'When Home Becomes a Hospital' Transcript
March 23, 2023
Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode!
Dan Gorenstein: Bruce Leff remembers the fear that permeated the country in late 2020.
Bruce Leff: Everyone was feeling a little bit desperate.
Clip: For the third day in a row, the U.S. topped its all-time coronavirus record on Friday.
BL: Everyone was concerned for their own health and for the health of everyone in the country.
Clip: Yesterday, we lost 933 lives to this virus.
Clip: You’ll start to see closer to 2,000 deaths per day.
BL: Hospitals were completely overwhelmed with COVID. They were bursting at the seams.
Clip: Hospitals are warning that their running out of ICU beds and trained staff.
Clip: Over 100% capacity if that’s possible.
Clip: It’s dire when you’re counting how many ventilators you have left.
DG: Seeing hospitals drown under the flood of COVID patients hit especially hard for Bruce.
He’d spent nearly three decades trying to convince people that a lot of patients in the hospital could actually be treated in their homes.
Dozens of randomized control trials showed that under so-called hospital-at-home programs, patients were less likely to die or be readmitted to the hospital when cared for at home. And that it cost less than a typical hospital stay, too.
But Bruce, a doc and researcher at Johns Hopkins in Baltimore, says there were only about two dozen hospital at home programs nationwide pre-pandemic.
BL: There was no way for hospitals to get paid for providing hospital-at-home care in traditional fee for service Medicare.
DG: The federal Centers for Medicare and Medicaid Services, or CMS, had funded a few small pilots, but they still wondered: Could sick people get high quality care away from the the hospital? Would care at home lead to fraud, abuse?
But with COVID, CMS saw hospital-at-home in a whole new light.
BL: We and colleagues have been working on this for a long time. And then, you know, bam, because of the pandemic, it moved through very, very quickly.
DG: On November 25, 2020, the agency announced Medicare would pay the exact same for a stay in the hospital or at home.
In three weeks, CMS made possible something Bruce had fought for for three decades.
BL: All of us in the hospital at home community were really excited and really wondered whether hospital at home could rise to the occasion.
DG: Two and a half years later, 276 hospitals across 37 states can now offer hospital at home, and Congress made sure it’ll stick around through at least 2024.
This rapid growth is part of a larger movement that’s raised an important question: What kind of care can safely be delivered in patients’ homes?
Today, a front row look at the explosion of hospital at home, what we’ve learned, and what we still don’t know.
From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstien. This is Tradeoffs.
DG: David Mercurio’s problems in the hospital started right away.
David Mercurio: The first two nights when I was there, about 3:00 in the morning, two patients outside in the hallway, yelling and screaming and swearing and throwing things. I mean, was I in a hospital or was I in a nuthouse?
DG: The construction business owner landed at UMass Memorial — an academic medical center 50 miles west of Boston — after he woke up at home with a raging fever and little control of his body.
It took doctors three days to identify the problem: a rare tick-borne illness.
After a few more days, David’s wife Melanie says her husband was fed up.
Melanie Mercurio: He was saying to every attending, every resident who came in, I want to go home. I want to go home.
DG: Doctors and nurses constantly came in and out, standard procedure given his condition, but it left David sleep-deprived and cranky.
And data show people over 65 often become delirious or pick up new infections in the hospital.
The longer the 70-year old stayed at UMass Memorial, the higher the risk.
After a week, David’s doctors said he could finish his hospitalization at home.
Constantinos “Taki” Michaelidis: The vision was always how do we bring all the best parts of the hospital to the patient and the family and keep away the parts of the hospital that are perhaps more harmful.
My name is Constantinos Michaelidis, although everybody calls me Taki. I’m an internal medicine physician by training and medical director of the UMass Memorial Health Hospital at Home Program.
DG: CMS’ hospital-at-home program made perfect sense for UMass Memorial.
They were in the middle of a capacity crisis in late 2020.
CM: 60, 70, 80, sometimes 100 patients in our emergency department waiting for that hospital bed for hours and sometimes, frankly, even days.
DG: They had run a field hospital in the early days of the pandemic, which eased federal health officials’ concerns about them delivering care beyond the hospital.
In February 2021, UMass set aside $2 million to build the program.
CM: This was not a small investment and it was not a small amount of work.
DG: Taki described it as basically building a whole new wing of the hospital.
They had to staff up.
CM: We had to recruit a leadership team, recruit amazing paramedics and nurses and physicians to care for patients.
DG: Find vendors to offer everything from X-rays to meals to high-speed internet in patient’s homes.
