- Hospitals that implement home-based acute care realize benefits in costs and outcomes, including mortality, according to the literature.
- A Medicare waiver issued in late 2020 has spurred more health systems to implement home-care programs for acute conditions.
- Processes and cultural issues are among the key considerations when launching a hospital-at-home program.
As hospital-at-home programs increasingly become entrenched in core health system operations, one advocate says the benefits could hardly be clearer.
“This is probably one of the best-studied transformational ways of caring for someone that we have in the peer-reviewed literature,” said David Levine, MD, assistant professor of medicine at Brigham Health and Harvard Medical School.
Although the U.S. healthcare industry has gotten around to evaluating the hospital-at-home model only relatively recently, Levine said, high-quality studies go back “decades” in countries such as Australia and Italy.
Levine helped conduct what he described as the first randomized controlled trial of U.S. home hospital care for acutely ill patients. Published in January 2020 in the Annals of Internal Medicine, Levine’s study showed that costs per episode were 38% lower for home patients compared with a control group of hospital patients.
Utilization was significantly lower for lab tests, imaging studies and consultations, while 30-day readmission rates were 7% for home patients and 23% for the control group.
“We have a really deep, international evidence base for this kind of care model,” Levine said July 28 during a panel discussion that took place as part of the American Hospital Association’s Leadership Summit.
Bruce Leff, MD, professor of medicine with The Johns Hopkins School of Medicine, added that “some studies — not all — have shown important reductions in delirium [and] acute confusional states that may have long-term cognitive effects; [and in] the use of sedative medications, which can have cognitive effects in older adults. Some studies have shown actual better functional outcomes because you're at home and you can move around.”
In addition, he said, some meta-analyses have demonstrated reductions in mortality at six months.
“If we had a drug with that kind of outcome — if hospital-at-home were a drug and not a service delivery model — we would all be sitting on beaches in the Caymans counting our money,” Leff said. “But that’s never been our goal. Our goal has been to improve care delivery.”
Why the model is gaining momentum
In November, CMS announced the availability of an Acute Hospital Care at Home waiver, removing restrictions on treating patients in their homes. The waiver, which is in place for the duration of the COVID-19 public health emergency, makes home-based acute care services available to Medicare beneficiaries following ED visits or inpatient admissions. Hospitals are paid based on the same DRG codes they would use for analogous in-hospital care.
Six organizations, including Brigham and Women’s Hospital, originally were approved for the waiver. Since then, more than 125 have applied and taken steps to establish the infrastructure needed to provide home-based acute care.
“I think we're on the precipice of keeping this sustained in a much larger way,” said Linda DeCherrie, MD, clinical director of Mount Sinai at Home, the home-care program of Mount Sinai Health System, which also was one of the first six organizations to receive waiver approval.
The waiver may alleviate concerns for more organizations about whether revenue from hospital-at-home programs can make up for the associated costs. Before the waiver, Leff said, risk-based payment arrangements such as Medicare Advantage contracts represented the “sweet spot” for funding hospital-at-home programs.
With the influx of participants through the waiver, “You’ve gone from the boutique phase of hospital-at-home into an early-adopter phase,” he said. “And I think if payment is sustained over time, you'll actually see that curve move up quite a bit.”
The question, though, is what happens when the public health emergency ends. Until more is known about the fate of the waiver, Leff said, hospital-at-home programs face the prospect of ending up like “Cinderella at the ball” when the clock strikes midnight.
Getting started with hospital-at-home
Mount Sinai initially implemented hospital-at-home for “bread-and-butter medical admissions to our hospital,” said Albert Siu, MD, director of Mount Sinai at Home, which launched in 2014. The program then expanded to more-complex services such as post-chemotherapy care.
“If you're going to add value to your healthcare system, you really need to substitute [for] something that you would otherwise be bringing into your hospital, and not just supplementing the care for patients whom you might never hospitalize in your system,” Siu said.
Establishing a hospital-at-home program requires investments in clinical and support staff and mobile equipment. What may get overlooked are the requisite policies and procedures.
“When something happens in the middle of the night and somebody has to be called, we need an infrastructure for calls, just as there is somebody available 24/7 in the hospital,” Siu said.
Also important is a single medical record that can be accessed by all team members, including outside vendors who are providing services, he added.
Logistics and coordination likewise should be primary considerations, DeCherrie said.
“It is really challenging to make sure that every one of these vendors delivers things at the right time to the home,” she said. “Many of the vendors are used to working in an ambulatory, outpatient 9-to-5 environment.”
Health systems need to communicate to vendors “that this is a 24/7 operation, and [determine] how they're able to meet those requirements,” she added.
A big cultural shift
“The notion of hospital-at-home is something of a square peg in the round hole of U.S. healthcare delivery,” Leff said. “The element of culture change within a health system that has to happen to bring this along is not trivial. Getting the ED doctor to think beyond the dispositions of [either] upstairs to a hospital bed or home — and thinking about a hospital-at-home unit as a virtual unit of the hospital — those kinds of things are also a fairly important element of the implementation.”
But such a transformation is certainly viable, Levine said.
“It might be a different exercise, but we expend enormous resources on process improvement and making efficiencies and improvements in our hospitals right now,” he said. “And I think a lot of places have what it takes to do it [in the home] with some creativity and some partnerships in the community.”