Published in the September 2007 issue of Today’s Hospitalist
Scott Mader, MD, a geriatrician at the Veterans Affairs Medical Center in
Portland, Ore., often sees patients who are ill with chronic heart failure, community-acquired pneumonia and other serious conditions that normally require a three- to five-day hospital stay. But Dr. Mader knows that sometimes, admitting these patients will do more harm than good.
While their medical conditions might resolve, patients run a high risk of debilitating complications during their stay, such as reduced muscle strength, delirium, hospital-acquired infections, and overall psychological and functional decline.
Instead, Dr. Mader is in a unique position to offer some patients an alternative: acute medical care in their homes, not the hospital. That’s because the Portland VA has an innovative “hospital at home” program that provides acute, hospital-level care and home-based services to patients who would otherwise require inpatient care. Services include daily nursing visits and oxygen therapy as well as the durable medical equipment patients need to recover.
At the Portland VA, 75% of eligible patients agree to enter the program “and after three days, most are ready for discharge. As for the hospital, it has opened up beds for other patients and seen its complication rates go down.
Hospital at home programs exist in the U.K., Israel, Italy and Australia, but the concept is still relatively untested in the U.S. In part, that’s because the data on such programs have been mixed.
A July 2005 review of 22 individual hospital at home studies published in The Cochrane Library, for example, found that although the programs increased satisfaction for patients (though not for caregivers), overall length of treatment increased and outcomes did not improve.
But experts say those poor results stem from the fact that such reviews report summary results that combine findings from different types of hospital at home programs. Bruce Leff, MD, a geriatrician at Johns Hopkins University School of Medicine in Baltimore who has researched the hospital at home concept, says that there are several key elements in making these programs a success.
For one, hospital at home programs do well to limit the number of illnesses they treat. The Portland VA, for example, accepts patients with one of four target illnesses: community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease and cellulitis.
“As a geriatrician,” Dr. Leff says, “I think it’s best to keep seniors out of the hospital whenever possible. But you still need to be conservative with the kinds of conditions you elect to treat in a hospital at home program. It’s most effective to focus on illnesses where ‘less is more’ is the best approach.”
The study that started it all
The Portland VA has been so successful that it has helped set the standard for hospital at home programs in the U.S. It was one of three facilities that participated in a 22-month study led by Dr. Leff and published in the Dec. 6, 2005, Annals of Internal Medicine.
After reviewing the medical literature and determining the four target illnesses, Dr. Leff and his colleagues approached three sites: the Fallon Health Care System in Worcester, Mass.; Univera Healthcare and Independent Health in Buffalo, N.Y., which together treat managed care patients at a single site; and the Portland VA. Their aim was to study a hospital at home model that substituted entirely for acute hospital care.
During the study, patients were evaluated in the emergency room or ambulatory clinic. If they met eligibility criteria and provided informed consent, they were transported home in an ambulance, where they were met by a nurse.
Patients then received daily physician visits and one-on-one nursing care for an extended period (a mean of 16.9 hours), followed by at least two daily nurse visits and all the care that they’d normally receive in the hospital.
Eighty-four patients were treated in the hospital at home program. Findings showed that care was not only safe, but resulted in shorter lengths of stay (3.2 vs. 4.9 days) and lower mean costs ($5,081 vs. $7,480) when measured against a comparable inpatient group. The incidence of other factors, such as the use of sedatives and chemical restraints and incident delirium, was also reduced.
The role of hospitalists in the study was limited to referring patients to the program; internists and geriatricians took over patient care when patients were at home. As the hospital at home model evolves, however, some hospitalists are branching out to take on visiting-physician responsibilities.
Modifying the model
Since the research wrapped up, the Portland and Buffalo sites have continued their programs, although with some modifications.
The Portland program, which now treats between 60 and 100 patients a year, accepts patients of all ages. Previously, only patients age 65 and older were eligible.
In addition, the program now accepts patients who have already spent a few days in acute inpatient care. These patients are generally referred by the hospitalist group, which is led by Thomas Anderson, MD.
“The hospital at home program is a great way of transitioning patients back into the home,” says Dr. Anderson. “After the acute condition is under control, the keys to good long-term outcomes are educating patients and their caregivers and making sure patients comply with lifestyle and medication changes. When I refer a patient to this program, I know that my recommendations will be followed up on. Plus, the program helps free up beds for more critically ill patients.”