CM: We had to build all the wiring and the tubing and the plumbing so that we could care for a patient in the home.
DG: They had to create workflows and think about contingencies that would be unimaginable in a brick and mortar facility.
CM: If a nurse is walking between room A room B in the middle of the winter, that nurse is not thinking to him or herself, Oh, gosh, like I need a four wheel drive vehicle. Whereas we do think about that. We do make those investments.
DG: Some hospitals outsource this work to companies that specialize in building and running hospital-at-home programs.
With their help, hospitals have built programs in just 4 or 5 weeks.
UMass did it themselves, and after six months, they admitted their first patient in August 2021.
CM: The first month our average census was 2 to 4 patients at any given time, to make sure that our safety and quality outcomes were just as strong. And then after that, and only after that point did we slowly begin to grow the service.
DG: By the time David was admitted more than a year later, UMass had treated nearly 750 patients.
David was thrilled.
DM: This is the way I looked at it: They’re going to give me the same treatment they’re going to do in the hospital. And I trusted them in the hospital, so why wouldn’t I trust them there at home?
DG: His wife Melanie was more skeptical.
She knew David would be more comfortable at home, but would he be safe?
MM: He was still pretty weak at the time. I’m thinking to myself, are they doing this because he’s whining so much about wanting to go home and they’re just trying to pacify him and say, okay?
DG: The same concern that had stopped CMS for decades came to Melanie’s mind: Could David get the care he needed away from all the staff and support of the hospital?
She talked to David’s doctors, and then she turned to her daughter, who works at UMass.
MM: She said, mom, she said, don’t be afraid of it. It’s a great program. So after hearing that, I mean, I was all for it.
DG: The evening of David’s eighth night, Melanie drove lead-car in a caravan headed for home. Behind her a car with two nurses, and bringing up the rear, David in an ambulance.
DM: I went from the ambulance into my house and it’s like walking from the ambulance into a hospital bed at the hospital.
DG: Just like a normal intake, the nurses took David’s vitals.
But instead of a hospital bed, they set David up in his gray recliner in the family room with his Pomeranian, Kiwi Belle, by his side.
DM: Oh, it was fantastic.
DG: Instead of big beeping bedside machines, the nurses slipped a small white band on David’s arm.
That band would allow David’s UMass clinical team from the hospital to constantly monitor things like skin temperature, heart rate and oxygen level.
The wooden table next to his chair became a command center of sorts, filled with medications and a tablet that David would use for telehealth or emergencies.
MM: He was just happy to be home.
DG: David slept in his own bed that night free from midnight blood draws and hallway arguments.
For the next eight days, nurses came to the house twice a day, and at least one of those times, Taki or another doctor would join via video.
For a while Melanie worried that David had a blood clot.
When Melanie told the nurses, the hospital sent someone out to do an ultrasound as David sat in his recliner.
Delivering care at home, says David, sometimes meant having to improvise — a little DIY flavor.
DM: When they gave me the IV, my wife had some Christmas decorations that she used these little hooks, and they weren’t being used so they just hooked it to that. Whatever they needed, they did it right in my own house.
DG: David’s experience thankfully was relatively smooth.
But of course, sometimes, patients need to get back to a hospital.
CMS requires programs to be able to get them there within 30 minutes.
And that time frame raises the eyebrows of Michelle Mahon.
Michelle Mahon: We are talking about response needed in seconds, not minutes.
DG: Michelle is the assistant director of nursing practice for National Nurses United, the largest nurses union in the country.
For Michelle, the 30-minute rule starkly illustrates the inherent danger of hospital at home.
Remote monitoring technology, she says, can miss subtle cues that someone is at risk — things a nurse in a hospital often catches.
Mahon: We are with them all the time so we can see changes from day to day, maybe in the glossiess of their eyes or in the smell of their breath. These are the kinds of signals that are alert to us.
DG: Another concern critics raise: Instead of nurses and doctors, family members are often the ones constantly checking on a hospital-at-home patient.
Michelle says that’s also unsafe and unfair.
Mahon: The goal behind programs like hospital-at-home is to shift the burden of care to family members themselves, who, of course, are working for free, who are taking care of their loved one for free.
DG: There are no regulations around what hospitals can or should ask of family caregivers.
Melanie Mercurio says having David home did put extra pressure on her.
She helped him up and down the stairs. She gave him his meds. She collected his urine.
DM: You can just sum it up, she was my nurse.
DG: While she had more responsibilities, Melanie says she also though felt supported.
When she had questions, she used the tablet to call the 24/7 help line and got immediate answers from doctors or nurses.
