Sep 01 2022

Roundtable: What’s the Future of At-Home Acute Care?

Healthcare leaders with experience in providing acute care at home are weighing in on the growth and future of these important programs.

Hospital-level acute care provided at home is not a new concept, and in parts of the world with single-payer healthcare systems, models have existed for decades. In the U.S., Johns Hopkins Medicine has pioneered the "hospital at home” model since the 1990s, but programs were still limited for decades after.

In 2020, as a response to the flood of patients into hospitals due to the COVID-19 pandemic, the Centers for Medicare & Medicaid Services issued waivers to support hospital-at-home acute care, opening the gates for hundreds of healthcare systems to implement such services.

Though the CMS waiver is expected to expire at the end of the public health emergency, healthcare leaders are looking to Capitol Hill to step in to protect the gains made in supporting at-home acute-care programs.

To fully understand how hospital-at-home programs have fared at different healthcare organizations, HealthTech spoke to these leaders on lessons learned so far and the future of the model: Dr. Elizabeth De Pirro, medical director of Hospital at Home at Presbyterian Healthcare Services in Albuquerque, N.M.; Dr. Grace Jenq, associate chief clinical officer for post-acute care at Michigan Medicine in Ann Arbor, Mich.; Dr. David Levine, medical director of strategy and innovation for Brigham and Women’s Home Hospital in Boston; and Dr. Ania Wajnberg, a hospice and palliative medicine specialist at Mount Sinai Hospital in New York.

HEALTHTECH: Why and when did your organizations start implementing a program for acute care at home?

De Pirro: Hospital at Home started in 2008. At that time, New Mexico had very few hospital beds per capita relative to the rest of the U.S. One of the motivators was trying to find other means to provide hospital-level care for patients who met hospitalization criteria.

Jenq: In 2018, Blue Cross Blue Shield of Michigan approached us and asked what we thought about a program that would provide hospital care in the home. We thought it was a great idea. Over the past several years — and it does take years — we’ve built the infrastructure needed to execute the Hospital Care at Home program.

    Dr. David Levine quote

    Levine: We started the Home Hospital over seven years ago as a research study; we wanted to search for evidence that it was the right care model. We completed the first randomized, controlled trial in the U.S. back in 2016 and relaunched a larger trial in 2017-18, with successful results both times. That helped the model take off.

    Wajnberg: Mount Sinai has a very long history of providing care in the home setting, but not necessarily acute care. On that knowledge base, we began Mount Sinai at Home with a grant through the Center for Medicare & Medicaid Innovation. Our vision was always to improve patient care, reduce hospital complications, improve patient experience and hopefully reduce cost — the last not as the primary purpose, but for sustainability.

    HEALTHTECH: What was the impact of the ­pandemic on your program?

    Wajnberg: The CMS waiver was obviously a game changer, enabling more hospitals to explore practical models for treating sicker patients at home. Also, the huge explosion in telehealth made the idea of it, and the ability to scale through it, more palatable to both providers and patients. That allowed us to do more than we ever had before.

    Levine: When the first surge hit Boston in early 2020, we weren’t caring for COVID-19 patients. We kept doing what we do well, which is to take care of general-medicine patients. We got patients out of the hospital who needed hospital-level care, and we made room for COVID-19 patients.

    De Pirro: The CMS waiver expanded the program to a much wider population. We had to figure out how to care for these patients in a way that Medicare could look at them, from a computer or paperwork point of view, as though they were in the brick-and-mortar hospital.

    READ MORE: Is hospital at home the future of healthcare?

    HEALTHTECH: Has technology made programs like yours possible in ways they weren’t in the past?

    Levine: It really depends on the kind of patient. If a patient has to be on a continuous cardiac monitor, you need to bring that monitor into the home and transmit that data in near real time. As we begin to treat more kinds of conditions at home, we’re using more technology such as biometric sensors, point-of-care imaging and point-of-care laboratory diagnostics.

