An “Innovation Profile” of the Hospital at Home® program describes the potential cost savings and clinical improvements associated with keeping select patients with acute care episodes in the community.
Hospital at Home®, a model developed at Johns Hopkins University Schools of Medicine and Public Health, was implemented by New Mexico’s Presbyterian Healthcare Services. As a private not-for-profit health care system, Presbyterian sought to address the challenges of hospital bed capacity, hospitalization complications, and poor transition care for the elderly population. Focusing on nine diagnostic groups (congestive heart failure, COPD, community-acquired pneumonia, cellulitis, deep venous thrombosis, pulmonary embolism, complicated urinary tract infections, nausea and vomiting, and dehydration), the program initially sought to focus on eligible Medicare and Medicaid members, but later expanded to commercial health plan members. The patients lived alone in consistent domiciles within twenty-five miles of a Presbyterian emergency department. The patients were either diverted from hospital admission or were early discharges from an inpatient hospital unit.
Components of the comprehensive program included: referrals from multiple parties including outpatient providers; availability of necessary equipment such as oxygen, infusions, diagnostic services, and transportation; physician and nursing visits; additional tele-health monitoring; and discharge and care transition planning.
Compared to a group of patients admitted to non-intensive care hospital beds in the Hospital at Home® geographic catchment area (central New Mexico) with one of the same nine diagnoses and age sixty-five or older, 348 qualified patients were offered Hospital at Home®, of which 93 percent opted for the program. The mean length of stay for Hospital at Home® was 3.3 days (standard deviation: 2.8) while the mean stay of the traditionally hospitalized comparison group was 4.5 days (standard deviation: 3.2). Hospital at Home® patients experienced lower rates of falls (0 percent versus 0.8 percent) and lower mortality during admission (0.93 percent versus 3.4 percent). Readmission to the hospital within thirty days of discharge was similar (10.8 percent versus 10.5 percent). Hospital at Home® had higher overall patient satisfaction scores (90.7 percent versus 83.9 percent). Hospital at Home® patient costs were 19 percent lower than mean hospital costs for the comparison group, due to lower average length of stay and lower use of clinical testing.
Components deemed important to the success of the program included: the integration of the health plan, delivery system, and the medical groups; the monitoring of results and adjustment of processes and procedures; and the involvement of multiple parties including but not limited to billing, documentation, scheduling, intake, pharmacy, human resources, and policy development. Due to the success of the program, Presbyterian expanded the eligibility of patients by geography, health plan, and diagnosis.
It is well accepted that inpatient hospital care can add significant morbidity and mortality to acute and chronic conditions. By realigning our approach to the delivery of care into a more humane and safe setting, there are multiple benefits for our patients as well as the financial status of our health care systems. Several questions loom however: how does this expand to those patients without structured homes? Or to those that are not within close range of an emergency department or inpatient facility? What about those patients whose homes are not able to accommodate tele-health monitoring? How are physicians recruited and appropriately trained? How successful would program be without the necessary portable technology? In underserved areas, both rural and urban, this model is somewhat limited in its application due to the obvious lack of resources. Coordination through the multiple components of the program will be difficult for the typical non-integrated health system that works with multiple players and has poor resources. That being said, this case is fascinating in its possibilities, and in a patient-centered world, such coordination is the utopian ideal.
Kameron Matthews, MD, Esq.