“Hospital in the Home” is emerging as a frequently discussed concept in the medical community. Programs that allow patients to receive hospital-level of care in their homes have shown to be safer, less costly, and result in better patient outcomes. As a result, Hospital in the Home programs are gaining traction as an alternative option to acute inpatient stays.
To better understand the opportunities, benefits, and challenges of Hospital in the Home programs, we invited two of the nation’s pioneers and leading experts on the matter to join us on the Change Healthcare podcast: Dr. Bruce Leff, Director for The Center of Transformative Geriatric Research at Johns Hopkins University School of Medicine; and Dr. Allyson Kreshak, emergency medicine physician and Assistant Medical Director at UC San Diego Emergency Department.
Both helped innovate and steer Hospital in the Home programs for their respective hospital systems,and are optimistic that in-home hospital care can become the new standard of care for some patients. On today’s show, we dive deep into the Hospital in the Home trend and discuss:
- The genesis of Hospital in the Home programs and today’s modern home-based care movement (5:50)
- The quantifiable (and non-quantifiable) benefits of Hospital in the Home for patient outcomes (11:07)
- What contributes to a successful Hospital in the Home program? (16:41)
- The adoption challenges some Hospital in the Home programs have faced and the role of technology in the future of more streamlined home-based care (20:18)
- Which patients are appropriate for Hospital in the Home programs? (26:18)
- Top considerations to win buy-in to establish a Hospital in the Home program and common pitfalls to avoid (33:50)
- Steps to create internal infrastructure for a successful Hospital in the Home program (33:50)
- The practicalities of reimbursement models (44:00)
- The future of Hospital in the Home (46:12)
- Bio: Laura Coughlin RN
- Bio: Dr. Leff
- Bio: Dr. Kreshak
- Change Healthcare introduces InterQual 2019
- InterQual evidence-based clinical decision support web site
- InterQual 2019 brochure
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LAURA COUGHLIN: Good day. This is Laura Coughlin, Vice President for InterQual Clinical Development and Strategy at Change Healthcare. Thank you for joining us today. We have a great program planned for today with our two guest speakers. Dr. Bruce Leff who is a geriatrician and the director for The Center of Transformative Geriatric Research in the division of geriatric medicine at Johns Hopkins. And Dr. Allyson Kreshak who specializes in emergency medicine and is associate clinical professor at UC San Diego at the school of medicine in the department of emergency medicine. So we’d like to talk about this new trend that is happening across the country called Hospital in the Home. I’d like each of you and I’ll start with Bruce, tell me a little bit about yourself and how you got involved in the hospital in the home programs that are starting to pop up everywhere in the country. Bruce.
BRUCE LEFF: Sure. So thanks for having me. And my interest in home-based care goes back a little over 30 years. So I trained in primary care, internal medicine here at Hopkins. Hopkins Bayview. And as second year residents, we picked up a home-based primary care practice providing longitudinal care as residents to older adults in southeast Baltimore who were homebound and couldn’t easily access traditional ambulatory care. And for me, that was a pretty transformative clinical experience. I think I learned a lot about how to really talk to patients, how to take good histories, how to really hone a physical exam because I was a little bit further away from technology. I think I learned how to develop thoughtful and reasonable diagnostic workups for people who are a little bit further away from technology and from the hospital, and how to counsel patients and get them through some tough times. And I think I learned also a lot how to be a good guest in people’s homes. And I think taking care of people in their homes changes the way you practice because you get to see firsthand how people live and you get to witness firsthand how all the social determinants of health truly impact people’s lives and people’s health. So that was just a very transformative experience for me and part of that we would commonly see older people who became acutely ill say with pneumonia or heart failure exacerbations or the like, and many times they would refuse to go to the hospital because they had had very negative experiences when they were inpatients in the hospital. And those experiences have been well documented in scores of studies which led up to in the late 90’s the IOM’s reports on crossing the quality chasm and the like. To err is human and I think our patients recognized the challenges of being in the hospital well before the experts did. So as geriatricians, we thought hey how about why don’t we start to think about based on our experiences providing acute care in the home sort of on a shoestring when people got acutely ill and refused to go to the hospital, why don’t we see if we can actually develop that into some sort of real care model. And that’s what we started to do at Hopkins back in the mid-nineties in terms of developing the construct of Hospital at Home. So that was kind of the start of it for me.
LAURA: Allyson, tell us about your background.
