Published in the August 2018 issue of Today’s Hospitalist
FOR THE PAST FIVE YEARS, Per Danielsson, MD, the executive medical director for Swedish Hospital Medicine in Seattle, has been on what he admits has been a “quixotic” and very frustrating quest.
What windmill does he keep tilting at? The fact that traditional Medicare and most private insurers won’t pay for hospital at home services. Dr. Danielsson first proposed launching a hospital at home program at Swedish in 2013. But even though several Swedish campuses are at capacity and even boarding ED patients in the winter, his market has very little capitated care.
And while he has read all the studies that indicate hospital at home produces better outcomes, “there is no payment mechanism in the fee-for-service world,” he points out. “You can make all the clinical arguments you want. But if there’s no payment, it’s not going to fly.”
The past year, however, has given Dr. Danielsson some hope. First, his parent health system—Providence St. Joseph Health— recently asked him to present on hospital at home. And Swedish Medical Center has called on him to write a proposal for a small pilot that could be launched there by the end of the year.
There are even signs that the long reimbursement shutout may be coming to an end. Within the past couple of months, the secretary of Health and Human Services (HHS) directed Medicare to begin looking into what a payment mechanism for hospital at home might look like. That’s the most positive move to date toward payment, which Dr. Danielsson believes will have an “explosive” effect on the model’s growth.
“You can make all the clinical arguments you want. But if there’s no payment, it’s not going to fly.”
~ Per Danielsson, MD
Swedish Hospital Medicine
“In the executive summary of my first proposal in 2013, I said that every major health care organization is going to have a hospital at home program in 10 years,” he says. “That may still be correct.”
For CMS’ consideration
Champions of the model point to several trends they say now favor hospital at home: the growing availability of technology, an aging and computer-literate population, the continuing rise in the number of patients with chronic illnesses, and the ongoing push for payment reform.
Then there are these very auspicious developments: Last September, the Physician-Focused Payment Model Technical Advisory Committee (PTAC) unanimously recommended that the Centers for Medicare and Medicaid Services (CMS) adopt a proposal to create a bundled payment for hospital at home services, one that would include 30-day post-acute care.
While the HHS secretary in June announced that he wasn’t approving the proposal as written, he did direct the CMS to begin engaging with the hospital at home community. The proposal to PTAC on which the committee based its recommendation was submitted by New York’s Mount Sinai, which in 2014 received a $9.6 million grant from the Center for Medicare and Medicaid Innovation (CMMI) to set up a hospital at home demonstration project and test a 30-day bundle.
According to results of that project published online this June by JAMA Internal Medicine, the demonstration delivered a host of better outcomes compared to inpatient care. Those included lower length of stay (3.2 days vs. 5.5); fewer 30-day readmissions (8.6% vs. 15.6%), reduced ED visits and SNF admissions; and higher patient ratings.
“We’re very optimistic about the interest expressed by the HHS secretary,” says Albert Siu, MD, MSPH, a Mount Sinai geriatrician and lead author of the study. “We are happy to participate in those ongoing discussions.”
Overwhelming evidence
The fact that Mount Sinai’s results grew out of a government-funded demonstration make them “valuable” in spurring HHS and CMS interest, says Bruce Leff, MD, a geriatrician with Baltimore’s Johns Hopkins who has championed hospital at home for decades and supplied some of the model’s foundational research.
“We’re very optimistic about the interest expressed by the HHS secretary.”
~ Albert Siu, MD, MSPH
Mount Sinai
But, Dr. Leff points out, those results only add to what he calls an “overwhelming amount of clinical evidence over 30-plus years, including dozens of randomized trials” that support the use of hospital at home. “I don’t know of other health service delivery models that have actually been better studied.”
There’s also the fact that hospital at home has been widely adopted since the mid-1990s throughout Australia. That country’s Victoria state estimates that hospital at home there is deployed for about 5% of total admissions, allowing the state to avoid having to build a 500-bed hospital.
But Seattle’s Dr. Danielsson is convinced that hospital at home could be used for even more patients. As part of his campaign to launch a program, he retrospectively analyzed 380 random charts of patients admitted across five Swedish hospitals. He concluded that 11% of them could have been treated with hospital at home (or in a skilled nursing setting, if the patient was homeless).
“And those are just hospital medicine patients, so it’s a very conservative number,” he says. “I followed them all out through their hospitalizations and only one needed their care escalated to the ICU.” Extrapolating from that review, he estimates that hospital at home in his hospital system could safely handle 2,200 admissions a year, given that his program manages approximately 20,000 patients a year.
