A concept that challenges the conventional wisdom that the hospital is the best site of care for acutely ill patients has passed a real-world examination by New Mexico’s largest provider of health care, Presbyterian Healthcare Services. Its two-year study of Hospital at Home shows what you can accomplish when you keep sick patients in their own homes instead of admitting them to a hospital for acute inpatient care.
For starters, provided the patients receive high-quality hospital-level care at home, you get savings of 19 percent compared with traditional inpatient care for carefully selected patients, such as those experiencing exacerbations of chronic obstructive pulmonary disease (COPD) or heart failure (See “Primary Diagnoses of Patients Admitted to Hospital at Home,”).
And you get comparable and sometimes better outcomes, too, along with happier patients. Administrators at Presbyterian published their findings in the June 2012 issue of Health Affairs.
Bruce Leff, MD, an internationally known geriatrician and co-author of the Health Affairs article, has been refining and championing Hospital at Home with his colleagues at Johns Hopkins University School of Medicine for nearly two decades.
“It’s nice to see something you’ve been thinking about in your office for a long time finally bubble up and affect people in a positive way,” he says.
“Our work initially was inspired by two observations,” Leff says. The first was that some patients who truly needed hospital care would refuse to go. They gave many reasons — the food, the way patients are treated in a hospital, their fear of developing complications.
“The second was that we saw many patients who had been admitted to a hospital and should have been easily treated but came out much worse for the wear. They’d develop delirium, they’d fall, they’d experience adverse drug reactions, they’d acquire nosocomial infections. This made us leery of putting patients in the hospital.”
So they started looking for a better way.
After developing and testing the concept in the middle and late 1990s, in the early 2000s Leff and colleagues conducted a national demonstration and evaluation study of the Hospital at Home concept and published the results in Annals of Internal Medicine. In contrast to earlier models that looked at outpatient intravenous infusion as an alternative to inpatient infusion or that compared early discharge with longer stays, Leff’s pilot program was the first in the United States to completely substitute care in the patient’s home for acute inpatient care. Intrigued by the article, executives at Presbyterian decided to pursue Hospital at Home to see if it would benefit its members. At first, Hospital at Home was open only to Medicare Advantage and Medicaid patients covered by Presbyterian Health Plan, but it later was opened to people with commercial coverage.
An integrated health care system, Presbyterian offers a nurturing fiscal environment for Hospital at Home. That is, in an integrated system, hospital administrators have an incentive to keep patients out of their beds. Elsewhere, however, most hospital administrators in the fee-for-service world remain eager to fill their beds. One person’s savings is another person’s lost revenue. Increased bundled payments and capitation will change the incentives.
Leff’s work now is focused on disseminating the model, whose use requires payment of a licensing fee. So far, besides Presbyterian, the concept has caught the attention of the Veterans Health Administration, which has Hospital at Home programs at medical centers in Oregon, Louisiana, Pennsylvania, Connecticut, Idaho, and Hawaii. Programs also have been launched in Canada, Israel, the U.K., and Australia. Leff says he’s working with several other integrated health systems in the western United States, and safety net hospitals in the South, to help them implement Hospital at Home.
In the state of Victoria in southeastern Australia, a Hospital at Home program (Down Under, they call it Hospital in the Home) has been offered as a voluntary alternative to inpatient care at public hospitals since the 1990s. An official there claims that without Hospital in the Home, Victoria would have needed a new 500-bed hospital by now, at a cost of $500 million to $1 billion (Montalto 2010).
One important place where the idea has been slower to catch on, however, is in the corridors of the Centers for Medicare & Medicaid Services (CMS). Given the number of Medicare-age Americans with common conditions that might be amenable to Hospital at Home (see the graph below), you might think CMS would be eager to apply the concept to high-cost Medicare enrollees to reap major savings. That hasn’t happened yet.
“Lots of people at CMS know about our work, but there’s a certain hesitation on their part to create new payment codes [to enable traditional Medicare to pay Hospital at Home],” Leff says, adding that regulatory definitions of “hospital care” are also a factor. “We could have the same outcomes here as in Australia,” he says, “because the evidence supporting Hospital at Home is far more robust than the evidence for other programs that are reimbursed and other innovations that CMS is currently championing.
“Why CMS is so slow to move on this is a mystery to me. There is, in my view, an attitudinal bias that favors facility-based care rather than community-based care, i.e. Hospital, good! Community, less good!”
