Hospital @ Home

More and more providers are turning to acute care in the home. But how effective, and safe, is the new model?

---

February 2022 – The Journal of Healthcare Contracting

---

By Graham Garrison

When Bruce Leff, MD, is in his office space at Johns Hopkins seeing an older adult who is acutely ill, he thinks very hard on whether hospital admission is the best choice. “I know I can take care of the heart failure, or the pneumonia, or anything else,” he said, “but will they end up worse for wear, just by virtue of having been in the hospital?”

It’s a question hospitals and health systems have been grappling with for decades, including Johns Hopkins. And it’s one that came front and center during the pandemic as providers, strained by volume and workforce shortages shifted to new models of care.

Researchers started to think about the ability to provide acute hospital-level care in the home, instead of the bricks and mortar hospital in the mid-90s. Questions they asked themselves included: Who should be treated in Hospital At Home? What conditions? How do you choose the right patients?

“You want patients who absolutely meet threshold requirements for an inpatient hospital stay, but they’re not so sick that they need an ICU or have a high risk of deteriorating during the hospital stay, so we developed those kinds of criteria,” said Dr. Leff, professor of medicine and the director of the Center for Transformative Geriatric Research at the Johns Hopkins University School of Medicine.

Johns Hopkins conducted early studies on whether patients would actually sign up for this kind of care, and it seemed that they would. Anecdotally, researchers knew that many older adults refuse to go to the hospital if they can avoid it.

“There’s a very robust literature to suggest that the hospital is not always the most hospitable environment for older adults,” Dr. Leff said. Older adults can develop confusional states in the hospital, like deliria. It can cause long-term cognitive outcomes. “They develop more functional impairments, because it’s hard for them to get out of bed, and then they end up in a nursing home. They fall out of bed, they get nosocomial infections, all of that.”

Researchers at Johns Hopkins did some early clinical trials of Hospital At Home, and reported that patients did well with clinical, economic and positive patient experience outcomes. Back then, there was no fee for service payment for Hospital At Home. Johns Hopkins tried unsuccessfully to get a payment waiver from CMS to pay for Hospital At Home in fee-for-service Medicare in the mid-late 90s, but was unsuccessful. So, they pursued larger studies with Medicare Advantage plans and the VA. Within 2014, a Center for Medicare and Medicaid Innovation demonstration of Hospital At Home was conducted at Mount Sinai in New York. “Again and again, it proved out all the basic hypotheses we had about Hospital At Home,” Dr. Leff said. People opted in at high rates, there was better patient and caregiver experiences, clinical outcomes were excellent, costs were lower, and in many cases better than what they would be at the hospital.

Over the last few years, several commercial entities have entered into the Hospital At Home space. Dr. Leff thinks that has helped accelerate adoption quite a bit. “I think it’s fair to say that it is the most studied health service delivery innovation over decades. Depending on how you count, in the U.S. and the international literature, a lot has been done on this … and the theme and the results are very consistent across all those studies.”

Hospital At Home amid the pandemic

COVID has only accelerated its adoption. In March 2020, CMS announced the Hospitals Without Walls program, which provided broad regulatory flexibility that allowed hospitals to provide services in locations beyond their existing walls. In November 2020, CMS expanded on it by launching the Acute Hospital Care At Home program, providing eligible hospitals with “unprecedented” regulatory flexibilities to treat eligible patients in their homes.

“We’re at a new level of crisis response with COVID-19 and CMS is leveraging the latest innovations and technology to help health care systems that are facing significant challenges to increase their capacity to make sure patients get the care they need,” said CMS Administrator Seema Verma. “With new areas across the country experiencing significant challenges to the capacity of their health care systems, our job is to make sure that CMS regulations are not standing in the way of patient care for COVID-19 and beyond.”

The program was developed to support models of at-home hospital care throughout the country that have seen prior success in several leading hospital institutions and networks, and reported in academic journals, including a major study funded by a Healthcare Innovation Award from the Center for Medicare and Medicaid Innovation (CMMI).

