AS HOSPITALS BUILD out hospital at home programs, what can hospitalists expect?
“Your EHR is going to change a bit, and you’re going to start seeing indicators that say, ‘This patient is currently in the hospital but they’re right for home hospital,’ ” said Michael Maniaci, MD, enterprise physician lead for Mayo Clinic’s hospital at home program. Dr. Maniaci spoke at the UCSF hospital medicine conference this fall. “When you’re rounding at our hospital and you look at your list online, a green light pops up with an indicator that says, ‘Out of your 18 patients, these three have the right zip code, payer and diagnoses to be treated in hospital at home.’ ”
To identify those appropriate patients, “we’re using new AI models that review charts, see if patients require inpatient care for more than 24 to 48 hours longer, and then look at all the factors that might make them a good candidate for hospital at home.”
Patients are then scored according to their home hospital eligibility. “That’s what we see in our Epic list,” Dr. Maniaci explained.
“Anyone in an isolated location who connects to Amazon through their phone could connect to a hospital at home center.”
Michael Maniaci, MD
Eligible patients are then approached about home hospital by a dedicated acquisition advanced practice provider. Having that dedicated APP has been key to growing program volumes.
Dr. Maniaci serves as the medical officer for his hospital in Florida, where hospital at home for most stable patients is now the standard. “If the patient has the right diagnosis and wants to join the program but his or her medical team declines, I now go to the hospitalist and say, ‘Why aren’t you putting that patient in home hospital?’ Everyone knows that if you’re not getting eligible patients ready for hospital at home, we’re going to have that conversation.”
He is one of a core group of 12 dedicated hospitalists who cover the hospital at home rotation. Right now, two hospitalists cover the daytime service, each capable of taking care of up to 15 to 20 patients scattered throughout the health system. As for consults, he puts that order in the EHR just as he would for a hospitalized patient.
Sometimes the resulting consult takes place virtually; an APP or nurse may visit the home to help facilitate that virtual consult. Or patients may need to visit a specialist in-person—but that happens, said Dr. Maniaci, for only 5% of his home hospital patients.
Regulations and the future
There’s no doubt that regulations and policies need to catch up with the growing model. “A lot of local, state and federal rules link high-acuity care to buildings,” Dr. Maniaci pointed out. “Those rules will have to change. It’s silly that I have to physically be inside a hospital to do my job.”
And right now, he has to maintain a license in every state in which he sees home hospital patients. “The pandemic loosened some of those rules, but unfortunately they’re back,” said Dr. Maniaci.
He and his colleagues with the Advanced Care at Home Coalition, a nationwide group of providers, are advocating for a national license to be able to provide virtual care anywhere in the country. “But as of today, you have to have a license in a state to be able to practice.” (Another resource: The Hospital at Home Users Group has lists of CME related to home hospital as well as a directory of leadership courses.)
As for the CMS continuing to pay for hospital at home, Dr. Maniaci said the pandemic waiver has been extended through the end of 2024, and he expects those waiver extensions to continue. “This environment is not going away,” he added. New billing codes have been established for delivering hospital services in the home, And private insurers who are starting to see improved outcomes are getting on board
“A lot of payers are buying home delivery resource companies,” Dr. Maniaci pointed out. “They see the future.”
Health care delivered in the home is moving fast beyond just inpatient care. Already, hospitals are experimenting with “ED at home,” bringing emergency care to patients at home with mobile imaging. Cancer centers are also starting to offer home chemotherapy.
As Dr. Maniaci sees it, “I really believe that many hospitals in the future will become surgery centers or ICUs. For a lot of the lesser acuity patients, care will be done in the home setting.”
He also believes that decentralized health care can begin to address the kind of health care inequities and lack of access that many patients face, as well as the needs of a growing elderly population who will be increasingly less mobile.
Is hospital at home on this scale just for the Mayos and Johns Hopkins’s of the medical world? Absolutely not, he maintained; the model is scalable for any community hospital.
“Anyone in an isolated location like rural South Dakota who connects to Amazon through their phone could connect to a hospital at home center,” Dr. Maniaci pointed out. Meanwhile, he believes that hospitalists will have to get ready to see patients not only in the hospital, but in new settings like a group home, a shelter or a hotel. “This isn’t really in the future because it’s going on now in more than 200 centers across the country.”
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Phyllis Maguire is Executive Editor of Today’s Hospitalist.