Hospitalathome

Background:

Hospital-at-home programs enable individuals to obtain acute care services in the comfort of their home versus the hospital. The movement towards hospital-at-home services stems from the advancement of medical technology, improvement in home delivery services, and reducing reliance on inpatient care. (1,2) While hospital-at-home services gained more traction during the height of the COVID-19 pandemic, the concept is not new.

Dating back to the early 2000s, multiple studies were published with mixed results regarding the program’s use. On one hand, evidence supported that hospital-at-home services were feasible, safe, and efficacious for specific patient populations, mostly older with a subset of acute medical illnesses. (3) A systematic review of 22 randomized, controlled trials of hospital-at-home programs demonstrated that patients within this care model had similar outcomes compared to those treated in the hospital. (4) While promising, there were limitations to this systematic review, including the relatively small sample sizes available, and therefore the meta-analysis was underpowered to detect differences in mortality and readmission rates. (5) Given the heterogeneity of the studies, some believed that the evidence was not compelling and widespread implementation may be more costly than beneficial. A more recent 2012 meta-analysis of randomized controlled trials showed a 38% lower 6-month mortality rate compared to hospitalized patients. (6) Since then, further research has supported its use as more organizations adopted the model which illustrated improvement in patient outcomes and return on investment. (7)

Advantages:

1. Cost- it may reduce the cost of care by 30% or more (1) , total cost maybe lower (8)
2. Greater patient satisfaction (4)
3. Avoid shortages of beds in U.S. Hospitals (9)

Disadvantages:

1. Cost- may not be reduced from a health care organization perspective (5)
2. Concerns regarding patient safety (9)
3. Legal risk (10)
4. Insurance payers’ reluctance/lack of reimbursement (11)
5. Burden on family caretakers (5)

Components of Hospital-at-Home:

Depending on the organization, the services provided can vary. In general, hospital-at-home services include blood tests, electrocardiograms, and delivery of services from visiting healthcare providers including nurses, physicians, and paramedics. (12) Patient self-monitoring services can also be included along with other services, such as IV therapy and imaging.

At Oregon Health and Science University (OHSU) in Portland, OR, a patient also has access to their care team 24 hours a day, seven days a week. (13) Additionally, OHSU’s program includes daily video visits with a doctor or nurse, medication adjustments and delivery, medically tailored meals, physical and occupational therapy.

Implementation:

Running since 1994, Johns Hopkins Medicine in Baltimore, Maryland, serves as an example for a hospital-at-home care program. (14) The organization offers online tools to support the adoption and implementation of the program into other health care systems. The guide includes the following components: clinical eligibility criteria, implementation manual, financial planning and evaluation tools, patient recruitment and education tools, measurement tools, and patient-tracking mechanisms.

Another resource is American Hospital Association Hospital-at-Home webinar series. (15) The series offers advice from leaders in the field and covers implementing hospital-at-home programs as part of their partnership with American Academy of Home Care Medicine. (16)

COVID-19 and Hospital-at-Home:

Prior to the pandemic, the Centers for Medicare and Medicaid Services, along with private payers, did not reimburse for hospital care at home. (11) In December 2022, President Biden signed into law H.R. 2716, the Consolidated Appropriations Act (CAA). (17, 18) This legislation provided substantial financial backing and supported the extension of major telehealth waivers and acute hospital care at home. Immediately, 190 hospitals signed the waiver. (19) During the peak of the pandemic, the benefits were more apparent including conserving personal protective equipment, freeing up in-patient beds, and minimizing patients’ fear of exposure by keeping them out of the hospital. (12) Mount Sinai hospital in New York City, New York, tripled the number of participants in their program. (12) Atrium Health in North Carolina, cared for more than 17,000 people in their homes. (12) Since the use of the Acute Hospital Care at Home waiver, 144 systems, which includes 260 hospitals across 37 states have utilized the waiver. (20)

Despite the benefits, the waiver was set to expire in April 2023, but was subsequently extended to December 2024. (21) The Secretary of Health and Human Services, Xavier Becerra, plans to conduct a study which compares the quality and quantity of services within the two-year extension period in hopes of a new reimbursement model as a step towards making these services a permanent part of the health care system. (21)

References:

