In November, when the Centers for Medicare & Medicaid Services expanded its acute hospital at home program, it granted immediate waivers to six health systems with extensive experience providing acute hospital care at home, including Brigham and Women’s Hospital in Boston. In a recent interview, David Levine, M.D., M.P.H., who leads Brigham’s program, discussed its plans to scale up and the overall impact of the CMS waiver program.
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.”
Brigham, a Harvard teaching hospital, also has partnered with a Boston-based digital therapeutics and virtual care company called Biofourmis to create a turnkey solution called Biovitals Hospital@Home designed to help hospitals and health systems quickly stand up new hospital-at-home programs. (See interview with Biofourmis founder and CEO Kuldeep Singh Rajput, below.)
Levine pointed out that the key issue with all of the CMS “Hospitals without Walls” waivers is that there are only authorized during the public health emergency. “Once the public health emergency is over, technically all these things can go away.” He added that CMS is expected to work on a final rule that wraps a bunch of these waivers into a more permanent solution. “It is not clear if or when that would happen or what would be in that final rule or what requires more statutory work,” he said. “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?”
Brigham’s program is absolutely in a scale-up mode, Levine said. “Even before this waiver, we were scaling up our program because we saw the value of it. This gives us the opportunity to really scale up and meet our patients’ needs.”
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, he noted. “Another big factor is labor,” he said. 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.
Although he hasn’t yet done a research study on this aspect, 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.”
Levine’s group is about to publish two more studies: a qualitative evaluation of home hospital care — why people do so much better at home, and a study on reasons why patients decline hospital at home. (He mentioned that about one-third of patients offered home hospital decline.)
“We have also been looking at rehab at home — providing services you normally get at a skilled nursing facility. We finished a pilot on that just before the pandemic and a study and hope to relaunch it soon.”
Brigham also is working on new diagnostic pathways and pushing the envelope on what kinds of conditions and acuities can be cared for at home, involving new sensors and new specialists and clinical work flows. “One example we are working on is OR to home. It involves patients coming right out of the operating room for a major surgery going straight home.”
Finally, Levine is helping organize the burgeoning community of home hospital programs across the country by co-chairing a new group, the Hospital at Home Users Group, to share best practices, research and practice standards. “It is essentially a collection of all the active home hospital programs across the country now," he explained. "They are sprouting up like wildfire. There are about 25, but we are growing fast. People have been contacting us just in the past few weeks because they are starting up programs.”
A turnkey solution
Over the past few years Brigham has worked with a company called Biofourmis to refine and scale the Biovitals Hospital@Home platform for use in Brigham's Home Hospital Program. Now Biofourmis is making the platform available to other health systems.
In a recent interview, Kuldeep Singh Rajput, CEO of Biofourmis, described that effort.
“Our platform is designed to enable any hospital system that wants to set up a home hospital program to quickly deploy all the required technology and logistics using a turnkey solution to kickstart their program,” he said.
The system provides continuous monitoring of these patients with a patch worn on the chest that has the ability to track multiple parameters such as an electrocardiogram, heart rate, respiration rate, temperature, and activity. The kit also has a blood pressure cuff, scale, and other tools. “All the data from these sensors is transmitted via a tablet app which is given to the patient directly to the cloud,” Rajput said. The patient is able to look at their plan of care for that day and see reminders and notifications. There is two-way communication with the care team via text and video. The patient has an emergency button and can report any kind of symptoms to the physician and nurse teams.
Rajput said the program has been integrated with most major EHRs such as Epic and Cerner, and an important part of the platform is an analytics engine that can put context around alerts and reduce false alarms. He said many hospitals look at individual parameters such as heart rate in isolation. That works in the emergency room because that type of patient are non-ambulatory most of the time. But in the home, patients are ambulatory, so contextual information is important.
He said the analytics engine gathers a huge amount of data collected from the patient including activity intensity, position, posture, and time of day, and compares to a baseline of you as an individual. “We are comparing you to you rather than to a fixed population,” Rajput said. “It has demonstrated two important things, one of which is a reduction in false alarm burden of almost 70 percent compared to static alarms, which is critical to scaling a home hospital program,” he stressed. “The second thing is that a majority of these subtle physiological changes wouldn’t have been picked up by the clinician. We can give them early warning signs before an actual event and clinicians can intervene.”