“The development of this program was informed by extensive consultation with both academic and private sector industry leaders to ensure appropriate safeguards are in place to protect patients, and at no point will patient safety be compromised,” CMS said in a release. “CMS believes that treatment for more than 60 different acute conditions, such as asthma, congestive heart failure, pneumonia and chronic obstructive pulmonary disease (COPD) care, can be treated appropriately and safely in home settings with proper monitoring and treatment protocols.”

Participating hospitals are required to have appropriate screening protocols before care at home begins to assess both medical and non-medical factors, including working utilities, assessment of physical barriers and screenings for domestic violence concerns. Beneficiaries will only be admitted from emergency departments and inpatient hospital beds, and an in-person physician evaluation is required prior to starting care at home. A registered nurse will evaluate each patient once daily either in person or remotely, and two in-person visits will occur daily by either registered nurses or mobile integrated health paramedics, based on the patient’s nursing plan and hospital policies.

CMS said it anticipates patients may value the ability to spend time with family and caregivers at home without the visitation restrictions that exist in traditional hospital settings. Additionally, patients and their families not diagnosed with COVID-19 may prefer to receive care in their homes if local hospitals are seeing a larger number of patients with COVID-19. “It is the patient’s choice to receive these services in the home or the traditional hospital setting and patients who do not wish to receive them in the home will not be required to.”

Factors to consider

Mark Larson, principal, Sg2, has been studying the Hospital At Home model closely for several years. The programs he’s observed mainly treat medical conditions including congestive heart failure, COPD, and other non-surgical type diagnoses that can be treated safely in the home environment.

“You also have to think about, would the patient be able to have Hospital At Home in their home environment? Is there support there from a family member or a spouse? Because the home environment needs to be safe. So there’s the clinical side of it and then there’s the socioeconomic side of it – making sure the right support in the household exists.”

Typically, Hospital At Home programs are in larger geographical areas, urban or suburban areas. There aren’t many programs in rural areas, due to the logistics of delivering care in such a remote location, Larson said. It’s more time-consuming and not as efficient. “The numbers piece definitely comes into play.”

Larson said overall, clinical outcomes from Hospital At Home programs have been pretty good. “We’ve seen lower length of stays in some of the early pilots. We’ve also seen lower readmission rates, as well as lower skilled nursing utilization.”

If you have the same providers, you have the same nurses delivering care post-discharge, thus the chances of having issues with care transitions are lower. “Really it’s the same care team taking care of the patient during the acute care episode and post-acute care.”

Patients seem to like the program. Patient satisfaction scores for organizations like Mount Sinai in New York and others have been pretty high, Larson said. It’s no wonder – hospitals represent a changed environment for the patient. Alarms may go off in the middle of the night, nurses and doctors are coming in and out of the room at all hours of the day. “It can be very disruptive, especially for the elderly population.”

Questions providers must ask

Still, the Hospital At Home model is not for everyone, Larson cautions. “You have to be a pretty good-sized hospital or health system, and you have to have adequate volume in your marketplace, just as an entry point,” he said.

Larson offered the following as pieces that providers must consider:

Capability

Do you have the capabilities to deliver Hospital At Home? “Of course providers are really good at delivering care in the hospital,” Larson said. “They’re used to doing that. They’ve been doing it for years, serving their community well. But when you go out into the Hospital At Home environment, it’s a whole different ballgame.”

First and foremost, you need to have foundational home care nursing services. That’s key, because nurses are a core element to your service, Larson said. “The organizations who have elevated and delivered Hospital At Home and rapidly been able to scale it up have had a really strong home nursing care program.”

Second, providers must have physicians and nurse practitioners that can support the program. Typically, there are two different models, Larson said. In one model, providers actually go physically to the home as physicians and nurse practitioners when the patient needs it. There is also the virtual model, which is more scalable. When the home care nurse is providing hospital care in the home, they may call the physician or the nurse practitioner and have a visit with them on the status of the patient, the same as a rounding physician would do in a hospital. “You really need to have the physicians and nurse practitioners on board,” Larson said.