ALLYSON KRESHAK: Sure. I’m an emergency medicine physician. One of the assistant medical directors of the UCSD ED. And I’m also one of the medical directors of our UCSD managed care program and work closely with our ACO here at UCSD. And in serving in both those roles, I have become acutely aware of the emergency department as a gateway to hospital admissions. And over the years, we’ve seen just an exorbitant increase in emergency department volume, emergency department admissions, and the variety of patients who require admission to the hospital. As a result of this, it became apparent that we really need new options for patients. And based on that, we developed at UCSD a program where we’re able to provide an ED-based option, a disposition option for patients to receive care in the home as opposed to the hospital. And this is for lower acuity patients who would require short stays in the hospital up to three or four days. And through this program we’ve been able to transition them directly from the emergency department to their home and facilitated the provision of home-based care through home health nurses with oversight from their primary care doctor during these home health visits from the home health nurse. This program started as a pilot program and it was very successful. The majority of our patients enrolled in the program were actually 65 years of age and older. And through this program we learned that the systems that we had put in place are very feasible to continue and to transition to a permanent program that provides seniors and other patients as well, non-seniors an option for home-based healthcare.
LAURA: Great. So Bruce, you mentioned that in the 90’s, so is that really when you believe this kind of whole concept of doing a hospital level of care in a patients’ home got started? And why is it now, here we are almost 20 years later. It’s sad when you said crossing the quality chasm, that’s 20 years ago that we talked about that and we still have clearly huge issues in this country relative to quality of care and overall cost of care and outcomes for patients. So why now? It certainly came to our attention as this big buzz across the country around this and working with individuals such as the folks on this phone, InterQual has really developed some appropriateness criteria for this. But why is this catching on now from your perspective?
BRUCE: I think a few things. So first of all we started in the mid-nineties to try and develop a construct and start to prove it out as health services researchers and as geriatric clinicians. But hospital at home does have a history that goes back a bit further not in the United States but in places like the UK and Italy and Israel and Australia and New Zealand and I think the common denominator there are those are places basically with single-payer systems where economic incentives align to try and keep people out of the hospital if you can provide a high-quality service that comes in at a lower cost. So it started outside the United States and in fact one of the earliest studies was done by Archie Cochran, and maybe people don’t know Archie Cochran but most people have heard of Cochran database and Cochran meta analysis and systematic reviews and he did one of the first studies in the late 70’s treating people, doing a randomized controlled trial of people with myocardial infarction, or heart attacks. And people actually did better at home than they did in the hospital and certainly the treatment for cardiac conditions has changed and we may not want to do that now for most people. But even then there was evidence being developed that perhaps being treated at home, certain patients, certain conditions might do well. I think the reason things are starting to catch on now, and I would say especially over the last — I’d love to hear what Allyson thinks — but really over the last two to three years, two to four years, but really a lot in the last two years is, I think, finally the changes wrought by the Affordable Care Act. We’re now a little bit over 10 years out and I think we’re starting to see that that’s a lot of the philosophy of care that was baked into that really finally coming to roost. So the idea that readmissions to hospitals are not often an indicator of high-quality care, the idea that we should try to move care towards the community, the idea that we value quality in healthcare at all and not simply providing volume of care, the fact that there are a number of health systems I think some are in the neighborhood probably 10 to 15% of health systems that are experiencing significant hospital capacity issues. And the idea that building new buildings at least for some systems, not all, is not something that they want to do just because it costs a whole lot to capitalize hospital construction. And then once those buildings are built, systems realize that they then need to fill those beds to feed the fixed costs of those lovely bricks and mortar towers. I think also there’s a bit of a recognition that people don’t always want to be in the hospital, that they actually value being at home. Although there’s certainly variability there. And also I think finally over time again, now about 20 years out from the IOM reports on hospital safety and hospital quality that perhaps the hospitals for some people is not the safest place. And then I think the last thing that’s really contributed is the improvements in technology and the idea that as medical technology becomes more portable and miniaturized you’re actually able to take technology to the home and that as a tool, never a solution, but as a tool to enhance the capability of hospital at home in monitoring people. So I think a lot of things are coming to the fore. And of course, cost. Our current healthcare system, the costs are just unsustainable. So I think people are looking to the hospital at home as one tool of many. There are many things that can help with the problem to help bend the cost curve a bit.
