A Hospital Stay—In Your Own Home
By Howard Gleckman
Gleckman is a Resident Fellow at The Urban Institute and author of the book “Caring for Our Parents” This post ran originally on the “Caring for Our Parents” blog.
What if you could be admitted to the hospital—in your own bedroom?
That’s the idea of a health care model called Hospital at Home, which is aimed at elderly patients with diseases such as congestive heart failure, emphysema, urinary tract infections, or pneumonia.
According to a new study published in the journal Health Affairs, people receiving this care through the New Mexico-based Presbyterian Healthcare Services had equal or better outcomes than those getting traditional hospital treatment, and were more satisfied with their care. In addition, care at home cost nearly 20 percent less than a hospital stay.
Hospital at Home (HaH) was created by Dr. Bruce Leff and colleagues at the Johns Hopkins School of Medicine and Public Health. The idea is pretty simple, though a little hard to grasp at first.
Like anyone else, an HaH patient is admitted to the hospital, usually through the emergency department. But some carefully selected patients—if they choose–can be cared for at home instead of receiving treatment in a room at the hospital. All the necessary equipment, such as a bed, oxygen, or medications, as well as monitoring devices, is provided at home. Physicians and nurses visit regularly and the patient’s vital signs are constantly monitored remotely. As with any hospital stay, the patient is discharged at an appropriate time, after which she may receive separate post-acute care if she needs it.
While patients in the Presbyterian model may live alone, HaH patients often have the assistance of family caregivers who may supplement the care provided medical professionals. That can save money and potentially improve care, but also increases the burden on those family members.
Unfortunately, traditional fee-for-service Medicare won’t pay for HaH. Under Medicare rules, a patient must receive hospital care only in a hospital, and nowhere else. But integrated care programs such as Medicare Advantage and Medicaid managed care, as well as a few commercial health plans, do pay for HaH. A nice story in Kaiser Health News describes how Presbyterian and a few other health systems are planning to expand the model. In addition, the program is available on a limited basis through the Veterans Administration and is also being offered in Europe.
The Presbyterian results are striking. The HaH patients’ average length of stay was shorter (3.3 days v. 4.5 days), quality and patient satisfaction were higher. HaH patients were less likely to die during their admission. However, they were also slightly more likely to be readmitted to the hospital within 30 days, and about 2.5 percent of them had to be transferred from home to the hospital during their HaH admission.
The program also saved money. Why? Presbyterian concluded it was because those lengths of stay were shorter and, interestingly, because it reduced the number of diagnostic tests these patients received. After all, a doctor can’t just send a patient down to imaging for yet another MRI when she is at home.
One other fascinating result: Once Presbyterian realized how well care at home works, it decided to take a step back to the future and has now deployed physicians to do medical house calls.
Implementing Hospital at Home is not easy. As the researchers at Presbyterian note, it requires careful care coordination and significant changes in payment structures. But it is a model that has great promise—both for patients and health systems.
Final note from Naomi: As Howard points out, the Hospital at Home model is promising both in terms of cost savings and in improving quality of care. According to the Johns Hopkins folks, spending on all patients cared for at home under this model is reduced by about one third and they experience fewer complications like delirium and other side-effects of hospitalization that require sedatives or even restraints. But to get traditional fee-for-service Medicare to agree to cover this kind of care will require facing up to the powerful hospital lobby and its significant financial interests. As Bruce Leff, a geriatrician and health researcher at Hopkins tells Kaiser Health News ; “Right now hospitals make money by filling beds. If I go to hospital president and say, ‘I’ll do a patient’s care at home,’ Medicare doesn’t pay for that. It’s hard for them to give up revenue in that way.”