In the COVID-19 pandemic, the number of hospitals offering acute care at home has surged. Chief Healthcare Executive spoke with doctors and leaders around the country about their experiences.
Debra Barshinger didn’t want to stay in the hospital.
She knew she needed treatment after a kidney infection led to sepsis. Barshinger, who lives just outside of the city of York in central Pennsylvania, spent a night at WellSpan York Hospital, and she was grateful to have another option.
Doctors explained she could continue to receive care through WellSpan’s hospital-at-home program. “That made me very happy,” she says.
Barshinger went home, and a nurse appeared about an hour later. She recovered quickly and lists several reasons why she was glad to go home. She could be in her own bed, which was much more comfortable. Instead of sharing a room with a stranger, she was home with her husband. And she raves about the care she received from her nurses.
“I had a great experience with the nurses,” Barshinger says. “They couldn’t have done any more.”
More hospitals around the country are launching hospital-at-home programs. It’s yet another way healthcare has evolved in the COVID-19 pandemic.
Before the pandemic, only a few hospitals were offering such programs, but the federal government allowed more hospitals to offer home hospital programs after the arrival of COVID-19.
Today, 276 hospitals in 37 states have been authorized to provide acute care at home, according to the Centers for Medicare & Medicaid Services. Industry analysts expect more health systems to develop home hospital programs. President Biden and Congress signed off on an extension allowing hospital-at-home programs - and telehealth programs - to continue through 2024.
Many healthcare leaders are pressing the government for permanent reforms allowing those programs to continue, and leaders of those programs say it’s inconceivable that the government would pull the plug. Still, healthcare leaders and analysts acknowledge that some health systems may be waiting for more clarity before moving ahead with their own programs.
In this special report, Chief Healthcare Executive® spoke with doctors and administrators from several health systems about their programs. They tout strong clinical outcomes, high patient satisfaction, and staff fulfillment. Healthcare leaders warn that the programs require substantial investment, commitment and planning, or they will run into problems.
Still, the doctors running hospital-at-home programs speak enthusiastically about the early returns they are seeing, and say they see more health systems offering care outside the four walls of the hospital.
“I think every hospital system, if they're not already looking into this, is going to be,” says Michael Nassif, director of hospital-at-home at Saint Luke’s Health System in Kansas City, Mo.
“I truly think 10 years from now, we're gonna say, remember how crazy it was we used to stick Grandma in the hospital for five days just to get … IV antibiotics, and you get confused and debilitated,” he says. “And I look forward to when we see that as kind of an archaic process and that there are better healthcare delivery models and more patient-centric healthcare delivery models.”
(Healthcare leaders talk about hospital-at-home programs in this video. The story continues below.)
Promising clinical outcomes
For health systems offering acute care at home, doctors and administrators say they screen patients to ensure they can be managed successfully in their residence. Patients who need intensive care aren’t candidates for home-based programs. Chief Healthcare Executive spoke with hospitals offering acute care at home, and systems that are preparing to take that step and offering some home-based options.
Under CMS rules for acute care at home, hospitals must visit with patients in person at least twice each day. In the Saint Luke’s program, patients are typically visited three or four times a day, Nassif said, adding that the one-day record for visits in his program is 11.
Patients are monitored at home via technology, such as a patch on the skin, that allows systems to see their vital signs, and they have 24/7 access to their health systems if problems arise. Health systems typically require patients in those programs to be within a manageable distance of the hospital.
David Levine is one of the nation’s leading experts and advocates for hospital-at-home programs. He’s the clinical director of research and development for Mass General Brigham’s “Healthcare at Home” program. Mass General Brigham has provided hospital-level care in patient’s homes for more than eight years.
“I've been very impressed, honestly, that our outcome metrics have for the most part stayed pretty solid,” Levine says. “And, you know, things like our readmission rates, and things like patient experience, a lot of our safety metrics, have all stayed quite steady through the years.”
Hospital officials at several systems interviewed by Chief Healthcare Executive said the readmission rates in home-based programs have been lower than in the brick-and-mortar hospitals.
“Our ED utilization rate and readmission rate is much better,” says Vipul Bhatia, associate chief medical officer of post-acute and continuing care services at WellSpan Health in Pennsylvania.
Since launching its hospital-at-home program in July 2022, the readmission rate has been “somewhere in the low 8% range,” Nassif said.
The average hospital readmission rate for all causes is 15%, according to data analyzed by Definitive Healthcare. For patients with pneumonia, the median readmission rate is 17%, according to a study published by Jama Network Open last May.
Augusta University Health, which has run a hospital-at-home program since February 2021, has seen a readmission rate of 7.3%, says Lauren Hopkins, AU Health’s assistant vice president of virtual care and community engagement. AU Health is offering services below acute care, but the system has CMS approval for acute-level care and is waiting to receive state-level authorization in Georgia.
