LIKE HOSPITALISTS across the country, Per Danielsson, MD, medical director for post-acute care at Swedish Health Services in Seattle, was having a tough November. The covid census was rising, even before the expected Thanksgiving bump, and colleagues kept telling him that they were stressed and weary.
Then came this announcement: To enhance hospital capacity during what could be a crushing winter, the CMS had decided—at long last—to pay for hospital at home services for Medicare fee-for-service beneficiaries. The agency invited individual hospitals to apply for a waiver that essentially eliminates the need for 24/7 onsite nursing. If approved, hospitals could begin providing hospital-level care for 60 DRGs to eligible Medicare patients in their homes.
For Dr. Danielsson, that decision was “the best news I’ve had in seven years.” That’s how long he’s been proposing different hospital-at-home models and pilot programs to his hospital and health system, as well as regional and local health plans, striking out every time. Evidence and experience both here and abroad have long established the model’s excellent outcomes and quality profile. But the lack of reimbursement—particularly in the monster fee-for-service Medicare market—was a hurdle he couldn’t clear.
Considered the godfather of hospital at home, Bruce Leff, MD, of Baltimore’s Johns Hopkins, has been pioneering research on the model for 25-plus years. See “Moving toward the hospital of the future,” for Dr. Leff’s comments on Medicare’s new waiver process.
Until now. What the CMS is calling its Acute Hospital Care at Home program is temporary, designed to provide hospitals flexibility through the current public health emergency. But the CMS has already made permanent other pandemic-driven innovations, including many telehealth capabilities. If hospitals can collectively deliver good performance and great care for hospitalized Medicare patients at home, the chance that Dr. Danielsson and other hospital at home proponents have worked toward for years might become permanent.
SWEDISH HEALTH SERVICES: A work in progress
After the CMS announcement, Dr. Danielsson expedited work his group had previously completed to put potential program pieces in place to begin hospital at home in January. That’s if Swedish’s waiver application is approved.
“It’s kind of like building a hospital without the bricks and mortar,” he says. “You need to make sure you have redundancies in place and back-up systems so you can reliably provide high-quality care.”
Dr. Danielsson’s most recent design for hospital at home was one in March that would have been activated if the Swedish hospitals and ICUs reached capacity. That threshold was never reached.
“This is a once-in-a-generation opportunity.”
~ Per Danielsson, MD
Swedish Health Services
But “we did sign contracts with vendors to supply our remote patient monitoring, so we already have that in place.” Patients hospitalized at home will receive a tablet with video access to the program’s eventual command center as well as a Bluetooth-enabled blood pressure cuff, pulse oximeter and thermometer. “We also bought 500 oxygen concentrators.”
IT and staffing hurdles
Dr. Danielsson points out that Swedish and its parent organization, Providence, already have a massive telemedicine presence, which can provide technical expertise and support to hospital at home. But speaking in mid-December, he noted that many program pieces weren’t yet in place, something he and what he calls “a small army of competent people” are now working to secure.
For one, “we were always going to launch a more traditional hospital at home program under our home health license,” he explains. But that’s not kosher for the CMS waiver program. Facilities can apply only under their hospital license, and all documentation related to hospital at home care has to be part of the inpatient record.
“We’re having extensive discussions with our Epic team,” he points out. “We may be able to use our existing EHR.” Another condition of the CMS program: Hospitalized patients at home must be visited in-person twice a day, and RNs can determine whether paramedics can do those visits. But in Washington state, paramedics are under the umbrella of emergency medical services and don’t provide home services.
“We’re going to lobby the governor to provide an exemption, and we’re hopeful we’ll get a state waiver during the pandemic,” says Dr. Danielsson. He also envisions being able to use home health nurses who have experience visiting patients’ homes, although “we’ll look for a subset who have recent acute experience.”
The program has yet to be given its own budget number, and its command center still needs to be built. “We’ve identified the space where we’re going to do that, so we think that can be done quite quickly.” Pharmacy, infusion, and DME need to be brought on board.
And Dr. Danielsson needs to choose the dedicated hospitalists and APCs who will work with the program. “They have to be,” he says, “excellent clinicians with great communication skills.”
ATRIUM HEALTH: Building on covid hospital at home
A research article in the November Annals of Internal Medicine delivered the impressive results of a hospital at home program launched in March 2020 by the Charlotte, N.C.-based Atrium Health.