MM: You never feel abandoned on this program. And that’s what I loved about it. So it’s not like, oh, no, he’s coming home. I’m not going to know what to do. It wasn’t like that at all.
DG: After eight days, David was discharged from hospital-at-home. He’s one of thousands of patients nationwide who have gotten this care since November 2020.
When we come back, what we’ve learned and what we still don’t know about caring for people in their homes.
DG: Welcome back.
When Medicare started paying for hospital-at-home in November 2020, it launched one of the country’s largest experiments in providing hospital-level care in patients’ homes.
That experiment was set to end along with the COVID public health emergency, but this past December, Congress extended it through at least 2024.
So what have we learned in the last 2 ½ years. And what questions remain unanswered?
Here to help us break all of that down is Tradeoffs producer Ryan Levi. Ryan, how are you, sir?
RL: I’m doing well, sir. Thanks so much.
DG: So, Ryan, I’ve been covering hospital at home for several years, as you know. And the big promise is patients can avoid some of the worst parts of a hospital stay: the chaos, the bad sleep, the petri dish of possible new illnesses.
But as we’ve said, even with strong evidence from early adopters that this approach could improve care and lower costs, it took a pandemic for regulators to take this more seriously.
So, Ryan, are we any closer to definitively saying that a patient can enjoy the comfort of their home without giving up the good parts of hospital care?
RL: Here’s what we can say, Dan.
I talked with four hospitals who launched hospital-at-home programs during the pandemic: UMass Memorial, Kaiser Permanente, the Mayo Clinic and Intermountain Healthcare. And collectively they’ve treated thousands of people at home and anecdotally, they all say patient health and safety has stayed steady or even improved compared to their brick and mortar patients.
At a higher level, federal officials put out some preliminary data that was also in line with the positive evidence we’ve seen in earlier studies. But CMS made it clear that they think it’s too soon to draw any big conclusions.
DG: So it sounds like we’re pretty much where we were before the pandemic started: strong evidence pointing to this care being safe but not definitive enough yet for CMS to go all in.
RL: Yeah I think that’s right.
Federal health officials are collecting data from all of these hospitals, which should give us a clearer picture, hopefully, but it seems like we’re going to have to wait a little longer to see that picture.
DG: Any idea how much longer?
RL: If only I knew! I’ve asked CMS several times for more updated data, Dan, but no luck so far. I’ll probably be calling them again when we’re done with this interview.
DG: Go get it!
RL: I will say, Congress has directed federal health officials to release a study that compares hospital-at-home to traditional hospital care by the fall of 2024. And lawmakers want data on patient demographics, conditions, outcomes, death rates, and costs.
DG: OK, so while we’re waiting on CMS for more data, we also know with so many more hospitals doing this, there are some new insights, there are some lessons learned. And I know you’ve been talking to providers and researchers about this. What have they told you, Ryan?
RL: The biggest thing I heard from supporters — people like Bruce Leff at Johns Hopkins who has been working on this for 30 years — is that hospitals are excited to dive into this space.
BL: I think if you ask me and my colleagues how many hospitals would apply, I think we probably would have said 40 to 50. But to see over 250 hospitals go for this is really, really remarkable.
RL: Now we should be clear: We’re still only talking about roughly 4% of U.S. hospitals having the go-ahead from CMS on this, Dan, so it’s far too soon to call hospital-at-home mainstream.
But Bruce and other providers I talked with think with an extra two years of certainty on Medicare funding, even more hospitals will feel confident enough to jump in to the game.
DG: I know one of the big concerns pre-pandemic at least was that hospital-at-home would only be feasible for big, urban academic medical centers, and that smaller hospitals, more rural hospitals would struggle creating inequities in access to this care.
Have we learned anything more about what kind of hospitals are doing this?
RL: I couldn’t find any definitive analysis on this, but researchers say there are some rural hospitals doing this, although they’re still well out-numbered by big facilities in cities.
There are three rural hospitals in Illinois, Appalachia and Alberta, Canada, that are actually running a randomized control trial to see how this works in their communities, so hopefully we’ll have more evidence on the rural piece soon.
But Bruce says it’s become clear that it takes a lot to build and sustain a hospital-at-home program — you need new technology, new systems, new vendors — and that’s going to limit who can do this.
BL: I think to be successful you need leadership that values this approach to care and has the wherewithal to get it implemented. And that system has to have some resources to be able to do it.
RL: Something that surprised me, Dan, is that even though some 270 hospitals have the OK from CMS to run hospital-at-home programs, researchers like Bruce say only about half of them have actually treated a real-life patient.
