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March/April 2013
Hospital at Home: Patient Care Model of the Future?By Jaimie Lazare Hospital at Home, a pioneering healthcare model, allows for acute hospital-level care to be provided to elders in the comfort of their homes. Caring for older adult patients in their homes has been shown to improve patient care and reduce healthcare spending. Additionally, at-home visits allow physicians to treat patients where they are most comfortable and assess their living situations. Since the 1940s, the number of physician house calls had continued to decline. In 1998, however, Medicare increased its reimbursements for house calls to about 50%, which incentivized an increase in the number of house calls performed by family practitioners, geriatricians, and internists.1 While the trend toward house calls continues to steadily increase, another program has taken the at-home patient care model one step further. Hospital at Home offers select patients the option to receive acute hospital care at home. Studies have reported that treating acutely ill older adult patients diagnosed with conditions such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) at home rather than in a hospital has many benefits. Hospital at Home has resulted in lower costs, shorter duration of hospital-equivalent treatment, fewer procedures, reduced geriatric complications, improved activities of daily living, and better patient and caregiver satisfaction.2-4 “Hospital at Home has been well studied. A new meta-analysis in the Medical Journal of Australia found a 24% reduction in readmissions for Hospital at Home and about a 20% reduction in mortality, which is really quite remarkable,” says Bruce Leff, MD, who developed the Hospital at Home model and is a geriatrician and professor of medicine at Johns Hopkins University in Baltimore. In fact, the number needed to treat (the number of people who need to receive a treatment to prevent one death) patients at home compared with the hospital is 50. This is remarkably low compared with other well-regarded treatments. For instance, 2,000 people need to take an aspirin daily for one year to prevent one nonfatal heart attack, he says. Home Sweet HomeStephen C. Acosta, MD, medical director of Program at Home at the Portland VA Medical Center in Oregon, says patients with COPD, community-acquired pneumonia, CHF, and cellulitis can be cared for in the home with appropriate screening from referral sources and can avoid hospital complications. This is important because the literature suggests that hospitalizing older adult patients rather than utilizing home care produces a higher incidence of urinary tract infections, hospital-acquired infections, and delirium. “The medical home is changing, and the paradigm is shifting now that we’re realizing there is a tremendous opportunity to provide better care in nonhospitalized settings. However, the majority of medical professionals still believe that delivering hospital-level care in somebody’s home is unsafe, yet that’s not true,” says Mark McClelland, DNP, RN, a nurse researcher at the Cleveland Clinic in Ohio. “We all know how unsafe hospitals are with infection rates and iatrogenic diseases, which are all well documented. This is a further impetus to develop alternatives to inpatient hospitalizations.” Many patients who are eligible for Hospital at Home comprise the aging demographic. Among elder hospitalized patients, there have typically been some well-documented side effects. “Getting admitted to the hospital often confuses patients and may cause delirium in hospitalized patients,” McClelland says. “Fewer Hospital at Home patients required a rehab placement after hospitalization than patients hospitalized as an inpatient. Patients admitted to their homes show increased functionality compared to patients that were admitted to the hospital.” Selection CriteriaThe criteria for choosing the right Hospital at Home patients started with a framework that hospitalized older people with many chronic conditions or comorbidities who are at greater risk for iatrogenic complications, functional decline, adverse drug reactions, delirium, and falls, Leff explains. “We did not want to exclude people from Hospital at Home because they had other chronic conditions. We think people with multiple chronic conditions are probably in many ways candidates for Hospital at Home because they tend to be most susceptible to problems that can develop from just being in the hospital,” he says. “A patient presenting to the emergency department with dementia, heart failure, COPD, osteoarthritis, and mobility difficulties would not necessarily be excluded from Hospital at Home,” he continues. “Rather, the exclusion criteria are related more to a patient’s acute status. On the inclusion side, your older adult patient needs to have a Hospital at Home condition that requires a hospital admission. But patients are excluded if their acute illness is so severe that they require hospital care. If your older adult patient is in shock or having a heart attack, then he isn’t a good candidate for Hospital at Home and will require usual inpatient hospitalization.” Patients whose conditions require extensive testing and several complicated procedures are unlikely to be considered as candidates for Hospital at Home. “We don’t want people who need to be in an intensive care setting, who are likely to be unstable and may need to be transferred to an intensive care unit setting, or who are going to have hospital courses that are very technically intense,” Leff notes. “So we’re trying to find people who are not going to need several MRIs, CT scans, multiple biopsies, and other procedures; we want people who need to be in the hospital but are likely to have a less intensive course. The selection criteria we developed and validated really have been very good at identifying those people.” Other factors enter into patients’ consideration for treatment in their homes. “In addition to the medical criteria, there are certain other criteria, more social criteria in terms of the suitability of the home environment for Hospital at Home. So patients need to have a house or dwelling with a roof, climate control, and running water,” he says. Added AdvantagesMcClelland says the Hospital at Home model provides physicians, caregivers, and other healthcare professionals with an option to enjoy working in an environment different from a hospital. “Imagine a primary care setting where physicians are able to spend half of their time seeing patients in the office and then the other half of the time seeing hospitalized patients in their homes. Many nurses would also be very attracted to this acute level of care, which up to now is only in the hospital.” He notes that while for more than 70 years hospitals have been the epicenter of the healthcare industry, Hospital at Home will help to