Medicare believes that treatment for more than 60 different acute conditions can be treated appropriately and safely in home settings with proper monitoring and treatment protocols
Medicare has given a boost to a home-based program that’s closer to inpatient acute care than to traditional home care. In fact, it is acute care, reimbursable at inpatient rates – but it is administered to patients in their homes. And even though the agency’s recent actions are intended to last only for the duration of the COVID public health emergency, proponents of “hospital at home” programs – often referred to as HaH – are hopeful that its impact will be longer-lasting.
In November, the Centers for Medicare & Medicaid Services expanded its previously announced “Hospitals Without Walls” initiative with its Acute Hospital Care At Home program, providing eligible hospitals with more regulatory flexibilities to treat eligible patients in their homes. The agency believes that treatment for more than 60 different acute conditions, such as asthma, congestive heart failure, pneumonia and chronic obstructive pulmonary disease (COPD) care, can be treated appropriately and safely in home settings with proper monitoring and treatment protocols.
Participating hospitals must ensure that a registered nurse evaluate each patient once daily, either in-person or remotely. Two in-person visits by either registered nurses or mobile integrated health paramedics must be made daily. (Prior to the November announcement, hospital-at-home programs were required to provide onsite nursing services 24 hours a day, 7 days a week, and the immediate availability of a registered nurse for care of any patient.)
Participating hospitals must have appropriate screening protocols before care at home begins, to assess both medical and non-medical factors, including working utilities, assessment of physical barriers and screening for domestic violence concerns. Beneficiaries can only be admitted from emergency departments and inpatient hospital beds, and an in-person physician evaluation is required prior to starting care at home.
Remote monitoring can be continuous or intermittent, and the intensity should be appropriate to each patient’s management needs. All patients must have at least two sets of vital signs obtained daily, in-person by clinical team staff.
Hospital-at-home programs have flourished in countries with single-payer health systems, but their use in the U.S. has been limited, according to the Commonwealth Fund. In Victoria, Australia, for example, every metropolitan and regional hospital has a hospital-at-home program, and roughly 6% of all hospital bed-days are provided that way. Nearly 60% of all patients with deep venous thrombosis were treated at home in 2008, as were 25% of all hospital patients admitted for acute cellulitis.
A hospital-at-home pioneer in the United States – Johns Hopkins – reports that compared to similar hospitalized patients, HaH patients experience lower rates of mortality, delirium sedative medication use and restraints. In addition, HaH programs result in:
- Cost savings of 19% to 30% compared to traditional inpatient care.
- Lower average lengths of stay.
- Fewer lab and diagnostic tests compared with similar patients in acute hospital care.
Which patients can benefit most?
As of late January, 38 health systems with 92 hospitals in 24 states were enrolled in CMS’ program. Two of them were Presbyterian Healthcare Services in Albuquerque, New Mexico, and Mount Sinai Health System in New York. Elizabeth De Pirro, M.D., medical director, Presbyterian Medical Group; and Pamela Saenger, M.D., MPH, lead provider at Mount Sinai Hospitalization at Home, spoke at a recent webinar about patient selection, sponsored by the Hospital at Home Users Group.
Presbyterian established its program – Presbyterian Hospital at Home – for its own health plan and Medicare Advantage in 2008, explained De Pirro. The program provides hospital-level care at home for six different diagnoses, and serves patients 18 years old and above, who live within a 25-mile radius of a Presbyterian hospital. She cited a 30-day readmission rate of 5.6%, and a 90-day readmission rate of 6.4%.
Mount Sinai launched its Hospitalization at Home program in 2014 and began admitting COVID-19 patients in May 2020. To date, the HaH team has treated more than 1,100 patients, ages 18 and over. Over 95% of referrals come from the ED or inpatient floor, with a smaller number from the home or clinic. The 30-day readmission rate in the first three quarters of 2020 was 6.3%.
Selecting suitable patients for HaH is a critical first step in the program’s success, said De Pirro and Saenger. It’s incumbent on the HaH team to stay in continual touch with their referral sources, to educate them on the program, they said.
