Published in the August 2012 issue of Today’s Hospitalist
HEADING UP one of the country’s most comprehensive hospital at home programs, internist Melanie Van Amsterdam, MD, occasionally runs into skepticism from colleagues. Isn’t the program, they ask, really just a glorified version of home health?
Not at all, Dr. Van Amsterdam responds, noting that even she has been surprised at the level of acuity that can be treated at home. “We took 75 pounds of fluid off one heart failure patient in three weeks,” she notes. (She adds that following a patient for three weeks is unusual.)
She has also treated patients on 15 liters of oxygen, even though program guidelines exclude patients who need more than six liters. “If patients refuse to go to the hospital, we treat them,” says Dr. Van Amsterdam. While the program has criteria for eligibility, she adds, “We’ve broken almost every one of those rules.”
Since 2008, Dr. Van Amsterdam has served as lead physician for the hospital at home program at Albuquerque’s Presbyterian Healthcare Services, which was modeled after a program developed by Johns Hopkins Schools of Medicine and Public Health. Results from the program, which were published in the June issue of Health Affairs, should silence any remaining skeptics. According to the study, the hospital at home program spent 19% less on its patients than the health care system spent on a comparable group of patients who were hospitalized.
Fewer costs, better satisfaction
As an integrated system, Presbyterian maintains not only eight hospitals and many outpatient clinics, but New Mexico’s largest health plan. That’s critical because neither Medicare Part A nor B pays for hospital at home services.
Presbyterian’s program is limited to its own insured patients, as well as some Medicare Advantage and Medicaid patients. The success of the program over the years has also attracted other commercial payers.
The program is now staffed by two full-time internists and two full-time and two part-time nurses, as well as several part-time home health and telemedicine nurses. (A full-time advanced clinical nurse specialist also recently came on board.) Between the program’s launch in October 2008 and April 2012, it treated close to 600 patients, with each provider’s daily census capped at five.
Cost savings came from a shorter length of stay for hospital at home patients “3.3 days vs. 4.5 “and from fewer tests being ordered. Mortality rates for the hospital at home patients were better (0.93% vs. 3.4%), as were rates of complications such as falls. And patient satisfaction scores for hospital at home patients was 90.7, besting the system’s hospital score of 83.9.
The study also found no statistically significant difference in 30-day readmission rates between the two groups (10.8% for hospital at home vs. 10.5% for admissions). But study data were drawn from 2009-10, Dr. Van Amsterdam points out, before the program hired more full-time clinicians.
With the new hires, weekend continuity is much better, so fewer patients are being sent to the hospital on weekends. “I’m now betting that our readmission rate is actually lower,” Dr. Van Amsterdam says.
Start-up time and logistics
But just because Presbyterian’s program slashed costs doesn’t mean that hospital at home is coming soon to a hospital near you. Many organizations interested in the system’s results, says Dr. Van Amsterdam, have come to call. So far, however, those groups have been the Kaiser Permanentes of the world.
“It takes systems that are fairly large, capitated and integrated, with the population to draw from,” she notes. “Systems also have to be able to afford to float considerable start-up costs.” While she doesn’t say what those costs were, she points out that it took 150 people working in 12 teams over nine months to get the program off the ground.
That time was spent finding vendors to supply in-home equipment, working out the logistics of where prescriptions would be filled and sorting out reimbursement details.
“A hospital doesn’t really fit into a box,” Dr. Van Amsterdam notes. “We squeezed into home care and had to figure out all the regulations that don’t apply because we’re under home care.”
Right patients, right physicians
An ongoing challenge, says Dr. Van Amsterdam, is “finding the right patient with the right level of illness.” When the program began, about 90% of its patients spent at least one night in the hospital, with only 10% referred directly to the program from an ED or clinic.
Now, she says, those figures are reversed. She and her colleagues electronically monitor the EDs covered by the program, and reach out to new providers within Presbyterian to let them know the program is available.
An ED triage nurse has been another referral source. And the hospital at home providers now do some work in Presbyterian’s house call program, visiting some patients with chronic illness. That house call program now refers patients to hospital at home as well.
Such an initiative, Dr. Van Amsterdam adds, is also limited in terms of which physicians make a good fit. While a few Presbyterian hospitalists have worked with the program on a PRN basis, she says that most hospitalists are uncomfortable outside the hospital.
“They’re used to working in a system, being able to call an ICU or a medical emergency team if a patient is crashing,” she points out. “With hospital at home, they don’t have that onsite back-up.”
ED physicians are even less interested. “They want to basically ‘treat and street,’ ” says Dr. Van Amsterdam. “They don’t want to be involved in continuity of care.”
Instead, the program has had success with physicians who, like her, “have had rural or indigent experience and have done home visits. They have a certain comfort level being on their own.”
The luxury of time
Dr. Van Amsterdam was formerly a primary care physician within the Presbyterian system. She says she now revels in the amount of time she’s able to spend with hospital at home patients, rather than cramming patients into 15-minute slots.
“The first time I evaluate someone, it’s going to be a couple of hours,” she says. Subsequent visits typically last 40 minutes. Patients included in the Health Affairs study received an average of 3.5 physician visits and 6.4 nursing visits.
Her wish list for the program includes better electronic integration. A major upgrade now underway should integrate the various EMRs for the hospitals, clinics and providers.
But the No. 1 change she’d like to see is in reimbursement. Our big limiting factor is payer sources, and that’s what hospital at home needs to fly,” Dr. Van Amsterdam says. “I would like Medicare to recognize us.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.