Farewell Hospital, Hello “Homespital”

“Care can move out of the hospital. It’s time to open our eyes, get up, and get moving.”

Bruce Leff, M.D., Director, The Center for Transformative Geriatric Research, Johns Hopkins Medicine
Image Credit: Shutterstock.com

Hospital systems are increasingly investing in hospital-at-home programs, a previously niche offering that’s become a significant trend amid the pandemic. In hospital-at-home programs, patients with certain conditions are offered high-acuity care within their homes, aided by 24/7 remote monitoring, daily provider visits, and—for some programs, if needed—access to home care support such as food. The programs typically provide all monitoring and communication tools, as well as a hospital bed, when needed, Kaiser Health News reports.

This shift is being accelerated by improvements to automation and Artificial Intelligence (AI), such as chatbots, enabling “care anywhere” in the U.S. and across the globe. The growing appetite for home care is a response to three main drivers: increasing access problems (wait times), growing patient and family expectations (choice, convenience, quality), and society’s inability (or unwillingness) to continue to pay for the costs of delivering healthcare in formal institutions, which are being outstripped by demand.

In November 2020, the hospital-at-home industry received a boost when Medicare announced it would reimburse hospitals for home care as part of a broader effort to enable hospitals to focus on Covid-19 patients by limiting the number of hospitalized non-Covid patients. Since that announcement, more than 100 hospitals have received approval from Medicare to participate in hospital-at-home care—although, according to KHN, not all of them are set up yet.

Most recently, two major stakeholders—Kaiser Permanente and Mayo Clinic—have invested a total of $100 million in Medically Home, a company that provides resources for hospital-at-home care. The two organizations estimate that 30% of patients currently admitted to hospitals nationally have conditions eligible for in-home care. These systems join several others scaling up their hospital-at-home services, including Johns Hopkins Medicine, Presbyterian Healthcare Services, and Massachusetts General Hospital, KHN reports. (A complete list of CMS-approved hospital at home programs as of April 9, 2021, can be found here.)

“I’m practicing the best medicine I have in 18 years here with this new system,”

Michael Maniaci,, M.D., Mayo Clinic

Hospital@Home is not a new concept – Dr. Bruce Leff, who is quoted above, prompted Johns Hopkins to ask 26 years ago, “Could acute medical illness that normally requires hospital admission be well managed in a patient’s home instead?” The result was Hospital at Home (HaH) — an option for some patients with community-acquired pneumonia, heart failure exacerbations or chronic obstructive pulmonary disease, cellulitis, and (recently) other conditions. And HaH is still going strong today.

“Especially for patients who have been in the hospital a lot, to know that they can actually go home and sleep in their own bed and be with their family and have their pets by their side, it’s just really reassuring.”

Margaret Paulson, Mayo Clinic Home Care Program

According to Dr. Leff, research indicates that hospital-at-home programs can produce better health outcomes for patients than being admitted to a hospital. At the same time, the programs can also save hospitals money by limiting their need to expand, reducing readmissions, and helping patients avoid nursing homes. Raphael Rakowski, the co-founder of Medically Home, said hospital-at-home models also prevent facility transfers while patients get better.

“We stay with the patient until they’re fully recovered, and that averages anywhere from 20 to 30 days, sometimes longer.”

Raphael Rakowski, Co-Founder Medically Home

What types of conditions can be treated using the Hospital@Home model? – In the Clinically Home version, the admission eligibility criteria, and protocols that physicians and other caregivers use to ensure standardized and safe care include approximately 100 diagnostic-related groups (DRGs). Among them are asthma exacerbation, early sepsis, seizure disorders, and gastrointestinal conditions or diseases. Its founders believe that with the expanded list of DRGs, the model has the potential to vastly increase the number of patients treated at home and deliver care at half of the traditional hospital costs.

Technology developments also allow patients who require treatments like kidney dialysis and some infusion therapies to receive those at home. Traditional home hemodialysis is very similar to in-center hemodialysis. One of the significant benefits of HHD is that treatment schedules can be tailored to a patient’s specific health condition and lifestyle. Traditional HHD treatments are generally performed three times a week for four hours per session, but patients may be prescribed additional treatments by their nephrologist. In 2019, CVS Health announced the start of a clinical trial for a new home hemodialysis device.

Home infusion therapy (to deliver antimicrobials, hydration solutions, parenteral nutrition, antineoplastic drugs, analgesics, cardiac infusion therapies for heart failure, immunoglobulins, and other biologics and drugs) allows patients of all ages to be discharged earlier from the hospital or even avoid hospitalization altogether. Studies show that patient satisfaction with home infusion therapy is high, clinical outcomes are good, and patients are no more likely to suffer side effects or adverse reactions at home versus inpatient clinical settings.

What about diagnostics in Hospital@Home programs? – Advances in technology have created a whole new world of possibilities for in-home diagnostics. A comprehensive review of these options is beyond the scope of a blog post. (For a more detailed look at digital sensors in health care, see my previous blog post.) But the graphic below illustrates some of the available options for in-home diagnostics.