Bruce says that’s to be expected given how much work it takes to get up and running.
But it’s also an important reminder of the other barriers beyond Medicare payment that still exist — things like convincing doctors and nurses to refer their patients, hiring and training staff, and making sure there are enough patients to make a program worth offering.
DG: OK, plenty of barriers out there and regulators are still waiting on more data.
But there seems to be a growing number of providers and insurers who are convinced this works and I’m guessing they’re moving onto more nuanced, complex questions.
Is that a fair assessment?
RL: It is, Dan.
There are still critics who want hospital at home stopped in its tracks, most notably the union National Nurses United, who think this is an unsafe money grab by hospitals that will lead to physical hospitals closing their doors.
But this seems to be a minority opinion, and among folks who like hospital-at-home, there are still several big unanswered questions they’re trying to work through. And I want to touch on three of them: which patients are best for this, who should be providing the care, and how should it all be paid for.
DG: Great, let’s start with the types of patients who are and are not a good fit.
RL: We see a lot of people with conditions like pneumonia, heart issues and infections, and the evidence strongly suggests they can safely be cared for at home.
And pretty much everyone agrees that patients who require surgery or intensive care or just want to be in they hospital, they should be in a physical hospital.
Beyond that, there’s some disagreement. Some hospitals treat people with cancer or who have just had organ transplants at home. Bruce Leff is in that camp.
BL: I do think a lot of what goes on now in hospitals can be done in the home. Everything? No, but I think hospitals of the future become big ICUs, big ERs and operating rooms.
RL: Other hospitals think this care should be much more limited.
The medical director of one of the oldest hospital at home programs in the country told the New York Times that if a patient needs continuous monitoring of their vitals, like what David Mercurio had, that patient should be in the hospital, not at home.
DG: And, Ryan, what about people’s social situations? I know there have been a lot of equity concerns around whether hospital-at-home might exacerbate racial and economic health disparities.
I’m wondering, do people need to have one kind of setup for this to work?
RL: Equity is absolutely one of the biggest areas experts say we need more research on, Dan. But several providers I talked with think hospital-at-home could actually help address disparities.
There are examples, Dan, of people in public housing or other low-income housing who get hospital-at-home.
Taki Michaelidis at UMass Memorial says one-third of their patients have been on Medicaid, the public health insurance program for low-income and disabled Americans.
CM: We firmly believe if you have a roof and you have running water and you’re interested in being cared for in home hospital care, we would love to bring home hospital care to you.
RL: There are some studies that show hospital-at-home can be even more beneficial for people on Medicaid than Medicare.
And a lot of people I talked to said getting into someone’s home allows them to better address social determinants of health like food insecurity.
DG: OK. Let’s move onto your second question: Who should be providing this care? What’s the debate there, Ryan?
RL: So in hospitals, registered nurses provide the lion’s share of people’s care, right? And nurses are also the ones at people’s bedsides for a lot of hospital-at-home programs.
But hospitals can also use folks called “community paramedics” who have less training and are less expensive than nurses.
DG: Which is part of the reason why nurses unions so strongly oppose this idea because it could lead to hospitals needing fewer nurses.
RL: Absolutely, but again, even among active hospital-at-home programs, there is a real open question about how often a patient needs to see a nurse or a doctor in-person and how much care can be done by other providers or can be done virtually.
There’s no doubt some health systems see hospital-at-home as a way to save money, and lower labor costs are going to be a piece of that.
I talked to Nathan Starr about this. He runs the hospital-at-home program at Intermountain Healthcare in Utah.
Nathan Starr: Typically in a hospital, one nurse will take care of five to six patients 24 hours a day. At home, what we’ve definitely found is patients sleep, and so our nighttime nursing ratios can be very minimal. We have a nurse who’s available 24/7, but they can take care of a lot of patients because we don’t get a lot of calls.
RL: Nathan says his hospital is spending 30 to 40 percent less on hospital-at-home patients without any dip in outcomes.
DG: Which leads us nicely into your third question, Ryan, about money.
Right now Medicare pays hospitals the same whether the patient is in the hospital or at home. But if some hospitals can spend 30 to 40 percent less on patients at home, maybe Medicare should cut hospital at home rates?
RL: There’s a lot of interest in figuring out how to right-size these payments, Dan.
Several providers I talked with said future hospital-at-home payments should actually be lower than normal hospital payments.
DG: How would that actually work given that hospitals may want some kind financial incentive here?