LAURA: Allyson, I’d like to hear your thoughts. And when you’re commenting on that, you mentioned you started as a pilot. So talk a little bit about what has happened since, and has that sort of been institutionalized within your organization?
ALLYSON: Correct. Yeah. We are in the process of transitioning the program to a hospital-level supported program. And the program is very much still alive at UCSD. But I agree with everything that Bruce said from the system level where we really need to focus on providing patients with other options. And a lot of this, as he mentioned, these programs can help to decrease hospital readmissions and just admissions for lower-acuity patients. There’s also the patient satisfaction level where patients are, can be happier in their home receiving care and not have to stay in the hospital. There’s also the harder to measure instances of avoiding dementia, of avoiding falls, avoiding hospital acquired infections, and this particularly applies to the older population. By keeping a senior population out of the hospital, they don’t have to go through a period of recovering after an acute hospitalization. And I think that these are harder outcomes to measure, but I do believe that they’re real. So from that regard, the hospital at home for the senior population is I think that it’s just a great option for that population. And then finally, there is the cost and that is very real in today’s day and age with the Affordable Care Act and accountable care organizations. So we found through our pilot program that costs were significantly lower for those patients who received care at home for equivalent diagnoses of those patients who were admitted to the hospital. So for all those reasons, I think that these Hospital at Home programs are worth pursuing.
BRUCE: If I could just build on Allyson’s comments which were spot on, you know the notion that hospital at home can reduce adverse outcomes is very well proved in the literature. So in our work, when we did a multi-site national demonstration of Hospital at Home in the early 2000’s, we did that in several Medicare-managed care plans in a Veterans Affairs health system around the country and we took our time to very carefully measure outcomes, complications that older people commonly experience, like incident delirium so developing an episode of acute confusion and attention. And the important issue to think about with an outcome like that is that even though I think probably both Allyson and I were taught in medical school that delirium is a transient event. You develop acute confusion and you kind of come back to normal. Over the years, research has shown that people who experience incident delirium likely take a longer-term cognitive hit and there are some people who believe that incident delirium may play a role for some patients in the pathway towards dementia. So we found a 75% reduction in incident delirium for people who are treated at home. And the reason that likely occurs is because when you’re treated at home, basically home becomes what hospitals try and do to alleviate the risk factors for delirium. You’re in a familiar environment. You’re more likely to walk around because you’re in that familiar environment. You have your own food and beverages around so you’re more likely to drink and eat and you’re less likely to need a sleeping pill. Because again, your home is quiet. I don’t know if you’ve ever been in a hospital at two o’clock in the morning, but it’s a circus. People are trying to sleep and then the Zamboni is rolling down the halls cleaning the floors and the nurses are yacking it up and it’s just nuts. The other really important outcome to highlight in these studies is that there have been several systematic reviews of the dozens of randomized controlled trials of Hospital at Home. And when you put those together in systematic reviews, what you find is that there’s about a 20% reduction in mortality. So dead or alive at six months, advantage to Hospital at Home with what we call a number needed to treat. So how many people you have to treat in Hospital at Home to avoid one death at six months and that number is 50. That’s an incredibly, incredibly low number. So if Hospital at Home were a drug, I’m pretty sure I wouldn’t be on the call with you right now like I’d be on the beach in the Cayman’s counting money because that would be a blockbuster drug. The challenge is there’s a huge difference between disseminating and defusing drugs into practice than it is to implement scale and spread health service delivery into practice. But it is a very, very powerful intervention in terms of providing patient benefit.
LAURA: So it sounds like the benefits are clear from both of your backgrounds and experiential, plus what’s clearly published in the literature. I think this is one of the areas where we have seen more literature than in many other areas of medicine added together. So given all that, what’s needed really for a successful program? Bruce, can you address that?