Image Credit: Bregje Van Den Heuvel, Radboud Universiteit, the Netherlands

Recently we’ve begun to add in-home lab testing to the mix. Home tests can be used to screen for, diagnose, or monitor disease. Most are available over-the-counter (OTC) in local supermarkets or pharmacies or directly from manufacturers by Internet, phone, or mail order. However, a few home tests must be prescribed by a healthcare practitioner (for example, those that monitor anticoagulants). There are a variety of tests cleared by the U.S. Food and Drug Administration (FDA) for home use. Some are used for screening, such as pregnancy tests, hepatitis C tests, drug tests, or fecal occult blood testing for colorectal cancer. Others are monitoring tests, such as cholesterol tests, prothrombin time for blood-thinning and clotting, and blood glucose for diabetes. Some home tests, like those for pregnancy or blood glucose, produce immediate results. Others are sold as collection devices—you use the device to collect a specimen (for example, urine or stool) and then mail the device containing the sample to the laboratory for evaluation. For example, there are currently two FDA-approved home tests for HIV, the virus that causes AIDS. One test provides results at home within 20 minutes. The second test requires you to collect a small blood sample by pricking your finger at home and collecting a drop of blood on special filter paper that is then sent to a laboratory for analysis. Home collection kits that are mailed to a laboratory for analysis include allergy tests for home allergens, hepatitis C, microalbumin for kidney disease screening, TSH for thyroid function, paternity testing, and PSA testing to screen for prostate cancer. Test results are generally available within a week or two of mailing the specimen to the analyzing laboratory.

What are some of the challenges to deploying Hospital@Home programs? – While the goal is to shift 10% or more of hospital patients to home settings, existing programs handle far fewer cases, sometimes serving only a handful of patients. Challenges to scaling up include maintaining the current good safety profile in the face of rapid growth and finding enough medical staff — especially nurses, paramedics, and technicians — who travel to patients’ homes. Those health care systems most attracted to hospital-at-home programs run at or near capacity and want to free up beds.

Another challenge is physician resistance to Hospital@Home programs. Physicians – both in the community and in the hospital’s emergency department – are reluctant to refer patients, even though they support the concept in principle. Time constraints are another barrier. Physicians who refer patients to the program must screen them carefully and make arrangements to introduce them to the idea of at-home hospital care. For many, it’s simply easier to admit patients.

The chief financial officers (CFOs) of hospitals may also present a challenge, especially those who remain unconvinced that the beds freed by treating patients at home will be filled with patients needing more complex and intensive services. Hospitals that have already expanded with expensive inpatient facilities now face the challenge of needing patients to fill up their beds to recoup their investments.

Medicare’s payment decision gave momentum to the Hospital@Home movement. But the natural experiment it created with its funding ends when the pandemic is declared over. Because of the emergency, Medicare paid the same as it would for in-hospital care, based on each patient’s diagnosis. Will hospitals be as enthusiastic if that is not the case in the future? Commercial insurers are unlikely to pay unless they see lower rates since there are already concerns about overuse.

Finally, some worry that the broad expansion of hospital-at-home efforts could exacerbate health care inequities. Suburban and rural areas – and even some lower-income urban areas – can have spotty or nonexistent internet access. How will that affect the ability of those areas to participate, to communicate with physicians and other hospital staff members miles away? Social factors play a big part, too. Those who live alone may find it harder to qualify if they need a lot of help, while those in crowded households may not have enough room or privacy. Another possible wrinkle: Not all patients have the necessary human support, such as someone to help an ill patient with the bathroom, meals, or even answering the door.

“I love the concept for a resourced household where someone can take this job on. But there’s a lot of situations where that’s not possible. What If I have a full-time job and two children, when am I supposed to do this?”

Alexandra Drane, CEO of Archangels

My take – We are in the midst of a medical revolution driven by exponential technology: artificial intelligence, sensors, robotics, 3D printing, big data, genomics, and stem cells. The future of healthcare is much less centered around institutions. Today’s $3 trillion healthcare industry is rapidly becoming decentralized, dematerialized, demonetized—and, ultimately, democratized. It will be more continuous, more integrated. As healthcare becomes more data-driven, it also is becoming more personalized and proactive, and less reactive. The “homespital” will help alleviate the mounting phenomenon of “hallway medicine.” The term “bed-blockers” is sometimes used to describe people using hospital services and beds that could often be taken care of at home. Current estimates are that 30 to 40 percent of bed-blockers could be shifted to home care. And some hospitals estimate that up to 70 percent of what’s done in clinical institutions today could be done in the home. HaH’s potential for downward pressure on acute care utilization (e.g., via reduced total costs) and amenability to alternative payment models (e.g., bundled or global payments) represent important delivery and payment reform strategies. And, HaH can provide a new vehicle for integrating nonmedical services (e.g., broadband access, food security) into acute care at a time point when patients may require increased support due to the complexity of their illness. Finally, anchoring care delivery in the home provides a new vehicle for integrating social needs into care delivery.

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