    Jenq: This program wouldn’t have been possible 10 years ago; the technology that existed was too awkward. More technology for remote monitoring is available now, and the cost is becoming much more reasonable.

    Wajnberg: The impact of technology falls into two categories. One is optimizing the monitoring capabilities, which allows us to provide better care for patients and to accept different types of patients. The second piece is scale. Home-based care is very staff-intensive. Telehealth can help with scale and efficiency for these programs very directly.

    De Pirro: Video visits certainly allow us to care for more patients. Also, as part of the expansion of our Complete Care program, which serves elderly patients with multiple comorbidities, we’ve started remote monitoring. Having a robust remote monitoring system allows you to serve patients who are a little sicker than you could before.

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      HEALTHTECH: Were there infrastructure ­challenges in creating your program? How important is ­technology to your programs?

      De Pirro: Our IT collaborators spent a lot of effort and time developing a virtual hospital in Epic to accommodate the hospital-at-home model. Getting the pharmacy piece to function appropriately, so that we were tracking and documenting everything, was one of the biggest technology challenges. Medication management is an integral part of hospitalization, and it has to be in home care too.

      Jenq: IT is absolutely essential. Our IT team created the Care at Home platform within Epic. We’re trying to use artificial intelligence to help providers identify patients eligible for home care. IT built systems for putting in orders and routing them for documentation and billing purposes. The technology used in the hospital to ensure patient safety, such as preventing drug interactions, had to be built for Hospital Care at Home. And without our patient monitoring kit or an electronic medical record, it would be impossible to achieve a program like this.

      DISCOVER: 4 considerations for the future of hospital-at-home programs.

      HEALTHTECH: What has the feedback been from providers and patients?

      Wajnberg: A lot of support has to be there to make this model work well — medication deliveries, oxygen deliveries, technology and connectivity — things doctors don’t have to think about in a hospital setting. There’s definitely a learning curve, but our providers are excited to be part of something new. It doesn’t happen that often in healthcare that you get to build a new model. Generally, the patients are thrilled to be home instead of in the hospital — readmissions go down, complications go down. We’ve measured, for example, delirium, medication errors, falls, pressure ulcers, all the things you look at in a hospital setting, and all of those were reduced.

      De Pirro: We’ve learned that appropriate providers for a home-care program tend to be doctors who have a primary care background. On the other hand, nurses who have more hospital experience do very well in this setting. All the providers love the fact that there is more time to spend with the patients. The feedback from patients has been almost unanimously excellent. They love being home. Research shows that patients tend to eat better and be more active at home than in the hospital. All of that is reflected in our low readmission rates.

        Dr. Ania Wajnberg quote

        Levine: Home Hospital patients report very good experiences, not only quantitatively, but also qualitatively. They have a locus of control in the home. They’re more comfortable there. Our clinical teams say it’s one of the most authentic, refreshing types of care they’ve ever delivered.

        Jenq: Over 70 percent of patients either strongly agree or agree that this is something they would recommend to their own family. Providers are equally happy, especially about the level of close monitoring that we’ve been able to provide.

        HEALTHTECH: What are the major obstacles to wider adoption of the hospital-at-home model?

        Levine: Regulatory and payment issues are the biggest hurdles. The two bills in Congress that would extend the Medicare waiver beyond the public health emergency would give us more time and data to understand the implications of the hospital-at-home care model.

        Jenq: Often, patients and families don’t even know that there’s this option; we need to get the word out. There are also barriers with providers. Emergency room physicians, hospitalists, oncologists, surgeons — for them to relinquish control and let other people take care of their patients in another setting isn’t easy. The third major hurdle is how you scale it up to manage all the pieces that need to come together for safe and effective care in the home. How do you do that for 100 patients versus 10?

        Wajnberg: One big hurdle is making this model more widely available as an insurance benefit and option for patients. The other is building the infrastructure to support these services.

        EXPLORE: How the future of smart hospital strategy brings care to the home.

        Chris Gash/Theispot

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