Get Set for the Modern House Call
A new healthcare program, Hospital at Home, is being tested at Mount Sinai and hospitals around the US, with the aim of reducing costs and the negatives which can accompany hospital admission. Developed by Bruce Leff, director of the Center for Transformative Geriatric Research at Johns Hopkins University School of Medicine, the "modern house call" uses enabling technologies such as videoconferencing and sensors to monitor vitals and blood pressure, with data fed back to physicians. Caregivers can also monitor other factors such as patient housing, family situation and socio-economic status. Hospital at Home is one of several programs which have helped save almost $30m in recent years, and although it is popular with patients, the fee-for-service reimbursement system remains an obstacle.
When Tiana Thomas went to the Mount Sinai emergency room last winter with an infection in her transplanted right kidney, she expected to be admitted to the Manhattan hospital for a round of high-potency intravenous antibiotics. But she was worried. “The guy next to me in the ER was hacking like he had the flu,” says Thomas, 30, a resident and community services manager for the Workforce Housing Group in New York. And she feared being exposed to far more menacing threats on the hospital ward. The immunosuppressant medication she takes to keep her body from rejecting the organ makes her vulnerable to infection.

To her relief, Thomas was sent back to her apartment. Over the next 10 days, while she prepared her own meals and worked from home, nurses dropped by to administer the antibiotic infusion and check her vital signs, and a doctor visited via video. She was “discharged” having never left home. “No one should be in the hospital who doesn’t have to be,” she says.

That’s the underlying philosophy of Hospital at Home, a novel health delivery model that is being tested at Mount Sinai and hospitals around the country. Conceived by Bruce Leff, director of the Center for Transformative Geriatric Research at Johns Hopkins University School of Medicine, the program aims to reduce costs while avoiding the discomforts, falls, infections, deconditioning and delirium that often accompany a hospital stay, particularly among older adults. “The hospital can be a very difficult and dangerous environment for old and frail people,” Leff says. “One of the most challenging decisions we make is whether to send a patient to the hospital when there’s a significant likelihood that they will suffer” from being there.

A multitude of enabling technologies – such as videoconferencing and sensors that feed data on blood oxygen levels, blood pressure and other vitals back to providers – will over time make these modern-day house calls even more attractive. New penalties for hospital readmissions will help, too. The setup benefits both older patients needing care for chronic conditions and younger ones getting post-surgery rehab.

A similar pilot program called Independence at Home allows Medicare patients to get their primary care in house calls; participants include Boston Medical Center, Virginia Commonwealth University Medical Center in Richmond, and the University of Pennsylvania Health System. Bringing the doctor or nurse practitioner to the patient allows better management of complex issues, experts say, and can head off hospital care or a move to the nursing home. A plus of both programs is that providers get a window into patients’ lives and factors like housing, family situation and socio-economic status, all of which affect well-being.

Although some patients need the monitoring that only a hospital can provide, research shows that patients with certain conditions – heart failure, some types of pneumonia, flare-ups of chronic obstructive pulmonary disease, and stubborn bacterial skin infections known as cellulitis – do as well or even better outside the hospital than patients inside. Hospital at Home patients cost less to treat and recover more quickly. Moreover, in the familiar environs of home, they are less likely to experience disorientation and delirium, Leff says.

And patients are sold. “Ninety-five percent of eligible patients pick the option,” says Karrie Decker, administrator of Presbyterian Healthcare at Home, a program of Presbyterian Healthcare Service in Albuquerque, New Mexico, that launched 11 years ago. Over the past 10 years, Presbyterian has avoided 2,000 admissions and saved over $4 million thanks to the hospital at home program. A recent Centers for Medicare and Medicaid Services study found that the Independence at Home service saved over $25 million at the 17 sites where it was being tried in 2015.

The Veterans Health Administration has seen similarly positive outcomes with its 15-year-old Hospital at Home Program, says David J. Shulkin, the VA’s undersecretary for health. And other perks have emerged. Hospital at Home proved particularly useful in New Orleans after Hurricane Katrina closed the VA hospital, says Kenneth Shay, director of the Veterans Health Administration’s geriatrics programs, who helped implement the program at a handful of VA hospitals. And home-based care lends itself to patients with spinal cord injuries, the focus of the program in Tampa, since wound care and complications like urinary tract infections and pneumonia can often be easily treated at home.