BRUCE: Yeah. So if we’re talking about what’s necessary to really get hospital at home scaled, I think a few things are worth thinking about. One construct to apply here, I don’t know if you’re familiar with Everett Rogers diffusion of innovations? He was sort of the guru of how do new ideas actually get into practice? And he did his original work with, original research on farmers and how they would take up new technologies in terms of new kinds of seed or new kinds of fertilizer and the like. And he found that there were several attributes of new innovations that would help understand how quickly they’d be diffused. So when was relative advantage? So is the new thing better than the old thing? And I think for Hospital at Home, we can say that there’s strong evidence to suggest that there is. Another is observability. So can people see the new thing before they can actually try it out? And I think 20 years ago there were really no Hospital at Home programs, and now there are probably about 20 around the country and people can actually go and touch those programs and have a look and talk to people who do them. So I think that helps. The next is trial ability. So can you try out the new innovation relatively easily? And the answer to that is probably no. So I’m sure Allyson would say that if you’re going to develop hospital at home, it’s sort of like you’re building a hotel and you have to build the whole hotel and staff it up and get it ready before you can take care of your first guest or your first patient. And then complexity. Usually simple innovations do best and hospital at home is not a simple model. So that’s against. And then the last one is compatibility. So how compatible is the new thing with the values of the people you’re asking to adopt it? And I would say that most community-based interventions are less compatible with our medical system which seems to value facility-based, high-tech, highly specialized approaches to care. So I think that’s part of the reason why hospital at home has had challenges. In addition there has not been a payment model for hospital at home yet in the fee-for-service sector. I think that’s going to be changing soon. We’ve been doing a lot of work on policy and payment development, but that still does not exist. And then the last thing is really leadership in healthcare. So I think leadership is still pretty focused on facility-based care, building buildings, and that is something that I think is starting to change but it’s a pretty hard wired thing. You know you do see leadership out there that is making those sort of adjustments and changes but it’s not yet the majority. So I think we’re still in the early adopter with what Rogers would call the early adopter stage of Hospital at Home. But I think that is going to be changing over time.
LAURA: Allyson, what other thoughts do you have of what contributes to a successful program?
ALLYSON: I would agree with everything that Bruce said. Based on our experiences, I think getting buy-in from the different levels of involvement is absolutely critical. And starting from the top, truly operationalize the program there has to be support from hospital leadership. And as Bruce just mentioned that’s slowly changing and I think with the advent of the ACO’s that will continue to change as the cost efficiency becomes ever more critical to also providing a high-value care. So from that perspective, highlighting true hospital leadership, importance of decreasing readmissions which the hospital leaders are very familiar with. Highlighting the importance of creating inpatient capacity for higher acuity patients is another angle as well. And by keeping lower acuity patients at home, that opens up beds within the hospital for higher acuity patients who truly require inpatient care to come into the hospital system. That’s an avenue to highlight as well. And we found that that worked very well. The patients in our program were med-surge level patients who didn’t require monitoring. And by providing equivalent care at home for these patients, we were able to free up beds in the hospital for the higher acuity patients to come in. then moving from hospital leadership focusing on department leadership, whatever department this program arises in within the health system there has to be obvious support from the department leader. And then it’s down to the front line teams, the physicians, the nurses, the care managers, the social workers, the members of each of these teams have to buy in as well. And the champion of any home hospital in the home program really has to make an effort to reach out to each of these groups and just highlight the benefits of these programs. How it can help our patients. How it can increase the satisfaction that our patients have. How it can avoid undesirable outcomes from being admitted to the hospital. That was the approach that we took. And then finally there’s also getting buy in from the other departments. And when I say other departments I mean the in our program specifically we had primary care doctors overseeing the patients’ care at home. And we had to go to the family medicine department and the internal medicine department and talk to the physicians of those departments and highlight what they already know that some of their patients could receive great care at home and be very happy receiving that care. We just had to highlight and reassure them that the systems in place were reliable and that the program could be successful. And it took a lot of work to onboard all these different individuals, but in the end once we put out the education and showed them that the systems in place were reliable there wasn’t a whole lot of resistance. Everybody wanted this program to succeed.
BRUCE: Can I just build on that a little bit and just point out even though Allyson and I have never met, Allyson is an extremely unusual person because to my knowledge at least in the states Allyson may be one of the, Allyson’s program might be one of the few that originated from an emergency department origin. Usually programs are coming from primary care or geriatricians, occasionally surgeons. And I think the emergency department tends to be one of the most critical nodes in developing a successful program because the emergency department physicians are not on board with thinking about admitting a patient to a hospital at home service, then the program dies very quickly. So Allyson’s embrace of hospital at home is fantastic. It’s not the most common and I think we’re going to need education for primary care physicians about this, education for specialists about this, and ongoing education for emergency medicine physicians about this. Because I think again we’re trying to change mindset and convince people that doing acute level care at home is actually feasible and safe and in fact for many patients preferred. And then the issue of assuring people that you can actually do this care at home, I think another of the challenges for hospital at home which people are working on is the notion of creating the logistics and supply chain to do hospital at home really well. You’re in the hospital, you’re sitting on the ward or you’re sitting in the emergency department and you order an intravenous antibiotic for someone. You put in that order and a lot of stuff happens behind the scenes and then the medicine comes to you and you give it to the patient. That’s sort of hardened, redundant supply chain doesn’t quite exist for most hospital at home programs yet. But I think what you’re going to see if you’re going to see industry get involved like the Amazon’s and the drug distributors and we’ll be at home doing a hospital at home visit and we’ll put in an order to change an antibiotic and a drone five minutes later will be dropping off the intravenous bag. And I think that’s going to happen. I think it’s going to happen relatively quickly. Change happens slowly until it speeds up.
