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Acute Care Makes Itself at Home

 |  By Jennifer Thew RN  
   October 15, 2015

The shift to value-based care could lead to expanded hospital-level acute care in patients' homes.

This article appears in the October 2015 issue of HealthLeaders magazine.

For patients in need of the level of care and interventions given in an acute care setting, the hospital is often the only option. And while necessary to handle acute exacerbations of illnesses, hospital admissions can lead to the development of a host of other problems for patients.

"We all know that hospitals can be very dangerous places for older adults," says Amy Berman, BS, RN, senior program officer at the John A. Hartford Foundation, a New York City–based private philanthropy working to improve the health of older Americans. "They commonly experience things like functional decline, complications, and other adverse events when they're inpatient," she says.


Amy Berman, BS, RN

According to data collected by the Department of Health and Human Services Office of Inspector General, in 2008 an estimated 13.5% of Medicare beneficiaries experienced adverse events during hospitalization, and an additional 13.5% experienced adverse events that resulted in temporary harm.

The John A. Hartford Foundation has been working to find a solution to hospital-induced complications among geriatric patients since 1995, when it began working with the Johns Hopkins School of Medicine and dedicating funds and other resources to support the creation, study, and dissemination of a safe, high-quality, cost-effective alternative to inpatient acute care that is now known as the Hospital at Home model.

Though two decades show Hospital at Home—which brings inpatient-level acute care for specific diagnoses to a patient's home—delivers outcomes equal to or better than and at lower cost than those obtained in the hospital, the program's adoption has been limited due to constraints in reimbursement. But as the healthcare industry shifts to new payment models spurred on, in part, by the Patient Protection and Affordable Care Act, Hospital at Home may finally have a shot at becoming a mainstream mode of delivering care.

Care and candidates

Geriatrician Bruce Leff, MD, professor of medicine at the Johns Hopkins University School of Medicine in Baltimore and director of geriatric health services research, is one of the founders of the Hospital at Home concept. In the mid-1990s, he noticed inpatient acute care admissions were contributing to poor outcomes among his elderly patients, specifically those with multiple chronic conditions.

"They would often experience bad outcomes just for having been taken care of in the hospital," he says. The patients were "developing confusion or delirium, developing functional impairment, having adverse drug reactions, losing functional capacity, and needing to go to a nursing home because they were operating just on the margins of functional capacity."

Even though there were times when his patients needed the care and interventions that could be provided only in a hospital, Leff says he felt conflicted about recommending hospitalization knowing it could cause his patients to deteriorate. So he began to contemplate what an alternative to an inpatient acute care stay would look like. Along with colleagues from Johns Hopkins and the John A. Hartford Foundation, he developed the Hospital at Home model to allow providers to bring the essential elements of acute care to a patient's home.

To be clear, Hospital at Home is not home care. The interventions and level of care are equal to that provided on a general medical-surgical unit at a traditional brick-and-mortar hospital. Patients with specific conditions deemed in need of hospitalization by an emergency department or clinic physician can receive necessary interventions like oxygen therapy, nebulizer treatments, IV infusions, or diagnostic test like x-rays in the comfort of their homes. They also receive extended nursing care for the initial portion of their admission, and then at least daily nursing visits, based on clinical need. The physician makes one or more home visits per day and is available for any urgent or emergent situation.


Bruce Leff, MD

A set of admission criteria developed by Leff is used to assess whether the patient is a good candidate for Hospital at Home. "You don't want people who need an ICU," he says. "You don't want people who are going to be unstable and probably have to go to an ICU. In truth, you like to be able to identify people who are not going to have very high tech–driven admissions."

The original model focused on those with diagnoses of community-acquired pneumonia, heart failure, chronic obstructive pulmonary disease, and cellulitis but has now evolved to also include patients with dehydration, urinary tract infections, deep vein thrombosis, and pulmonary embolism. "The reason we focused on those conditions was because they were common reasons for admissions to the hospital for older adults," Leff explains, "and they are conditions which are usually readily diagnosable at the start of an episode of care."

Cost and quality results

Since its inception in 1995, there have been multiple studies showing the Hospital at Home model delivers quality care while decreasing costs. That's what Albuquerque, New Mexico–based Presbyterian Healthcare Services wanted to achieve when it implemented the program in 2008. PHS is an integrated system with eight hospitals, a health plan, and a medical group, and reported 2013 total operating revenue of $2.5 billion.

