Hospital at Home Programs
Imagine being presented with the choice of being cared for at home by family members or cared for in a traditional hospital setting. For many years, patients recovering from complex orthopedic procedures, like hip and knee replacements have had surgery at outpatient surgical centers, and then recover at home after being discharged on the same day as surgery.
Is recovering from an orthopedic procedure at home with a combination of in-home visits and remote monitoring different than dealing with recovery from congestive heart failure, a pulmonary embolism, or even a bone marrow transplant?
A recent article in MPR NEWS 4/29/23, “Post-pandemic, even hospital care goes remote” looks at the new healthcare delivery concept of “HOSPITAL AT HOME.”
Beginning with the COVID-19 pandemic in 2020, the Mayo Clinic started a “hospital at home” program. The program is a combination of in-home visits, remote vital sign monitoring, and teleconferencing with a remote command center led by a physician. Initially, the hospital at home program was started to deal with the large number of COVID-19 patients. Around the country, healthcare systems were overwhelmed by the large number of Covid-19 patients and the systems began the “hospital at home” programs. As the demand created by the pandemic increased, healthcare system innovators began to offer hospital at home programs for patients with a wide variety of ailments. The article describes the experience of a Bone Marrow Transplant patient from the Mayo Clinic in Jacksonville, FL being treated at home successfully and immediately after his bone marrow transplant. Yes, he recovered from a bone marrow transplant! There are now over 250 healthcare systems that utilize “hospital at home” care.
Michael Maniaci, MD, an internist who directs the virtual care, “hospital at home” program for the Mayo Clinic reports that people do better, are more mobile, and recover faster with at home hospital care. Dr. Maniaci initially was very skeptical about home-based hospital care. Now he is an advocate and believer: for the appropriate patient and family situation, he thinks this can be a very successful model for a specific group of patients in future healthcare delivery systems.
At home hospital care is made possible because of remote monitoring systems used at home which can instantly transmit vital signs including blood pressure, heart and respiratory rates, pulse oximetry, patient weights and other parameters routinely assessed in the inpatient in-hospital setting. The Mayo Clinic studied 700 patients during the evaluation process: none of the patients died at home and readmission rates into the hospital were less than 10%. The decision to be treated at home is driven by shared medical decision making: options are discussed with the patients and their families. The patients decide whether to opt into the hospital at home care model. According to Dr. Maniaci, about 75% of patients who are eligible for this care model will choose it.
Most hospital at home programs include 2 to 3 in person visits provided by nurses or paramedics daily. When necessary, video conferencing occurs between the home visiting care provider, and a physician based in a remote command center often located many miles from the patient’s home. If patients are not improving, they are readmitted to the traditional hospital setting as deemed appropriate and necessary.
Many studies have shown that hospitals in general are associated with inherent risks: these inherent risks include medication errors, hospital acquired antibiotic resistant infections (MRSA, VRE), and the disruptive nature of being in the hospital setting for the patient and their families.
Is hospital at home safe? Are large hospital systems just trying to reduce costs? Are hospitals just shifting more care to patient families and reducing services?
Since this care model was developed during the crisis of the Covid pandemic, some in the healthcare industry are not convinced that this is an optimal care model for patients and their families as the nation moves past the pandemic. Some contend that hospitals are being paid for in-hospital care, but are downloading services to families of the patients in their homes.
"This is crisis standard of care being normalized to the normal standard of care — it's substandard care by its definition," says Michelle Mahon, assistant director of nursing practice at National Nurses United.
It remains to be seen how the outcomes on a long-term basis will be with hospital at home based programs.
Although there are real concerns about the standards of care and outcomes of at home hospital care, the innovation provides an opportunity for patients and their families to be more invested in the daily care of their loved ones. Dr Maniaci feels at home hospital care allows caregiver to have a better understanding of the environment in which their patients are living.
The American Hospital Association says early data show there are also potentially big cost savings from lower hospital readmission rates for patients receiving care at home. Faced with increased costs and lowered reimbursements, this may be helpful to large healthcare systems.
Currently, at home hospital in only being funded and approved by a waiver from Centers for Medicare and Medicaid Services, the federal agency managing those programs. The waiver ends in December 2024. An extension is needed by Congressional action before December 2024.
Proponents of hospital at home state that this is a benefit for patients who have conditions which do not require intense hospitalization, outcomes appear to be similar to being in the hospital with low readmission rates, and there are large cost savings realized by healthcare systems, which embrace at home hospital care.
Opponents argue that this is a cost shift from healthcare systems to patients and their families. The opponents argue that not all families are in positions to provide around the clock hospital at home care. Nursing associations indicate that the lack of professional nursing care for the ill is a net negative for patients and their families.
Innovation often requires that industries reevaluate their practices and traditional methods to provide services. In home hospital care likely represents a new innovation in healthcare which may be appropriate for select families and patients. Clinical studies and evaluation will be needed to determine the effectiveness of this change in healthcare delivery. Regardless, by completing your ACP you are giving yourself a choice.