RL: So, one option would be for to Medicare pay a lump sum to a hospital for each patient that’s lower than what the hospital would get for an inpatient, but high enough that the hospital could still make a profit. Some hospitals have already done this with private insurers, but making it happen in Medicare I’d say is one of the biggest conversations happening right now in this space.
DG: So here, final question: Based on your all the conversations you’ve had, what do you think hospital-at-home will look like in 5 years? What’s your best guess?
RL: Let me find my crystal ball here. I’ve hidden it here somewhere.
DG: Sorry I had to ask.
RL: It’s a reasonable question. I think it’s really going to depend on what the evidence shows.
If CMS comes out with data showing lots of people in lots of places received good, safe care in their homes for a fraction of the cost, I think we’ll really see this take off.
But in a lot of ways, Dan, hospital-at-home is just the tip of the home-care iceberg.
There are people working on primary care at home, rehab at home, mental health care.
The pandemic turbo-charged the movement to move more care into the home, and that seems likely to stick around.
DG: Tradeoffs producer Ryan Levi, thanks for your reporting.
RL: Anytime, Dan.
DG: I’m Dan Gorenstein, this is Tradeoffs.
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Selected Reporting and Research Hospital at Home:
Hospital-at-home steps out of the COVID-era through new Atrium Health, Best Buy partnership (Annie Burky, Fierce Healthcare, 3/7/2023)
Your Next Hospital Bed Might Be at Home (Helen Ouyang, New York Times, 1/26/2023)
The New Hospital at Home Movement: Opportunity or Threat for Patient Care? (Eileen Appelbaum and Rosemary Batt, Center for Economic and Policy Research, 1/24/2023)
The push for more in-home care options may come with risks (Tina Reed, Axios, 1/12/2023)
Health systems bet on hospital-at-home (Mari Devereaux and Alex Kacik; Modern Healthcare, 11/21/2022)
A national qualitative study of Hospital-at-Home implementation under the CMS Acute Hospital Care at Home waiver (Ksenia Gorbenko, Abigail Baim-Lance, Emily Franzosa, Heather Wurtz, Gabrielle Schiller, Sybil Masse, Katherine A. Ornstein, Alex Federman, David M. Levine, Linda V. DeCherrie, Bruce Leff and Albert Siu; Journal of the American Geriatrics Society, 10/5/2022)
Family Caregiver Considerations for the Future of Hospital at Home Programs (Susan Reinhard, Selena Caldera, Elizabeth Burke and Tyler Cromer; AAPR Public Policy Institute and ATI Advisory; 8/2022)
What We Learned From The Acute Hospital Care At Home Waiver—And What We Still Don’t Know (Bruce Leff and Arnold Milstein, Health Affairs Forefront, 6/27/2022)
Acute Hospital Care at Home: The CMS Waiver Experience (Douglas V. Clarke, Jillian Newsam, Douglas P. Olson, Danielle Adams, Ashby J. Wolfe, and Lee A. Fleisher; NEJM Catalyst; 12/7/2021)
Hospital-at-Home Interventions vs In-Hospital Stay for Patients With Chronic Disease Who Present to the Emergency Department (Geneviève Arsenault-Lapierre, Mary Henein, Dina Gaid, Mélanie Le Berre, Genevieve Gore and Isabelle Vedel; JAMA Network Open; 6/8/2021)
Bruce Leff, MD, Director, The Center for Transformative Geriatric Research, Johns Hopkins
Constantinos “Taki” Michaelidis, MD, Medical Director, Hospital at Home Program, UMass Memorial Health
Michelle Mahon, RN, Assistant Director of Nursing Practice, National Nurses United
Nathan Starr, DO, Medical Director for Home Services, Castell; Director of Telehospitalist Program, Intermountain Healthcare
The Tradeoffs theme song was composed by Ty Citerman, with additional music this episode by Blue Dot Sessions and Epidemic Sound.
This episode was reported by Ryan Levi and mixed by Andrew Parrella and Cedric Wilson. Editing assistance from Cate Cahan.
Special thanks to: Amy Bassano and Priyanka Shah
Additional thanks to: Stephanie Anthony, Selena Caldera, Javier Cepeda, Lauren Dunning, Mary Giswold, Julia Harris, Mark Howell, David Levine, Manu Malhotra, Ateev Mehrotra, Rob Moskowitz, Tricia Neuman, Kemar Osbourne, Margaret Paulson, Jennifer Podulka, Jason Resendez, Tina Sandarangani, Jerome Siy, the Tradeoffs Advisory Board and our stellar staff!