Bringing the hospital to the patients

A handful of programs around the country provide hospital-level care to patients without admitting them to the hospital.

Melanie Van Amsterdam, MD, ACP Member, treats the same sorts of patients as a traditional hospitalist. The most common diagnoses she sees are community-acquired pneumonia, congestive heart failure and chronic obstructive pulmonary disease. “We also have cellulitis, nausea/vomiting/dehydration, complicated urinary tract infections, and stable pulmonary emboli and deep vein thrombosis,” she said.

There's just one big difference: Dr. Van Amsterdam sees her patients in their homes, rather than the hospital.

Photo by Thinkstock
Photo by Thinkstock.

She is the lead physician for the Hospital at Home program of Presbyterian Healthcare Services in Albuquerque, N.M., one of a handful of programs around the country that provides hospital-level care to patients without admitting them to the hospital.

The concept of Hospital at Home was developed more than a decade ago by Bruce Leff, MD, FACP, a professor of geriatrics at Johns Hopkins University in Baltimore. “We as geriatricians often felt significant anxiety about sending our patients to the hospital, because while we knew we might be able to turn around their heart failure or cure their pneumonia, the hospital environment might cause them to come out worse than when they went in,” Dr. Leff said.

Acting on these concerns, Dr. Leff and colleagues piloted and proved the benefits of a model for providing home care to patients sick enough to be in the hospital. But it's taken a long time for the rest of the health care system to take note. “Up until relatively recently, it was much more us pushing out trying to spread the word. Over the last year, we've had substantial inbound interest in the model,” Dr. Leff said. “Change is in the air right now.”

Hospitals and hospitalists that are ready to consider this kind of change can find successful examples in Albuquerque and the Portland Veterans Administration (VA) Medical Center in Oregon, among others.

How it works

All programs admit similar types of patients. The first requirement is that patients be sick enough for hospital admission. “You don't want to provide this care to people who could be treated at home with an oral antibiotic or a minor adjustment in their medications. Then the model becomes an extra cost to the system as opposed to a savings,” said Dr. Leff.

This determination is made in part by questioning the referring physician, who may be an outpatient physician, an emergency department doctor or a hospitalist, according to Dr. Van Amsterdam. “We say, ‘Hey, if there was no Hospital at Home, would you admit this patient?’ If [they say] ‘no,’ we set [the patient] up in home health,” she said.

On the other end of the spectrum, some patients are too sick for the program. “We don't take GI bleeders [or] necrotizing fasciitis,” said Dr. Van Amsterdam. “We don't do ICU care at home,” said Dr. Leff. “We developed and validated clinical criteria to pick the patients who need to be in the hospital but are unlikely to have a highly technical hospital course.”

Given the limited availability of diagnostic technology, patients should also have a relatively certain diagnosis. “You don't really want to take diagnostic dilemmas into Hospital at Home,” Dr. Leff said.

Then there are the logistical requirements—patients should live within about 20-25 minutes of a hospital in case they need to be admitted or visited urgently, should have a phone, and most basically, should have some kind of home. “We've done Hospital at Home in some unusual places—hotel rooms, RVs—but we like them to have electricity, running water,” said Dr. Van Amsterdam.

Some living situations turn out to be too unusual for effective care. Stephen Acosta, MD, medical director of the Portland VA's Program at Home, once made a home visit to a patient whose wife was a hoarder. “They lived in a tent next to their home, which was filled with stuff to the roof,” said Dr. Acosta. “It wasn't raining, so we could actually do a fairly decent exam of this gentleman, [but] it's not acceptable to do daily wound dressing changes in someone's driveway.”

The status of caregivers is often a consideration, said Dr. Van Amsterdam. “Can [the patient] get to the bathroom at two in the morning? We're not there at two in the morning….We take all kinds of levels of function, but we need to make sure they're safe in their homes.”

The schedule

If there's an emergency, of course, a Hospital at Home clinician will come out at 2 a.m., but that's a relatively rare occurrence. Dr. Van Amsterdam works week-long shifts of 24/7 coverage but says that's she only had to make middle-of-the-night visits to Hospital at Home patients four times in four years. A triage nurse takes all initial calls from patients and only contacts a physician when he or she can't resolve the issue.

A typical schedule entails patients being visited once or twice a day, by physicians, nonphysician providers (NPPs) or nurses. In the Albuquerque program, for example, a physician or NPP visits once a day and then a nurse comes once daily or more often, if needed. Most Hospital at Home clinicians see a maximum of six patients a day.

Treatment prescriptions such as multiple daily infusions can necessitate multiple nurse visits, noted Dr. Van Amsterdam. The clinicians work together as best they can to simplify these logistics. “We try to help the nurses out. I might start the vancomycin infusion and then the nurse will come and finish it. Or I'll push the [furosemide] or ceftriaxone,” she said.