LAURA: Yeah. You can get to some critical mass and it takes off and there certainly are all of these unusual players such as you mentioned Amazon and even some of the large retail pharmacy chains doing home deliveries, that kind of thing. The Uber and Lyfts of this world getting involved in healthcare. So I think we’re seeing that coming from all angles. So Allyson, what kind, you mentioned med-surg patients. Let’s talk a little bit about what kinds of patients from actually both of you, we’ll start with Allyson, are appropriate for this kind of program? It’s certainly been our focus of our work that we’ve been trying to do with all of you to really understand that and wrap our brains around it. Bruce, you mentioned safe care. That’s always sort of the mantra. We want safe and effective care and great if the cost follows that’s fabulous. So want to talk a little bit about the kinds of patients that might be appropriate for these kind of programs?
ALLYSON: Sure. Absolutely. I think you just hit the top priority which is patient safety. And obviously for any program to succeed, there has to be a fundamental safety inherent to all the systems in place. And what we did with our program was we before we began to set the program up we looked retrospectively to see what patients in our health system with which diagnoses had stayed in the hospital for a relatively short period of time, two to three days up to 72 hours. Based on that we were able to identify a list of diagnosis that may be appropriate to receive a short-term home healthcare as an alternative to hospitalization. And once we had a list of the diagnosis, we were able to move forward. These were low-acuity patients. These weren’t patients who required cardiac monitoring. Again they’re hospitalizations were less than 72 hours. And this was to implement and test the system to make sure that we develop a safe system for the patients. Once we had a list of eligible diagnosis in place, we established other criteria such as the patient has to have the suitable home environment. And that was a self-reported trait from the patients. We didn’t go to the home to assess the home prior to discharging them. We asked that the patient have somebody at home with them, that they didn’t live alone to build in another level of safety. The patient had to have an active primary care doctor within our health system who was agreeable to follow them at home during the acute care episode. And finally the patient couldn’t be obviously critically ill. So the majority of our patients had low acuity medical issues, but not so low that they didn’t require acute care. So for example, we took patients with UTI’s or PILO or pneumonia, or patients who were fluid overloaded and needed a gentle diuresis. Those are the types of patients who we enrolled in our program. And the success rate was very high. We had of 70 patients who were enrolled we only had two that required ultimate admission to the hospital and that was because of the change in antibiotics that they needed. Their IV antibiotics that they were initially receiving were not successful and they had to be changed. So overall I think patients selection for any home-based hospital program is essential and building in layers of safety to make sure that the care that they’re going to receive is successful because the resources around the patient are in place.
LAURA: Bruce, how about from your perspective?