Return on investment
Mass General Brigham in Boston has nearly five years’ experience providing home hospital care. Over the course of the past two to three years, it has offered such care to over 1,000 patients, most often those who present to the ED for acute illnesses that require hospitalization, including infections, heart failure, asthma and other acute conditions.
In December 2019, physicians within Mass General Brigham reported the results of a randomized controlled study of hospital-level care at home for acutely ill adults. The study found that the cost of care was nearly 40% lower for home patients than control patients. Home hospital patients had fewer lab orders, used less imaging and had fewer consultations. The team also found that home hospital patients spent a smaller portion of their day sedentary or lying down, and had 70% lower readmission rates within 30 days than control patients.
Huntsman at Home™ a program of the Huntsman Cancer Institute at the University of Utah, was launched in 2018. Patients who have been referred by their oncologist and who live within a 20-mile radius of the flagship hospital in Salt Lake City may participate. (In July 2020, Huntsman expanded its program into rural Utah, including Carbon, Emery and Grand counties.)
The HaH team is led by Huntsman Cancer Institute nurse practitioners working in conjunction with HCI oncologists, and is operated in partnership with Community Nursing Services, a home health and hospice agency that provides registered nurses. Other cancer care specialists such as social workers and physical therapists contribute to patient care.
In May 2020, Huntsman at Home reported the results of a 14-month study comparing outcomes for 169 cancer patients who participated in the program, and 198 who did not, as they lived outside the service area. During the first 30 days of enrollment, Huntsman at Home patients were 58% less likely to be admitted for an unplanned hospital stay, and those who were admitted to the hospital had a shorter length of stay. Huntsman at Home patients had 48% fewer emergency department visits. They also had 48% lower cumulative charges for clinical services when compared to controls. Results over 90 days were similarly robust.
Speaking at a user group’s webinar about logistics and operations issues in February, Karen Titchener, MS, director of strategic management for Huntsman at Home™, said such programs are “a machine that has to keep flowing.” Daily operations must be fast, responsive and efficient, and patient flow from acute to community must be seamless. There must be good communication within the team, and with staff, patients, oncologists, patient and family, she said.
In addition to the clinical team, HaH programs demand that a day-to-day manager oversee logistics. Huntsman has four cars in the field, each with equipment and supplies for EKGs, bladder scans and IV access, as well as first-dose pharmacy bags. Titchener has found that staff can be expected to make three to five visits in an eight-hour day; four to six visits in a 10-hour day; and six to eight visits in a 12-hour day.
The key to success in the hospital-at-home program lies in flexibility, she said. “Your program will evolve. Don’t write anything in stone. And don’t be afraid to change. You learn from something that didn’t work, and you adapt and move forward.”
Sidebar:
Are your customers ready?
Hospital-at-Home programs call for a great deal of time and commitment. At a recent webinar sponsored by the Hospital at Home Users Group, Elizabeth De Pirro, M.D., medical director, Presbyterian Medical Group in Albuquerque, New Mexico; and Pamela Saenger, M.D., MPH, lead provider at Mount Sinai Hospitalization at Home, New York, listed some of the questions any health system interested in HaH must ask itself:
How intensive is our patient monitoring?
- Can we provide telemetry, continuous vital signs monitoring?
- What is the frequency of touchpoints? In-person vs. telehealth?
- How about after-hours availability – community paramedicine, urgent RN/provider visits?
What are our diagnostic capabilities?
- Which labs can/can’t we perform? How long to result? How frequently can we monitor?
- How quickly can we get new meds to the home?
- Do we have the capability to do EKGs? X-ray? Ultrasound/dopplers? Line placement?
- Are specialist consults possible?
What clinical capabilities and ancillary services can we provide?
- Foleys, wound vacs, tubes & drains, IV pumps, midlines/PICCs?
- Can we deploy physical therapy, occupational therapy, speech/swallow therapy?
- Which DME can we get to the home – and how quickly?
- Who will provide food delivery for patients with access issues?
- Home health aides?
How about social and safety considerations?
- Does the home have any infestations?
- Access to electricity, water and food?
- Substance abuse?
- Are there weapons in the house?
- If there are pets, are they a threat to strangers?
- Can IVs and other equipment be kept clean and safe?
- How about special populations, such as people who are homeless, or who live in a group home or assisted living?