"We felt that this program would give us the opportunity to improve clinical outcomes for patients who were sick and that were hospital-appropriate patients," says Karen Thompson, OTR, CCM, director of hospice and Hospital at Home at PHS. "We felt that if we could provide that same level of care in their home, the outcomes would be better, they would be more satisfied—not only the patient but also the caregiver—and have a reduction in cost overall."

A study by Melanie Van Amsterdam, MD, who served as lead physician for PHS' Hospital at Home and House Calls program for the past decade, as well as Johns Hopkins' Leff and others, that was published by Health Affairs in June 2012 includes metrics that demonstrate the success of the PHS effort. 

The 323 patients enrolled in PHS' Hospital at Home program from January 2009 to December 2010 had an average length of stay of 3.3 days versus 4.5 days in a comparison group receiving treatment in an acute care hospital. In addition, the PHS group had no reported falls versus 0.8 in the comparison group, and a mortality rate of 0.93% versus 3.4%.

The Hospital at Home group was at 100% compliance for five core metrics while rates in the comparison group ranged from 91% to 99% depending on the specific intervention. The patient satisfaction rate for the Hospital at Home group was 90.7%, while it was 83.9% for the hospital group. All of these outcomes were achieved with a 19% cost savings. The current patient satisfaction rate is now more than 97%, and the program has seen more than 1,000 patients since it began at PHS. Van Amsterdam (who continues to practice in the program, but gave up her lead physician role in July) attributes some of the savings to the necessity of using resources more wisely in a home setting.

"Patients are paying their own room and board," she says. "Also, we have limited diagnostic tools in the home. We don't have CT scans in the home, which means we don't use them. And how many times have you seen someone go into the hospital and they get a CT scan for indications that, normally, in the home we wouldn't think about it?"

A new era

Despite its solid patient outcomes, adoption of the Hospital at Home model has been limited in part because of the way traditional reimbursement structures are designed, Leff says. "There's no payment mechanism for this in Medicare fee-for-service yet."

Organizations with alternative payment models, such as the Veterans Health Administration, or integrated systems such as PHS, have more flexibility and incentive to adopt Hospital at Home.

"The reason you're able to build a Hospital at Home at a place like Presbyterian is because they have an integrated delivery system and they are the payer for and provider of care," Leff explains. "So they provide Hospital at Home for people who are enrolled in their own Medicare Advantage and Medicare Managed Care plan. For those patients that they insure and pay healthcare costs on, if they can provide high-quality service at a lower cost, it behooves them to do that."

Through its Innovation Center, the Centers for Medicare & Medicaid Services is evaluating whether it is beneficial to support delivery and payment of care through a Hospital at Home–style program. In 2014, the center gave the Icahn School of Medicine at Mount Sinai in New York City a three-year $9.6 million award to create and test a Mobile Acute Care Team to provide hospital-level acute care in patients' homes. The Mount Sinai Hospital is a 1,171-bed, tertiary care teaching facility.

While it is still early in the program, the MACT has seen 40 patients as of August 2015. Linda V. DeCherrie, MD, clinical director of the MACT has been seeing patients in their homes for the past 12 years as part of the Mount Sinai Visiting Doctors program. That program provides home care for about 1,200 patients under a traditional fee-for-service model, but has not involved hospital care at home. DeCherrie says she has hope for expansion of acute care in the home.

"I really think that this is the way of the future. That there are these certain diagnoses that we can care for safely at home," she says. "It's just that there's been no payment mechanism to do that."

The John A. Hartford Foundation, which supported the original development of the model, is hopeful, too. The organization gave Mount Sinai an additional $1.6 million grant for further analysis of the results.

"If we assume a similar experience with the MACT," says the John A. Hartford Foundation's Berman, "we might expect nationally that about 611,000 discharges for persons 65 and over might potentially be eligible and would want the Mobile Acute Care Team. If they were even able to reach half of those people who were eligible and receptive and we assumed 20% savings over usual care, that would be a savings of around $1 billion per year. If we were to make it available everywhere, we could reasonably assume that it would be over $2.9 billion a year."

Leff is cautiously optimistic about the model's proliferation.

Mount Sinai is leading the demonstration under the CMS Innovation Center challenge grant, "and I think that will potentially inform the development of a payment mechanism," he says. "I'm not sure if that happens in five years or 10 years. That's really at some level the million-dollar or trillion-dollar question. Will Hospital at Home get out there? I think it will. There are reasons to think that the demo will be successful and then move forward. It will probably be a slow process until it becomes a fast process."

Reprint HLR1015-7

Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.


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