BRUCE: I think Allyson’s description pretty much mirrors the way we started approaching things a while back. And I think the issue is you need to make sure you’re taking patients who meet threshold criteria for being admitted to the hospital which people will sometimes argue about, but for which entities like InterQual have developed reasonable criteria. Understanding that many of those decisions are still made at the bedside in an emergency department or in a clinic. And that older people with multiple chronic conditions and functional impairment sometimes get least involved and will often get admitted to the hospital whether they need to or not just because they’ve made it to the emergency department and no one knows what to do with them. And I agree the notion of you want people who need to be in the hospital, but are not so sick that they need intensive care, not so sick that they’re likely to become unstable in the future. During the hospitalization of people who are unlikely to require a highly tech oriented mission, that was kind of the approach that we took when we developed our first set of eligibility criteria. And then I think I would just add that over time that range of diagnosis expanded quite a bit so in a center for Medicare and Medicaid innovation demonstration that was done at Mount Sinai that I was collaborating on the range of DRG’s that were taken care of reached out into the several dozen. So once you have the ability to do this, you can really start to apply it to a lot of conditions. And then the other thing I would add is as technology improves, and as the ability to monitor people at home improves you actually will be able to go a bit deeper within any particular illness, a bit deeper into the trench and start to take patients who are a little less stable but safe to take care of at home because the monitoring can be done because you have the ability to react quickly. So you know a colleague, David Levine at Brigham and Women’s was using some monitoring in some of his trials. There’s a commercial entity called Medically Home. Full disclosure, I do some consulting for them. They have created basically a mission control type unit where their hospital at home physician doesn’t make in person visits but is able to monitor people via two-way biometrically enhanced telemedicine and visits are made by nurses and nurse practitioners. And because they have that monitoring 24/7, they can take people who are bit sicker than the ones we would have been comfortable taking when we did our pilot work way back when. And I think that will actually improve both the healthcare case and the business case for hospital at home because once you can do that, you can start to create the critical mass of patients that will start to get the attention of people in the C-suite because then they’ll say oh wow, this program can be bigger. This program really can make a dent in things. And I think they’ll start to pay more attention. But I think the severity of people that you take is dependent on kind of the capabilities of the program that any particular health system is able to field and that will improve slowly over time as technology and monitoring improve. Again using that as a tool and never really is a solution to anything.
LAURA: Right. So Allyson you had mentioned a lot of the sort of buy in if you will as that you had as an organization might want to start to garner some ground swell if you will of support for starting your program. So what would you advise people of going about starting a program like this and certainly any pitfalls they should watch for? Do people have to do it on their own? Can they partner? What do you know about? What could you advise people about from that perspective?
ALLYSON: Sure. I think as clinicians are essential, focus should always be the patient first. And I think if the patient is made the central focus of any program and that’s a good starting point. So pointing out the benefits to the patient, the comfort of the patient, the satisfaction of the patient, and as we had mentioned avoiding some of the deleterious aspects of hospital admission in particular for the older patients, the delirium, the falls, the hospital acquired infections, so focusing on the patient would be central when starting to talk about the most administrative aspect of healthcare. Focusing on the potential to decrease hospital readmissions. Focusing on the ability to make inpatient beds available would be another avenue to pursue with the C-suite. And then as far as talking about the program with the providers I think most clinicians want to make sure that once patients leave their immediate care that any plan put in place is safe. And for that, it takes convincing them that the system is safe. So showing them that the healthcare providers, the home health nurses, or the home health provider is going to be reliable and ensure them that there’s been a partnership with this home health provider in the past and the familiarity with that group is there. Ensuring them that the patient is able to get their medications. Those kinds of things are very important for the providers to know that once the patient leaves their care that the patient is going to be okay. And then as far as pitfalls are concerned, I think that making sure that the patients are selected appropriately. So making sure that the home is set up, is safe for the patient. Making sure that this was a critical to our patient population, making sure that the patients were aware of any co-pays that they may have to pay with their insurance for home healthcare. This can be variable depending on the patient and it’s one pitfall that I think has to be addressed up front. If the patient has a co-pay they need to know what their potential co-pay would be before they go home so that they don’t get hit with a big bill. And that was something that we really had to develop very carefully with our billing department prior to sending the patients home. So that’s something I would highlight as an important pitfall for providers to be aware of.
LAURA: So did you have a home health agency like affiliated with UC San Diego that’s just part of your whole organization and that’s how you’re delivering the actual hand’s on services to the patients in their homes? Or was that like a partnership with an unrelated kind of group that had to be trained and that sort of thing?
ALLYSON: We had a partnership with an independent home health agency. It was a very reliable home health agency and we discussed this program closely with them before moving forward with the program. They were very reliable. So that was one avenue that we pursued. There’s certainly the model where the home health agency is billed within the health system as well.
LAURA: Bruce, from your perspective same kind of model and just thinking about setting up a program, that sort of infrastructure that’s required once you get past the buy in? So the actual nuts and bolts of how do you do this? How do you deliver with this? Is this through partnership? Is this through a staff that an organization already has within the hospital? What have you guys experienced?