“We aggressively use virtual care and community paramedic visits as well as advanced therapies such as IV medications in the home.”
~ Stephanie Murphy, DO
That program was the health system’s first actual foray into hospital care at home, although it had planned pre-pandemic to launch just such a service for traditional inpatient diagnoses. The current at-home program cares for only covid patients who would otherwise be hospitalized in 10 Atrium hospitals throughout the greater Charlotte metropolitan area.
Through mid-November, that program’s virtual acute care unit had treated more than 1,200 covid patients, representing about 25% of Atrium Health’s total hospitalized covid census in that area.
The health system’s virtual hospital also maintains a covid virtual observation unit, enrolling all asymptomatic or mildly symptomatic patients who test positive. While that arm of the program is not considered part of hospital at home because the patients don’t require admission or hospital-level care, it has so far treated more than 10,000 patients.
Unbelievably, Atrium Health got its covid hospital at home program off the ground within two weeks. How was such rapid implementation possible?
Two longstanding programs already in place within the health system “gave us the backbone and infrastructure,” explains Stephanie Murphy, DO, the hospitalist who directs Atrium Health’s hospital at home and one of the article’s co-authors.
The first is a transitional care program, which hospitalists and hospitalist APCs have led and staffed for five years. That program was designed to follow complex patients at high risk for hospital readmissions for up to 60 days post-discharge.
The transitional care program features an actual outpatient clinic. But within the model, “we aggressively use virtual care and community paramedic visits as well as advanced therapies such as IV medications in the home,” Dr. Murphy notes.
The second foundational program that Atrium Health’s hospital at home drew on was a robust telemedicine service. As Dr. Murphy points out, hospital at home uses the same Vidyo technology platform as does telemedicine for virtual home visits, as well as the same remote equipment, like Agnes stethoscopes.
“We had many of the interdisciplinary teams in place, so we could transform them to hospital at home pretty quickly.”
~ Kranthi Sitammagari, MD
“That allowed us to quickly move providers from inpatient telemedicine care to hospital at home because they were familiar with the equipment,” she says. “We also piggybacked on the physician connection line service to coordinate, triage and admit patients into the virtual hospital.”
Hospital at home also utilizes the same health IT platform and EHR as telemedicine, says Kranthi Sitammagari, MD, Atrium Health’s medical director of quality. And “we had many of the interdisciplinary teams— hospitalists, nursing staff, community paramedics—in place, so we could transform them to hospital at home pretty quickly.” Without all those pieces available to pull together, both Drs. Murphy and Sitammagari believe it would have taken at least six months to get hospital at home off the ground.
They are now applying for grants to expand their program to patients beyond covid. Also, Dr. Sitammagari says, “we recently received approval of our Medicare waiver application process.” That waiver, he adds, “may rapidly transform the future of the hospital at home in this country. Many leading health systems are trying to scale it up.”
HIGHMARK HEALTH-ALLEGHENY HEALTH NETWORK: A joint venture
The Home Recovery Care program in western Pennsylvania is still another model, one launched jointly by both a provider system—Allegheny Health Network—and a payer, Highmark Health. The program was first made available in November 2019 to patients in some Highmark health plans and expanded in early 2020 to members of Highmark’s Medicare Advantage plans.
“These patients don’t get lost to follow-up.”
~ Harshit Seth, MD
Allegheny Health Network
Patients in three Allegheny Health Network hospital EDs are now screened for program eligibility. Home Recovery Care covers about 150 DRGs, and covid patients have been admitted over the course of this year.
“One of the best parts of the program is that these patients don’t get lost to follow-up,” says Harshit Seth, MD, medical director for Home Recovery Care and system medical director for Allegheny Health’s hospitalist services.
After their in-home admission, patients are monitored for 30 days while a recovery care coordinator makes sure primary care appointments are scheduled and prescriptions are filled. The coordinator also connects patients to community resources.
That recovery care coordinator is provided through a joint venture with Contessa Health, one of several companies nationwide that work with hospitals and health systems to provide turnkey hospital at home programs. Contessa provides a proprietary technology platform, evidence-based protocols and best practices, eligibility criteria and personnel in the ED to screen for potential patients, and experience facilitating inpatient care at home and assessing home conditions.
That, Dr. Seth says, “made the workflow of hospitalists and ED doctors very easy” and helped clinicians more readily accept the new model. Now, with several quarters of patient satisfaction and quality data (Contessa also provides data analysis), “clinicians have realized that this care model might be more beneficial than inpatient hospitalization for certain patient subsets.”