For either model, providers must demonstrate the safety and value of the program to a patient, to the hospitalists in the hospital and the emergency department physicians and leadership as well. “You don’t start with a big program,” Larson said. “Obviously you start the program slow, and you build upon your success.” Showing good results demonstrates that this is a good avenue for the provider.

“This is not a small undertaking,” Larson said. “Providers need to become very strong administratively and logistically. As some health systems deliver more care in the home, they will need to become very logistically strong, whether through a partner or developing their own technology, to be able to say, OK, there’s an admission. We need this, this, and this going into the home. Here’s the timing, here’s the schedule. We need the nurses on site right away, all these things need to be orchestrated. And without that logistical capability, it becomes very challenging.”

Cost

Providers need to be able to look at services and understand whether or not they have the ability to provide care more cost effectively in the home. “Cost is certainly the biggest piece,” Larson said. “From a financial perspective the biggest opportunity is when you don’t look at just the acute care visit, but you’re looking across the episode of care. In other words, the hospital piece is important, the acute care piece, but there’s also that 30-day post-discharge piece, where there might be skilled nursing care or other care post-discharge, or potentially a readmission.”

Organizations that have been successful often contract with Medicare Advantage payers, and they’ll go at-risk on that the full 30-day episode. “The numbers we’ve seen are you can save close to $1,000 per patient if you look at that entire episode,” Larson said. “If you only look at the acute care piece, the savings isn’t as significant – it can be $200 to $400 in savings. So I think that’s a key financial piece.”

Another important piece is that often when you’re negotiating with payers with Hospital At Home, they’re looking for a discount off of what they typically would pay you for acute care in the hospital. “So you have to factor that discount into it, and obviously negotiate that with the payers when you’re developing a program,” Larson said. “And that’s a big deal. Contracting for Hospital At Home is a big portion of the hard work that has to be done.”

Capacity

Does the hospital or health system have capacity constraints? Larson said a lot of the academics, tertiary quaternary providers gravitated to Hospital At Home because they were at capacity during COVID, and some even before COVID. They saw Hospital At Home as an opportunity to potentially decant patients from the acute care environment and have them receive care in the home.

“Hospital At Home patients are typically lower acuity, and lower payment. The contribution margin for these patients is also much lower than the typical average population served,” Larson said. “So if you have a patient that goes into the Hospital At Home, receives care in the home, you’re potentially swapping a lower contribution margin patient out to Hospital At Home with the opportunity to bring a higher contribution margin patient in that needs higher acuity care.”

Larson said there are two points to this strategy to consider. First, you’re serving a population that you’re more set up to manage – higher acuity care – especially in a larger tertiary care center. Second, you’re able to bring higher contribution margin patients into that environment. “For hospitals that are thinking they might have to build a new tower, maybe this is an opportunity to reduce the number of future beds built.”

The future of medicine

Larson predicts that every market is going to play out a little bit differently, but as far as care being delivered in the home, “we’re already seeing a pretty significant shift.”

The organizations that have the higher need are going to move faster. “So when you think about it, where is the shift occurring?” Larson asks. “It’s maybe less capital investment, brick and mortar investment, but more investment in operations, logistics, and care that providers can deliver in the home. I think something else you need to consider is, can you recruit and retain nurses who are willing to provide care in the home? That’s not for every nurse. Some nurses are much more comfortable going into hospitals and ambulatory sites to deliver care.”

What’s ultimately driving the shift is the technology to enable more remote monitoring, and consumers, who would prefer to receive care outside the traditional four walls of a hospital. “We really do expect more entrepreneurial companies to deliver things like home diagnostics and making it much more seamless to the process,” Larson said. “Right now it’s still a little clunky, but it’s going to get there. It’s going to be more about making it convenient for the consumer and more cost effective for the health system as well, hopefully in the future.”