Most days it is difficult to identify any positive developments arising from the pandemic, but one innovation that has received a boost is the hospital-at-home movement. Because payment models are always a stumbling block to such change, the Centers for Medicare & Medicaid Services created a waiver program to increase the capacity of healthcare systems to provide care outside a traditional hospital setting, including in the home, and dozens of health systems have launched these initiatives.
One such program, the Huntsman at Home program of the University of Utah Health System’s Huntsman Cancer Institute (HCI), is the first one that is oncology-specific. In a research paper published in The Journal of Clinical Oncology, the program’s leaders documented impressive decreases in emergency department visits and rehospitalizations in oncology patients. Then last year they expanded the program to three rural Utah counties. Approximately 1,100 patients have been through the program to date. For this ground-breaking work, the editors at Healthcare Innovation chose Huntsman at Home as the winner of the publication’s top Innovator Award for 2022.
Work started on the program in. 2017, when University of Utah Health System officials began evaluating the concept systemwide. “We thought that getting the input of somebody who was an expert in it would be a good idea,” recalls Kathi Mooney, Ph.D., R.N., the Louis S. Peery and Janet B. Peery Presidential Endowed Chair in Nursing and Distinguished Professor of Nursing at the University of Utah. She adds that many of the hospital-at-home programs developed in countries that have socialized medicine or one-payer systems. As she happened to be attending a conference in London, she reached out to Karen Titchener, M.S.N., N.P., R.N., who was running such a program for two major hospitals in London. “We were able to convince her to come help us develop our program.”
Although ultimately a decision was made not to move forward with a systemwide hospital-at-home program at the time, there was interest at the Huntsman Cancer Institute. “My background has always been in oncology and looking at symptom management,” Mooney explains. “I thought it would be a potentially very appropriate model in oncology to address some of the issues of ED use and rehospitalization due to symptoms that are not adequately under control. Some acute conditions require hospitalization that might be done at home just as well.”
The team developed the program and opened it in the Salt Lake City area in March 2018. It initially served the 25-mile radius of the cancer center — the Wasatch Front urban communities.
Huntsman at Home teams include HCI doctors and advanced practice registered nurses. They partner with Community Nursing Services for specialties such as registered nurses and nursing aides, physical therapists, pharmacists and social workers
“We did an evaluation and then in July 2021, we extended the program to three rural counties in southeastern Utah — Carbon, Emery and Grant counties,” Mooney says. “We wanted to do that because of the equity issues of not just providing services to patients who live close to the cancer center. We wanted to further evaluate and demonstrate how we might do this with a combination of remote and on-ground care to patients living at geographic distance from the cancer center.”
Titchener, who has been doing hospital at home for 20 years, says this project was intriguing enough to lure her to move from England to Utah to start it up. “I'm always one looking at the doors of opportunity. For me, it was an exciting prospect. In the London program, we saw 3,500 patients per month, and I had a staff of 85, so it was a massive program,” she says. “Here, we had to transition to a fee-for service world, so I would say my first couple of years involved a huge learning curve, and trying to work out doing it on a smaller scale. Kathi was a great mentor and I've kept her by my side from day one. Together, we're pioneered this vision. It was a bit of a leap of faith.”
Titchener and Mooney say they also have worked closely with Anna Beck, M.D., director of supportive oncology and survivorship and an investigator at Huntsman Cancer Institute (HCI). She is both an oncologist and a palliative care physician, and helped provide the medical backup and support as the program was rolled out.
“From my experience in the UK, I realized that when you're setting up a program, you really need to engage your stakeholders,” Titchener says, “so before we did this, we had six months’ worth of meetings with some of the key players and oncologists. One of the early adopters said, ‘You're trying to teach us something that we didn't learn at medical school.’ And it is true that you are trying to do something different — it's not home health, and it's not inpatient care. You're trying to do this higher level of care in the home, and that freaks some people out.”
The focus of the Huntsman program was not on particular types of cancer, but more on symptom management. “We knew the kinds of things that people were coming to the emergency room for — it was nausea, vomiting, pain, dehydration. We looked at why people were people getting readmitted,” Titchener explains. “Why would people come into the emergency room? Those were what we really targeted. Medical oncology was among the first engagers. With one surgeon, we developed a pathway where we would get the patients out early. Even if they lived out of state, they would stay locally, and then we would look after them until they had her sign-off. So rather than them sitting in an acute bed, they would be discharged at day four or five and come to us. Once they have their sign-off in the second week, they could return to home.”
The research that the team published in The Journal of Clinical Oncology showed that in the 30 days after study entry, Huntsman at Home participants had 55 percent fewer hospitalizations, 45 percent fewer emergency department visits, and shorter hospital stays by one day. They also had 47 percent lower costs during the same 30-day period compared with patients who did not participate in Huntsman at Home. “We felt that there were both dramatic effects on healthcare utilization plus equivalent cost reductions,” says Mooney. “One thing that we didn't look at and we are studying right now is patient experience. We are looking at patient-reported outcomes of their symptoms, and their evaluation of the program. We also want to look at family caregivers, and caregiving, because one of the questions about building home-based program is: do you put more burden on families?”
Despite the promising results, the payment systems in the U.S. can inhibit the expansion of such innovation, says Sachin Apte, M.D., chief clinical officer at HCI and physician-in-chief of the cancer hospital. “There are other health systems that would like to get in this space. We have proven that it provides benefits for the patient, caregivers and community, but you also have to have a system that's solvent and sustainable,” he stresses. “It's one thing to do a demonstration project that can provide evidence to help change people's minds. But as you know, changing Washington, D.C., is not the easiest thing. Due to the public health emergency, there is a waiver for hospital at home for patients who meet inpatient criteria, but we don't have guidance on how long it will go on.” The concept of hospital at home makes sense, he adds, “but what we struggle with is getting payers to go along with that, because in our current system, you get paid for what you do now, not what you prevent.”
The Huntsman at Home team is experimenting with different remote patient monitoring technologies as well as communication tools to keep everyone on the care team connected.
They say one challenge has been that that this model of care doesn't fit well with how EHRs and documentation are set up between different sets of providers. They have had to provide nurses read-only access to disparate systems, and sometimes rural providers will e-mail results of an assessment. If the team believes it is appropriate, they will enter that information from the e-mail into Epic.
Huntsman’s promising results have drawn interest from other oncology programs around the country. “We feel it's important to share our experience and to help change the reimbursement system,” says Mooney. “We have to get momentum. The more people that we can get to step up with programs and see the advantages for their patients, cancer or otherwise, the more likely it's going to become a model that we can try out with insurers to have alternative payments for.”
There is international interest, as well, Titchener adds, “because we were the first oncology-specific program. My London program had some oncology patients in the mix, but it wasn't specifically oncology. The interest in this is because it's specific.”
Besides the July 2021 expansion to three rural counties, the Huntsman team also wants to increase the number of patients they receive from the emergency department of the university hospitals. “One mode of hospital at home is as a substitute for hospitalization; another is to try to prevent people from escalating to needing acute hospital care,” Mooney says. “We want to be proactive and take patients who are at high risk for escalation and very carefully monitor their symptoms and address those at home before it necessitates ED visits or hospitalizations. We've started developing a predictive tool that could identify patients with characteristics likely to lead to hospitalization, so that we can proactively bring them into the program in that sub-acute way and decrease their utilization of unplanned hospitalization or ED visits as a way to get their acute episode needs taken care of.”