Home-based acute care extends care beyond hospital walls
Market forces, the pandemic and patient preferences are enabling the transition to home-based hospital-level care, and patients are all in favor.
The idiom that states “necessity is the mother of invention” fits hand in glove with the Hospital at Home movement.
Several forces and crises within healthcare are converging to expand the scope of care, to reinvent traditional beliefs that the best acute care must be delivered within the walls of a brick-and-mortar facility. And technology is finally at a point to enable this shift in care locations.
Patients are getting on board with receiving increasingly intensive care in their homes. And, most importantly, reimbursement and federal policy appears to be supportive of the change.
While hopes are high, the initiative is embryonic and healthcare organizations must achieve a massive mind-shift in strategy and determine how to scale small pilots into larger numbers.
Projects on the rise
Foundational research on hospital at home movement goes back nearly 30 years, to work by Bruce Leff, MD, of Johns Hopkins to flesh out the concept of providing acute-level care to patients in their own homes. Despite the longstanding awareness of the potential for providing hospital-level care in the home, uptake has been slow – acute-care facilities have tradition behind them, and payers’ reimbursement policies strongly influenced inpatient care.
But recent factors have added impetus to the hospital at home movement. A recent report by The Chartis Group declares that “care at home has reached a tipping point,” noting that executive support has risen dramatically in recent years, especially after the crisis that was the COVID-19 pandemic. In Chartis’ 2022 survey of hospital executives, “nearly 40 percent of respondents reported that they weren’t even in the planning stages for hospital at home,” the report noted. “Less than two years later, nine out of 10 respondents recognize the increasing need for care at home and strongly agree on the urgency to develop a comprehensive approach to remote care in the home.”
Changes in federal policy, in tandem with the urgent need to provide remote care during the COVID crisis, have hyper-accelerated the movement to offer acute care in the home. The pandemic and resulting care challenges prompted the Centers for Medicare & Medicaid Services to launch the Acute Hospital Care at Home initiative in November 2020, which allowed “certain Medicare-certified hospitals to treat patients with inpatient-level care at home.” The exception enables the waiver of requirements for round-the-clock nursing services on premises, among other requirements. Though the pandemic crisis has ended, the waiver has been extended until December 31.
The CMS waiver thus created a regulatory and payment pathway for hospitals to provide acute hospital at home services, and about 319 hospitals in 37 states have opted into the program as of mid-March, according to research by Chartis. Such programs are supported by advances in technology enabling remote care; health monitoring equipment that can seamlessly and continuously check patients’ vital signs; and the ability to provide diverse services and care in patients’ homes.
Appropriate care
Hospital at home care particularly shines in managing patients with acute illnesses and particularly those who are socially vulnerable. Research by Mass General Brigham published in the Annals of Internal Medicine earlier this year examined clinical characteristics and outcomes from 5,858 patients nationwide who received care at home under the CMS waiver, according to Medicare claims filed between July 1, 2022, and June 30, 2023.
Those patients had medically complex conditions – 42.5 percent had heart failure, 43.3 percent had chronic obstructive pulmonary disease, 22.1 percent had cancer, and 16.1 percent were diagnosed with dementia. The five most common discharge diagnoses were heart failure, respiratory infection (including COVID), sepsis, kidney/urinary tract infections and cellulitis.
Studies over the years have been able to show “pretty significant findings with respect to readmission cost (and) a whole bunch of outcomes that are important to patients, as well as clinicians, as well as the health system as well as society,” says David Levine, MD, clinical investigator for Brigham and Women’s Hospital and Harvard Medical School. When the pandemic upended the industry, “we were having extraordinary capacity crises in our facilities, we were able to really turn to our home hospital team in a big way to create capacity.”
