Image by Getty Images
Image by Getty Images

Bringing the hospital home

Pilot projects are providing inpatient-level care in patients' homes.

Once more concept than reality, treatment of patients sick enough to be admitted at home instead of in the hospital has gained some traction, fueled by improved technology, evidence of cost-effectiveness, and full hospitals.

Several recent U.S. studies, including a randomized analysis, have found that home-based hospital treatment of some lower-acuity patients is not only more cost-effective but can show other benefits, such as increased mobility. One such program, initially launched by Mount Sinai Health System in New York with funding from a CMS Health Care Innovation Award, has led to the proposal of a new home hospitalization payment mechanism, though federal officials have raised some concerns about its current design.

In the spring of 2019, the first World Hospital at Home Congress was held in Madrid, drawing more than 400 attendees from 40 countries, more than had been anticipated, according to organizers. In the wake of that conference, a North American users group has been created to work on issues related to implementation, program standards, reimbursement, and other challenges.

Bruce Leff, MD, FACP, who developed the Hospital at Home model at Johns Hopkins in Baltimore more than two decades ago, described the surge in interest over the last 18 months as “really exponential” based on the questions and calls he's fielding from hospital systems and other health entities.

“I think that there's a growing feeling that we just can't keep doing business the way that we are doing it and keep building buildings,” said Dr. Leff, a professor of medicine at Johns Hopkins University School of Medicine. “The culture is starting to shift and I think the expansion of the capability of telehealth and telemedicine are making these models a bit more feasible and scalable.”

Mount Sinai, after its successful pilot, is working to pursue contracts with commercial payers. In late 2019, Pittsburgh-based Highmark Health, a Blue Cross and Blue Shield-affiliated payer/provider, announced that it would begin to offer home-based care, starting in western Pennsylvania.

But Dr. Leff and other proponents are quick to note that hurdles persist, with reliable reimbursement the most pressing.

While the Physician-Focused Payment Model Technical Advisory Committee, which advises the Department of Health and Human Services (HHS), supported Mount Sinai's recommendation for a payment mechanism for home-based hospital care, HHS officials have been more equivocal. They expressed interest in June 2018, but said that there needed to be additional measures to protect patient safety and avoid misaligned financial incentives given that home-based care is likely less costly.

Moreover, there are numerous regulatory and other practical logistics of recreating a hospital environment in a patient's home. Albert Siu, MD, who directs Mount Sinai at Home, noted that it's easier to get a pizza delivered after midnight in New York City than to get oxygen to someone's home outside of business hours.

Another sizable hurdle to wider implementation is overcoming negative perceptions, said Bruce Kinosian, MD, FACP, an associate professor of medicine at the University of Pennsylvania's Perelman School of Medicine and a staff physician at the VA Medical Center in Philadelphia, where he works in that facility's home hospitalization program. “Providers who make decisions about where patients go,” he said, “think that patients are safer in the hospital than at home.”

Assessing cost-effectiveness

The recent randomized study, published online Dec. 17, 2019, by Annals of Internal Medicine, found that the average cost of home-based hospital care was 38% lower than that for inpatient controls. The 43 patients in home-based care got fewer lab tests, imaging studies, and consultations compared with the 48 hospitalized patients. Their length of stay was somewhat longer, averaging 4.5 days versus 3.8 days for hospitalized patients, but their 30-day readmission rate was much lower: 7% versus 23%. (Length of stay was measured from admission to care at home after an ED visit to discharge from home hospital care.)

The patients, who wore sensors, also were more mobile when treated at home. They spent only a median of 18% of each day lying down versus 55% when hospitalized. David Levine, MD, the study's lead author, credits the more enticing home environment. “It's not enjoyable to walk out to the nursing station and listen to the alarms buzzing, versus you might enjoy walking out to your family room to sit in a nicely lit area,” said Dr. Levine, an assistant professor of medicine at Harvard Medical School and Brigham and Women's Hospital in Boston, where he directs the Home Hospital program.

Despite the difference in activity, decline in functional status was similar between the two groups, which surprised Dr. Levine. One possibility is that the way functional status is measured is not nuanced enough to catch differences, he said. Another factor might be that physicians ordered less physical and occupational therapy for the home-based patients, which might have undercut the benefits of greater physical mobility.

Dr. Levine and the other authors noted that their study was not large enough to definitively prove at-home care's safety, one of the primary concerns raised in by HHS officials. (In its favorable recommendation, the advisory committee also cited patient safety concerns, suggesting steps such as external monitoring for adverse events.)

Among the 91 study patients, four treated at home and seven in the hospital had a safety event, some of which included delirium as well as a few deaths within the first 30 days after discharge.

But the benefits of the home-based hospital care were notable enough that leaders at Brigham and Women's halted the study early so the option could be offered to more eligible patients at the two hospitals involved.

Another recent study, which was published in the August 2018 JAMA Internal Medicine and reported Mount Sinai's findings from its CMS-funded pilot, reflected some similar advantages for home-based care.

