Hospital at Home 'cheat sheet': 6 Qs on the care model, answered

If "Hospital at Home," is a term you've been hearing more often, you're not alone. The term was coined more than two decades ago, but has gained popularity in the last year as hospitals look to innovative care-delivery models to preserve bed capacity and limit COVID-19 exposure risks during the pandemic.

Below is a breakdown on what the Hospital at Home care model entails, how it originated, which health systems have mastered it and more. 

What is it?

The model entails providing hospital-level care to acutely ill older adults in the comfort of their own homes with the goal of fully substituting acute hospital care, according to Baltimore-based Johns Hopkins Medicine

What are its origins?

The Hospital at Home model dates to 1995 and is the brainchild of John Burton, MD, former director of geriatric medicine and gerontology at Johns Hopkins School of Medicine in Baltimore, and Donna Regenstreif, PhD, a former leader at the John A. Hartford Foundation, a nonprofit organization dedicated to improving care of older adults.

Drs. Burton and Regenstreif envisioned a model to provide safe and effective hospital care at home. A team of geriatric researchers led by Bruce Leff, MD, a professor of medicine at Johns Hopkins, developed the basic clinical model and its patient eligibility criteria. 

From 1996 to 1998, the researchers conducted a 17-patient pilot trial to prove the model's safety and feasibility, followed by a national study at three Medicare managed care organizations and one Veterans Affairs hospital from 2000 to 2002 to further assess its safety and benefits. The latter effort marked the first time the model was fully implemented as a replacement for hospital care, according to Johns Hopkins.

In 2011, Johns Hopkins helped the healthcare startup Clinically Home develop its own home-based care model, which relies more heavily on telemedicine than the original model.

How does the model work?

In Johns Hopkins' model, the process starts with healthcare staff identifying eligible patients using validated criteria. This step often occurs in the emergency department or ambulatory care sites. Patients who are eligible and agree to participate are evaluated by the physician who will oversee their home-based care and are then transported home, often by ambulance. 

The patient will receive extended nursing care during the initial portion of their "admission," which then tapers off to daily nursing visits based on clinical need. A physician will also visit the patient daily for an evaluation and will implement any necessary diagnostic measures or treatments at home. Such measures include electrocardiograms, echocardiograms, X-rays, oxygen therapy and intravenous fluids or antibiotics. For some procedures like MRIs and endoscopies, patients will need to make a brief trip to the hospital. 

In the Clinically Home model, physicians perform video visits with the patient and nursing staff, instead of doing house calls, according to an article from The Commonwealth Fund, a healthcare policy research firm.

This care process continues until the patient is stable, and at the time of discharge, care reverts to the patient's primary care physician.

What are the model's benefits?

Over the last two decades, mounting evidence has pointed to the model's clinical and financial benefits for patients and healthcare organizations.

Johns Hopkins' first national study of the model, which was published in Annals of Internal Medicine in 2005, found patients treated via the Hospital at Home model had:

  • Better clinical outcomes
  • A shorter average length of stay (3.2 days versus 4.9 days)
  • Higher patient and family satisfaction 
  • Fewer lab and diagnostic tests compared to similar hospitalized patients
  • Fewer complications often associated with hospital stays, such as delirium, infections and the need for sedative medications or physical restraints
  • Lower care costs by up to 30 percent compared to traditional inpatient care 

Many patients are attracted to the convenience and comfort of receiving care in their own homes. The model also allows caregivers or family members to remain at the patient's bedside, which is not always possible in hospitals today due to COVID-19 visitor restrictions.

For hospitals, the model can translate into greater cost-savings and more clinical efficiency. The model also offers unique benefits during the pandemic, including conservation of personal protective equipment, greater bed availability and the ability to keep infectious patients out of the hospital.

What systems have mastered it?

New York City-based Mount Sinai Health System and Albuquerque, N.M.-based Presbyterian Healthcare Services were both early adopters of Johns Hopkins' Hospital at Home model.

Presbyterian Healthcare Services launched its program in 2008. More than 92 percent of patients presented with the option for at-home care take it, according to a 2016 case study of the organization's program. In 2012, Presbyterian researchers published a study showing Medicare Advantage or Medicaid patients treated through the program had 19 percent lower care costs, along with similar or better outcomes than hospitalized patients.  

Mount Sinai launched its program in 2014 after receiving a $9.6 million grant from the CMS Innovation Center. The health system found patients participating in its Hospitalization at Home  program had an 8.6 percent 30-day readmission rate, compared to 16.1 percent for similar hospitalized patients, according to a case study from the American Hospital Association. Patients who received home-based care also had fewer ED visits (5.8 percent versus 11.9 percent) and reported a better patient experience (67.8 percent versus 45.6 percent).

West Des Moines, Iowa-based UnityPoint Health is yet another health system that's found success with the model, which it adopted in 2018. The health system owns all the services provided under its model, which streamlines operations and allows the organization to get a patient home from the ED within two hours. In 2020, UnityPoint Health lowered its 30-day ED readmission rate for patients in the Hospital at Home program from 27 percent to 4 percent, achieved a 98.9 percent patient satisfaction score and saw an estimated cost reduction of more than $6,000 per patient, according to data shared with Becker's

Other prominent systems are also jumping on the bandwagon. In June 2020, Rochester, Minn.-based Mayo Clinic and Salt Lake City-based Intermountain Healthcare both rolled out their own models to deliver hospital care at home.

In November 2020, CMS launched its Acute Hospital Care at Home program, which allowed hospitals to receive Medicare reimbursement for at-home care services provided to patients for more than 60 conditions. As of April 5, more than 100 healthcare organizations were approved to participate in this program.

Is your health system ready to implement a Hospital at Home program?

Before adopting a home-based care model, health systems must ensure they have the necessary resources, roles, organizational culture and reimbursement models in place.

Johns Hopkins outlines six questions health systems should ask before implementing such a model:

  • Is your health system experiencing problems from a lack of hospital capacity?

  • Does your health system have established home healthcare delivery capabilities?

  • Do you have physicians with the interest and ability to care for patients in the home environment?

  • Does your health system experience a large volume of Medicare admissions for common problems such as community-acquired pneumonia, heart failure or chronic pulmonary disease?

  • Does your institution view itself as an innovator in developing and implementing new models or systems of care?

  • Can your health system align payment, providers and the hospital for this model?

Editor's note: This article was updated April 7 at 4:20 p.m. CST. 

More articles on patient safety and outcomes:
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