In 1994, the state of Victoria, Australia, began piloting a model to treat a subset of would-be-inpatients at home through daily physician touch points, remote monitoring technology, and clinical support staff performing home visits to administer drugs, conduct tests, and monitor vital signs. The following year, geriatricians at the Johns Hopkins School of Medicine began a three-year, 17-patient pilot of their own similar model and found that it improved cost, readmissions, and patient experience. Later analyses, including a 2009 study on the Victorian model and a 2012 meta-analysis of 61 randomized control trials across five continents, found similar outcomes: hospital-at-home leads to statistically significant reductions in mortality, readmission rates and costs, and increases in patient experience, compared with inpatient counterparts.
Fast-forward over 25 years. Despite this data, going into 2020 hospital-at-home was gaining traction but was not predominant by any means. Take Australia, a global leader—by 2018 the country's public sector hospital-in-the-home programs saw about 595,000 bed-days, or 5% of overall public acute bed-days. And the private system's model was closer to a 1% share of all private hospital bed-days. But these numbers far outpace uptake in a majority of other countries, where hospital-at-home has remained in "pilot phase" even after two decades of global experience.
The 'Hospital-at-home revolution': A confluence of Covid-19, technological innovation, cost pressures, and consumer insight
Several factors limited uptake over the years, including reimbursement models that favor inpatient care, difficult cultural shifts required to triage acute patients away from the hospital, a lagging digital infrastructure to support home care, and limited patient eligibility for most programs.
But all of this changed in 2020. Elective procedures and in-person care were limited to minimize the risk of patients and staff contracting Covid-19, and virtual alternatives became the default. There was a rise in patient complexity after that care restarted. Virtual care and remote monitoring start-ups had their time to shine, and they collected more proof-of-concept data in one year than was otherwise conceivable. Leaders had to rapidly adapt to a virtual-first model. The conversation about shifting from volume to value became more common. Patients realized that most things in their lives could now be done virtually, and that there's no reason health care should be different. And of course, adoption of hospital-at-home models skyrocketed.
- In Canada, British Columbia announced a $42M hospital-at-home program last November.
- In Israel, Sheba Medical Center and start-up partners scaled up remoted monitoring solutions to care for Covid-positive patients coming off the Diamond Princess cruise ship.
- In Europe, where hospital-at-home models have been around for years, Covid helped spur further progress. For example, Hôpitaux de Paris saw a 20% increase in their hospital-at-home enrollment in just three weeks.
- In Australia, private providers are forming new-in-kind partnerships to launch direct-to-consumer models for their patients.
- In the UK, West Hertforshire Hospitals Trust launched a virtual Covid-19 hospital that saw almost 400 patients in its first 21 days of operation.
- The U.S. government announced it would begin reimbursing hospitals for hospital-at-home care, and 116 health systems have since entered into hospital-at-home contracts.
The risks of hospital-at-home becoming "just the next hospital”
With this buzz comes the risk of providers rushing to implement models that lack critical elements. I've had multiple conversations about hospital-at-home with executives over the last month and one cautionary tale continues to arise: "acute care bias”. The idea is that if an acute provider launches a program that offers the same hospital care, provided by the same hospital staff, in someone's house, then clinicians will operate with an inpatient mindset, costs will remain high, and patients will have a poorer experience (considering they see hospital-at-home as home care and NOT as hospital care).
One interviewee put it candidly: "It's so easy to think of hospital-at-home as 'hospital 2.0.' But it's not. And thinking that way will trap these models with the same problems hospitals themselves have struggled with for years—an emphasis on over-treatment, too expensive, and a hospital-first culture."
Fortunately, the global leaders I've spoken with have shared a few key principles to keep in mind to avoid this pitfall.
- Embrace the partnership option. Increasingly, hospitals are choosing to not be the lead provider of their hospital-at-home arrangements, and instead serve as the convener or funder for them. These providers start with the premise that hospital-at-home is a unique care model, and work backwards to decide who is best suited to deliver that care. Since it's not in-hospital care, non-hospital providers are often the answer. This is why emerging enablement partners like Contessa, Datos, Remedy, and Huma are growing in popularity in the global hospital-at-home race.
- Overinvest in cultural and behavioral change. History tells us that scaling a hospital-at-home model is often a change management problem. Providers need to be okay with turning away acute patients and telling them to go back home—the opposite of their core competency. Interviewees told us that if inpatient staff are expected to spend a small amount of their hours staffing a hospital-at-home program, they risk treating the home visits as inpatient rounding. These providers prioritize educating and nudging hospital-at-home staff to use a patient-first lens instead of a hospital-first one when delivering this care.
- Take care to prevent exacerbating inequities. What happens when a person is an ideal hospital-at-home candidate, but their home is not suitable for receiving care or they have unstable housing? Those patients are generally admitted to the inpatient setting which, according to decades of studies, has poorer health outcomes than hospital-at-home models. We heard in calls that leaders are exploring congregate, intermediary remote monitoring settings in the community where these patients could go to access to the same benefits that other hospital-at-home patients can receive.
Have a hospital-at-home model you want to share with us?
We will be spending the next several months scanning the globe for what makes a good hospital-at-home model and finding what best practice truly looks like. If you have questions or your own model you would like to share, please email me directly at TrigonoP@advisory.com.