Leff is optimistic that Hospital at Home will be adopted more rapidly by other parts of the United States health care system. “Whether they realize it yet or not, accountable care organizations (ACOs) have a strong incentive to adopt this model,” he says. “They should be doing it sooner rather than later.”
A section of the Patient Protection and Affordable Care Act (ACA) addresses ACOs, which can include hospitals, as they apply to Medicare fee-for-service beneficiaries. Now that the act has survived Supreme Court review, and assuming that it remains unaffected in the aftermath of the election, perhaps ACOs and ACO-like entities will experience a growth spurt and adopt Hospital at Home to generate some of the shared savings they are supposed to enjoy.
But this model does not depend on the ACA.
Patients eligible for Hospital at Home, Leff says, need to be in a hospital but don’t require high technology or specialty consultation and meet previously developed and validated medical safety criteria. He and his co-authors attribute the 19 percent reduction in costs for caring for such patients at home to shorter lengths of stay (mean LOS 3.3 days vs. 4.5 days for an inpatient comparison group) and fewer tests. Leff says the shorter LOS was largely a consequence of less unnecessary testing.
“Typically a patient who is admitted to a hospital is seen by multiple specialists. One of them notices that a certain test hasn’t been done in a while and decides to do it. A vicious circle follows with these supply-sensitive services, with testing leading to more testing without improving outcomes. In Hospital at Home, an MRI, say, can be arranged if a patient needs one, but being away from the technology leads to more appropriate use of it,” Leff says.
He suspects that improved outcomes — fewer falls, less mortality — seen in Hospital at Home patients in comparison with inpatients (See “Comparable or Better Outcomes Achieved with Hospital at Home,” below) stem from many factors.
“Bad outcomes in older patients come from multiple causes,” he says. “For example, the lower rate of falling could be due to a 75 percent reduction in delirium, keeping patients in a familiar environment, and enabling them to retain muscle function.” A suspected but not-yet-proven reduction in nosocomial illnesses may lie behind the lower mortality rate seen in the Hospital at Home patients, he says.
Since the publication of the Health Affairs article, Presbyterian has been deluged with requests from hospital administrators nationwide for more information, according to Scott Shannon, director of finance for home health care. Some want to come onsite, while others are content with a telephone chat to determine whether Hospital at Home would be feasible at their institution. In fact, requests for information have been so voluminous that Presbyterian has had to resort to a form of triage to deal with all of them.
Melanie Van Amsterdam, MD, is the lead physician for Hospital at Home and Medical House Calls at Presbyterian. The latter cares for patients who are homebound for any reason. Physicians who serve the Hospital at Home population also make medical house calls. Van Amsterdam says the physicians who are most comfortable working in these programs are independent thinkers with experience in treating indigent patients or patients in rural settings. Those whose comfort level is lowest are hospitalists, she says, primarily because they’re separated from the onsite support system to which they have become accustomed.
Physicians who thrive in these programs also have to be comfortable with a substantial amount of daily travel, Shannon notes. Albuquerque is a mixed urban and rural environment; physicians need to drive 30 to 70 miles per day to see their patients.
On the other hand, what they don’t need to do is to make after-hours calls or unplanned calls. During the two-year study period, there were only 15 nursing visits and three physician visits of this nature, most of them early in the study. Van Amsterdam attributes these low numbers to good patient selection and high-quality care provided by nurses and physicians during scheduled visits.
“We try to preempt unplanned calls,” she says. “If I see a patient in the morning whose condition is deteriorating, I will schedule a nursing visit for that afternoon to make sure the patient is stable throughout the night.”
More general keys to success are having an integrated health plan, an existing home care program, support from high-level administrators, and a funding source, Van Amsterdam and Shannon say.
It also helps to have willing vendors — the providers of durable medical equipment and mobile diagnostics.
“The vendors know they won’t make a lot of money, but they want to be associated with Hospital at Home nonetheless,” Shannon says. “It’s prestigious, and their involvement lets some get a foot in the door so they can serve some of our other programs.”
Van Amsterdam says vendors’ involvement with Hospital at Home also helps them improve their customer service because they receive direct feedback from physicians, who usually don’t interact with vendors.
Looking back on her hands-on experience in providing hospital-level care for patients in their own homes, Van Amsterdam says her greatest surprise is that the program has succeeded.
“I’m not the kind of person who thinks a lot about where my career will be in five years,” she says. “When Hospital at Home began, I thought, ‘This will either be the best experience or the worst experience of my career.’ But now I say, ‘Wow! I still have a job, and it’s going well.’”
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