we could handle ourselves, we did it, and if we couldn’t handle them, we connected them with community-based organizations.”
Serving the highest-cost and most at-risk patients requires innovation and creativity with access to a wide range of professionals. The concierge service of taking care of their every social need is necessary to cut the high cost of repeated ED visits for care that could be provided in a primary care setting.
“For healthier patients, it’s overkill,” Afshar notes. “But for these patients, it has to be fully integrated with case management, substance use help, and all of that integrated with a primary care team.”
When these groups work together, there are unprecedented outcomes. The pilot project worked so well that the health plan expanded it in 2022 to 1,000 members with a baseline cost of $20 million.
“We’re close to finishing that contract and hopefully will launch this nationally to target the highest-risk patients,” Afshar says. “We can capture these patients before they arrive in the emergency room upstream, and we can render services before they need a higher level of care.”
REFERENCE
- Afshar P. Hospital-at-home: The good, the bad, and the ugly. Pop Health Manag 2023; Oct 13. doi: 10.1089/pop.2023.0211. [Online ahead of print].
A case management-style hospital-at-home program produced $6 million in savings and cut hospitalizations by 53% in one year.
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