1. Parker G, Bhakta P, Katbamna S, et al. Best Place of Care for Older People after Acute and during Subacute Illness: A Systematic Review. Journal of Health Services Research & Policy. 2000;5(3):176-189. doi:https://doi.org/10.1177/135581960000500309
2. Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive Discharge Planning With Postdischarge Support for Older Patients With Congestive Heart Failure. JAMA. 2004;291(11):1358. doi:https://doi.org/10.1001/jama.291.11.1358
3. Leff B. Hospital at Home: Feasibility and Outcomes of a Program To Provide Hospital-Level Care at Home for Acutely Ill Older Patients. Annals of Internal Medicine. 2005;143(11):798. doi:https://doi.org/10.7326/0003-4819-143-11-200512060-00008
4. Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care. The Cochrane Database of Systematic Reviews. 2005;(3):CD000356. doi:https://doi.org/10.1002/14651858.CD000356.pub2
5. Shepperd S. Hospital at Home: The Evidence Is Not Compelling. Annals of Internal Medicine. 2005;143(11):840. doi:https://doi.org/10.7326/0003-4819-143-11-200512060-00015
6. Caplan GA, Sulaiman NS, Mangin DA, Aimonino Ricauda N, Wilson AD, Barclay L. A meta-analysis of “hospital in the home.” The Medical Journal of Australia. 2012;197(9):512-519. doi:https://doi.org/10.5694/mja12.10480
7. Leff B. Why I Believe in Hospital at Home . NEJM Catalyst. Published online February 5, 2017.
8. Frick KD, Burton LC, Clark R, et al. Substitutive Hospital at Home for older persons: effects on costs. Am J Manag Care. 2009;15(1):49-56.
9. Klein S. “Hospital at Home” Programs Improve Outcomes, Lower Costs But Face Resistance from Providers and Payers | Commonwealth Fund. www.commonwealthfund.org. Published April 20, 2023. Accessed April 24, 2023. https://www.commonwealthfund.org/publications/newsletter-article/hospital-home-programs-improve-outcomes-lower-costs-face-resistance
10. Simon DA, Cohen IG, Balatbat C, Offodile AC. The hospital-at-home presents novel liabilities for physicians, hospitals, caregivers, and patients. Nature Medicine. 2022;28(3):438-441. doi:https://doi.org/10.1038/s41591-022-01697-3
11. Pifer R. What’s holding up hospital at home? Healthcare Dive. Published March 17, 2022. https://www.healthcaredive.com/news/hospital-at-home-himss-cms-doctors/620539/
12. Weiner S. Interest in hospital-at-home programs explodes during COVID-19. AAMC. Published September 28, 2020. https://www.aamc.org/news-insights/interest-hospital-home-programs-explodes-during-covid-19
13. OHSU Health Hospital at Home | OHSU. www.ohsu.edu. Accessed April 24, 2023. https://www.ohsu.edu/health/ohsu-health-hospital-home
14. Hospital at Home | Johns Hopkins Health Care Solutions. Johns Hopkins HealthCare Solutions. Published 2010. https://www.johnshopkinssolutions.com/solution/hospital-at-home/
15. Hospital-at-Home | AHA. www.aha.org. https://www.aha.org/hospitalathome
16. American Academy of Home Care Medicine. www.aahcm.org. Accessed April 24, 2023. https://www.aahcm.org/
17. QualityNet Home. qualitynet.cms.gov. https://qualitynet.cms.gov/acute-hospital-care-at-home
18. House TW. Bill Signed: H.R. 2617. The White House. Published December 29, 2022. https://www.whitehouse.gov/briefing-room/legislation/2022/12/29/bill-signed-h-r-2617/
19. DeCherrie LV, Leff B, Levine DM, Siu A. Hospital at Home: Setting a Regulatory Course to Ensure Safe, High-Quality Care. The Joint Commission Journal on Quality and Patient Safety. Published online December 2021. doi:https://doi.org/10.1016/j.jcjq.2021.12.003
20. Carani TAB Arielle. Hospital at Home Programs Extended, But Final Push Is Needed. Health Law. Published January 25, 2023. Accessed April 24, 2023. https://www.cmhealthlaw.com/2023/01/hospital-at-home-programs-extended-but-final-push-is-needed/
21. Park E, Dwyer A, Brooks T, Clark M, Alker J. Consolidated Appropriations Act, 2023: Medicaid and CHIP Provisions Explained. Center For Children and Families. Published January 6, 2023. https://ccf.georgetown.edu/2023/01/05/consolidated-appropriations-act-2023-medicaid-and-chip-provisions-explained/

Submitted by (Annessa Kernberg)