Taking the hospital out of hospital care


Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD

With retail health clinics popping up left and right, the delivery of care is leaving the confines of the physician’s office and heading for shopping plazas and storefronts. Now hospital care is also on the move and changing venues.

We are seeing several models for the delivery of hospital care outside the traditional setting. Convenient care clinics, such as those housed in retail pharmacies and staffed by nurse practitioners, handle health problems like diagnosis and initiation of treatment for infections. Freestanding emergency departments provide 24-hour emergency care like a hospital-based emergency department, but many of them provide services beyond treatment of the acute episode so patients can return to the facility for follow-up care if need be. Urgent care centers occupy the middle ground: They are for patients who are too ill or injured for the convenient care clinic, but not sick or injured enough to need full-fledged emergency department-type care.

Richard G. Stefanacci, DO

Richard G. Stefanacci, DO

Today’s portable equipment and rapid electronic transfer of data is also making it possible to deliver hospital care in the home—the 21st century version of the old-fashioned physician house call.

The Hospital at Home program, developed by the Johns Hopkins Schools of Medicine and Public Health, has been getting a lot of attention. It provides hospital-level care in a patient’s home as a substitute for inpatient hospital care and has been utilized by health systems across the country and is covered by several health insurance plans as well. Hospital-at-home programs have been designed primarily to avoid admissions in the first place, although decreasing length of stay is also a goal.

One study of a hospital-at-home program showed that it was 32% less costly than traditional hospital care.

Some data show that the out-of-hospital follow-up care saves almost 20% compared with care given in a hospital. And outcomes? These patients show comparable or better clinical outcomes compared with similar inpatients, and they show higher satisfaction levels. A 2012 Cochrane review of hospital-at-home treatment of patients with acute exacerbations of COPD found that the strategy reduced readmissions and mortality rates. Another study found between 21% and 37% of patients with acute exacerbations of COPD who go to the ED may be eligible for hospital-at-home care.

Subacute units inside nursing homes are another example of hospital care delivered in a nontraditional setting. Typically, entry to these units requires a three-day acute care hospitalization under Medicare fee-for-service rules. But Medicare Advantage plans, realizing the benefits of providing easier access to this level of care, are allowing admission without any hospital stay.

In some cases, the subacute unit avoids admission to the hospital by providing such services as intravenous medications with 24/7 nurse monitoring, which saves money and should be far less disruptive to patients and their loved ones.

The savings resulting from this shift of care outside of the hospital to these alternate sites for initial assessment and treatment can be significant. The most significant reductions in spending come from the shift in hospital care to the home and nursing home setting. One study of a hospital-at-home program showed that it was 32% less costly than traditional hospital care.

Health systems today are taking on greater financial risk for the care they provide. Of course there will still be a need for traditional hospital care. But these new models for delivering hospital care outside the hospital will become more common and accepted as the incentives for health systems change.

The faster we get away from a health care system geared toward volume and “heads in bed” to one that improves population health, the better.

Richard G. Stefanacci, DO, MGH, MBA, is a member of Managed Care’s Editorial Advisory Board. He worked as a health policy scholar at CMS. He is currently chief medical officer of the Access Group, a health care consulting company. He is also an associate professor at the Jefferson School of Population Health.