Hospital At Home: Bringing The Hospital to You
While we think about video visits being an alternative to office visits, what about transitioning entire hospital stays to the home? A challenge sure, but Johns Hopkins has been working on this since its first pilot project in 1995 (anyone remember what the internet communication was like then?). Since then, hospital at home has scaled to several different healthcare organizations including Mayo Clinic, Marshfield Clinic, Partners Healthcare, Intermountain, Mount Sinai as well as others internationally. Let us look at how it works and what opportunities are out there.
What Exactly Is a Hospital-At-Home?
Following the John’s Hopkins model, a patient presents at an emergency department and staff evaluate whether the individual is a good candidate for hospital at home. These individuals need hospital care, but with the right treatment protocols they are at low risk of clinical deterioration and less likely to need any type of surgical procedure. After the individual is transported home, they have access to 24/7 nursing, receive daily physician visits (virtual or in-person), and have any diagnostics completed in their home, all while being monitored remotely by their care team. After the individual is stable and ready for regular discharge, the hospital at home physician transfers care back to the primary care provider (PCP) [How it Works John’s Hopkins].
Opportunities
Operations: keeping people out of the hospital can lead to an increase in access for inpatient beds, which in the time of COIVD means consumers can continue to receive the care they need (e.g. non-urgent surgical cases)
Cost of Care: hospital at home has shown to cost as much as 30% less than the traditional brick-and-mortar admission [1]. Which when looking at the $1 trillion dollars being spent on hospital care year alone, and if only 5–10% of that is acceptable for hospital at home, means there is a potential market savings of up to $30 billion per year on the conservative side.
Quality: equal or better outcomes compared to those seen in a facility either from a clinical perspective along with decreased length of stay and readmissions [2]; not to mention the decreased probability in second order effects of admissions including: hospital acquired infection, falls, medication errors, etc.
Patient Satisfaction: patient satisfaction rates are high across organizations who have implemented hospital at home. For example, Marshfield Clinic in Wisconsin boasts a 90% satisfaction rate with the care and can be additionally helpful in preventing the need for some individuals to travel 2+ hours to the nearest hospital [3].
Challenges
So why don’t we see more hospital at home programs throughout the US?
Reimbursement: hospital at home has not typically been covered by Centers for Medicare and Medicaid Services (CMS) which means there is a decreased financial incentive for implementing these. Unless an organization is integrated with its own health plan, or some other downside risk arrangement, it may be difficult to make a business case for implementation. Especially since a hospital at home consumer means you may be passing up a guaranteed $10,000-$20,000 admission in the hope that it will be backfilled with another (at least in a fee-for-service model) [2].
Cultural Shifts: As with anything in healthcare, getting the right people on board is one significant barrier. Emergency physicians are typically seen as the gatekeepers of these programs, and to be successful organizations need to one, bake evaluation into physician workflows, and two get them comfortable in sending home individuals they are used to admitting. Additionally, the intensivists, also need to be comfortable with technology to ensure success at home [2].
Scalability: one of the central reasons we have hospitals today is that it makes more economical sense to keep expensive human resources in one place. Moving these resources outside of the building to spend time traveling to homes, may not be the most effective use of time, so there will be a significant need to identify other care staff that could provide care in the home, while other staff manage from a central hub.
Who’s Succeeding in This Space?
One example of a health system succeeding in this space is Marshfield Clinic, an integrated delivery network located across Wisconsin. Marshfield Clinic began delivering their hospital at home program, Home Recovery Care, in 2016. Through partnership with Contessa Health, Home Recovery Care offers care in two main buckets [Marshfield, Home Recovery Care]
- Recovery at Home: Where an individual at home receives twice daily contact with a nurse, while a physician manages care remotely. During this time at home, an individual’s vitals and biometrics are monitored, they may receive diagnostics, medications (including IVs), and other care during their nursing visit, and have access to 24/7 nursing, as well as support services including social work and a recovery care coordinator [4].
- Post Acute Rehabilitation: After an individual’s ‘hospital stay’ they can then be transferred to post-acute care and receive physical or occupational therapy in their home and receive video visits from their physician during this time.
Since beginning in 2016, where care only covered 6 diagnosis groups, the partnership has scaled to over 150 different conditions, and to other hospitals throughout the Wisconsin region. They currently realize success via partnership with their health plan as well as bundled payment agreements with others [4].
In addition to health systems driving care outside the hospital, there are also several organizations building out infrastructure to do just that. One example is Dispatch Health, which brands itself as “an integrated, convenient, high touch care delivery solution that extends the capabilities of a patient’s care team and provides definitive, quality care in the home [About Us, Dispatch Health].”
Dispatch Health currently treats 43 different conditionsin an individual’s home by providing them with a home visit from a Nurse Practitioner or Physician Assistant, along with one of their Dispatch Health Medical Technicians (DHMT) who are then able to provide medications (e.g. Intravenous fluids), run diagnostics (e.g. ultrasounds), collect labs, and provide basic procedures [How it Works, Dispatch Health]. Once an individual is assessed that individual will be monitored remotely by an internal medicine physician, receive daily nursing visits, and have access to an emergency call button.
The results seem to speak for themselves, which as of February 2021, have provided high acuity care to over 220,000 individuals, with an estimated cost savings of $227 million [5] (which when going back to the previous figure of $30 billion market, shows the opportunity out there). These results may show why they continue grow and partner with health systems and payors across the country, such as their recent collaboration with Humana to provide at-home care in several states [5].
How has COVID Impacted Hospital at Home?
With the COVID surge in the fall of 2020, CMS enacted a temporary waiver to cover care outside the hospital. As of February 2021, 41 health systems, in 26 different states meet CMS’ approval for hospital at home [6]. While this is a temporary waiver as part of its Hospitals without Walls Initiative, we could assume that these programs will fit into a future Center for Medicare & Medicaid Innovation (CMMI) program, and lead to permanent expansion of these delivery programs.
What Does This All Mean?
With consumers adapting to the luxuries of being able to receive what they need in their home; it is hard to believe they would not want their healthcare to be just as convenient. Further, this consumer base is usually living with some sort of long term, chronic condition, so why force them to spend the time traveling to a hospital that only leads to expensive care with a possibility of adverse outcomes (such as an infection in the middle of a pandemic).
From a health system standpoint, if operating in a value-based environment it is hard to deny the potential costs savings of keeping these individuals healthy and out of the hospital. Additionally, with hospitals likely having to continue to manage limited inpatient access, keeping these lower acuity individuals out of the hospital could provide secondary benefits such as an ability to increase inpatient surgeries due to an increased access, without the need to be concerned about expanding an expensive real-estate portfolio.
While there will likely always be a time and place for hospitals, this surely represents a unique opportunity on delivering cost efficient and consumer-oriented healthcare to those who need it.
Sources
[3] https://contessahealth.com/marshfield-clinic-expands-home-recovery-care-to-minocqua-weston/
[6] https://qualitynet.cms.gov/acute-hospital-care-at-home; accessed 2/18/2021
