My favorite quote about the acute hospital-at-home movement comes from David Levine, M.D., M.P.H., who leads the program at Brigham and Women’s Hospital in Boston: “If home hospital were a drug, everyone would buy it.”
Levine was referring to research his team published in the Annals of Internal Medicine that demonstrated that only 7 percent of home hospital patients were readmitted within 30 days compared with 23 percent of inpatients. Research has found that home hospital care can reduce decrease healthcare costs by nearly 40 percent compared with usual hospital care. “In heart failure, if a drug reduces readmission rates by a percent, everyone buys it,” he says.
During the pandemic, approximately 100 health systems took advantage of a waiver from the Centers for Medicare & Medicaid Services to provide acute care services in the home setting. But the waiver ends whenever the public health emergency does, so that investment in innovation is threatened. A 16-member group called the Advanced Care at Home Coalition is seeking to get a legislative extension of the waiver in the short term to ensure that there is stability and predictability around the investments that hospitals are making. “A second goal is to develop a permanent strategy,” says Mara McDermott, the coalition’s executive director. “We're learning a lot from the data and from the experience on the ground about what the best practices are and what might better serve patients, so it would be using that data and information from the waiver to inform a permanent solution.”
There are bipartisan bills in the House and Senate that would extend the waiver for two years after the public health emergency ends. Although there is no obvious opposition to the bills, McDermott says the biggest hurdle in Congress has been bandwidth, because there are so many COVID-related policies and other issues such as events in Ukraine. “There's a lot of competition for time and attention of Congress,” she says. “This model’s not as familiar to Congress as other things. At this point of the pandemic, many members of Congress and their staff have had a telehealth visit, but that is not as true for hospital at home. We're spending a lot of time explaining how it works.”
One executive involved with the coalition is Stephen Parodi, M.D., executive vice president of external affairs, communications, and brand at the Permanente Federation and an associate executive director for the Permanente Medical Group. Kaiser Permanente has launched hospital-at-home programs in the Pacific Northwest and in Northern California.
Parodi says these programs have encountered challenges in hiring a new workforce with new skill sets. “You also need a logistics platform, both from an IT perspective, and then weaving together all the goods and services that need to get in a home in a timely fashion. That's probably one of the biggest challenges.”
He adds that even though considerable research has been done on hospital at home in other countries, there's a need to demonstrate success at scale in the United States. “I think what CMS is going to want to see is what's actually possible when it comes to both the quality safety for these patients — and then, at scale, the cost and affordability relative to a standard brick-and-mortar hospital,” he says. “Smaller demonstration projects have been done sponsored by CMMI, and all of those are favorable in terms of the measures that I'm speaking to, but I think the big picture question is, can this be done at a much larger scale? The waivers are kind of a patch,” he says. “They allowed us to get off the ground. But you really are going to want a larger framework, just like we have for brick-and-mortar hospitals for this type of care.”
A number of Medicaid and Medicare programs are trying to incentivize medical providers to address underlying social determinants of health. Because hospital-at home programs see people in their homes, they can more easily identify social issues impacting healthcare than inpatient hospitals can. “What's interesting is that we're at the ground level of actually developing a new part of the care delivery system,” Parodi says, “and we can deliberately weave in equity, inclusion and diversity, which wasn't the case with prior developments within the healthcare industry.”
Another question that needs to be addressed is how the hospital-at-home model will work in rural settings. Blessing Health System, a three-hospital health system in rural Illinois, Missouri and Iowa, is taking advantage of a grant opportunity through Ariadne Labs, which is a partnership between the Harvard School of Public Health and Brigham and Women's Hospital in Boston, to become one of two U.S. health systems to test Brigham’s model of home hospital services in a rural setting.
Mary Frances Barthel, M.D., chief quality and safety officer at Blessing, is leading the three-year randomized control trial that will seek to involve at least 55 patients. They are targeting patients who need inpatient level of care, but where that care can be provided in the home, such as patients with pneumonia, COPD, congestive heart failure, or infections for which the patient might need IV antibiotics.
“We have a large population of elderly patients, and a large geographical area that we serve,” Barthel says, adding that providing the care in the patient's home allows for patients to sleep in their own bed, eat their own food, have their families around them without having those families drive every day to communicate with the doctors and, see their loved ones. “There are a lot of benefits for an appropriately selected patient,” she says.
Blessing is working with technology from a company called Biofourmis. “The patients have a tablet, and they have a sticker that goes on their chest, which allows me to see their ECG monitor, their heart rate, the respiratory rate, and their pulse-ox 24/7,” Barthel explains. “A Bluetooth-enabled blood pressure cuff allows me to see their intermittent blood pressure readings. I can see that information from my laptop or cell phone, so that allows me to really closely monitor these patients’ condition.”
A nursing shortage is a significant challenge, Barthel says, both in traditional care settings and in this new home hospital model. “That's been kind of a restraint for us, because we just have one nurse at the moment. We're working on onboarding several other per-diem nurses so that we can have seven-day-a-week coverage,” she says. “But that has been the main reason that we've been pretty slow to get out of the gate. Our goal over the three years is to get to a point where we're admitting one person a day and discharging one person a day. We'd have a rolling census of three or four patients at a time. Once we get to that point, we'd like to expand to have hubs at our other two hospitals.”
During a recent webinar panel discussion, Mary Giswold, M.D., chief operating officer at Northwest Permanente, said that scaling up hospital-at-home programs in the Northwest could help alleviate capacity issues. “In Oregon and Washington, we have the lowest beds per 1,000 in the country. During the pandemic, we admitted over 1,200 patients to our program, which created bed capacity for other people,” she explained. Hospital at home allows for a more flexible creation of hospital beds than building brick and mortar in the Portland metro area, she added. “We now have multiple health systems that are creating these programs, because we are really under-bedded in our area, and we can do this a lot faster than someone can go through a certificate-of-need process, and actually build new construction these days.”
