Practice Management

Hospital at Home: Delivering hospital-level care without the hospital

How to implement a new model of care


 

The United States spends one-third of the nation’s health dollars on hospital care, amounting to $1.2 trillion in 2018.1 U.S. hospital beds are prevalent2, and expensive to build and operate, with most hospital services costs related to buildings, equipment, salaried labor, and overhead.3

Despite their mission to heal, hospitals can be harmful, especially for frail and elderly patients. A study completed by the Office of the Inspector General (OIG) found that 13.5% of hospitalized Medicare patients experienced an adverse event that resulted in a prolonged hospital stay, permanent harm, a life-sustaining intervention or death.4 In addition, there is growing concern about acquired post-hospitalization syndrome caused by the physiological stress that patients experience in the hospital, leaving them vulnerable to clinical adverse events such as falls and infections.5

In the mid-1990s, driven by a goal to “avoid the harm of inpatient care and honor the wishes of older adults who refused to go to the hospital”, Dr. Bruce Leff, director of the Center for Transformative Geriatric Research and professor of medicine at Johns Hopkins University in Baltimore, and his team set out to develop and test Hospital at Home (HaH) – an innovative model for delivering hospital-level care to selected patients in the safety of their homes.

More than 20 years later, despite extensive evidence supporting HaH safety and efficacy, and its successful rollout in other countries, the model has not been widely adopted in the U.S. However, the COVID-19 pandemic amplified interest in HaH by creating an urgent need for flexible hospital bed capacity and heightening concerns about hospital care safety, especially for vulnerable adults.

In this article, we will introduce HaH history and efficacy, and then discuss what it takes to successfully implement HaH.

Hospital at Home: History, efficacy, and early adoption

The earliest HaH study, a 17-patient pilot conducted by Dr. Leff’s team from 1996 to 1998, proved that HaH was feasible, safe, highly satisfactory and cost-effective for selected acutely ill older patients with community-acquired pneumonia, chronic heart failure, chronic obstructive pulmonary disease or cellulitis.6 In 2000 to 2002, a National Demonstration and Evaluation Study of 455 patients across three sites determined that patients treated in Hospital at Home had statistically significant shorter length of stay (3.2 vs 4.9 days), lower cost ($5,081 vs. $7,480) and complications.7 Equipped with evidence, Dr. Leff and his team focused on HaH dissemination and implementation across several health care systems.8

Presbyterian Healthcare Services in Albuquerque, N.M., was one of the earliest adopters of HaH and launched the program in 2008. The integrated system serves one-third of New Mexicans and includes nine hospitals, more than 100 clinics and the state’s largest health plan. According to Nancy Guinn, MD, a medical director of Presbyterian Healthcare at Home, “Innovation is key to survive in a lean environment like New Mexico, which has the lowest percentage of residents with insurance from their employer and a high rate of government payers.”

Presbyterian selected nine diagnoses for HaH focus: congestive heart failure, chronic obstructive pulmonary disease, community-acquired pneumonia, cellulitis, deep venous thrombosis, pulmonary embolism, complicated urinary tract infection or urosepsis, nausea and vomiting, and dehydration. The HaH care, including physician services, is reimbursed via a partial DRG (diagnosis-related group) payment that was negotiated internally between the health system and Presbyterian Health Plan.

The results demonstrated that, compared to hospitalized patients with similar conditions, patients in HaH had a lower rate of falls (0% vs. .8%), lower mortality (.93% vs. 3.4%), higher satisfaction (mean score 90.7 vs. 83.9) and 19% lower cost.9 According to Dr. Guinn, more recent results showed even larger cost savings of 42%.10 After starting the HaH model, Presbyterian has launched other programs that work closely with HaH to provide a seamless experience for patients. That includes the Complete Care Program, which offers home-based primary, urgent, and acute care to members covered through Presbyterian Health Plan and has a daily census of 600-700 patients.

