July 2, 2020

Is it Time for Hospital at Home?

by Teresa Breen and Michael Cuello

THE GIST

Health systems should revisit the hospital at home model for the COVID-19 era, to address emerging consumer demand for care outside the hospital setting and achieve the longer-term goals of providing flexible, lower-cost acute care capacity

THE FACTS

  • Amid COVID-19, more than a third of consumers feel unsafe in a hospital setting
  • In late March, due to COVID-19, the Centers for Medicare & Medicaid Services (CMS) temporarily waived regulatory requirements to allow hospitals to use non-hospital spaces to treat hospital patients
  • Hospital-level care at home has been proven to be safer and cheaper, provide better patient outcomes, and increase patient satisfaction
  • While hospital at home has been evaluated for over 20 years, several large health systems, including Adventist Health, Intermountain Healthcare, and Mayo Clinic have launched hospital at home programs across May-June 2020

OUR ANALYSIS

1. Delivering hospital care at home allows hospitals to deploy asset-light, flexible acute care capacity, which meets consumer demands for safety and convenience

While hospital at home models have been around for the past few decades, they have been in place primarily in either research-focused academic programs (like Johns Hopkins or Mount Sinai) or in integrated delivery systems with their own health plans (like Presbyterian Healthcare Services or Geisinger). While some capacity-strained systems find a return on investment by using hospital at home to shift low-margin medical cases out of the hospital, the historical lack of payer coverage, both from fee-for-service Medicare and most commercial plans, prevented broad adoption of the model, even in systems heavily invested in value-based care. The current COVID-19 crisis has changed the calculus of how health systems are assessing hospital at home. In the near term, a program can offer flexible capacity to swiftly manage future pandemic surges or seasonal demand fluctuations by providing hospital-level care to patients in their homes. The pandemic has also changed the way consumers wish to receive care: they are now more accustomed to virtual care, and many are reluctant to enter hospitals for fear of COVID exposure. Moreover, visitor restrictions make patients even more reluctant to be admitted. In the longer term, hospital at home can reduce the need for expanding inpatient capacity while reducing overall care costs, improving care quality, and increasing patient satisfaction.

Medicare reimbursement challenges have been partially abated in the near term by CMS’ “Hospitals Without Walls” temporary waiver, allowing non-hospital space to be used for patient care during the COVID emergency. Increasing patient and provider interest in the model is likely to result in a renewed lobbying effort for more permanent Medicare reimbursement—ever more likely, the longer temporary waivers are in place. In the meantime, growing numbers of commercial and Medicare Advantage plans are open to the model, although coverage usually requires one-off negotiations.

2. Creating a high-acuity hospital at home program from inception provides hospitals the most flexibility and opportunity to scale

Hospitals should focus hospital at home programs on higher-margin, higher-acuity patients from the start, as it is easier to “scale down” to include lower-acuity conditions, rather than resource a lower-acuity, home health-based program for more complex patients. Some experienced organizations estimate that anywhere from 25 to 30 percent of inpatients could ultimately be directly admitted or have their care completed in hospital at home. (The model can be used to step down patient care after discharge from the intensive care unit.)

Many of the earlier hospital at home programs focused on lower-margin medical admissions that were “setting-sensitive”: inpatients who could potentially be managed in an alternative, lower-cost setting. Common admitting diagnoses included chronic disease exacerbations, such as congestive heart failure (CHF) or chronic obstructive pulmonary disorder (COPD), and patients requiring intravenous antibiotics for pneumonia, urinary tract infections or cellulitis. Inpatient cost avoidance was the main argument used to justify the investment.

Some organizations estimate that 25 to 30 percent of inpatients could be directly admitted or have their care be completed in hospital at home

While focusing on cost avoidance still makes sense, systems are increasingly bullish on using the model for a wide variety of acute conditions, including post-op management. Given the high rates of COVID infection in postacute care facilities, the “SNF at home” concept has been gaining traction to support post-op management for elective surgeries, especially joint replacement. Given the number of patients requiring rehabilitation (and patients’ fear of long-term care facilities), hospital at home could be foundational for bringing back elective surgery volumes, particularly for older patients.

3. A successful and scalable hospital at home program requires integration of a customized technology platform, redundant supply chain and flexible workforce—most partner with outside companies to fill these gaps

A scalable hospital at home program must have three integrated components: a purpose-built technology infrastructure, a multifaceted supply chain, and a tiered workforce with both a virtual and traveling component. If a health system is only focused on managing lower-acuity patients, it can potentially build the program out of its existing home health and telemedicine capabilities. A hospital at home program treating high-acuity patients, however, will require much more sophisticated infrastructure, especially an immediate and redundant supply chain. A patient discharged from the ICU to a home setting requires rapid access to imaging, lab and pharmacy services.

A range of clinical staff can be deployed to patients’ homes, matching care need with skill level. While registered nurses have typically been the lynchpin, some programs are using paramedics as a more flexible and lower-cost option, arriving with the resources of a fully equipped ambulance. This infrastructure must be anchored to a command center, staffed by physicians and advanced practice providers, that is monitoring and communicating with the patient and family virtually, 24/7.

While a system should leverage existing workforce and technologies, integrating these components is no easy feat. We’re seeing most systems select a vendor partner, such as Contessa or Medically Home, to provide the technology and supply chain management backbone, and coordinate a health system-managed workforce, while utilizing as many system assets—like lab and pharmacy—as possible.

4. Scaling hospital at home beyond the pilot phase requires buy in from the CFO, physician leadership, admitting physicians—and patients themselves

Even with capabilities, protocols, and processes in place, care transformation will be slow to start. New hospital at home programs are lucky to admit a dozen patients in their first two months of operation—suffice it to say it’s not an investment with an immediate return. Changing behavior and culture is one of the greatest barriers to adoption, both among system leaders, and among frontline doctors who will admit and refer patients.

In the launch phase, the hospital at home program should be removed from traditional workflow, existing key performance indicators, and physician incentives, and should ideally be staffed with physicians and clinicians who are dedicated to the program. Even with a robust payment model, it could take several years to see an ROI—having system CFO support is crucial, with the expectation that the investment is a strategic one that makes sense in the short-term based on patient demand and flexible capacity needs, with a longer-term eye toward the shift to value.

Changing behavior and culture is one of the greatest barriers to adoption, both among system leaders and frontline doctors who admit and refer patients

As the majority of patients treated in a hospital at home program come in through the emergency department, buy-in among admitting clinicians is key. According to experts, this must be more than a simple workflow triaging effort. Instead, a grassroots educational effort is needed to ensure clinicians across the system fully understand program capabilities, and trust that patients they admit will be as safe and cared for as they would be within the hospital itself.

Lastly, consumers are conditioned to believe the safest place to receive acute care is in an actual inpatient hospital bed, so many will be skeptical about receiving the same level of care at home. Since patients must opt into the model, effective patient communication about the hospital at home program should include:

  • Messaging that clearly communicates the model is similar to being cared for in a hospital unit. Asking whether patients want to be admitted to a “unit in our hospital” or “one of our hospital units we set up in your home” will relay to patients they are receiving the same level of care in either scenario. This scripting is better than asking if they want to be “treated at home”, which makes it seem as though they are being offered lower-level, less-safe care.
  • A detailed description of the care process and technology used in the home setting. Teaching patients about how the program works can include setting up a “home-model room” for families to directly experience what the model is like.
  • Reminders that hospital at home allows patients to remain with their loved ones. Given the current COVID pandemic, most hospitals either don’t allow or else significantly restrict visitors. Hospital at home allows patients to be with their family members throughout their “stay”.