Moving Hospital Care Into the Home: A Pandemic-Fueled Surge

March 18, 2021
Industry leaders had already been increasingly recognizing the value of hospital-at-home programs. Then the COVID-19 pandemic happened.

Home-based hospital care evolved in a big way in 2020 as hospital and health system leaders saw the opportunity to send patients home with the right tools to care for them, when possible, while also preserving critical resources and protecting the vulnerable during the COVID-19 pandemic.

Historically, there have been different variations of the hospital-at-home model going back to the mid-1990s, and while programs have ramped up in recent years, the crisis has caused interest to skyrocket. Although it’s not for everyone or every condition, patient care leaders are increasingly seeing hospital-at-home programs as one viable solution to bending healthcare’s unsustainable cost curve: one study published last year in the Annals of Internal Medicine reviewed 43 hospital-at-home patients and 48 patients receiving traditional hospital care, finding that hospital-at-home care was 38 percent less costly than traditional hospital care. The researchers found that only 7 percent of hospital-at-home patients were readmitted within 30-days, compared to 23 percent of patients receiving traditional hospital care.

That study was led by Brigham and Women’s Hospital and Partners HealthCare System in Boston, a city where David Levine, M.D., is the medical director of strategy and innovation for Brigham Health Home Hospital. As the pandemic began to unfold last spring, one of the key decisions hospital-at-home program executives had to make was whether or not they’d try to care for COVID-19 patients—in addition to those with other conditions—at home. During a recent virtual panel discussion on moving care delivery into the home, presented by Healthcare Innovation, Levine said his organization opted against it since there were lots of PPE supply issues in Boston early on in the pandemic, which would have made it tough to appropriately care for COVID patients in their homes. But by providing care for patients with infections, heart failure exacerbations, and many other conditions, Brigham was still able to create a lot of capacity for the hospital during the pandemic. In fact, Levine says the acute hospital care at home has grown into a full-service line at Brigham.

Other organizations, however, have decided to care for COVID patients in the home. During a Midwest surge last fall, leaders at the Sioux Falls, S.D.-based Avera Health ramped up the health system’s existing Avera@Home Care Transitions initiative to meet the needs of COVID patients who are at least moderately ill, and/or have multiple or some comorbidities that make them likely to get sicker as the illness progresses, says Rhonda Wiering, vice president, clinical growth and innovation for Avera@Home. Specifically, patients who test positive, have COVID-19 symptoms, and are at high risk can be referred to the health system’s Care Transitions program by their physician. These patients receive regular phone or video nurse calls and telehealth equipment. Avera@Home also delivers an at-home monitoring kit to the patient’s house. The kit allows the patient to monitor their oxygen levels, blood pressure, temperature and COVID symptoms, with all data transmitted instantly to the care team, according to health system officials.

At Avera, experienced nurses are supported by internal medicine physicians, and this team is providing virtual care all day, every day for COVID patients, usually for the first seven to 10 days of their illness, or until they get over the worst part of it. During one day in the middle of the region’s surge, Care Transitions was caring for 1,142 patients at home, 159 of whom were on oxygen. “In most cases, these 159 patients would have been hospitalized. Among these moderately and severely ill patients, we are seeing success in keeping them out of the hospital, yet we are also monitoring them in order to get them hospital care at the right time, when intervention is needed,” Wiering notes.

In Danville, Pa., Geisinger started its at-home care journey more than a decade ago, focusing specifically on heart failure management, so it had the infrastructure in place to shift its model for COVID-positive patients. The first thing it did was embed a nurse case manager with a very strong clinical background in emergency room care, Joann Sciandra, vice president of care coordination and integration at Geisinger, explained during the Healthcare Innovation virtual panel discussion. That nurse works very closely with the health system’s ER physicians, and as patients come in with COVID, if they are stable enough, they are sent home, when appropriate, with tools including a pulse oximeter to monitor blood-oxygen levels, and a digital thermometer and acetaminophen to reduce fever and any muscle aches or pains. Geisinger divided up COVID patients into three categories, based on need, with the most serious being those who needed 24-hour monitoring, which is provided by Current Health, a leader in home-based technology solutions. “Technology is one thing that really allowed us to do this,” Sciandra stated.

At the same time, while technological advances and operational imperatives are pushing more and more care and care management into the home environment, there are structural impediments and challenges to creating an architecture of remote care delivery. In the eyes of Christopher McCann, CEO and co-founder of Current Health, it’s not the continuous monitoring or data integration between devices and systems that pose the biggest challenge; rather, it’s simple broadband issues. “In our populations, we find that between 25 and 50 percent [of people] don’t have home internet. And that’s not just in rural America; it’s in downtown Manhattan, Los Angeles and San Francisco,” he said as a panelist during the Healthcare Innovation virtual event. These patients are also the ones who most need to be addressed—due to low socioeconomic status and old age—but can’t get equitable access, McCann added. “The problem is really hard to solve; we [have] provided plug-and-play cellular activity for patients in the home, but getting that right has taken significant investment, and we still don’t have it right. [More than half] of the support we deal with daily relates to home connectivity,” he reported.

Federal help has come, but will it last?

To take pressure off hospitals during the surging pandemic, the Centers for Medicare & Medicaid Services (CMS) in November took several steps to increase the capacity of healthcare systems to provide care outside a traditional hospital setting, including in the home. Its Acute Hospital Care at Home program is an expansion of the CMS Hospital Without Walls initiative launched earlier last year as a part of a comprehensive effort to increase hospital capacity and maximize resources, while keeping Americans safe. Now, this updated 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. In late January, according to a CMS web page on the initiative, the program has grown to include 92 hospitals in 24 states.

In Boston, Brigham has been gradually building its program over the past five years, and was one of six health systems with extensive experience providing acute hospital care at home to be granted a waiver by CMS in November to scale up its program. Levine, who credits the waivers as “an amazing opportunity for Americans to get care in their homes,” explained that the federal agency has created two tiers for its program, depending on how advanced a specific organization is in its hospital-at-home work. To get a waiver, it’s on the applicant to demonstrate they have the ability to truly take good care of patients at home. They need to prove they have the right contracts and standard operating procedures, as well as the right care teams, noted Levine. The program also has to report to CMS, either every week or every month, depending on which tier it’s in, whether any patients unexpectedly died while at home, and if any patients escalated their care—meaning they went from home back to the hospital—as well as if there were safety reviews of any cases.

Speaking to the fact there are now more than 90 hospitals who have signed onto the CMS program in just a few months, Levine called it “phenomenal uptake.” But where does it go from here? It’s authorized under the public health emergency (PHE), which he believes will likely continue for the entirety of 2021. “In discussions with CMS, it’s not entirely clear what [will happen next], but a lot of us hope it will become a permanent benefit for Medicare beneficiaries,” he said, noting that it’s too early to tell if that could happen without Congressional action.

Nonetheless, Levine and others interviewed for the piece are quite bullish on continuing their hospital-at-home journeys and demonstrating its impact through research. “If home hospital were a pill, everyone would pay for it,” he said. “Every single payer would pay for a cardiology pill if it meant that patients would get readmitted 70 percent less often.” 

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