CMS recently announced “unprecedented flexibilities” in providing acute hospital care for patients in the home, but the concept of “hospital at home programs” isn’t new at all. Johns Hopkins in Baltimore has operated such a program since 1994 and found it to be very effective: it costs about 32% less than traditional hospital care, mean length of stay by one-third, lowers the risk of complications by 24% and has shown no difference in use of subsequent medical services or readmissions. Moreover, in countries with single-payer systems – such as England, Canada, Israel and Australia – whose payment policies facilitate or at least don’t discourage it, this type of care has flourished. In Australia, for example, 60% of all patients with DVT were treated in the home in 2008 as were 25% of patients admitted for cellulitis.
A hospital at home system could produce dramatic savings for the US Medicare program and private payers, as shown by some pilots of the model which achieved savings of 30% and more per admission while delivering equivalent outcomes as traditional hospital care. Accountable care organizations are also taking note of these statistics.
The Johns Hopkins program description has very specific parameters, honed from almost three decades of hospital at home care:
- Narrowly defined criteria are employed to identify those patients whose needs may be met at home by visiting professionals. This type of care can best be implemented for conditions with defined treatment protocols, such as CHF, COPD, community-acquired pneumonia and cellulitis.
- The suitability of the home must be assessed to ensure heat, air conditioning and running water.
- Patients are outfitted with biometric and communication devices needed to oversee care, and the patient’s vital signs are monitored constantly and electronically.
- An attending physician is assigned to the patient and this individual explains the treatment protocol to the patient, including the various clinical staff who will be providing needed care.
- The physician visits the patient daily, or in some models, communicates with the patient via telemedicine equipment, and once the patient is stable and able to resume activities of daily living, he or she is handed off to the primary care provider. In one model, the hospital physician maintains oversight for at least 30 days to assure a seamless transition and avoid complications.
The Johns Hopkins model’s success is worthy of study (read more here), and program materials make it clear that an emergency or community physician makes the initial referral for hospital at home care after evaluating the patient’s needs. This program isn’t suitable for everyone, but in specific cases, it can be beneficial and cost-effective. CMS’s recent expansion is geared at alleviating the burden of our nation’s hospitals as a result of another COVID wave.
One might be tempted to think this type of program will replace traditional home care; on the contrary, these are acute services that would usually require hospitalization. We believe home care agencies can naturally complement hospital at home services after discharge, and so does Home Health Care News. In 2019, an article discussed the synergy between acute care and home care for proper hand-off between the care “settings.” In addition, given the healthcare system’s focus on social determinants of health and their impact on wellness, even non-skilled home care providers can play an important role in hospital at home programs.