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Hospital at home: National study shows low mortality, and other encouraging results


David Levine of Mass General Brigham talks about the key findings, and why he hopes to see more health systems delivering acute care in the home.

A national study examining hospital-at-home programs reveals that the programs have had a low mortality rate.

Hospital-at-home programs had a mortality rate of 0.5%, according to the findings published Jan. 9 in the Annals of Internal Medicine. David Michael Levine, clinical director for research and development for Mass General Brigham’s Healthcare at Home and the lead author of the study, says he was heartened to see such a low mortality rate.

But in an interview with Chief Healthcare Executive®, Levine says there’s another finding that is just as important, and perhaps even more significant. The study suggests that people being treated in hospital-at-home programs are truly in need of acute care, he says. Health systems aren’t choosing people with minor conditions for their hospital-at-home programs.

“I think, for me, the biggest takeaway was really the acuity and the complexity of the patients that were treated,” Levine says. “There's sometimes the concern that all these patients aren’t actually, you know, ‘hospital level.’ And I get that, right? People want to make sure we're using resources appropriately. And so that was really one of the more interesting pieces there.”

“These are acutely ill patients,” he adds. “And so to me, that was a really reassuring takeaway that these are hospital-level patients that are getting care.”

Levine and his fellow researchers examined outcomes for all 5,858 patients nationwide who were cared for in hospital-at-home programs under waivers from the federal government in a one-year span. They examined Medicare fee-for-service claims between July 1, 2022 and June 30, 2023.

Patients had a host of complex conditions, including 42.5% with heart failure and 43.3% with chronic obstructive pulmonary disease. More than 1 in 5 (22.1%) had cancer, and 16.1% had dementia.

“These were very, very complex patients,” Levine says. (See part of our conversation with David Levine. The story continues below.)

Looking at national data

Beyond the mortality rate, researchers found other encouraging outcomes, including a 6.2% escalation rate, meaning the patient returned to the hospital for at least 24 hours. He found that to be reassuring, but he also adds that more research is needed to determine an appropriate escalation rate.

“No one knows what the exact correct number is for escalation,” Levine says. “You certainly don't want it to be zero, because then, you haven't picked sick enough patients. And you certainly don't want it to be too high, that patients are always returning back to the hospital. We think anything under 10% is probably in the realm of that's probably the right percentage.”

Within 30 days of discharge from hospital-at-home programs, 3.2% of the patients died, 2.6% went to a skilled nursing facility, and 15.6% were readmitted.

Levine says the study’s value also comes in the fact that it analyzed patient outcomes from across the country.

“That was why this was so exciting,” Levine says. “This is the first time we get to look at national data of the care model.” Previously, studies looked at a few sites.

The study found similar outcomes among patients across racial and ethnic groups, which Levine found heartening.

“I think this to me was the second big takeaway, honestly, and was really reassuring that we were seeing equity of care delivery, with acute hospital care at home,” Levine says. “That is really exciting, you know, because we don't see equity of care delivery in the United States. We know that disadvantaged groups have worse outcomes when they get hospital care.”

The study does illustrate that few patients receiving acute care at home are living in rural areas. Only 1.7% of those in the study lived in rural communities, and Levine says he hopes that number will improve in the future.

“I'd like to see rural hospitals being able to provide this care model as well, as long as our data look good,” Levine says. “I don't want to bring a care model to a place where the data don't make sense. But I would really like to see more diversity in geography in the future. And I think we’ll see it. I think we'll see it in the future.”

The paucity of programs in rural areas likely is tied to difficulty in staffing those programs.

“I think staffing is a huge issue. huge issue,” Levine says. “It's a big issue in all of healthcare, it's even even more challenging in rural areas. And so when you talk about creating a new service line in a rural area, oh my goodness, to staff that service line is very challenging, whether it's an in-hospital service line, a home hospital service, you name it. It is a big challenge to attract new talents to the area in order to staff it.”

Hoping for an extension

More health systems have launched hospital-at-home programs since the beginning of the COVID-19 pandemic, as the government provided waivers to make it easier for hospitals to deliver acute care in the home.

The government has approved waivers for hospital-at-home programs in 308 hospitals across 129 systems, in 37 states, according to data from the Centers for Medicare & Medicaid Services. Some health systems are offering programs outside of the Medicare waiver program.

Healthcare leaders have said some organizations are waiting to move ahead with hospital-at-home programs until they know that the government will fund them on a permanent basis. President Biden’s administration and Congress agreed to an extension of waivers for hospital-at-home programs, and telehealth programs, through the end of 2024. Healthcare advocates are pressing for permanent reforms to allow the continuation of home hospital programs.

“At the very least, I would like to see it extended for at least several years,” Levine says. “If it can become permanent, I think that would be a huge boon to Medicare beneficiaries across the country.”

Levine also hopes the results of this new study showing the effectiveness of hospital-at-home programs can help add important insight for policymakers.

“I do think that this manuscript will add a substantial aspect to the debate that hopefully happens in Congress, that it will at least lend some more detailed evidence,” he says.

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