Incentives and innovation
Of course, that kind of estimate poses a big threat to hospitals whose business model is still based on filling hospital beds. Baltimore’s Dr. Leff is very encouraged by what he says is growing interest in hospital at home among commercial insurers, venture capital firms, start-ups that want to partner with hospitals to operationalize such programs, and ACOs.
However, only “health systems of a certain type” will offer hospital at home in the future, says Dr. Leff. Those would typically include systems operating above capacity, for one, so they “have an incentive to try to decant beds instead of spending capital on building new ones,” he says.
“I don’t know of other health service delivery models that have actually been better studied.”
~ Bruce Leff, MD
Johns Hopkins
Other likely candidates are health systems that have shown “some innovative spirit” and want to become competent at moving care out of the hospital and into the community. Health systems that have developed home health assets, usually in the form of a skilled home health care agency, are also prime candidates.
Dr. Leff says the “holy trinity” of elements for a successful hospital program are payers, hospitals and providers. “If you can’t line those three up,” he says, “you can’t even start the conversation.”
Non-Medicare funding
One of the longest running and most robust hospital at home programs is in the Veterans Health Administration. Dayna Cooper, MSN, who directs Home & Community Based Programs for the Veterans Affairs department, oversees such programs at seven VA hospitals, with two more being launched this year.
“Some VA centers are at capacity, and some even go on divert like community medical centers,” Ms. Cooper says. “This program benefits both our veterans and our bottom line.” Hospital in home (the VA term for its programs) is available for patients admitted with heart failure, COPD or community-acquired pneumonia, or those with an early discharge.
The early discharge option “is particularly true for wound care or patients who have pneumonias or infections that require long-term antibiotic therapy,” she points out. “Rather than discharging them to a nursing home or subacute unit, we transfer them to hospital in home.” The program is also part of the VA’s comprehensive home care services, which includes home-based primary care.
“A lot of times, patients transition from hospital in home to home-based primary care for continued follow-up,” Ms. Cooper explains. “These tend to be chronic problems, and home-based care avoids hospitalizations.”
“I appreciate that the CMS is worried about abuse, but not paying for hospital at home is one of those rules that costs the system a lot more money.”
~ Elizabeth De Pirro, MD
Presbyterian Healthcare Services
Albuquerque’s Presbyterian Healthcare Services launched its hospital at home program in 2008. An integrated system with its own health plan, Presbyterian—which offers hospital at home as a benefit to its own health plan members, including those in its Medicare Advantage plan—has since treated more than 1,300 patients under the model. Daily census averages between one and two patients a day.
Elizabeth De Pirro, MD, lead physician with the program, finds it enormously frustrating not to be able to scale that program up to include fee-for-service Medicare.
“I appreciate that the CMS is worried about abuse,” Dr. De Pirro says. Still, she likens the CMS’ refusal so far to pay for hospital at home to Medicare’s not picking up patients’ rehab tab unless they have been admitted for three days. “They’re concerned about fraud, but it’s one of those rules that costs the system a lot more money.”
Physician staffing
Presbyterian’s hospital at home is part of a much broader home health program. Since it launched hospital at home, Presbyterian initiated a house calls program that has evolved into an advanced illness program called “Complete Care.” Complete Care is home-based primary care for high-risk health plan members.
Dr. De Pirro, an internist who is the one full-time physician with the hospital at home program, says that she and her team of nurse practitioners “act like hospitalists when we’re doing hospital at home, but then follow patients with primary care once they’re discharged.”
Marshfield Clinic in Marshfield, Wisc., launched a hospital at home program in 2016—and over the past year, has expanded that program from six conditions to more than 150 DRGs. Like Presbyterian, Marshfield also maintains its own insurance program, and plan members can take advantage of hospital at home.
Marshfield’s program is a joint venture with Contessa, a Nashville-based company that offers hospitals a turnkey program it calls Home Recovery Care. While the program is led by Marshfield physicians, Contessa organizes RNs to visit patients at home. The company also employs five recovery care coordinators who coordinate patient care and “do all the administrative piece,” says hospitalist Swetha Gudibanda, MD, the program’s medical director.
“The hospitalists see the patients for the first time in the ER, and we take patients within a 40-mile radius.”
~ Swetha Gudibanda, MD
Marshfield Clinic
Marshfield’s program is also unusual in that its physicians are hospitalists. Dr. Gudibanda is one of four hospitalists who each work in the program one week a month, then spend the rest of the month doing hospital medicine. The hospital at home role, she points out, is very comfortable for her because of her past experience working in primary care and in nursing homes.