Mount Sinai launched one of the nation’s first hospital-at-home programs in 2015. Since the launch, Mount Sinai has seen lower readmissions and shorter hospital stays, says
Ania Wajnberg, associate professor in the department of medicine at the Icahn School of Medicine at Mount Sinai.
“I’m so excited about how it’s taken off,” Wajnberg says.
The benefits of rest
Doctors are seeing fewer issues of patients experiencing delirium in the home-based setting.
Nassif says St. Luke’s hasn’t had any patients with delirium, calling that the “most surprising” development since the system launched its program last summer.
“I knew it'd be better, but we've literally had zero delirium, zero patients confused and ripping out their IVs, and not knowing where they are,” Nassif says. “It's really amazing when you keep people at home and with their loved ones and comfortable environment, how much better they do in terms of both confusion and delirium.”
Doctors who spoke with Chief Healthcare Executive stress the value of patients getting better rest and more sleep at home, as opposed to being in a large hospital.
Emily Downing, clinical officer of population health and home care services at Allina Health System, says the value of a good night’s sleep can’t be underestimated.
“We know having uninterrupted sleep is critical for patients to heal and recover and have normal cognitive abilities,” Downing says.
Some hospital programs, such as WellSpan, say patients are less apt to fall at home than they are in the hospital.
Doctors working in the programs say patients who are treated at home avoid some of the risks of being in the hospital.
“They're not around a whole bunch of other patients who have infections,” Levine says. “They are able to move about their surroundings because they're used to them, they're not going to trip on lines and chords getting to a bathroom they've never used before at night.”
Health systems must engage in serious planning to protect patients in hospital-at-home programs. They need emergency plans to quickly get patients to the hospital if they go into distress. Health systems also need to plan for issues such as severe weather in ensuring clinicians can visit patients in the home.
With careful planning, hospital-at-home programs provide a viable way to care for patients and potentially improve patient safety, says Marcus Schabacker, president and CEO of ECRI, a nonprofit organization focused on improving patient safety. Health systems need proper staffing and the right technology to serve patients safely.
“If done right, I think it can help in reducing the risk of preventable harm,” Schabacker says.
“It is a new care venue which can be safe and effective,” he adds. “But it requires thinking about it. It requires purpose and requires us to establish criteria on how to make sure that everybody stays safe: workforce, patients, families.”
Being in the home
In addition to screening patients for hospital-at-home programs, health systems also have to examine the residence to be sure patients can be managed safely at home.
Wajnberg of Mount Sinai says that one of the most challenging aspects “is ensuring the safety of their home environment.”
Doctors interviewed by Chief Healthcare Executive say in rare instances, they’ve found the residences in such poor condition that they couldn’t offer patients hospital-at-home.
However, in some cases, doctors and systems say they’ve had some work to do.
Understandably, patients that have been feeling ill for some time haven’t kept up with cleaning. In a few instances, patients admitted to describing themselves as hoarders.
Nassif of Saint Luke’s recalls a conversation with a patient who wanted to get treated at home. Nassif says the patient told him, “I'm not a hoarder, but I'm a gatherer and I'm a little nervous.” Saint Luke’s will do some light cleaning and, on a couple of occasions, has called in a crew to do deeper cleaning.
The hospital-at-home program provides an opportunity to help some patients with housing needs, Levine says.
Mass General Brigham has helped patients get enrolled in programs offering assistance with housing needs. For patients in public housing with issues such as leaky windows or holes in the floor, the health system will push the landlord or superintendent to make necessary repairs.
“We bring an element of a power dynamic with us, when there's a doctor or a nurse in somebody's home,” Levine says.
Doctors say another useful element is not only seeing where patients live, but how they live. They gain insight into some of the challenges patients are facing, such as food insecurity.
“We see the things patients have shame about addressing in brick and mortar,” says Constantinos “Taki” Michaelidis, medical director of UMass Memorial Health.
Clinicians can see what patients are eating and help them adjust their diets, which Hopkins of AU Health calls one of the added benefits of home-based programs.
“I think that has helped tremendously by having a more focused attention on patient education right and the importance of following their diet,” Hopkins says.
In hospital-at-home programs, clinicians can also see what other medications they are taking.
Justin Precourt, chief nursing officer at UMass Memorial Health, recalls visiting one patient who had seven shopping bags packed with prescriptions.
“She gets them filled and had no idea of what she would be taking,” he says. Clinicians managed to get her onto a proper medication regime and tossed the medications she didn’t need.
Over and over, doctors and leaders who discussed their hospital-at-home programs with Chief Healthcare Executive shared one overwhelming sentiment: Patients would much prefer to be at home than in the hospital.
“To me, the positive impact on patients that we’re seeing and patient response to the program is in and of itself the right reason to do it,” Precourt says. “It really has been a huge patient satisfier.”
WellSpan’s program has earned high marks from patients, says Bhatia.
“We routinely conduct patient experience surveys and caregiver experience surveys for everyone that has been through the program, and we are in the high 90s,” he says. “So very highly satisfied patient population here.”
