Nurse Checking Patients Blood Pressure in Home

HaH models haven’t been widely used in the U.S. — but that might all be changing as hospitals look for more effective ways to care for patients in a home setting.

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Hospital at Home Models: Reducing Costs and Improving Outcomes

  • Jennifer Boese
  • 11/6/2019

Hospital at Home (HaH) models work. First and foremost, they offer up unique opportunities to provide high quality, safe, and cost-effective care. While other countries, like England, Israel, and Australia have long used the model, it has yet to gain traction in the United States — but that may be changing. As the U.S. health care system looks to keep patients in efficient care settings while delivering on quality and patient satisfaction, the HaH model is becoming a more attractive option.

Hospital at Home is representative of what health care reform is attempting to achieve — a high-quality clinical program that provides patient-centric, individualized care, while making the most effective and efficient use of the health care dollar. Health Affairs

Dr. Bruce Leff, a professor of medicine at the Johns Hopkins School of Medicine and Public Health, pioneered the school’s development of the HaH model in the mid-90s. While Hopkins led the way, other early adopters included the Icahn School of Medicine at Mount Sinai (Icahn/Mount Sinai), Presbyterian Healthcare Services, Advocate Health Care, Veterans Affairs Health System, and Marshfield Clinic. The collective experiences of these facilities have helped provide evidence in support of the model’s viability.

In 2017, both Icahn/Mount Sinai and Marshfield Clinic submitted their respective HaH models to the Physician Focused Payment Model Technical Advisory Committee (PTAC) for consideration. PTAC is the advisory body that recommends Alternative Payment Models (APMs) to the federal Department of Health and Human Services (HHS). HHS expressed great interest in both submissions and is “exploring a model that allows beneficiaries with certain acute illnesses or exacerbated chronic diseases to receive hospital-level services in their homes.” While HHS has yet to release that model, it demonstrates the promise and interest in providing acute care in the home.

What’s driving interest in HaH?

As the name suggests, HaH provides hospital-level care to patients in their home or in a similar setting. HaH models have been used in the United States for more than two decades, but there is likely growing interest in this approach, as it aligns with or addresses various issues, such as:

  • Protects vulnerable patients from contracting other illnesses during longer hospital stays
  • Decompresses busy emergency departments (EDs)
  • Addresses a patient’s desire to recover at home in a more comfortable care setting
  • Fits well into health care’s move towards value-based payments (bundles or other APMs)
  • Aligns with the ongoing movement toward delivering care in the home
  • Leverages the use of telehealth and other virtual care delivery, like remote patient monitoring
  • Complements other services, like palliative care

Overview of three HaH models

When Johns Hopkins launched its HaH program, it focused on a small number of conditions, such as community-acquired pneumonia, exacerbation of congestive heart failure, and chronic obstructive pulmonary disease. As time went on and experience grew, other conditions were added. When Icahn/Mount Sinai submitted its proposal to PTAC in 2017, it listed 18 categories of illnesses covering more than 44 diagnosis-related groups (DRGs) that had already used HaH. Even further, Marshfield Clinic’s Dr. Narayan Murali recently suggested looking beyond DRGs altogether and considering anything that could be done on a general medical-surgical floor.

If we look at three versions of the HaH model — Johns Hopkins, Icahn/Mount Sinai, and Marshfield Clinic — patients are evaluated based on medical eligibility criteria for the related conditions. Patients must:

  • Be clinically stable
  • Need inpatient-level hospital care
  • Have a stable and safe home setting
  • Agree to receive care at home under the program

Admissions to the HaH program generally come from a physician office, an ambulatory setting, or an ED. Typically, a physician examines the patient, an admission order is written, and the patient is transferred to the home. While at home, the patient receives daily visits from the physician and at least one visit per day from a nurse. Other therapeutic and diagnostic services are provided as needed.

John Hopkins model

In the Johns Hopkins model, the patient receives nursing care at least once per day, the physician makes at least one visit per day, and physicians and nurses are available around the clock. This model uses prescribed care pathways, including illness-specific care maps, evaluations, and discharge criteria. Additional therapeutic or diagnostic services provided at home may include electrocardiograms, echocardiograms, x-rays, oxygen therapy, intravenous fluids or antibiotics/medicines, respiratory therapy, and skilled nursing services, among others.

