Home Health Care Redesign/Reform Hospital at home: Which patients are eligible?

Hospital at home: Which patients are eligible?

November 2023

WHEN THE MAYO CLINIC started its home hospital program several years ago, it focused on hospitalists’ bread-and-butter conditions like CHF, COPD and pneumonia. But the list of eligible diagnoses keeps growing and now includes post-surgical and bone marrow transplant patients, according to Michael Maniaci, MD, enterprise physician lead for Mayo’s hospital at home program. Dr. Maniaci spoke about the program at UCSF’s hospital medicine conference this fall.

“You want patients who are sick enough to be in the hospital,” he said. “But they’re clinically stable enough that they don’t need advanced imaging, ICU care, or an immediate procedure or surgery.” Other exclusion criteria include uncontrolled mental illness; unstable arrhythmia; or the need for IV pain meds, telemetry, or 24/7 assistance with daily activities.

Post-surgical protocols set up in the supply chain make it possible to treat patients at home with rehab and physical therapy. “Patients at home tend to get up more themselves than in the hospital and work with their own family members,” Dr. Maniaci pointed out. “Out of the thousands of patients we’ve taken care of over the last few years, I’ve had to send only one to a skilled nursing facility. Usually, patients don’t need a lot of post-acute services because they recover faster.”

“This isn’t glorified home health.”

Michael Maniaci, MD
Mayo Clinic

As he explained, patients in participating Mayo hospitals can access home hospital in different ways. Some patients come to the emergency department and are found to need inpatient care. “But instead of sending them upstairs to the wards,” he said, “we move them home to receive treatments.”

Or patients who need an immediate surgery or procedure or ICU- or stepdown-level care are admitted to the hospital. Then, “instead of recovering in the hospital for five to seven days,” Dr. Maniaci said, “we move them into hospital at home as long as they’re clinically stable.”

As for patients who would otherwise be placed in observation, or those getting any of several dozen different outpatient surgeries or procedures, or those traveling long distances who can’t be cared for in their home, Mayo maintains a “care hotel” model. And yes, that model takes place in actual hotels.

“We rent a hall of rooms and install virtual technology for 24-hour-stay patients, many of whom are ambulatory,” said Dr. Maniaci. “We can adjust drains and Foleys, inspect wounds, collect lab work and deliver medications, if necessary.”

Program outcomes
Since Mayo launched home hospital and care hotel in June 2020, the programs have treated more than 6,100 patients. The two programs combined have saved more than 15,000 hospital bed days since that launch, and readmission rates for home hospital patients are lower than for those who stay in the hospital.

Patients in the home hospital program have an illness severity of 2.8, which is higher than the average acuity of patients in the hospitals being covered. “This isn’t,” said Dr. Maniaci, “glorified home health.”

Patient experience has been excellent, with more than 90% of program enrollees saying they’d recommend it. More than a dozen quality metrics have been introduced in phases, not only for the physicians but for all the vendors—labs, home health agencies, physical therapists, traveling nurses and paramedics—in the supply chain.

Then there’s the issue of cost savings. Previous studies have found that delivering care at home in older hospital at home programs costs about 30% less than treating patients in the hospital. But Dr. Maniaci cautioned that scaling up a program like his comes with a lot of start-up costs to set up a command center and manage a far-flung supply chain.

“When your hospital at home program daily census reaches between 15 and 20 patients, you should at least break even,” he said. “Most likely, there’s between 5% and 10% savings from reduced cost at a census greater than 20.”