More hospitals are now offering acute care at home. It’s another indication of how the COVID-19 pandemic is driving changes in hospitals and healthcare.
Since the COVID-19 pandemic’s emergence, home hospital programs have grown dramatically across the country, and that surge in interest looks to continue.
Forrester, the research and consulting firm, projects the number of hospitals delivering acute care at home will triple in 2022.
David Levine, who directs the home hospital program at Brigham and Women’s Hospital, said it’s difficult to predict the expansion of such services nationwide. But Levine said at the current rate, the number of home hospital programs should at least double.
Last year, the Centers for Medicare & Medicaid Services gave broad approval for healthcare systems to get reimbursed for home hospital programs. Previously, a handful of systems had home hospital programs, but CMS issued a temporary waiver allowing more hospitals to launch home-based programs due to the pandemic.
As of Nov. 8, 187 hospitals in 34 states have been given federal approval to provide acute care at home. (See the full list here.)
Before the pandemic, a few healthcare systems, such as Brigham and Johns Hopkins Medicine, had already launched hospital-at-home programs.
Proponents of home hospital programs say they can provide top-notch acute care in a more comfortable setting, with studies showing improved patient outcomes. Home hospital programs can also be more cost-effective, supporters say.
“We showed massive reductions in 30-day readmission rates, we showed patients moved a lot more, we showed really high patient satisfaction,” said Levine, a doctor of internal medicine.
“This model is exceptionally powerful for getting patients the care where they want it,” he said.
The question for many healthcare providers is whether federal regulators will move from allowing Medicare reimbursements on a temporary basis to a permanent one.
Dr. Janis Orlowski, chief health care officer for the Association of American Medical Colleges, said she suspects it will come in time. But CMS is going to want to gather a lot more data, she said.
“I think that will be based on the quality and safety and they will study that,” she said.
More research needed on outcomes, costs
The early research on home hospital programs is indeed promising, Orlowski and others have said.
“In talking with individuals, it’s because they’ve been very selective on who can do this,” Orlowski said.
Some researchers have said that as home hospital programs expand, more research will be needed to measure patient outcomes and the true cost of those programs.
Healthcare leaders are very interested in home hospital programs and the pandemic has clearly fueled the interest, Orlowski said. She said hospital systems and federal regulators will be looking for more research on their effectiveness, both from medical and financial perspectives.
It’s not a lock that hospital-at-home services will save money, Orlowski said.
“I think it’s more of an open question,” she said. “People think telehealth is cheaper. When you have to have physicians and set things up, and you have to buy the communications and stuff like that, it ends up, it’s not cheaper.”
Brigham’s home hospital program has grown substantially in the past two years; the average daily census for home-based patients has gone from 4 to 16, Levine said. The expansion of the home hospital program has also helped create additional capacity for the entire system.
Levine stresses patients are getting appropriate care at home. Under federal regulations, healthcare systems offering home hospital programs must visit patients in their home twice a day.
“This is acute care at home,” Levine said. “Anything less is truly insufficient.”
Patients need to be screened carefully to determine if they are candidates to receive hospital care at home, he said. Some patients may be too sick to treat outside the hospital.
“We don’t want to do ICU level care at home,” Levine said. “We want to do hospital care at home.”
In assessing candidates for acute care at home, Levine said doctors must weigh more than medical considerations.
Levine said such questions include: “Is there running water in the home? If the forecast is very cold, is there heat in the home? Is there domestic violence in the home?”
Hospital systems need to carefully consider the toll on families if a patient is going to receive acute level care at home, Orlowski said.
“One thing they have to really be aware of is the tremendous burden of work it places on the home and the resources that are needed,” she said.
The expansion of hospital-at-home programs has angered some healthcare professionals.
The California Nurses Association/National Nurses United has vocally protested some of Kaiser Permanente’s plans to substantially expand its home base program. The nurses’ union argues the move could endanger patients who need 24/7 care, including care provided by nurses.
The union contends Kaiser’s approach amounts to heavy virtual monitoring of patients, derisively referring to the plan as “Home All Alone.” Some nurses picketed in the San Francisco area last week.
“Nurses are horrified by Kaiser’s attempts to redefine what constitutes a hospital and what counts as nursing care,” the union said in a statement. “Not only does this program endanger the imminent safety and lives of patients, it completely undermines the central role registered nurses play in the hands-on care that patients need to safely heal and recover.”