Another important milestone came in 2014 when Icahn School of Medicine at Mount Sinai in New York was awarded $9.6 million by the Center for Medicare and Medicaid Innovation (CMMI) to test the HaH model during acute illness and for 30 days after admission. A case study of 507 patients enrolled in the program in 2014 through 2017 revealed that HaH patients had statistically significant shorter length of stay (3.2 days vs. 5.5 days), and lower rates of all-cause 30-day hospital readmissions (8.6% vs. 15.6%), 30-day ED revisits (5.8% vs. 11.7%), and SNF admissions (1.7% vs. 10.4%), and were also more likely to rate their hospital care highly (68.8% vs. 45.3%).11

In 2017, using data from their CMMI study, Mount Sinai submitted an application to the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to implement Hospital at Home as an alternative payment model that bundles the acute episode with 30 days of post‐acute transitional care. The PTAC unanimously approved the proposal and submitted their recommendations to the Secretary of Health and Human Services (HHS) to implement HaH as an alternative payment model that included two parts:

1. A bundled payment equal to a percentage of the prospective DRG (diagnosis-related group) payment that would have been paid to a hospital.

2. A performance-based payment (shared savings/losses) based on (a) total spending during the acute care phase and 30 days afterward relative to a target price, and (b) performance on quality measures.12

In June 2018, the HHS secretary announced that he was not approving the proposal as written, citing, among other things, concerns about proposed payment methodology and patient safety.13

Hospital at Home: Present state

Despite additional evidence of HaH’s impact on lowering cost, decreasing 30-day readmissions, improving patient satisfaction and functional outcomes without an adverse effect on mortality,14, 15 the model has not been widely adopted, largely due to lack of fee-for-service reimbursement from the public payers (Medicare and Medicaid) and complex logistics to implement it.

However, the COVID-19 pandemic created an urgent need for flexible hospital bed capacity and amplified concerns about hospital care safety for vulnerable populations. In response, the Centers for Medicare and Medicaid Services (CMS) introduced its Hospitals without Walls initiative that allowed hospitals to provide services in other health care facilities and sites that are not part of the existing hospital.16 On November 25, 2020, CMS announced expansion of the Hospital without Walls initiatives to include a Hospital Care at Home program that allows eligible hospitals to treat eligible patients at home.17

With significant evidence supporting HaH’s safety and efficacy, and long overdue support from CMS, it’s now a matter of how to successfully implement it. Let’s explore what it takes to select and enroll patients, deliver acute care at home, and ensure a smooth post-acute transition within the HaH model.

Successfully implementing Hospital at Home

HaH implementation requires five key components – people, processes, technology, supply chain, and analytics – to select and enroll patients, deliver acute care at home, and ensure a smooth postacute transition. Let’s discuss each of them in more detail below.

Selecting and enrolling patients

Patients eligible for HaH are identified based on their insurance, as well as clinical and social criteria. Despite a lack of public payer support, several commercial payers embraced the model for selected patients who consented to receive acute hospital care at home. The patients must meet criteria for an inpatient admission, be medically stable and have a low level of diagnostic uncertainty. Advances in home monitoring technology expanded clinical criteria to include acutely ill patients with multiple comorbidities, including cancer. It is important that patients reside in a safe home environment and live within a reasonable distance from the hospital.

CareMore Health, an integrated health care delivery system serving more than 180,000 Medicare Advantage and Medicaid patients across nine states and Washington D.C., launched Hospital at Home in December 2018, and rapidly scaled from a few referrals to averaging more than 20 new patients per week.

Sashidaran Moodley, MD, medical director at CareMore Health and Aspire Health, in Cerritos, Calif., shared a valuable lesson regarding launching the program: “Do not presume that if you build it, they will come. This is a new model of care that requires physicians to change their behavior and health systems to modify their traditional admission work flows. Program designers should not limit their thinking around sourcing patients just from the emergency department.”

Dr. Moodley recommends moving upstream and bring awareness to the program to drive additional referrals from primary care providers, case managers, and remote patient monitoring programs (for example, heart failure).

Linda DeCherrie, MD, clinical director of Mount Sinai at Home, based in New York, says that “educating and involving hospitalists is key.” At Mount Sinai, patients eligible for HaH are initially evaluated by hospitalists in the ED who write initial orders and then transfer care to HaH hospitalists.

HaH also can enroll eligible patients who still require hospital-level care to complete the last few days of acute hospitalization at home. Early discharge programs have been implemented at CareMore, Presbyterian Healthcare Services in Albuquerque, N.M., and Mount Sinai. At Mount Sinai, a program called Completing Hospitalization at Home initially started with non-COVID patients and expanded to include COVID-19 early discharges, helping to free up much-needed hospital beds.

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