Icahn/Mount Sinai model outcomes

A recent study published in the Journal of the American Medical Association (JAMA) Internal Medicine in 2018 reveals the following outcomes when compared to patients receiving inpatient care:

  • Reduced hospital length of stays
  • Reduced rates of 30-day hospital readmission 
  • Reduced emergency department visits
  • Reduced skilled nursing facility admissions
  • Increased patient satisfaction
  • No difference in rate of adverse events

Icahn/Mount Sinai model

The Icahn/Mount Sinai model, which was granted a Health Care Innovation Award under the Center for Medicare and Medicaid Innovation (CMMI), tested the model with a 30-day period of home-based transitional care included. Under the model, a physician or nurse practitioner (NP) begins the episode by writing the admission note and orders. Once at home, the physician or NP provides home-based acute care services, including physical exams, illness and vital signs monitoring, intravenous infusions, and wound care. Nurses visit regularly and the physician visits at least once per day (in-person or virtually). Access to these physicians and clinicians is available 24/7.

Once the acute care phase of this model is finished, the patient is discharged, a discharge summary is completed, and a 30-day post-acute period is initiated. During this transitional phase of care, a social worker visits at least one time and nursing visits continue. These interactions provide education, self-management support, coordination with primary care and specialists, as well as rehab and any additional outpatient testing that is needed.

Marshfield Clinic/Contessa model outcomes

Marshfield Clinic cites the following outcomes from their program:

  • 35% reduction in mean length of stay
  • 22% increase in patient satisfaction
  • 90%+ patient acceptance rate

Marshfield Clinic model

The Marshfield Clinic model (in partnership with Contessa) offers both a 30-day acute home recovery model and a 60-day post-acute recovery model. This model uses a recovery care coordinator (RCC) who facilitates interactions throughout the model. Patients are risk-stratified (using Contessa’s platform), with the RCC following clinical protocols based on those stratifications.

An acute care RN meets with the patient twice per day for roughly three hours total, and facilitates additional clinical services as needed. The admitting physician meets virtually with the patient while the RN is present. In the transitional phase, any rehab or other services continue, and the RCC monitors patient biometric data and the care plan. A social worker is also used to connect patients to any needed or useful community services to address any psycho-social needs. Overall, this model is operationalized using three inter-connected elements — care model, administrative design, and informatics platform — which demonstrate the level of sophistication to which HaH models have evolved.

Because there is no specific reimbursement for a HaH model under Medicare Fee-For-Service (FFS), Marshfield Clinic is currently using the model primarily with Medicare Advantage and other health plans in a bundled payment arrangement.

HaH opens doors for other programs

HaH has a proven track record of delivering high quality, cost-efficient care that satisfies patients. Combined with the health care system’s ongoing move towards value-based care, ongoing technological advancements, and desire for individuals to recover at home, HaH is positioned well for the future. The model also presents opportunities to build out complementary programs, such as observation at home, palliative care at home, and rehabilitation at home. But with this opportunity comes considerations.

Three considerations before adopting an HaH model

  1. The HaH model is a newer way of thinking about acute care. While health care is transitioning towards innovative care delivery pathways, the idea of receiving hospital level care at the home is still relatively foreign. In fact, some physicians and patients have opted out of the model when presented with the option. Buy-in from physician and clinical leaders and patient perspectives will be important to help determine viability and utilization of a program for your organization.
  2. The current reimbursement system continues to reinforce a brick and mortar approach to health care. Under Medicare’s traditional FFS approach, there are higher levels of reimbursement for inpatient or ED care with no specific reimbursement for a HaH model. This has made some organizations reluctant to move in this direction. However, Medicare Advantage popularity continues to grow and reimbursement is moving towards value (versus FFS’s volume) through APMs like bundles or Accountable Care Organizations. As this trend continues, a HaH model helps make the case financially as well as clinically. Familiarity with alternative financing models, including contract negotiations, will be an asset if considering a HaH model.
  3. There are new workflow, operational, and technological considerations that come with HaH. Sophisticated use of technology and data analytic platforms can help scale and deploy the model. Data analytics, telehealth, and virtual care delivery, claims and workflow management, and risk-stratification can facilitate and improve your overall success.

How we can help

High patient satisfaction rates and quality outcomes combined with cost efficiency make HaH intriguing for acute care, and also sets the stage for developing similar models for palliative or rehabilitation care at home. CLA’s health care professionals are at the forefront of the industry as these and other models emerge. We are here to help you create opportunities during health care’s ongoing transformation.