While the pandemic provided an accelerant to the hospital at home movement, other factors are moving it forward. Many hospitals are operating at high capacity, says Colleen Hole, vice president of clinical integration and chief nurse executive for Atrium Health Medical Group. “Our hospitals are running at 110 percent to 120 percent occupancy in this market,” she says. “And Charlotte is a growing market, and we really can’t afford nor spend the time to keep building brick-and-mortar beds to manage the growth. Money and time are precious, and it doesn’t make sense to keep building beds. But we can deliver hospital-level care in the home and with the same – or in some cases, better – outcomes.”
Moving appropriate acute-care patients to their homes also may help reduce inpatient load factors that are leading to staff burnout, executives contend. Additionally, home acute care could offer more opportunities to expand the number of healthcare roles, which could draw clinicians back into care roles. However, executives note that home acute care, by itself, won’t reverse staff shortage and burnout trends.
Pioneers expand efforts
A variety of healthcare organizations are leading the industry with their hospital at home initiatives.
For example, the Kaiser Permanente Care at Home program is operating in four of the organization’s regions, says Vivian Reyes, MD, regional medical director of hospital operations for The Permanente Medical Group. She is the national physician lead for the initiative, which is expected to expand to all its regions.
“We began our hospital at home journey before the pandemic,” Reyes notes. Its program was designed to provide a sustainable model for the organization and meet patient preferences. “Something that is really important to us is that if we can admit patients into our program before they end up in a brick-and-mortar emergency department or in the hospital itself, then that’s better for the patient.” The Care at Home program was formed on suggestions gleaned from focus groups involving both patient and care teams.
Kaiser’s program builds on its existing integrated services or its extensive provider relationships in regions. Patients didn’t believe “that physicians needed to physically be in their homes to provide good, high-quality care,” Reyes says. Patients receive more holistic care because they sleep better and are safer in familiar surroundings. Quality metrics in the home have been as good, if not better, than for patients treated in hospitals. ”It’s a real win-win, because it’s better for the patient for them to be in their home surrounded with their family, their pets and generally just a good healing environment.”
At Mass General Brigham, the organization has been building its Hospital at Home program since a pilot research project about 10 years ago, Levine says, and though those positive results, “we were able to show our executive team that this was something worthwhile pursuing.” Growth of the program was further spurred by the pandemic and the organization now sees itself as “on a journey to become a national leader in developing hospital at home across the continuum of care,” says Heather O’Sullivan, president of healthcare at home for Mass General Brigham.
The organization’s hospital at home program has grown to provide care for about 40 patients daily, O’Sullivan notes, anticipating growth to 50 patients a day during this year. It’s logged 3,400 admissions to the program since November 2020, and about 19,000 inpatient bed days have thus been saved, she says. Patients who could benefit from the program are identified by a dedicated clinician and admission coordinator.
The program succeeds because, behind the scenes, it has a full array of social workers, physical and occupational therapists, pharmacists, dietitians and others, with care documented in the system’s Epic records system, enabling full visibility to care provided in patients’ homes. “Patients love it and ask for it again; they like the intimacy of care provided in the home,” O’Sullivan says. “And it’s satisfying to clinicians because they can see the improved quality outcomes.”
Patient satisfaction is also driving the Hospital at Home program for Atrium Health, a North Carolina-based integrated system operating in the Southeast. “Our patients love it, absolutely love,” says Colleen Hole, vice president of clinical integration and chief nurse executive for Atrium Health Medical Group. Just to back that up, the organization has produced an introductory video of patients gushing over the care they get and how they feel about it. Additionally, the program was featured in February on the NBC Nightly News as a potential solution to overcrowded emergency departments and hospital facilities.
Atrium’s program has grown methodically – it now delivers acute care to as many as 60 people a day, achieving reduced costs and readmissions, while boasting of the ability to provide care in the home for as many as 150 diagnoses.
Mainstays of the Atrium program are community paramedics, who provide routine visits into homes and can link in care from nurses and physicians, who also maintain contact with patients, often via virtual visits. The community paramedics “started life in most cases as EMTs (and have worked) almost a decade or two on an ambulance,” Hole says. “They're highly skilled in taking care of really sick people. So that technical expertise and knowledge coupled with the physicians and virtual nurses, really, we call it a three-legged stool. So they work really synchronously as a team and then undergirded by pharmacists, social work care management, physical therapists, you know, all of the other roles that you would see in a hospital most of which can be delivered virtually.”