reshape this concept as it augments primary care. Acosta says Hospital at Home provides physicians with a tremendous opportunity to interact with patients. “You find out things in their homes that you never would’ve picked up in the hospital. You also realize the limitations that people have when they’re hospitalized and the patients’ needs when they’re transitioned back home,” he says. “You see how people function, why things don’t get done, why the system doesn’t work for people, and why things do work out great—easy things you never see working in the office. But the flip side to that is that it takes time; you can’t do a house call in two minutes.” “Physicians should understand that adopting Hospital at Home is like building a new kind of system for their hospital. What we have found is that adoption of the model is driven by local hospital, health system, and payer considerations,” Leff says. Acosta notes that Hospital at Home is not geared toward volume. “It would be geared best for people who use the system immensely, and that goes both for the VA and Medicare. Older adult patients will benefit from the Hospital at Home model as opposed to people who require general healthcare,” he says. McClelland notes that physicians need to initiate dialogue if they are interested in learning more about instituting Hospital at Home. “Physicians need to begin to talk and to establish a dialogue with their home-care community and to find out what the capacity is in their home-care community. Home healthcare organizations have very strong relationships with their hospital partners, so establishing Hospital at Home is going to be a partnership between a hospital and a home-care agency. Because Hospital at Home will be driven from the home-care world, I would encourage physicians to reach out to home-care providers to find out what they’re doing,” he says. Footing the Bill“My connection with Hospital at Home began when the Centers for Medicare & Medicaid Services [CMS] released the healthcare innovation challenge. They were giving huge amounts of money for the development of innovative care delivery models. I felt that Hospital at Home fit that bill nicely,” McClelland explains. “So working with Presbyterian Healthcare Services in Albuquerque, New Mexico, I put in a $19 million grant application to CMS. What we were going to do was expand the Hospital at Home program to five different locations across the United States. Through a series of solicitations, we recruited five partners across the United States who were committed to implementing this model. Unfortunately, that’s where the story ends because CMS did not fund my grant application. “Hospital at Home is, in my opinion, a model that is waiting to happen, and it will happen. It has been used internationally throughout Europe for 10 years now, and there have been different variations. It hasn’t taken off in the United States primarily because the third-party payers don’t recognize it because they don’t have payment codes,” McClelland adds. The economic implications of implementing the program offer compelling results. “The concept of avoided hospital admissions really works economically in a socialized system like the VA and Kaiser [Permanente], where saving cost in terms of hospitalizations makes fiscal sense for the organizations, unlike private hospitals that depend on admission, health insurance, and Medicare money,” Acosta says. He explains that McKesson, a healthcare services and IT company, has a proprietary set of admission and hospitalization criteria called InterQual. “InterQual criteria are used by probably 85% of the country’s hospitals, but the criteria do not determine the actual payment. Nonprofit hospitals also use InterQual, but all hospitals that are not part of a socialized system like HMOs or the VA make decisions based on a fee-for-service model,” he says. “The Portland VA Medical Center is operating on its own budget and through the Hospital at Home program, we have saved the medical center in terms of soft savings over $700,000 in 2011. So the program pays for itself,” Acosta says. “But in terms of following a cohort of patients with multiple admissions in the past and comparing the costs between Hospital at Home and hospital costs, we have not done that analysis yet.” Right now there’s no mechanism to pay for Hospital at Home in a fee-for-service environment, Leff says. “Medicare will pay for a hospital stay, an office visit, a physician house call, and for home healthcare, but there’s no payment code in Medicare for Hospital at Home. If you live in a fee-for-service world, this is a very difficult model to underwrite. If you’re in an integrated delivery system or managed care environment, then the model makes a lot more sense,” he says. “For instance, we’ve had a number of adoptions of the model in the VA healthcare system. The VA is basically a managed care system where medical centers get global budgets, and then they have to figure out how to spend that money. Every dollar that they save falls straight to their bottom line. It’s also a really nice fit for integrated delivery systems,” Leff adds. “Presbyterian Healthcare Services, which adopted the model, has Medicare Advantage, a Medicare managed care product. They have their own health plans for people they insure. Since they are in a situation where the hospital is running a little bit above capacity, they are able to provide Hospital at Home for their health plan patients,” Leff explains. “They were able to save money on those people who would’ve gone to the hospital who now go to Hospital at Home. They found that they had a 19% savings. Those patients who would’ve gone to the hospital but did not left beds open for Presbyterian to take care of other patients who might’ve been fee-for-service patients. “We’re most proud of the fact that we approached this initially as geriatricians who were most interested in improving outcomes and results for our patients,” Leff says. “We started with the observation that older adults who go into the hospital often come out worse for the wear because of the hospital environment, and we have proved that providing hospital care in the home for some of those patients results in better outcomes for patients and cost savings.” — Jaimie Lazare is a freelance writer based in Brooklyn, New York.
Ready for Hospital at Home?Organizations seeking to adopt innovative care models often need to develop new systems and roles while overcoming resistance to change. To successfully implement Hospital at Home (www.hospitalathome.org), you need to ensure that the conditions at your facility are right and that needed resources are readily available. Ask yourself the following questions:
If you answered yes to one or more of these questions, then Hospital at Home may be appropriate for your organization. — Source: Hospital at Home
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