Background: “Hospital at Home” (HaH) models of care have existed for over 20 years in the U.S. Demand for healthcare value has driven renewed attention to HaH, including from the Centers for Medicare and Medicaid Services. The COVID-19 pandemic has only magnified consideration of alternative sites of care. Where studied, HaH models have had desirable impacts on readmission rates, patient safety, patient satisfaction, and cost. Despite this, adoption and scaling of HaH remains difficult due to a number of factors: complex logistics, cumbersome supply chain management, coordinating the clinical workforce, and lack of a workable payment model.
Purpose: To create and deploy a sustainable and scalable model for multidisciplinary hospitalist teams to provide safe and high-quality care in patients’ homes as a substitute for hospitalization.
Description: Our organization has built a tech-enabled in-home medical practice model in more than 25 U.S. cities utilizing mobile teams of emergency medicine physicians, advanced practice providers, and medical technicians. These teams have provided a broad range of diagnostic and therapeutic services to over 200,000 patients in 2020. 6-7% of these patients require escalation to the emergency department (ED), and 75% of those are admitted to the hospital. Our innovation leverages this existing practice infrastructure to support novel hospital at home capabilities. We built a team of hospitalist physicians, hospitalist-trained APPs, operations leaders, clinical nurses and nurse navigators. That team designed standardized clinical workflows and built processes for managing complex logistics including point-of-care labs, in-home imaging, IV medications, oxygen, remote monitoring, and safe escalation protocols. We developed evidence-based stratification protocols around clinical and environmental risk and paired risk assessments with MCG criteria to demonstrate level-of-care necessity. The care model includes twice-daily nursing visits and once-daily hospitalist visits during the acute illness, followed by a 14-day period of post-acute remote nursing oversight. Beginning in late 2019, we aligned with a payer partner for a deliberately measured launch in one city. Through 50 patients with that partner, only 2 (4%) were escalated to the ED during the high-acuity phase of care. Two (4%) were re-admitted to the hospital within 30 days. Unexpected mortality rate was 0%, serious safety event rate was 0%, and net promoter score was +96. Patient acceptance rate was 98% when offered HaH vs. hospitalization. Average medical cost savings was >$5000 per patient. 38% of patients were referred directly by primary care providers as an alternative to hospitalization. Conditions treated to date include pneumonia, COPD, CHF, complicated UTI, hyponatremia, cellulitis, wound infection (co-managed with a wound surgeon), and cirrhosis. We are in the final stages of a national partnership with a large payer, and, in collaboration with a large health system, launched this service in a second city in November 2020.
Conclusions: HaH care models have proven difficult to adopt and scale. Multidisciplinary hospitalist-led teams are uniquely positioned to design and provide HaH services. Our model is unique in that it leverages an existing in-home care model to identify and treat appropriate patients. In contrast to hospital-to-home programs, which focus on early hospital discharge and/or observation monitoring, our model also addresses full hospital substitution.