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May 18, 2018

Why Brigham and Mount Sinai are bringing the ED to your living room

Daily Briefing

    A small but growing number of hospitals—including Brigham and Women's Hospital and Mount Sinai—are providing in-home treatment for patients who present at the ED with conditions that would typically merit hospitalization. 

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    Why treat patients at home?

    In-home care can help patients avoid some of the risks and stressors of hospitalization, Michelle Andrews writes for Kaiser Health News. According to KHN, when patients go to the hospital, they face risks for infection, delirium, and sleepiness—plus, hospitals are loud,. And for caregivers, the additional tasks that come with visiting a loved on the hospital—such as navigating an unfamiliar setting, hunting down parking, and synching their schedule to catch the clinical team—can add stress to an already tense situation.

    On the financial side, the at-home setup also offers the potential for cost savings, Andrews reports.

    According to KHN, the at-home care setup is already common in Australia, Canada, and the United Kingdom.

    What leading health systems are doing

    Under a setup Brigham launched a few years ago, patients who are acutely ill but don't need 24-hour, intensive care can opt for in-home care, Andrews reports.

    In one example, Andrewsprofiles the experience of an elderly woman with pneumonia who a doctor called "a perfect candidate for" the program. The woman was transported via hospital transportation to her home, where a doctor and nurse were already waiting for her, Andrews reports. The care team checked the woman's IV, attached a monitor, and then left. They were able to monitor her remotely. The woman was "discharged"—the equipment was removed from her house—after three days without complications.

    According to David Levine, a doctor at Brigham, the program was met with skepticism by staff members at first, but they've grown to accept it. "They very quickly realize that this is really what patients want, and it's really good care," he said.

    Meanwhile, Mount Sinai launched its Hospital at Home program in 2014, and since then has treat more than 700 patients who would otherwise have been hospitalized at home. Mount Sinai refers patients into the program from certain EDs along with its primary care practices and urgent care centers, Andrews reports. Originally, Mount Sinai's program covered six conditions, such as diabetes, heart failure, and pneumonia. It's since expanded to cover several other conditions, such as asthma, cellulitis, and high blood pressure. 

    The benefits of home care

    Both Brigham and Mount Sinai have seen success with their programs, Andrews reports.

    Research on Mount Sinai's program found that, for the two-year period ending in December 2016, the average length of stay for an acute care patient was 3.1 days at home, compared with 5.3 days in the hospital. Meanwhile, 30-day readmission rates were 7.8% for patients at home, compared with 16.3% for those in the hospital.

    Brigham's Levine led a study published earlier that compared the health care use, experience, and costs of hospital and home-care patients at Brigham Health in 2016. The study observed 20 patients that had a condition such as asthma chronic obstructive pulmonary disease, heart failure, or an infection and found that there were no adverse events for home-care patients and that the at-home patients' treatment costs were roughly half of patients treatment in the hospital.

    According to Andrews, one of the main reasons for the lower expense was the lower staffing demand at home compared with at the hospital. While the hospital has to be staffed all day and all night, that isn't the case at a patient's home. Home-care patients were also found to have fewer lab tests and total visits from specialists.

    Further, the study found that while both hospitalized and home-care patients were satisfied with their care at about equal rates, home-care patients were more physically active. "By moving people to their home we automatically are able to customize what they need and tailor it to them and that's part of the place where we see a lot of cost savings," said Levine.

    Separately, Bruce Leff, a professor of medicine and the director of Johns Hopkins Medical School's Center for Transformative Geriatric Research, also looked into the benefits of home care through patients at Veterans Affairs medical centers and Medicare Advantage plans. He found home-care patients had fewer complications, better outcomes, and lower costs. In addition, Leff also that caregivers reported being less stressed the home-care setup.

    However, Leff also noted logistical hurdles to home care. "It's still easier to get Chinese food delivered in New York City than to get oxygen delivered at home," he said.

    Finding funding

    Despite the benefits of home care, insurers are largely reluctant to buy into it, which can create funding hurdles, Andrews reports. Brigham can bill insurers for a house call from a physician, but the rest of the home care services are paid for by grants and funding from Partners HealthCare's Center for Population Health, according to Levine.

    According to Linda DeCherrie, the clinical director of the mobile acute care team at Mount Sinai, insurers are worried about where home care will ultimately end up. "[Insurers] don't want to be paying for an admission if this patient really wouldn't have been hospitalized in the first place," she said.

    Mount Sinai launched its program with a three-year from CMS' Center for Medicare & Medicaid Innovation and focused on Medicare patients. According to Andrews, the program has broadened its reach to encompass certain Medicaid beneficiaries and some patients with commercial insurance. The health system works with Contessa Health, a company with home care expertise, to negotiate contracts with insurers for hospital-at-home services, Andrews reports.

    Separately, Cathryn Donaldson, a spokesperson for America's Health Insurance Plans, said insurers have no position on home care. She added that "there are Medicare Advantage plans that do cover this type of at-home care," she said (Andrews, "Shots," NPR, 3/7; LaPook, CBS News, 2/7).

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