BRUCE: I would say yes, yes, yes and I think I’ve seen just about every sort of permutation, well maybe not every but I’ve certainly seen a variety of permutations and how health systems have decided to build hospital at home. I think one thing that programs tend to underestimate, not always but they tend to think only about the care provision. They forget about issues and I think Allyson was alluding to this notion of thinking about the IT infrastructure you need behind this and thinking about the issue of dropping and reconciling bills which for Hospital at Home since it’s not a standard service it’s not always the easiest thing to do. So it’s not simply people on the front lines providing care which is utterly critical, but it’s all the support things that happen in a hospital that also need to happen for Hospital at Home because at some level you’re creating a whole new service for the hospital in the same way that 50, 60, 70 years ago we did not really have intensive care units. And now we have those. But people seem to think that those somehow materialized overnight in full form. But those evolved too. So new services evolve and they have to be constituted in whole. The issue of whether you’re doing things in partnership or using your own assets, I think one thing that anyone in healthcare understands is that healthcare is a hyper local kind of enterprise. So if you’re in a place where if your system has an amazing home health asset, home health agency, you might want to use that. If they don’t and you have one in the community you might want to use that. And I think that goes for most of the services for hospital at home. I would say that as Allyson explained the idea of having important conversations with your partners about what this model is, is critical. Getting things into contracts with time restraints that you need to provide great care is essential. And then those things really need to be tested because even though you may have discussed it and may have it in writing, once translating that into actual workflow is often a challenge. So as one of my colleagues Al Soo who is the media pass chair of geriatrics at Mount Sinai in New York and who really has led the development along with Dr. Linda DeCherry at Sinai for their Hospital at Home program is fond of saying it’s easier to get Chinese food delivered in New York City to your door through a blizzard at two o’clock in the morning than it often is to get oxygen delivered at twelve noon on a sunny spring day in a timely way. And I think that goes back to that supply chain issue and logistics and we really do need to work on that.
LAURA: So you both mentioned and sort of referenced payment for all of this. And so it’s not formalized yet. I certainly know I mean CMS through their innovation center has done studies. What are you guys seeing from payers out there beyond Medicare or Medicaid as a payer? Sort of the commercial world and their interest and either helping to sponsor these programs or figure out how to reimburse for this. Have you seen any developments there? Bruce. Maybe start with you.
BRUCE: I think first of all on the Medicare side, I think we will be seeing some developments moving forward. We had again with my colleagues at Mount Sinai, we submitted a proposal to something called the PTAC, the physician-focused payment model, technical advisory committee to the secretary. This was about two years ago when put in a proposal for a basically a 30-day bundled payment for a hospital at home admission in 30-days post acute care. And that was approved by this special committee at Health and Human services and was referred to the secretary and there were other proposals for other types of payment mechanisms to take care of high-need, high-cost populations and the secretary passed on those, but did ask leadership at CMS to continue conversations with hospital at home parties. And that has gone on and I think there will be progress there. On the non-federal payer side, we are seeing more interest, much more interest from commercial payers who especially when they have a big footprint in a particular market, are in a position to create contracts and payment mechanisms for hospital at home. So we are definitely starting to see that. And then sort of federal but not Medicare or Medicaid, but the VA health system is really an excellent for hospital at home because the VA’s, all the major VA medical centers have home-based primary care programs which provide more of that ongoing longitudinal care. But they often conserve as an amazing substrate on which to build Hospital at Home programs. So they’re now at least a dozen or so VA programs out there that are doing hospital at home of various types and I think that’s a great thing as well because I think that lines up so nicely with a lot of the strategic initiatives of the VA to reduce queuing on the inpatient side, to provide care in the community, to provide high-value care to veterans in the community. So I think we are seeing those things. And then on the non-fee-for-service federal side, Medicare Managed Care is an excellent option for Hospital at Home and we’re seeing a lot more interest in Hospital at Home among the larger Medicare Advantage plans.
LAURA: Great. Allyson, anything to add to that?
ALLYSON: No. I think that summarized it really well. There’s just as a little bit of an addition for the providers who are receiving the care at home as well depending on where on the spectrum the reimbursement is there’s also some transition of care available to providers to make sure that they are reimbursed for the care they provide when the patient’s in the home. That is dependent on the patient having an observation stay or an inpatient stay. With our unique stance from the emergency department, we were able to leverage our ED observation unit prior to discharging several of these patients to the home and that built in an extra level of safety prior to discharging these patients to home. The systems in place like that the care providers can take advantage of this transition of care as well for providing ongoing care in the home to the patients. So there are systems in place, it just has to be a little bit of research done into pursuing them.