In a statement to KGO-TV in San Francisco, Kaiser said it had no plans to reduce nursing staff.
"Nurses have always and will continue to play a critically important and highly valued role in the care team,” Kaiser said in the statement. “There are no plans to limit the role of nurses in hospitals any acute care-at-home programs at Kaiser Permanente.”
In May, Kaiser Permanente and the Mayo Clinic announced an investment of $100 million into the Medically Home Group, a Boston-based firm, to expand hospital-at-home programs. Both Kaiser and the Mayo Clinic launched home hospital programs last year.
In announcing the investment in Medically Home, leaders of the two hospital systems touted it as an evolution in healthcare.
“This partnership is a significant step in our commitment to providing the right care in the right setting for every patient as we continue to help lead the transformation of health care," Greg A. Adams, chair and CEO of Kaiser Foundation Health Plan Inc. and Hospitals, said in a statement.
Even as health systems expand home hospital programs, Orlowski said she doesn’t see that leading to fewer jobs for nurses.
“Nurses are needed in these programs,” Orlowski said. And she said there’s going to continue to be a heavy demand for bedside nurses.
Brigham uses technology to monitor patients getting acute care at home. Patients in the home hospital program wear a patch on their skin that transmits their heart rate and other vital signs. Doctors can view the readings on their smartphones, Levine said.
Still, Levine stressed that Brigham and other healthcare systems with home hospital programs have doctors and nurses regularly visiting their patients in person.
What hospitals should know
For hospitals looking to launch their own home healthcare programs, Levine said they need to consider a crucial question first.
“I think one of the most important things is to ask the question: Why do you want a home hospital program?” Levine said.
“Is it the thing to do or is it going to serve a specific need in your system? Maybe it’s going to create capacity in a very safe way.”
Hospitals need to carefully consider a host of factors as they move forward with such programs, Orlowski said.
For Orlowski, those questions include: “What’s the role it’s going to play in your delivery of health? Do you have the resources? Is senior leadership really committed to making this a real strong part of your program?”
Healthcare systems must consider response plans when patients getting acute care at home have a medical emergency. Inside the hospital, doctors and nurses can respond in seconds if a patient is going into cardiac arrest.
Hospitals are typically selecting patients at low risk of emergency for home-based programs, Orlowski noted. But she said contingency plans are crucial.
“You have to have a plan for when someone’s heart stops,” Orlowski said. “You have to have a plan for 10 minutes before that, when there are warning signs when there might be trouble.”
“What are the steps? You can’t make it up when it happens,” she said. “You have to have a well-developed protocol.”
Another open question: how do home-based programs fit into health equity?
Concerns could come on opposite ends of the socio-economic spectrum. Home hospital programs shouldn’t be solely reserved for affluent patients with more resources, Orlowski said. At the same time, they also can’t be perceived as reduced care for families with lower incomes.
Levine said he’s heard criticism that home hospital programs are simultaneously geared to the rich and those with modest incomes. He said neither is true.
For families with lower incomes, Levine said Brigham will help provide Internet access at home if needed for patients. “It’s an equity issue for us,” Levine said.
Looking to the future
As home hospital programs expand, healthcare systems and academic medical centers are going to have to think about how they train physicians.
It’s not easy to have both high-level clinical skills and the sensitivity to care for patients at home.
“Training is a key issue,” Levine said. “No one trained me to provide acute care at home when I was in medical school or residency. We definitely have a pipeline issue.”
“We’re asking for acute level skills as well as community skills in the same person.”
Some hospitals may be waiting to launch home-based acute care programs because they want to be sure the federal government will allow full reimbursements permanently.
Insurance companies are going to want to see more about the quality and cost of hospital-at-home programs, Orlowski said.
They’ll also want to be sure patients want it. But Orlowski suspects insurance companies eventually will cover acute care programs at home.
“Insurers often follow the federal government,” Orlowski said. “If Medicare makes it permanent, I think insurers will go for it.”
Levine is hoping the federal government makes that commitment.
“Thousands of patients are cared for in this model,” he said. “It would be a shame if we backpedal on this level of care.”
The greater use of home-based acute care only adds to the ongoing evolution of hospitals.
With the growing use of procedures on an outpatient basis and the emergence of acute care at home, hospitals in the future are likely going to look quite different.
In the future, hospitals may largely be focused on operating rooms, labor and delivery, intensive care, burn units and other tertiary care, Orlowski said.
“The pandemic has really made us look at how we deliver healthcare,” Orlowski said.