FOR MORE THAN 20 years, hospital at home projects have posted impressive results. They’ve lowered rates of mortality, readmissions and falls; reduced incidents of delirium and infections; improved sleep and mobility; and produced better patient experience ratings.
Those outcomes have always begged the question: Why hasn’t hospital at home become more widespread?
A huge limiting factor, of course, has been Medicare’s refusal—until the pandemic—to pay for hospital services delivered at home. But according to Michael Maniaci, MD, enterprise physician lead for Mayo Clinic’s ambitious hospital at home program, Advanced Care at Home, most home hospital programs in the past have been extremely limited and not scalable.
“It used to be a model where doctors would get in a car and make house calls while nurses would show up to do infusions, and they’d see about five patients a day,” Dr. Maniaci explained, speaking at UCSF’s fall 2023 hospital medicine conference.
“On any given day, I’m taking care of hospital at home patients in three different time zones.”
Michael Maniaci, MD
Because those programs relied on clinicians actually visiting patients, most hospital at home programs extended only five or 10 miles from their hospital hub. As a result, they offered very little coverage.
But today, in what Dr. Maniaci called version 2.0 of home hospital, hospitals are using virtual care and technology to expand their reach and their services. “It takes the highest cost resources—the physicians and the bedside nurses—and it makes them virtual, interacting with patients through technology,” he said. “Instead of delivering all of the services ourselves, we build a supply chain just like Amazon, and we execute care through that chain.”
Mayo’s hospital at home program, which was launched in 2020 at several of its sites around the country, uses a command center in Jacksonville, Fla. While that’s where Dr. Maniaci is based, he’s not limited to where he sees patients.
“On any given day,” he said, “I’m taking care of hospital at home patients in Florida, Wisconsin and Arizona with patients in three different time zones. That’s my list for the day.”
The technology you need
The ambitious Mayo system uses a lot of technology to connect clinicians to patients. “This includes a lot of biometric devices,” Dr. Maniaci said, “and it centers around some sort of communication device, like a tablet, that gives patients virtual access to the command center.”
The Mayo program also uses Medically Home’s Cesia software to run the system. “This is where a lot of hospitals falter with homegrown at-home programs,” Dr. Maniaci said. “They don’t have the software to drive all the connections patients need. You need to build an ecosystem of decentralized health care.”
Say a patient enrolled in home hospital needs a bag of IV fluid. “That happens instantaneously in the hospital,” he noted.
For a patient at home, however, a doctor has to enter the order in the EHR, a pharmacy has to receive the order and prepare it, a courier has to pick it up along with all the medical supplies needed—tubing, an IV pump—and deliver it to the patient. Then a nurse or other medical professional has to hook up the pump, start the IV, monitor the patient and then dispose of the waste. “And that’s one set of orders for one patient—once.”
So how do you run a hospital at home program that, like Mayo’s, has the capability to treat more than 100 patients, each with 10 to 15 (or more) orders a day? You can’t do it without a supply-chain driven software system, Dr. Maniaci said.
“That’s really what it takes to drive hospital at home at scale,” he explained. “You have to build and connect a supplier network that can mimic the services you supply in the hospital.”
The Mayo command center coordinating all those clinical and supply networks functions like a virtual ward. Teams of MDs/DOs, RNs, pharmacists and case managers “all work to replicate the rapid response and the capabilities you have in the hospital, without duplicating the bad part of the hospital experience,” said Dr. Maniaci. “You give people all the care they need, and then you leave them alone.”
With the right supplier network and software in place, you can include patients in hospital at home who live up to 30 miles from each hospital or supply hub. Set up networks around different hospitals, he said, as Mayo has done across the country, and one command center linking them all can reach nationwide.
For more on hospital at home, read:
Phyllis Maguire is Executive Editor of Today’s Hospitalist.