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As Value Trumps Volume, Some Hospitals Try Treating Patients at Home

Mount Sinai among organizations that bring doctors, nurses directly to patients

Under pressure to reduce costs while improving quality, a handful of hospital systems have embarked on an unusual experiment: They are taking the house call to the extreme, offering hospital-level treatment at home to patients who in the past would have been routinely placed in a hospital room, according to a post on the New York Times’ Well blog.

And as awareness spreads of the dangers that hospitalization may pose, particularly to older adults, patients are enthusiastically seizing the opportunity.

Back in the late 1980s, Dr. Bruce Leff noticed that hospitals can be scary for older patients while making house calls to homebound patients, part of his primary care training at Johns Hopkins University School of Medicine. When some of his patients fell ill, they simply refused to go to a hospital.

He understood why: He had seen firsthand the delirium, infections, and deconditioning that too often land older patients in nursing homes after hospitalization. “Being in the hospital could be toxic,” said Leff, a geriatrician who is now a professor of medicine at Johns Hopkins.

So Leff and his colleagues had an idea. What if patients could be hospitalized in their own beds?

Some patients need the moment-to-moment monitoring that only a hospital can provide. The first task was to determine which common conditions required admission but could be treated with technologies placed in the home. These would be patients who clearly needed to be hospitalized, but who weren’t going to need an intensive care unit. Intravenous medications and X-rays can be readily adapted for the home; ventilators cannot.

Leff and his colleagues settled on four diagnoses that could be treated without the patient’s being in the hospital: heart failure, exacerbations of emphysema, certain types of pneumonia, and cellulitis.

“I’m a doctor. I can talk to a patient; I can examine a patient; I can bring home oxygen and IV meds and fluids; I can do home X-rays. I can do quite a bit,” Leff said. “We felt that it could be done, and the hypothesis was that by doing so, we could reduce harm.”

With a grant from the John A. Hartford Foundation, Leff and his team offered outpatient hospital-level care to nearly 150 patients with these four diagnoses who would otherwise have been treated at one of three hospitals, and compared those patients with a similar group who were hospitalized in the usual way. They called their program “Hospital at Home.”

The findings, published in Annals of Internal Medicine, were promising. Offered the opportunity, most patients agreed to be treated at home. They were hospitalized for shorter periods, and their treatments cost less. Moreover, they were less likely to develop delirium or to receive sedative medications, and no more likely to return to the emergency room or be readmitted.

The results caught the interest of hospital systems nationwide. But payers were less enthusiastic. When it comes to fee-for-service Medicare, there are no existing payment systems even now to reimburse hospital-level care provided in the home.

But systems like the Veterans Affairs and Presbyterian Healthcare Services, in Albuquerque, were not so constrained. Presbyterian has its own health plan and so, not limited by the lack of fee-for-service reimbursement, began offering a hospital-at-home option in 2008.

Dr. Melanie Van Amsterdam started out as the program’s only full-time doctor. She spent hours searching through hospital records for patients who might be eligible for the new program: sick enough to require a hospital stay, but not so sick that they might need to go to an intensive care unit. Some of the patients she approached said no, but more than 90% agreed.

Even with the most careful admitting criteria, however, the unexpected happens. Van Amsterdam and her team have had to move patients to the hospital for worsening medical conditions, sometimes by calling 911. Still, it is an infrequent occurrence: only 2.5% of these patients must be moved into a traditional hospital.

The challenge of knowing which patients are appropriate for hospitalization at home bothers Dr. Bruce Vladeck, a health care consultant and former administrator of the Health Care Financing Administration.

“I think in order to make this work in a way that makes clinical and ethical sense, you really have to be careful about evaluating your patients on the front end,” Vladeck said.

At Mount Sinai Hospital in New York — whose program is funded by a nearly $10 million grant from the Centers for Medicare & Medicaid Services — hospitalization at home is called “mobile acute care,” but the principle is the same. Patients with a set of specified diagnoses, expanded from Leff’s earlier work, are approached in the emergency department after the emergency doctor has decided they need to be admitted.

Those with worrisome vital signs — heart rate too high, blood pressure too low — are not eligible. Nor are patients without electricity or running water at home, or without space at home for oxygen or intravenous supplies, should they be needed — a pertinent question for residents in Manhattan apartments.

To measure the costs of patients who are hospitalized at home, patients will be followed for 1 month after their home hospital stay, during which they are eligible for services ranging from health coaching to home doctor visits. The team at Mount Sinai will collaborate with Leff and his colleagues at Johns Hopkins to compare outcomes with those of a similar group of patients who are hospitalized and to measure patient satisfaction.

But before gearing up to enroll their first patient this past November, the Mount Sinai team arranged a complex system of backups. Patients have 24-hour physician and nurse coverage, and an arrangement with emergency medical service providers ensures that rather than reflexively transport all patients to the hospital if they are called, the providers will deliver all the care they can at home.

The trend toward taking hospital patients out of the hospital “will continue to evolve and get tested, but I think this will see its day,” Leff said. In the past 2 years, he has received calls from at least a hundred system administrators eager to learn more about how to hospitalize patients in their homes.

“My sense is that over time, hospitals will become places that you go only to get really specialized, really high-tech care,” he said.

 Source: Well; April 27, 2015.

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