Hospital at Home Initiatives Look Increasingly Viable for Health Systems

Initiative gathers steam as Medicare ponders 2 APMs and new Mount Sinai study confirms improved outcomes.  

With a study by the Icahn School of Medicine at Mount Sinai demonstrating improved outcomes for patients participating in Hospital at Home (HaH) services, and two alternative payment models (APM) under review by Medicare, more healthcare systems may explore the possibility of offering this innovative model of care.

As health leaders examine the advantages of launching HaH programs to deliver acute services in the home environment versus traditional inpatient care, here's a look at the latest developments and thoughts to consider.

2 APMs Under Consideration

Hospitals providing HaH services have demonstrated improved outcomes and lower costs; however, without a specific fee-for-service payment mechanism available through Medicare, adoption has been slow. That appears to be changing.

• On October 20, 2017, the Physician-Focused Payment Model Technical Advisor Committee (PTAC) recommended full implementation of an alternative payment model (APM) for HaH to the U.S. Department of Health and Human Services. HaH-Plus care, which was submitted by Icahn School of Medicine at Mount Sinai, bundles acute HaH care with a 30-day post-acute period of home-based transitional care.
   
• The objective of the Mount Sinai study, published in the June 25 online edition of JAMA Internal Medicine, was to evaluate the complete data on clinical outcomes, patient experiences, and safety of the HaH payment model recommended by PTAC. "Creation of an APM for such a model of HaH care," the study says, "would establish Medicare billing codes, allowing clinicians to bill directly for HaH services and paving the way for broad-scale adoption of the HaH program in the United States."
   
• On May 7, PTAC also recommended a different Home Hospitalization APM that was submitted by Personalized Recovery Care, LLC (PRC), a joint venture between Marshfield Health System, Marshfield, Wisconsin and Contessa Health, Nashville, Tennessee.
   
• This second recommendation explains, "Because the PRC HH-APM model addresses the important need of providing home-based hospital-level acute care for eligible patients, and the differences from the HaH-Plus APM model that we previously recommended could enable more and different physician practices to participate and more patients to benefit, implementation of both models would be desirable to enable a better understanding of the relative advantages of the different approaches."

Both recommendations are under evaluation.

Study Demonstrates Improved Outcomes

The three-year Mount Sinai study demonstrated improved outcomes for patients receiving care at home, compared to those admitted to the hospital. Results included:

• Shorter length of stay (3.2 days vs. 5.5 days)
   
• Lower rates of hospital readmissions (8.6% vs. 15.6%)
   
• Lower rates of emergency department visits (5.8% vs. 11.7%)
   
• Fewer transfers to skilled nursing facilities (1.7% vs. 10.4%)
   
• More likely to rate their medical care highly (67.8% vs. 45.6%)

Historically, the study notes, cost savings for these programs range from 19% to 38%.

Cautions to Consider

In an invited commentary to the JAMA Internal Medicine article, authors caution that "The HaH-Plus proposal also raises several important clinical and policy issues that need to be addressed before HaH programs (and the payment models to support them) could be implemented more broadly."

The commentary outlines multiple points for consideration. A partial list of their recommendations includes:

1. Quality and safety requirements do not currently do not exist for HaH programs but should be paramount to ensure a minimum standard of care.
    
2. Bundled payments should account for unintended consequences. "For example," the authors say, "policies would have to be in place to guard against inappropriate conversion of outpatient encounters to HaH episodes, which might unnecessarily increase care intensity and undercut potential cost savings, or inappropriate conversion of inpatient stays to HaH episodes, which might jeopardize patient safety and outcomes."
    
3. The authors also suggest that more work is needed to design a true bundled payment for the HaH model because the program upon which it is designed at Mount Sinai "was not actually reimbursed on a bundled basis. Certain elements (e.g., professional fees for emergency medicine and primary care providers) were billed separately outside of the program without a financial reconciliation; therefore, key technical details (e.g., benchmarking, risk-adjustment, quality measurement) require further development and refinement."

Questions to Ask

Researchers at the Johns Hopkins University Schools of Medicine and Public Health developed and successfully tested its Hospital at Home concept in a National Demonstration and Evaluation Study.

Johns Hopkins Healthcare Solutions now provides technical assistance to and collaboration with other health systems that want to offer these services. According to the institution's Healthcare Solutions website, among the questions health systems should consider when exploring HaH development:

• Is your health system experiencing problems from a lack of hospital capacity?
   
• Does your health system have established home health-care delivery capabilities?
   
• Do you have physicians with the interest and ability to care for patients in the home environment?
   
• Does your health system experience a large volume of Medicare admissions for common problems such as community-acquired pneumonia, heart failure, or chronic pulmonary disease (COPD)?
   
• Does your institution view itself as an innovator in developing and implementing new models or systems of care?
   
• Can your health system align payment, providers, and the hospital to develop [a Hospital at Home service]?