LAURA: So Allyson, given your you’d mentioned earlier some program goals sort of like expanding into new areas. I think Bruce you did as well. But we’ll start with Allyson. Kind of in this next coming year or the next three to five years, what’s on the horizon for either additional patient populations, perhaps pediatric, I don’t know the whole conundrum of observation level of care or observation status that’s out there. This has certainly been a hot ticket in the marketplace. So any particular areas you guys are focusing on or seeing that will be up and coming?
ALLYSON: I think it was mentioned before by Bruce with the growing advantage of technology that we have in home-based care I think that’ll open the door tremendously to increasing the population that can be served at home with a Hospital in the Home program. So as technology develops and becomes more accessible that’ll help to advance these types of programs. As the programs expand, I would love to see this be a standard “admission option” from the emergency department. Traditionally right now we have inpatient admission, observation admission, ED observation or discharge. Those are our main options when sending a patient out of the ED or transfer to another hospital. But it would be great to see these programs grow so that this becomes a standard option for eligible patients. So that I would love to see. And then as these programs develop, I think it’ll be really important to really look at the patient’s home. So really expand the model to be all inclusive and look to see what it may be in the patient’s homes that are causing them to have to come to the emergency department and try to help these patients so that they don’t have to come back. So that they don’t have to have a hospital admission. And expand the Hospital in the Home program to really maximize the patient’s home environments to help their ultimate health. So that would be the five to ten year goal in my mind for where we can go with Hospital in the Home.
LAURA: Bruce, thoughts on that?
BRUCE: I would echo what Allyson said. The notion of somehow mainstreaming or normalizing Hospital at Home care so that hospitals, health systems, leadership, emergency medical physicians see hospital at home as hey, it’s just another unit in our hospital and we use that too. I think you’re going to see the range and depth of acuity and increase over time what’s taken care of in the home. And I would say I don’t know what the lags are, because I think lags in healthcare are the hardest things to predict but in mind the hospital of the future is going to be an emergency department, OR’s and an ICU of various types. And I think you’re just going to see many fewer what we now call med surg beds or typical inpatient beds. And I think those really should be moving to the community. A few weeks ago the first world congress of Hospital at Home was held in Madrid and unbelievably over 400 people showed up to that meeting. It kind of blew us away with folks who were helping to plan it. And you know the range of things that are taken care of in Hospital at Home around the world is just astonishing. So we heard papers and reports on bone marrow transplants being done at home. I think we’re really just starting to scratch the surface. You can do observation stays at home and an observation unit at home. If someone stays two midnights in your home obs unit you can admit them to hospital at home. I think you’re going to be seeing a whole lot more cancer care at home. I think you’re going to see pharma get very interested in the Hospital at Home paradigm for conducting their clinical trials because whenever their folks go to the hospital for side effects and clinical trials, they’re on the hook for that dollar. And I think if they can get taken care of at home, it’ll improve retention in clinical trials which I think benefits society if we can get innovations to people more quickly. So I think we’re at the start of something. It’s still going to take a while. Innovation takes time. But I think we’re on the path and developments over the last two to four years have really been very exciting and I think it’s just going to continue.
LAURA: And is pediatrics at all a focus area?
BRUCE: It hasn’t been a huge focus area. I know at Mount Sinai their pediatricians are starting to get interested in this. So I think they will be starting it up there.
LAURA: Allyson, are you seeing any move to the pediatric population?
ALLYSON: We did not focus on pediatrics for our programs. So I don’t have experience there.
LAURA: Just thinking about as a mother myself knowing how disruptive that is especially with kids with chronic conditions to keep going back to the hospital and a child being outside their home and their support system. One would think that might be an area that might be ripe down the road for these type of programs. Alright. Is there anything else you guys would like to share with us? You’ve been great guests and certainly are clearly very knowledgeable about this area of exciting innovation really in healthcare. Any other particular pieces that you’d like to share that I’ve not asked you about?
BRUCE: I don’t have anything but just a pleasure to talk and really nice to meet Allyson if only over the phone.
ALLYSON: Likewise. Thank you for the opportunity to share our experience with these programs. I certainly think that anything that can be done to help spread the growth of these programs would be beneficial for the patients tremendously. We’ve just had such positive feedback from our patients in this program and such great success with it.
LAURA: Awesome. Our thanks to you both and appreciate it and continued good luck as you expand these programs. And hopefully we’ll look to check in with you later down the road and see how much things have expanded and improved.
Take care. Thanks for having us.
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