Some hospitals are looking to build a new ward … in the patient’s home

by Summer Knight, M.D., MBA, consulting managing director, Deloitte Consulting LLP

As COVID-19 infections began to increase in my community outside of Philadelphia, my 92-year-old father-in-law developed a blood clot in his leg. While a clot can be extremely serious, we didn’t want to risk exposing him to the virus nor did we want to further stress our local hospital. Instead, after working through the details with his medical team, we chose to provide him with hospital-level care at home…also known as hospital@home (H@H).

At its most basic level, H@H is the concept of identifying people who are candidates for admission to the hospital and admitting them to their home where they receive the same level of quality, acute care. This high-level of care can take place in a variety of ways combining virtual check-ins with medical staff, remote monitoring of vital signs, video interactions, and onsite visits from nurses or other clinicians. To be clear, H@H is not an expansion of conventional home health. Rather, it is a redefinition of acute patient care. Think of it as a virtual hospital ward.

H@H has multiple benefits for a wide range of stakeholder groups, and we have known about the benefits for decades. For health care consumers, H@H results in higher patient satisfaction, lower infection rates, and better outcomes, per Bruce Leff, M.D., director of the Center for Transformative Geriatric Research at Johns Hopkins University School of Medicine, who launched and studied an H@H program in the 1990s.¹ For many elderly patients, hospitalization can mean being at higher risk for falls, delirium, and functional decline. The health care system can experience lower costs by eliminating the fixed facility costs of a hospital room. H@H can also make it possible to quickly expand bed capacity in situations such as surges.

COVID-19 has renewed interest in an old idea

H@H is not a new idea. Back in the days of horses and buggies, clinicians made house-calls and supported family members as they cared for patients in their homes. Over the years, acute care transitioned out of the home and into hospitals. Despite Dr. Leff’s findings, the idea never took root. Medicare and many private health plans didn’t cover hospital-at-home services, and technology was still a few steps behind.

The idea of providing hospital-level care in the patient’s home recently began gaining traction among providers and payers as COVID-19 illustrates how quickly a hospital can reach capacity in some hotspot areas. A recent study found that the cost of an acute care episode for H@H patients was 38 percent lower when compared to patients who received care in the hospital. H@H patients had far fewer lab tests, imaging studies, and consultations, and they also spent less time being sedentary in a bed. Moreover, fewer were readmitted to acute care after 30 days than hospitalized patients. ²

Although H@H programs are typically rare and the concept is just beginning to gain traction, some health systems have seen positive results:

• Presbyterian Healthcare Services in Albuquerque launched its H@H program in 2007. Patients are seen each day by a physician and nurses visit twice a day. The in-person visits are supplemented by video monitoring. The program, which is available to Medicare Advantage and Medicaid patients with common acute care diagnoses such as dehydration, urinary tract infections, deep vein thrombosis (DVT, like my father-in-law), cellulitis, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and community-acquired pneumonia, resulted in savings of 19 percent over costs for similar inpatients.^{3, 4} These savings were predominantly derived from lower average length-of-stay and use of fewer lab and diagnostic tests compared with similar patients in hospital acute care.
• New York’s Mount Sinai received a $9.6 million grant from the Center for Medicare and Medicaid Innovation (CMMI) to set up a three-year hospital-at-home demonstration project. In 2017, after the project concluded, Sinai proposed a hospital-at-home payment system, which was approved by Medicare’s Physician-Focused Payment Model Technical Advisory Committee, which recommends payment models to CMS.⁵  
• Brigham and Women’s Hospital (BWH) conducted a first-of-its-kind patient randomized controlled trial to study the efficacy of H@H. Researchers found that patients had, on average, 52 percent lower direct costs; three lab orders, compared with 27 for patients in the hospital; and imaging rates of 5 percent, compared with 50 percent for patients in the hospital.⁶ Like Presbyterian, BWH programs are limited to patients who have pneumonia, heart failure, chronic obstructive pulmonary disease, or infections.