That observational analysis, which compared outcomes from 507 patients in two groups, determined that the length of stay was shorter—3.2 days versus 5.5 days—for patients treated at home. Plus, their 30-day readmission rate was roughly half that of the hospitalized group (8.6% vs. 15.6%).

These sorts of findings don't surprise Dr. Leff, who pointed out that geriatricians have long understood the risks of a hospital stay, particularly for older and frail individuals. It can be a dilemma, he said, whether to hospitalize an already vulnerable patient who is struggling with pneumonia or worsening heart failure.

While those conditions will be treated, he said, “Will they get delirium and then get demented? Will they fall down? Will they get C. diff in the hospital?” Systematicreviews of randomized controlled trials of comparing care at home or in the hospital have shown reductions in six-month mortality among the patients treated at home, he noted.

Before a Medicare payment mechanism is set, though, HHS officials have recommended that additional safeguards be implemented, such as “establishing accountability for adverse events” and “ensuring proper clinical safeguards so only appropriate patients would be eligible.”

Dr. Levine said that there is already a built-in guard rail to discourage health systems from steering patients to home-based hospital care. “The problem is that it's not going to be good business for a hospital to move a patient home if they really needed to be in the hospital,” he said. “Because [if] push comes to shove, they're probably going to end up back in the hospital if they truly are too ill,” impacting metrics such as readmissions, he said.

Percolating interest

In the U.S., this model got an early start in the Veterans Affairs system; Dr. Kinosian said there are 11 VA facilities providing some home-based hospital care. But more commercial payers and health entities are expressing interest, according to Dr. Siu and other proponents.

In late 2019, Highmark Health started offering the option first to its privately insured patients seeking care through the ED at Allegheny General Hospital—part of its integrated health system—and it's now available to Medicare Advantage patients there. Highmark Health's venture with Nashville-based Contessa, called AHN Home Recovery Care LLC, will next expand to other hospitals in the Allegheny Health Network, said Monique Reese, DNP, a nurse practitioner and senior vice president of home and community care.

Similar to other programs' approach, the home care option will be limited to more chronic or lower-acuity medical issues, such as an exacerbation of chronic obstructive pulmonary disease or cellulitis or a urinary tract infection requiring IV antibiotics, Dr. Reese said. Along with an in-home visit daily with a registered nurse, patients will be seen daily by a hospitalist and recovery care coordinator via telemedicine, she said. A nurse practitioner or doctor will visit the home as needed, such as if there are new or worsening symptoms, she said.

Medically Home, a Boston-based company that launched several years ago, also relies on hospitalists to provide virtual care at home through a central medical command center, after the patient has been evaluated and admitted by a physician, most frequently from the ED.

The company's approach is to train nurse practitioners and community paramedics to provide and coordinate care in the home, including performing a physical exam with the assistance of a hospitalist video consulting from the command center, supported by a software platform that integrates biometric data and manages a complex supply network, said Pippa Shulman, DO, Medically Home's chief medical officer. If the patient's condition changes, a paramedic would be sent to consult with the physician by video or phone, she said.

As of mid-January, Medically Home had already contracted with two physician groups and was in the process of contracting with four health systems, she said.

“Where we get a lot of interest is from hospitals where on any given day they have more patients waiting in the ED than they have or will have beds available,” Dr. Shulman said. “What that forces them to do is to delay elective procedures, such as surgeries, and creates a real financial problem for the hospital.”

If some of those lower-acuity patients who are interested are treated at home instead, she said, “that allows the hospitals to actually have beds for what hospitals do best.”

Looking forward

If home-based care does take hold, how will hospitalists fit in? Dr. Kinosian sees a clear role for them, saying that home-based care could provide “a whole new venue in which to work.” For instance, a hospitalist service could decide to open up a home-based care program in order to free up bed space, and then a hospitalist could be hired to round on those patients, he said.

Paul Wallace, MD, a hospitalist at Philadelphia's Penn Presbyterian Medical Center, has accompanied Dr. Kinosian on some home-based visits with VA patients and is intrigued. He's exploring starting a pilot program at Penn Presbyterian. “After being a hospitalist for 20 years, I'm very acutely aware of the harms and burdens of hospitalization for elder folks in terms of deconditioning and delirium,” he said.

If reimbursement comes through, technology and other advances will make home-based hospital care only more feasible in years to come, Dr. Leff said. “I am certain that in the future I will be making a hospital-at-home visit, and I will want to change an antibiotic on someone,” he said. “And I will walk outside the front door and a drone will drop that off to me.”

Neither is the model inherently limited to lower-acuity patients, said Dr. Leff, who has done some advising for Medically Home. That company is already in discussions with some hospital systems about the possibility of transferring patients from the ICU to home rather a general medical-surgical ward, Dr. Shulman said.

“As confidence in the model improves and as tech gets better and the ability to monitor patients gets a bit better,” Dr. Leff said, “you can actually take care of sicker and sicker patients at home, again hopefully with better health outcomes, which we've seen so far.”