The program has enabled Atrium Health to save approximately 35,000 bed days, Hole says, freeing up capacity for other patients. “Most health systems are struggling to find beds for patients, so they hold (them) in the emergency department for several hours, even days sometimes.”
Prospects and challenges
These and other hospital leaders see great potential for care at home programs to equitably provide care to patients in a variety of settings, enabling caregivers to have an unobstructed glimpse into the home situations of patients, giving them insights to address a range of needs that comprise social determinants of health (SDOH).
Also, patients who are aware of home acute care as an alternative say they prefer it, and such programs help enhance patient experience.
“We've also seen patients increasingly telling us how they want to receive healthcare, (but) we've built health systems, frankly, around us, meaning healthcare providers – the patient has to come to us to seek care,” says Hole of Atrium Health. “Increasingly, we're going to go to them, be it virtually or in person, which this (hospital at home) model uses both. We've got to find innovative creative ways to take care of sick people.”
The potential to assess SDOH needs and meet the needs of all patients raises the potential to improve equity in healthcare, executives contend. As the industry increasingly embraces value-based care reimbursement, the case for home acute care will become stronger, they say. Additionally, such programs also may enable better care delivery by community and rural hospitals, whose reach can be extended cost effectively by such programs.
“Community centers and community hospitals are an ideal place for home hospital care, because our bread-and-butter care happens there,” says Levine. And in terms of rural areas, “one in five Americans live in a rural area, that's over 60 million people. The majority of home hospital care has been delivered in urban and suburban areas.” Levine’s organization and Ariadne Labs – a joint center for health systems innovation at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health – have conducted the first rural home hospital randomized controlled trial. Results of the study are currently being analyzed, he says.
Despite the momentum, hospital at home programs still face several challenges that must be overcome for the programs to flourish. In particular, most current initiatives are small, dwarfed by inpatient capacity that measures capacity in the thousands of hospital beds for most healthcare organizations.
Standing up these programs requires executive support and patience, because hospital care at home requires a parallel alternative way of delivering care to patients. Some executives say it’s analogous to creating and standing up an entire separate department-level service line within a facility – rather than just thinking it’s spinning off a few in-house clinicians and some technology to make home visits on the side.
Scaling acute care at home programs also has proven difficult because of the cost and challenges of providing a wide range of typically in-facility services out in the community. Organizations such as Kaiser Permanente and Atrium Health say they have advantages because, in some regions, they directly control a variety of services that span the continuum.
Finally, because such programs need committed investment, healthcare organizations are looking to assure that reimbursement for such care will continue. Because payer organizations typically follow the lead of federal regulation, many healthcare executives are hoping for federal legislation that endorses payment for such care, especially as the CMS waiver enabling hospital-at-home services ends on December 31.
But organization executives are optimistic, saying they believe that home-based acute care offers a solid option for cost-effectively addressing capacity issues.
Building a hospital at home program that has an eventual goal of caring for 50 patients is still cost effective, contends Tom Kiesau, chief innovation officer and leader of digital and technology transformation for The Chartis Group. For organizations now at constant full capacity, “Your alternative is to build a 50-bed facility, which now has an average cost of $2 million per bed,” he said. “That’s a $100 million facility. With a hospital at home program, there’s less capital involved and a better unit cost on the back end. That’s the value.”
The best part, to Levine, is that the model can be replicated by all types of providers. “I think one of the biggest surprises has been to see organizations that don't really consider themselves to be innovative, or particularly on the cutting edge, actually really turn to this model in a really nice way,” he says. “They’ve been able to show that it's not magic, it's not rocket science. It's still really good bread-and-butter medicine, but it's being delivered in people's homes.”