Hybrid hospitalist model
Dr. Seth adds that while the ideal census for the program would be between six and eight patients, the more typical census is four to five. He would like a dedicated team working exclusively on the at-home program, but hospitalists instead maintain a hybrid model.
“Hospitalists have both in-hospital and home recovery care duties, with protected time for scheduled virtual rounding of at-home patients,” he says. Moreover, the at-home program is staffed by “only a limited group of physicians.”
That’s because providing in-home virtual care is “for some clinicians more than others,” says Dr. Seth. (He finds that doctors fresh out of residency are usually more interested in participating.) Also, limiting the number of hospitalists in the program means “fewer pieces of the puzzle we have to put together with different doctors.” Speaking in mid-December, Christina Weir, vice president, enterprise clinical operations for Highmark Health, says the integrated program is in the process of filing for the Medicare waiver.
“We understand,” Ms. Weir says, “that the CMS has a sense of urgency in reviewing these applications and that it’s fast-tracking applications of mature programs already in place.” The program wouldn’t need to reconfigure any of its technology platform or IT; it would, however, have to provision more of the technology kits being used in patient homes in anticipation of new patient volumes.
It would also have to expand program staff. “Our program is fortunate in that Allegheny Health Network actually owns and operates all the clinical services we use in the home, including a home nursing and an infusion company,” Ms. Weir points out. The program may also need to expand the Contessa team in the EDs “because we will now have a bigger base to screen.”
Highmark Health plans to expand its participation into other states, including Delaware and West Virginia. To do so, it will seek provider-system partnerships like the one it has with Allegheny Health Net.
PRESBYTERIAN HEALTHCARE SERVICES: A tandem program
New Mexico’s Presbyterian Healthcare Services has one of the country’s longest-running hospital at home programs, launched in 2008 for its own health plan and Medicare Advantage members. With no CMS coverage, a constant source of frustration was not being able to offer it to Medicare fee-for-service beneficiaries.
“The door was closed for very long but now it’s open, and we want to keep it that way.”
~ Elizabeth De Pirro, MD
Presbyterian Healthcare Services
But “after 12 years of hoping the CMS would authorize the program, the actual time involved in receiving the waiver was about 48 hours,” says Nancy Guinn, MD, Presbyterian’s medical director of clinical transformation, population health.
Given its long track record with hospital at home, Presbyterian was one of six health systems in the country that received the first waivers.
“The door was closed for very long but now it’s open, and we want to keep it that way,” says Elizabeth De Pirro, MD, lead physician for the hospital at home program. She, along with one other physician and four APCs, staff that service, providing inpatient care at home to admitted patients as well as primary care when they’re discharged. According to Dr. De Pirro, she and those same staff plan to begin treating Medicare fee-for-service beneficiaries in their homes as well.
Getting IT right
Presbyterian’s IT department is already working to build the ability to appropriately document Medicare hospital at home admissions and to submit the data the CMS waiver requires.
But as Dr. De Pirro explains, the plan is to keep the current hospital at home program in place for health plan and Medicare Advantage members while establishing a tandem program for Medicare fee-for-service patients who qualify.
That’s because Medicare fee-for-service participation is based on admitting patients only from an actual hospital, either an ED or inpatient floor.
“That limits our ability to make the program available to many home-based frail patients who we often admit to hospital at home,” says Dr. Guinn. “We don’t plan to send them to an emergency room but will continue our current program for them.” She hopes the CMS will eventually allow patients to be admitted to hospital at home from urgent care centers, primary care offices and home health services.
“We’re going to scale up with our current hospital at home staff.”
~ Nancy Guinn, MD
Presbyterian Healthcare Services
Initially, Dr. De Pirro says, she doesn’t expect the new program for Medicare fee-for-service patients to have “a huge census. It’s a fine line between patients who are stable enough to be managed at home and those who need to be in an actual hospital until they’re more stable.”
With hospitals in New Mexico at capacity and elective procedures already suspended, it’s not the time to expand staffing for hospital at home.
Instead, “we’re going to scale up with our current hospital at home staff,” says Dr. Guinn. “They have all volunteered to take on the additional work of seeing more patients during this difficult time.” And if the program can sustain the larger census long term and if we have a sense the CMS program will continue beyond the public health emergency, then we will invest in expanded staffing.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Published in the January/February 2021 issue of Today’s Hospitalist