Hospital at Home care leads physicians to do other tasks that hospitalists would typically delegate. “If you're at a patient's house and they're short of breath, it's you. You're going to be giving them the nebulizer,” said Dr. Van Amsterdam. “You end up doing more old-fashioned internal medicine, where you talk to the patient, you have time to examine them, and you're really hands-on.”

Technological advances, including portable X-rays, handheld ultrasounds and laptop electrocardiograms, have made it possible to bring fancy diagnostics along, but physicians practicing in homes still tend to rely more on their history-taking and examination skills, according to Dr. Leff.

“Putting your stethoscope on someone's chest and making an assessment of that heart murmur with some level of confidence is important. Not that you can't get an echocardiogram at home, but it takes a little more effort,” he said.

The location also changes the patient-physician relationship, he added. “You need to act a little bit differently when you're in someone's home as opposed to sitting in a bed in a hospital on your turf.”

Some physicians enjoy these changes, while others find home practice is not for them. “There are some hospitalists who never want to leave the hospital and that's fine, and I think there are some hospitalists who sometimes yearn to spread their wings a bit and would actually not mind getting out of the hospital a bit,” said Dr. Leff.

Physicians who are asked to practice in the home, or even just refer patients to it, may also be nervous about the liability hazard of deviating from the standard of care by not admitting very sick patients to the hospital. “If something adverse happens, which statistically is actually fairly slim [odds] for Hospital at Home patients, then you may get sued,” said Dr. Acosta. “That needs to change. It will take some time.”

But when physicians do get into the home, the experience is enjoyable and the lessons learned can be useful back at the hospital, the experts said.

Dr. Acosta gave an example of a patient he treated at home. “His instructions were to use oxygen at four liters when you're up and active and two liters when you're not active. His oxygen concentrator was two rooms away,” he said. Rather than force the patient to walk across the house before and after any activity, Dr. Acosta revised the prescription to four liters during the day and two at night.

Such logistics might be useful to consider in future discharge instructions. “We don't think these things through sometimes,” he said.

Evidence support

The Hospital at Home model has been thought through, and investigated, multiple times. A recent meta-analysis, published in The Medical Journal of Australia on Nov. 5, 2012, included 61 randomized, controlled trials of hospital care in patients' homes. “Most of those are in the international literature, because that's where the model has mostly been done, because of the economics,” said Dr. Leff.

The analysis found a 19% reduction in mortality in patients treated at home instead of the hospital, as well as lower costs and readmission rates and a relatively low number needed to treat. “For every 50 people treated in the hospital at home compared to the hospital, you have saved one life, which is rather extraordinary,” Dr. Leff said.

The Albuquerque program's success at reducing cost and readmissions was reported in the June 2012 Health Affairs. “Our outcomes are better than the inpatient hospital. The cost is 19% less per episode. The patient satisfaction is higher. And most importantly, patients have less complications of hospitalization— less falls, less mortality, less nosocomial infections. So it's kind of a win-win program,” said Dr. Van Amsterdam.

Their results have gotten even better in the past year, with readmissions, or patients being admitted to the hospital for the same cause within 30 days of discharge from Hospital at Home, dropping from 10.5% to about 4%, according to preliminary data. Dr. Van Amsterdam attributed the improvement to hiring full-time physicians to work weekends instead of relying on coverage from a rotating group of outpatient docs. “When you don't do Hospital at Home frequently, you don't have the same comfort level,” she said.

The impressive readmission statistics are attracting the attention of both Medicare and the hospitals facing Medicare penalties for their readmissions. Currently, fee-for-service Medicare doesn't reimburse for hospital care in patients' homes, so programs have focused on other payment systems—the Albuquerque program takes only patients covered by Presbyterian's own health plan, and the VA is both the insurer and provider for its patients. The Hospital at Home model may also be a good fit for accountable care organizations (ACOs).

“Diverting people from admission would only be financially advantageous to a socialized system where it's not fee-for- service,” said Dr. Acosta. “I think we're just at the start of an expansion of Hospital at Home….You can't get penalized for readmission if you take care of them in the home.”

As Medicare experiments with alternative payment models, Hospital at Home is very much on the agency's radar, according to Erin M. Denholm, CEO of Centura Health at Home in Denver, which plans to launch a Hospital at Home program in June.

“I spent last year on the CMS [Centers for Medicare and Medicaid Services] innovation advisory council,” said Ms. Denholm. “They enthusiastically support Hospital at Home and they support it in an alternative financial model, not fee-for-service.” The Denver program will start with Medicare Advantage patients, and if successful, possibly expand to a local accountable care organization.

Dr. Van Amsterdam has also received interest in the model from some private insurers. “They may not wait for Medicare, and I think that would be great,” she said. “This program is a great way to take care of patients in a cost-effective manner and reduce readmissions. It's better for everybody.”