“These programs continue to gain traction because they have been shown to be effective in reducing complications while cutting the cost of care by 20% or more, with many programs showing higher satisfaction ratings among patients, providers and family caregivers,” Stack said. “It’s truly patient-centered care. And it’s made possible through advances in telemedicine, remote monitoring and the ability to set up safe alternative care settings outside a traditional hospital’s four walls.”
Beyond CMS’s waiver
Both DeCherrie and Dalton stressed that the hospital-at-home model is not new. “It’s been here in the United States for close to probably 20 years now, and it has seen widespread use in Europe and Australia for even longer,” Dalton said. “We're starting to see it accelerate here, too, and just as with virtual visits, I don't think there's any going back for the hospital-at-home model, and not just because patients will want it. There has been a groundswell of health systems participating in the program.”
DeCherrie’s organization, Mount Sinai, was well on its way to developing a hospital-at-home program before CMS announced its waiver. They already had obtained Medicare Advantage, commercial and managed Medicaid insurance contracts prior to the pandemic.
And insurers were receptive to the idea.
“When you go to a meeting with the health insurer and you are talking with its medical directors, they often get it right away,” DeCherrie said. “They can see the data — really good outcomes and patients are satisfied — and they're excited. And then you tell the CFOs, you're going to do a discount, and they say, ‘That sounds great.’ So those two folks are very excited.
“Then you get the operations people in, and start asking, ‘How are we going to do this?’ That's where it gets complicated because there are different ways to approach it. We do 30-day bundles of care.”
For Medicare fee-for-service, patients always start out in the hospital, DeCherrie noted. Patients can be admitted directly from the emergency department (ED), or they might stay a night or two in the hospital, because they're too sick to go right home, and then finish the last couple of days at home.
“That’s what’s required for Medicare,” DeCherrie said. “But for our Medicare Advantage bundles, we sometimes can admit patients directly from an office under particular circumstances.”
Program setup and expectations
Starting a hospital-at-home program is challenging because it must be up and running around the clock from the very start.
“This is hospital-level care,” DeCherrie said. “It's not like a doctor who's starting a new program for outpatients, who will add another half day a week of doing something, and then not be available the rest of the week.
The doctors need to be 24/7 on call. And you need to have emergency services that can go to the home lined up 24/7 at the very start. Then, you might only admit one patient in the first week.”
Although Mount Sinai set up quickly during the pandemic, it also is continually reevaluating the program’s actual cost. “Clearly, there is an upfront cost,” DeCherrie said. “But if you think it through and look at what kind of patients you have, which insurance and your geography, you should have all that data you need to accurately predict what it will look like and when you might be able to recoup.”