Looking at the Absolute Win-Win of the Hospital-at-Home Model

Jan. 29, 2021
The growth of participation in the Acute Hospital Care at Home program speaks to an opportunity that the incoming CMS Administrator should not fail to take advantage of in order to score a win-win for all stakeholders

As Healthcare Innovation Senior Editor David Raths reported on Jan. 26, “The number of hospitals taking advantage of regulatory flexibility to provide acute hospital services in the home continues to grow. According to a Centers for Medicare & Medicaid Services web page, the program has grown to include 92 hospitals in 24 states. To take pressure off hospitals during the surging pandemic,” he wrote, “the Centers for Medicare & Medicaid Services (CMS) announced in November several steps to increase the capacity of healthcare systems to provide care outside a traditional hospital setting, including in the home. The Acute Hospital Care at Home program is an expansion of the CMS Hospital Without Walls initiative launched in March 2020 as a part of a comprehensive effort to increase hospital capacity, maximize resources, and combat COVID-19 to keep Americans safe. This program creates additional flexibility that allows for certain healthcare services to be provided outside of a traditional hospital setting and within a patient’s home.”

The Acute Hospital care at Home program is not without boundaries. It involves several key requirements:

> Having appropriate screening protocols in place before care at home begins to assess both medical and non-medical factors;

>  Having a physician or advanced practice provider evaluate each patient daily either in-person or remotely;

>  Having a registered nurse evaluate each patient once daily either in-person or remotely;

>  Having two in-person visits daily by either registered nurses or mobile integrated health paramedics based on the patient’s nursing plan and hospital policies;

>  Having the capability of immediate, on-demand remote audio connection with an Acute Hospital Care at Home team member who can immediately connect either an R.N. or M.D. to the patient;

> Having the ability to respond to a decompensating patient within 30 minutes;

>  Tracking several patient safety metrics with weekly or monthly reporting, depending on the hospital’s prior experience level;

>  Establishing a local safety committee to review patient safety data;

>  Using an accepted patient leveling process to ensure that only patients requiring an acute level of care are treated; and

>  Providing or contracting for other services required during an inpatient hospitalization.

Still, even with those rigorous requirements in place, hospital and health system leaders are responding to the call, and taking advantage of an important opportunity—an opportunity for certain types of patients for whom the healthcare delivery system can effectively care for them better at home, thus improving their individual experiences, as well as conserving on expensive health system resources and improving clinical outcomes all at the same time.

Back in December, David Levin, M.D., M.P.H, who leads Brigham and Women’s Hospital’s hospital-at-home program, one of the 90, spoke with Raths about the logic behind the concept. As Raths reported on Dec. 21, “Levine, assistant professor of medicine and medical director of strategy and innovation for Brigham Health Home Hospital, said Brigham has been gradually building its program over the past several years, including doing research on its impact. It has grown into a full service line that helps the hospital with capacity issues. “We cared for nearly 80 patients during the first surge of the pandemic with Home Hospital, which meant a lot during that time,” he said. “We continue growing our program now. This CMS waiver is an amazing opportunity for Americans to get care in their homes. We have shown through randomized controlled trials  that the care is better, the outcomes are better and readmission rates are lower.”

The challenge, Dr. Levine told Raths, is that the waiver program is only authorized through the end of the current public health emergency. “Once the public health emergency is over, technically all these things can go away,” he said. Still, it’s anticipated that CMS will be developing a more permanent program. Per that, Levine said, “It is not clear if or when that would happen or what would be in that final rule or what requires more statutory work. I do think there is a concern. Why should institutions that have never dabbled in acute care at home invest in the program if in six months we are out of the public health emergency and they can no longer engage in that kind of work?”

Significantly, as Raths noted in his Dec. 21 report, “Levine’s team has published results of a randomized controlled trial in the Annals of Internal Medicine. The research demonstrated that home hospital care can decrease healthcare costs by nearly 40 percent compared with usual hospital care. In addition, only 7 percent of home hospital patients were readmitted within 30 days compared with 23 percent of inpatients. Among the factors that led to decreased cost were reductions in lab and imaging orders and fewer consultations,” Levine noted, telling Raths that “Another big factor is labor. Most patients don’t need anything at night, but the hospital setup is not agile enough to change the work force, so patients have a nurse outside their door checking on them all night.  With home hospital, there are reductions in utilization and labor facilitated by technology and monitoring patients continuously.” What’s more, “Levine posits that the reduction in readmissions could be because patients at home are more ambulatory and because the care is more tailored to their particular needs and family caregivers. “If home hospital were a drug, everyone would buy it. Right? In heart failure, if a drug reduces readmission rates by a percent, everyone buys it. This is over a 60 percent relative reduction. It has been shown over and over again in home hospital studies.”

Writing about the hospital-at-home programs in a report sponsored by the Commonwealth Fund, Sarah Klein wrote recently that “Such programs are well established in England, Canada, Israel, and other countries where payment policies encourage—or at least do not discourage—the provision of health care services in less costly venues. In Victoria, Australia, for example, every metropolitan and regional hospital has a hospital at home program, and roughly 6 percent of all hospital bed-days are provided that way. For specific conditions, the use of at-home care is significantly greater: nearly 60 percent of all patients with deep venous thrombosis (DVT) were treated at home in 2008, as were 25 percent of all hospital patients admitted for acute cellulitis.”

Indeed, Klein wrote that “Instituting this type of substitution in the U.S. could produce dramatic savings for the Medicare program and private payers, chiefly by eliminating the fixed costs associated with operating a brick-and-mortar hospital. Indeed, pilots of the model have already achieved savings of 30 percent and more per admission, while delivering equivalent outcomes and fewer complications than traditional hospital care. In addition to such savings, at-home care may also help avoid shortages of beds in U.S. hospitals.”

And that gets to the nub of this issue, at least in part. So here we have a new-ish model of care that could prove to be highly effective beyond the current national health emergency—and numerous patient care organizations are proving its effectiveness and its efficacy. But permanentizing any of this will require action on the part of Congress, and fairly significant regulatory change on the part of senior federal officials at CMS.

Of course, we are already in a very strange moment, as we’re still waiting for the U.S. Senate to approve the nomination of Xavier Becerra as Secretary of Health and Human Services, before Becerra can contribute to choosing the new CMS Administrator. So the resolution of this policy question will not be immediate.

But if ever there were a win-win proposition in the area of healthcare delivery innovation, it’s this model. As Klein noted in her report, just to take one example, that of Johns Hopkins Health System in Baltimore, “Johns Hopkins developed its hospital at home program as a means of treating elderly patients who either refused to go the hospital or were at such risk of hospital-acquired infections and other adverse events that physicians kept them at home out of concern for their safety. Early trials of its model (described in the box above) found the total cost of at-home care was 32 percent less than traditional hospital care ($5,081 vs. $7,480), the mean length of stay for patients was shorter by one-third (3.2 days vs. 4.9 days), and the incidence of delirium (among other complications) was dramatically lower (9 percent vs. 24 percent). One study of the program also found no difference in rates of subsequent use of medical services or readmissions. And patients and family members' satisfaction was higher in the home setting than among those offered usual hospital care, reflecting the convenience of the model.”

So this is that rare example of a care delivery model innovation with no downside. Everyone wins—the patients, the clinicians, the hospitals, and the payers. Let’s hope that this model is embraced by the incoming CMS Administrator, and that that official helps to lead the work to permanentizing it. It could prove to be a significant win in the ongoing shift to value in our healthcare delivery system.

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