Dr. Mader points out that early-discharge patients are often the most suited for the hospital at home program. “All the initial testing has been done, and the patients have a plan of care,” he says. “They’re just at the point where that plan needs a few days to work.”
And, he adds, the hospital at home concept makes sense to the hospitalists. “The hospitalists are often the first to realize that [complete recovery] doesn’t have to happen in a hospital bed.” By contrast, “it is much more labor intensive and time critical when your program needs to admit a patient from the ER or ambulatory clinic.”
Reimbursement is also easier with early-discharge patients or patients who were once hospitalized because hospitals can be paid under Medicare/Medicaid home visit rates. Currently, Medicare does not have any payment model for patients who were never inpatients and who enter a hospital at home program immediately after being evaluated in the ED or ambulatory clinic. Dr. Leff and his colleagues are currently working to develop a payment model for those patients.
Issues related to reimbursement under Medicare/Medicaid home-visit rates are one of the main reasons that the Buffalo program has switched completely to a “rapid response” model aimed at keeping previously hospitalized heart failure patients from being re-admitted, according to Bruce Naughton, MD, the geriatrician who leads the program.
The program treats about 85 patients a year, all of whom are informed of the hospital at home option during their initial inpatient stay. When patients return home, they have the option of calling a hospital at home physician (usually a geriatrician) if they feel ill; the physician can arrive at the home within 30 minutes to provide treatment or assess whether the patient should be transferred to the hospital.
Dr. Naughton notes that some managed care companies aren’t yet on board with reimbursement for hospital at home programs. Still, “the congestive heart failure program continues and is doing well, and patients with multiple readmissions are enrolling,” he says. “We are following usual and customary reimbursement for our rapid response, CHF home-care program.”
Both the Portland VA and Buffalo programs have continued to deliver substantial savings. Dr. Mader estimates that the Portland VA program saves the hospital about $100,000 per year. Dr. Naughton cites savings of up to $300,000 per year by reducing re-admission rates for congestive heart failure patients by 80%.
The role of hospitalists
Some hospitals don’t necessarily have the resources in terms of visiting physicians or nurses to launch a full-fledged hospital at home program that completely substitutes home care for hospital care.
But a number of hospitals are implementing some of the model’s concepts. Kevin Costello, MD, a geriatrician with the hospitalist program at Albany Medical College in Albany, N.Y., formed an early discharge program last October with help from Dr. Mader. The program, a collaborative effort between the department of medicine and case management and the Visiting Nurse Association (VNA) of Albany, incorporates some, but not all, of the principles of hospital at home services, providing home services to patients after they’ve been discharged.
“At first, we focused on the four target illnesses described in the Leff article, but then we expanded to include patients with other conditions such as complicated urinary tract infections, gallstone pancreatitis, and patients recovering from trauma or surgery,” Dr. Costello says. He and a VNA nurse evaluate all patients in their homes the day after discharge and are available via cell phone 24 hours a day. He and the visiting nurse also see patients based on medical necessity.
The program has treated 14 patients so far, and Dr. Costello says that initial results have been positive. “We’re not impacting the length of stay as dramatically as a substitutive home-hospital model,” he says. “But we are getting patients home more quickly and, in some cases, reducing re-admission rates.” When patients return to primary care or to the hospital, “I provide information regarding the post-hospital course to the receiving physician.”
Dr. Mader envisions a time when more hospitalists might want to vary their routine by serving as visiting physicians. (Currently, visiting physicians are mostly geriatricians or internists.)
“I’ve proposed this to our hospitalists before, and they’ve expressed some interest, but they have their hands full with inpatient work right now,” he says. “In the future, however, I could see a hospitalist doing two weeks of acute care followed by two weeks of hospital at home.” Dr. Anderson agrees. “Working as a visiting physician might give hospitalists a break from the intense pace of hospital medicine.” In fact, when Dr. Anderson was in private practice, he sometimes made housecalls to check on patients, and he’s never forgotten the experience.
“You learn a lot about patients when you see them in their homes,” he says. “You gain an understanding that you wouldn’t have when you treat them in the hospital.”
Dr. Mader says that given new medical knowledge, the time is right for hospital at home programs. “Years ago,” he explains, “we used to admit patients for diabetes treatment, then we realized that this made no sense. Patients need to be at home, doing their own thing, to give physicians a good understanding of how to help them manage chronic diseases. That’s one of the important benefits of hospital at home.”
Yasmine Iqbal is a freelance writer based in Wallingford, Pa., who specializes in health care.
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