Regulatory flexibility could open more front doors

On March 30, in response to the COVID-19 pandemic, the US Centers for Medicare and Medicaid Services (CMS) said it would temporarily allow hospitals and health systems to provide care outside of traditional facilities. The agency said it would allow virtual check-ins between a patient and their doctor by audio or video device. Previously, such check-ins were only available to patients who had an established relationship with their doctor under specific conditions. Clinicians can also provide remote patient monitoring services for patients, no matter if it is for the COVID-19 disease or a chronic condition. For example, remote patient monitoring can be used to monitor a patient’s oxygen saturation levels using pulse oximetry, according to CMS.

While there were a few H@H programs in place at the end of 2019, we have seen a significant uptick in interest, planning, and implementation of new programs. Some programs were already underway or being piloted while others were spurred forward due to the changes in telehealth laws due to capacity concerns related to COVID-19 surges.

H@H layers multiple capabilities

I predict that in the future, rather than building a new hospital wing, some forward-leaning organizations will build (or work with vendors to build) integrated hospital-at-home programs. While cost-effective, these are often complex programs requiring logistics of supplies, staff, and specialists. A H@H program typically requires a layering of seven capabilities: 

1. Workforce readiness: Align clinicians and staff to support and advance virtual offerings with a focus on improving quality, patient experience, and cost effectiveness. Hospitals will likely need both a highly coordinated virtual team and in-person team.
2. Clinical pathways and protocols: Moving patient care from a hospital to a home typically requires training clinical staff to reorient the provision of clinical pathways and processes for care delivery. 
3. Technology, infrastructure, and integration: Launch a scalable technology infrastructure to support the core of H@H. Integrate multiple systems, vendors, providers, and logistics. Ensure medical grade broadband connectivity to home that allows for the provision of virtual health tools for near real-time transmission of data and tel-video capabilities.
4. Supply chain: Make certain that each patient’s home has all the necessary medical equipment and supplies so that a nurse or family member can properly care for the patient. Often the most significant challenge is the need for a layered supply chain that supports initial supply drop for the diagnoses, specialty care, and urgencies.
5. H@H command center: Enable on-demand staff 24/7, real-time condition monitoring and management, service coordination, and network technology health analytics and monitoring. A command center should receive input from all sources including patient monitoring, transport, supply chain, specialists, and virtualists. Along with being able to receive data, the command center should also be able to act upon it.
6. Cognitive and analytics: Leverage innovative data-science techniques to generate meaningful insights on identification, stratification, intelligent routing, geospatial mapping, population health management, condition monitoring, and measuring outcomes.
7. Governance: Engage and align leadership. Identify medical policy issues that should be addressed to help ensure the appropriateness of admissions and discharge. 

COVID-19 is pushing us to consider not only new ideas…but also old ideas in new ways. The invisible virion that is causing a global impact has likely permanently disrupted health care. The pandemic is helping to change the belief that patients and clinicians have to interact in person for care to be effective. As with another virtual and digital programming, the COVID-19 pandemic appears to have accelerated interest in H@H programs, and the pace of adoption could move forward years sooner than we had initially predicted.

Most of my friends and colleagues know my mantra—humanizing health care is the future of health care. H@H could become an important part of the care delivery transformation and move us toward that ideal humanizing health care state. (My father-in-law, by the way, is doing great and back to living independently.)  

We would like to hear your opinion. As mentioned above, H@H programs thus far in the US have admitted patients with well-known diagnoses because clinicians understand how these diseases progress and how the body behaves during acute events. There are conflicting ideas about whether COVID-19 patients should be admitted to H@H programs. What is your perspective?

Endnotes

^{1.        Hospital at Home programs improve Outcomes, Lower Costs But Face Resistance from Providers and Payers, The Commonwealth Fund}

^{2.        Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial, Annals of Internal Medicine, January 21, 2020}

^{3.        The Hospital at Home Model: Bringing Hospital-Level Care to the Patient, The Commonwealth Fund, August 22, 2016}

^{4.        Costs for 'hospital at home' patients were 19 percent lower, with equal or better outcomes compared to similar inpatients, National Center for Biotechnology Information, June 31, 2012}

^{5.        Inside Mount Sinai’s Hospital-at-Home Program, Harvard Business Review, May 10, 2019}

^{6.        Hospital-Level Care at Home for Acutely Ill Adults: a Pilot Randomized Controlled Trial, Annals of Internal Medicine, January 21, 2020}

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