“The hospitalists see the patients for the first time in the ER, and we take patients within a 40-mile radius,” she explains. “All our subsequent visits with patients are virtual, through telehealth.” While the physicians have the option of visiting patients in their homes, “we don’t do it often.”
Eager to scale up
That’s the same physician model being used by Trinity Health, a health system with 94 hospitals in 22 states. Trinity Health’s Mount Carmel Health System in Columbus, Ohio, launched a hospital at home program earlier this year.
As Erin Denholm, MSN, RN, CEO of Trinity Health At Home explains, the hospital at home component is being built on the system’s Home Care Connect program, a high-tech home care model that includes an integrated and remote 24/7 call center. That call center was launched in 2017 and is staffed by RNs. Trinity Health’s home care program (without the hospital at home component) includes patients covered by traditional Medicare and some Medicare Advantage plans.
Funding for hospital at home in Columbus, on the other hand, is through a $350,000 innovation grant from Trinity Health, says Ms. Denholm. The Mount Carmel program now accepts patients with fee-for-service Medicare and other insurers, and the system is watching its hospital at home pilot closely. “We’re anxious to learn how to scale this up. I believe the CMS will approve a bundled payment within the next two years.”
In the meantime, hospitalists see eligible patients in the ED, then “round” on them via tablets once a day. (Nurses visit patients’ homes in person at least as often.) Once discharged, patients may transition to Home Care Connect “if they need it.”
Surprisingly, when Ms. Denholm first approached outpatient doctors to staff the program, she had no takers. “They didn’t have the bandwidth to help us develop the program because it required some administrative hours,” she says.
“We’re anxious to learn how to scale this up. I believe the CMS will approve a bundled payment within the next two years.”
~ Erin Denholm, MSN, RN
Trinity Health
However, her next meeting, which was with the Mount Carmel hospitalists, went much better. “Several were intrigued,” she notes. “They’re interested in using the technology.”
An affinity for independent practice
According to Dr. Siu of Mount Sinai, a mix of general internists, geriatricians and hospitalists staffed the system’s demonstration project, which ended up encompassing 19 different conditions and 65 DRGs.
“We had to provide additional training in home care because not everyone had that,” he says. “We also had to select individuals with an affinity for practicing home care medicine. You have to be comfortable with independence, as well as a level of uncertainty.”
An editorial that accompanied the Mount Sinai study this summer came to this conclusion: “a rigorous test of the HaH-Plus [the 30-day bundle] payment model in select conditions seems more appropriate than the wide-scale implementation recommended by the PTAC.” But Johns Hopkins’ Dr. Leff disagrees.
“I fully understand why the CMS needs to be very cautious and to get quality and safety right,” he says. “But efforts would be better spent in developing the larger quality infrastructure as we proposed in our PTAC application.” What’s also needed, he adds, is “studying the logistics and supply chains the model needs, not testing it further to see if it works. It’s time to move on and to start to build this thing.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Hospital at home outcomes
A STUDY in the June 2012 Health Affairs about the hospital at home program at Albuquerque’s Presbyterian Healthcare Services found it delivered 19% lower costs than inpatient care. Elizabeth De Pirro, MD, who’s now the lead physician of that program, ticks off other outcomes: “We have less mortality than the hospital, fewer falls and hospitalizations for infections, and fewer readmissions and medication errors. All the parameters for measuring inpatient care are pretty much better across the board with hospital at home.”
Dayna Cooper, MSN, who directs Home & Community Based Programs for the department of Veterans Affairs, oversees hospital at home programs in seven VA hospitals, with two more coming online this year.
“We find that patients tend to heal quicker at home because they’re more comfortable, less stressed.”
~ Dayna Cooper, MSN
Veterans Health Administration
“We find that patients tend to heal quicker because they’re more comfortable, less stressed, they eat and sleep better, and they have less delirium,” Ms. Cooper says. A 2008 write-up of a hospital at home program at the VA Portland Medical Center in Oregon—it’s since been discontinued, but it may be revived—noted that the program saved about $4,000 per patient per year.
And Marshfield Clinic in Marshfield, Wisc., launched a hospital at home program in September 2016 in partnership with Contessa, a company that takes risk and provides program coordinators and administration. That program has produced “big time improved patient satisfaction, including a 95% satisfaction rate,” says Swetha Gudibanda, MD, a hospitalist and the medical director of what the system calls its Home Recovery Care program.
