In an effort to reduce costs and provide higher quality of care, some hospitals are giving patients the option to receive hospital-level treatment from inside their homes rather than admit them as patients in inpatient units, Daniela Lamas reports for the New York Times' "Well" blog.
While some patients need "moment-to-moment" care, many do not and risk exposure to further harm—like hospital-acquired conditions, delirium, and deconditioning—if they are admitted to the hospital. Johns Hopkins physician Bruce Leff says, "Being in the hospital could be toxic."
So, Leff and his colleagues determined four diagnoses that could be treated from within a patient's home:
- Heart failure;
- Cellulitis, a bacterial skin infection;
- Emphysema, and
- Some types of pneumonia.
"I'm a doctor. I can talk to a patient, I can examine a patient, I can bring home oxygen and IV meds and fluids, I can do home X-rays. I can do quite a bit," says Leff, adding, "We felt that it could be done, and the hypothesis was that by doing so, we could reduce harm."
Early lessons from the first 'hospitals at home'
With a grant from the John A. Hartford Foundation, Leff and his team began a trial run, bringing hospital-level care to nearly 150 patients' homes who would have typically received treatment at one of three nearby hospitals. The program, called Hospital at Home, found that patients who opted to forgo care at a hospital facility were hospitalized for shorter periods of time and their treatments were less costly. The doctors published their findings in the Annals of Internal Medicine.
Ana Vanessa Fernandez, the daughter of hospital-at-home patient Martin Fernandez, says, "Hospitals help you, but there's so much noise that you can't sleep and you're lonely." But with Hospitals at Home, she adds, "there was no timing for visitors. There was no curfew. It's like being at home, but the hospital is home with you."
Albuquerque, New Mexico-based Presbyterian Healthcare Services began offering hospital-at-home services in 2008. Since then, the program has grown into a huge success, officials say. Melanie Van Amsterdam, the program's lead physician, says, "The hospital system is one where you get more information from the computer than you do from your own ears, eyes and nose," but in this program "I rely far more on my physical exam skills to take care of these patients." She adds, "You get a lot more comfortable with uncertainty, I think."
She acknowledges that issues can arise that require patients to be moved to the hospital for worsening medical issues, sometimes by calling an ambulance. But that only happens for about 2.5% of patients in the program.
Observers still skeptical, new pilot program in the works
Some observers remain skeptical of the idea. "I think in order to make this work in a way that makes clinical and ethical sense, you really have to be careful about evaluating your patients on the front end," says Bruce Vladeck, a health care consultant and former administrator of the Health Care Financing Administration. "And you have to be prepared to change your mind," he adds.
Vladeck serves on the advisory committee to a Mount Sinai Health System program known as "mobile acute care," which is funded by a $10 million grant from CMS.
That program will not allow individuals with irregular vital—like high heart rate or low blood pressure—or those whose homes lack running water or electricity to receive care from home. Eligible patients will be required to have 24-hour physician and nurse coverage and an agreement with emergency providers in case they need to be transported.
After eligible patients are "discharged" from their home hospital stay, they will be monitored for one month and their outcomes will be documented. The Mount Sinai team then will work with Leff and his team at Johns Hopkins to compare the hospital-at-home group with comparable patients who were hospitalized for their conditions.
Linda DeCherrie, an associate professor of geriatrics and palliative care medicine at Mount Sinai and clinical director of the new hospital at home program, says, "I am very confident that we're going to be able to show that patients want to be home, that we can do this safely, and that we can do this with savings."
Leff adds, "My sense is that over time, hospitals will become places that you go only to get really specialized, really high-tech care."
Payers are still figuring out how programs like this will be reimbursed, as there are no existing payment systems to reimburse such care (Lamas, "Well," New York Times, 4/27).
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