Debra Barshinger, the patient who was treated through WellSpan’s hospital-at-home program, says she relished being at home. She also says she felt as if WellSpan’s nurses were taking great care of her. While she was in her own home, she didn’t feel like she was on her own.
WellSpan’s nurses “were excellent,” Barshinger says.
Typically, nurses would spend about an hour in the home during the visits, she says. They administered her medications and spent a great deal of time talking with her.
“They weren’t rushing at all,” she says. “They answered all my questions. They made me glad I chose the hospital-at-home program. They couldn’t have been more attentive.”
It’s easy to see some of the advantages for patients, in addition to the comforts of their own bed and familiar surroundings. Some patients who have pets are also pushing to get out of the hospital to see their fur babies.
“Dog and cat owners are usually anxious to get home,” says Nassif of Saint Luke’s.
Health systems say they are seeing a number of benefits from hospital-at-home programs.
Nurses and clinicians enjoy working in the home-based programs. The nurses can get more uninterrupted time with individual patients.
“I think our nurses really like it,” says Wajnberg of Mount Sinai. “They love being one-on-one with patients.”
“In the brick-and-mortar, there's a million different logistical issues that are handled that don't involve talking to the patients,” says Nassif of Saint Luke’s. But he says nurses in hospital-at-home programs “spend considerably more time with the patients.”
While Saint Luke’s has only been operating its hospital-at-home program, Nassif says the program has retained all of its registered nurses since the launch.
In addition to spending more time with patients, he says the patients are more pleasant and more manageable in the home as opposed to the hospital, since they’re getting more rest and not as likely to suffer delirium.
“I think a lot of it is they see these patients how well they're doing, and the patients are so grateful,” Nassif says. “And they express that to the nurses.”
From a recruiting perspective, hospital-at-home programs appeal to nurses in giving them more time with patients and more autonomy, says Precourt. He says hospital-at-home programs offer great opportunities for nurses.
While they acknowledge hospital-at-home programs require a substantial investment in terms of manpower and technology, some are seeing financial benefits from treating people at home.
Michaelidis at UMass points to the savings for the system in reducing readmissions. “Those are real dollars,” he says. “That’s a lot of money we’re talking about.”
As Bhatia of WellSpan says, the hospital-at-home program frees up beds for those who need to be in the hospital, thus expanding the system’s capacity to serve patients.
“And that assists in the financial return,” he says.
Most expect to see more hospital-at-home programs in the future, especially if health systems continue to see success in providing hospital-level care at home.
Kevin Holloran, an analyst of the hospital sector for Fitch Ratings, says hospital-at-home programs are generating a great deal of attention, but some remain cautious. In a December interview with Chief Healthcare Executive, he noted some healthcare executives are likely waiting for more data to gauge the effectiveness and the safety of programs.
“I have not yet seen it be transformational,” he says. “We are still experimenting with it.’
Combined with telehealth, hospital-at-home programs could eventually be “a transformational bucket of care.”
Some executives say they can see the potential in offering home-based care, but aren’t putting dollars behind it yet. A November poll of healthcare executives by Sage Growth Partners found 27% said they would be investing in technologies to extend care into the home over the next two years.
Some executives say hospitals are waiting for more certainty from Washington about the permanent approval of acute care at home before they begin.
“I think economic feasibility is important,” says Stephanie Kovalick, the chief strategy officer of Sage Growth Partners. “Hospitals typically haven’t done something unless they get paid for it.”
Christopher McGhee is the CEO of Current Health, a technology company which helps health systems provide healthcare at home, including hospital-at-home programs. Current Health, a part of Best Buy Health, is working with more than 20 health systems on hospital-at-home programs.
Even in his role, McGhee says he understands why some healthcare leaders are hesitant. Many hospital systems are struggling with severe financial difficulties because of the pandemic, and some executives may be comfortable focusing on sustaining inpatient programs and putting “heads in beds”, rather than trying an unfamiliar new venture, he says.
In an interview at the HLTH Conference last fall, McGhee told Chief Healthcare Executive, “We’re also seeing a lot of hospitals recognize the future is going to be different, and we can’t just invest in what we’ve done in the past. We have to invest in the future.”
Health systems are also likely to launch more hospital-at-home programs to stay ahead of competitors, or at least keep up with their rivals.
“You’re rapidly being left behind if you’re not doing it,” says Michaelidis of UMass Memorial Health.
Levine marvels at the expansion and success of hospital-at-home programs in the pandemic, going from less than 10 before the pandemic to more than 200 today. "During a pandemic, with financial questions, with staffing questions, it's extraordinary," he says. "It's absolutely extraordinary."
And Levine expects it’s only the beginning.
“If we had 2,600 of them doing home hospital, that'll be amazing,” Levine says. “And I think we can get there, I really do think we can increase this by an order of magnitude. But I'm very encouraged by the number of hospitals doing this so far. And I think it's only going to increase.”