“We reduced patient costs between 17% and 30% and readmissions by 50%,” Dr. Gudibanda adds. “Plus, our length of stay went down 34%.”
Clearing hospital at home hurdles
WHAT ARE THE BARRIERS to getting hospital at home off the ground? For most hospitals, the lack of any payment mechanism through Medicare and most private insurers means the model is a complete non-starter.
However, several systems around the country have alternative funding, innovation grants or even their own health plans—and they still run into additional barriers setting up programs. Here’s a list of hurdles established programs say they’ve had to clear.
• Nursing. Albuquerque’s Presbyterian Healthcare Services launched a hospital at home program in 2008 when Presbyterian already had established home health care services. According to Darren Maestas, RN, the program’s manager, changes needed to be made in the nurses’ schedules.
“We have our nurses deliver medications to patients at home.”
~ Darren Maestas, RN
Presbyterian Healthcare Services
“We initially followed the home health model and scheduled day nurses from 8 a.m.-5 p.m., Monday through Friday, and evening nurses from 5 p.m.-9 p.m.,” Mr. Maestas says. “But that model didn’t work for patients being admitted to the program between 3 p.m. and 5 p.m. because the nurse shifts were changing.” The fix was establishing 12-hour shifts and a rotating schedule.
“We also discovered that hospital-level and emergency department nurses fared better in this role compared to home care nurses,” he says, “due to their interest and experience with high-acuity patients.”
• Pharmacy and supplies. Hospital pharmacies aren’t allowed to dispense medications to patients who aren’t in the hospital. A hospital at home program launched earlier this year by Trinity Health in Columbus, Ohio, has come up with what Erin Denholm, MSN, RN, CEO of Trinity Health At Home, “creative workarounds” by “sending patients home from the ED with a pharmacy kit” with appropriate medications. (Patients in the program are first seen in the ED by hospitalists who then round on them virtually via tablet once they’re home.) The system has also had to create a new contract for oxygen for these patients.
At Albuquerque’s Presbyterian, the hospital at home program contracted with an outpatient pharmacy to generate prescriptions. “We have our nurses deliver medications to patients at home,” says Mr. Maestas. “That eliminated the barrier to using our inpatient pharmacy.” Presbyterian also contracted with IV infusion companies, and Presbyterian covers that cost. Also, “providers carry a medication box for the first dose of IV and oral medication administration to avoid any delay with DME preparation and delivery.”
• Geography. Hospital at home programs run by the Veterans Health Administration have an easier time delivering medications to hospital at home patients than non-VA facilities, says Dayna Cooper, MSN, who directs Home & Community Based Programs for the department of Veterans Affairs.
Ms. Cooper oversees hospital at home programs in seven VA facilities, with two more launching this year. Her biggest barrier, she says, is that “we’re geographically bound by how far we can drive.” Typically, “we like to say within a 60-minute driving range. But a 60-minute range in Boston is a lot shorter than it is in San Antonio.”
The hospital of the future?
AS A CHILD, Bruce Leff, MD, who directs The Center for Transformative Geriatric Research for Johns Hopkins in Baltimore, remembers visiting his aunt in the hospital after her surgery for cataracts. He recalls that she spent a week there recuperating, with sandbags over her eyes.
“Now, to get a cataract removed as an inpatient would take an act of Congress,” Dr. Leff points out. “So much care since then has been pushed out of the hospital, and it should be.”
Dr. Leff, a staunch advocate of hospital at home and a consultant to many of the programs that are up and running, was the lead author of a study in the Dec. 6, 2005, Annals of Internal Medicine. That study looked at the feasibility and outcomes of a hospital at home program
Championing both hospital at home and home-based primary care, Dr. Leff says he’s convinced that rehab and observation stays—in addition to palliative care—will eventually migrate out of the hospital into patients’ homes. Oncology infusions could also be home-based, and “you can take people from the OR directly home with a new hip or knee.”
So what will heath care in the future look like? First, according to Dr. Leff, the system—as well as payment—needs to move away from a bias in favor of facility- and office-based care. That includes “getting beyond the notion of an in-person visit or contact,” he asserts. Many of his clinic visits could be done just as productively over the phone or via telehealth.
Drones operated by national retailers or national drugstore chains may deliver patients’ medications directly to their homes. And “hospitals will become, at some level, large intensive care units or places where you go to get very specialized procedures,” Dr. Leff predicts. “Everything else really can and should be moved into the community.”
