Home Sweet Hospital
May 28, 2020
Photo by Ronald Woan licensed under CC BY-NC 2.0
The coronavirus has left some hospitals empty and others overrun. One fix to both problems is to move care for certain conditions out of the hospital and into patients’ homes. It’s a decades-old idea that’s getting a lot of new looks.
Listen to the full episode below, read the transcript or scroll down for more information.
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The Basics: Hospital at Home
So-called hospital-at-home programs typically serve patients with conditions that are simpler to treat, like pneumonia and heart failure. A home admission can replace an inpatient stay altogether or end one early, allowing a hospitalized patient to complete recovery at home. Care is provided through a combination of in-home visits and telehealth.
Experts have long believed that the home is a safer, better and cheaper place to treat patients for certain conditions that typically require hospitalization, but hospital-at-home programs have been slow to grow in the U.S. Less than 1% of all U.S. hospitals have active hospital-at-home programs and most are very small.
With the pandemic putting new pressure on the capacity and finances of hospitals, this decades-old model is receiving a surge in new interest.
The Evidence: Better Outcomes, Lower Costs
More than 60 randomized controlled trials have evaluated the impact of the hospital-at-home model. Most have been done internationally since hospitalizing patients at home is much more common in single-payer systems, but a recent U.S.-based trial found similar benefits. Among the benefits supported across studies are:
Studies have also shown that patients hospitalized at home are more active, which can speed recovery, and have fewer imaging and laboratory tests done, which can help reduce low-value care.
COVID-19 Impact: Barriers Become Opportunities
Hospital-at-home programs are seeing unprecedented interest and growth during the pandemic. While barriers still remain, the coronavirus is catalyzing changes that are making those barriers easier to overcome than before. Whether these changes last post-pandemic remains to be seen.
Reimbursement
Pre-COVID: Some insurers, mostly managed care plans, have embraced the savings hospital-at-home programs offer, but Medicare still declined to cover it under the fee-for-service insurance many seniors have, severely limiting the pool of paying customers.
Post-COVID: In March, CMS began releasing emergency waivers allowing hospital care to happen in alternative settings during the pandemic. Many interpret their most recent guidance to mean Medicare will now cover hospital care provided in the home, but others believe further clarity is needed.
Implementation
Pre-COVID: Providing hospital-level care at home requires significant logistical and technical work. Launching a hospital-at-home program can cost hospitals serious amounts of time, staff and money.
Post-COVID: A handful of private-sector companies, led by Contessa and Medically Home, exist to help hospitals outsource the logistical and administrative work required to run a hospital-at-home program, allowing the model to scale much more quickly. These companies report new partnerships and many more inbound inquiries from hospitals during COVID-19.
Demand
Pre-COVID: Despite decades of evidence supporting the model, many hospitals and patients alike were hesitant. Hospitals saw little reason to disrupt their existing business models, and patients were skeptical of receiving care outside the traditional setting.
Post-COVID: The coronavirus has shown hospitals the pitfalls of relying so heavily on brick-and-mortar facilities, which have fixed capacity and require patients to come to them. As for patients, they are avoiding hospitals in unprecedented ways while also largely embracing telehealth. Together, these trends create more fertile ground for hospital-at-home.
The Tradeoffs
The evidence clearly suggests that hospitalizing certain patients at home can result in better outcomes and lower costs. The pandemic has revealed other benefits of the model, such as its ability to give hospitals the flexibility to ramp capacity up and down.
However, the model is not a panacea. There are many conditions that still require inpatient care and some eligible patients may still prefer being hospitalized. Hospital-at-home programs only exist at less than 1% of US hospitals, and they are even rarer in rural areas. Significant challenges to scale and sustainability remain.
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Episode Resources
Select Research and Reports:
Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial (David Levine, et al; Annals of Internal Medicine; 2020)
Hospital-at-Home to Support COVID-19 Surge—Time to Bring Down the Walls? (Shantanu Nundy and Kavita Patel; JAMA Health Forum; 5/1/2020)
Association of a Bundled Hospital-at-Home and 30-Day Postacute Transitional Care Program With Clinical Outcomes and Patient Experiences (Alex D Federman, et al; JAMA Internal Medicine; 2018)
The Hospital at Home Model: Bringing Hospital-Level Care to the Patient (Sarah Klein, Martha Hostetter and Douglas McCarthy; Commonwealth Fund; 2016)
A Meta-Analysis of “Hospital in the Home” (Gideon Caplan, et al; Medical Journal of Australia; 2012)
Episode Credits
Guests:
Bruce Leff, MD, Director, The Center for Transformative Geriatric Research, Johns Hopkins
Travis Messina, MBA, Cofounder and CEO, Contessa
Kavita Patel, MD, MPH, Nonresident Fellow, Brookings Institution
Raphael Rakowski, Cofounder and CEO, Medically Home
David Zaas, MD, MBA, President, Duke Raleigh Hopsital
The Tradeoffs theme song was composed by Ty Citerman, with additional music this episode from Kevin MacLeod, Lobo Loco and Blue Dot Sessions.
This episode was reported and produced by Leslie Walker. It was mixed by Andrew Parrella.
Additional thanks to:
David Levine, Linda DeCherrie, Nancy Guinn, DispatchHealth, Amy Berman, Nate Handley, Bob Kocher, Vidhya Aroumougame, the Tradeoffs Advisory Board…
…and our stellar staff!