Has the Time Come for Hospital at Home?
How patients with certain conditions get care in the comfort of their home
Herbert Prahl, a 73-year-old retired Lutheran pastor, was recently admitted to the Mayo Clinic hospital in Eau Claire, Wisc., for an infection of his vertebral spine. He underwent surgery so his doctors could take bone samples and determine what kind of bacteria were causing the infection. Afterwards, he was placed on powerful IV antibiotics.
Once Prahl was stabilized, he normally would have been transferred to a rehabilitation facility to continue receiving the antibiotics. But his doctors were making this decision on a Thursday, and there was no possibility of Prahl being placed in one over the weekend. So he was facing four additional nights in the hospital, followed by a transfer to an institution that was 40 miles from his home.
Then Prahl's nurses told him about an alternative: The Mayo Clinic was conducting a pilot of a new acute-care model, in which he could receive hospital-level treatment at home. Was he interested in going home to his wife right away? He was.
"With this technology, we can essentially be at the patient's bedside twenty-four hours a day, seven days a week."
Under Mayo's "hospital at home" (HaH) model, which it's implementing with the help of a Boston company called Medically Home, patients who have certain medical conditions and meet other criteria can be admitted to HaH either from a hospital, an emergency department or a primary care clinic. A portion of their house is converted into a hospital room, complete with a hospital bed, an IV stand, telemonitoring equipment and an audiovisual conferencing setup. Mobile x-ray and lab tests can also be performed at home.
A nurse visited Prahl three times a day at home for antibiotic administration. Otherwise, Prahl was cared for remotely by Mayo clinicians in a command center in Jacksonville, Fla., where the health system is conducting another pilot of hospital at home. Prahl could reach these doctors and nurses 24/7, and they could check in on him whenever they thought it necessary.
The Comfort of Your Own Home
Prahl felt he had better access to care at home than he would have had in the hospital. "The hospital is a busy place, and you had to wait for your doctor to make rounds. At home, they made sure I was taken care of, and the treatment was very adequate," he noted.
While he continued to receive antibiotic treatment, Prahl entered the rehab or "transitional" phase of his hospital-at-home stay, during which he was assisted by a physical therapist who came to his house. The retired minister was in the hospital at home for a total of 30 days.
Overall, Prahl said, the "human contact and the ability to be at home and not in a rehab facility was the best thing for me. I'd definitely recommend it to someone with the appropriate need."
What the Hospital at Home Studies Show
Hospital at home isn't new, and the Mayo Clinic isn't the only health care player experimenting with it.
Johns Hopkins University has had a hospital at home program since 1994, and its model has been implemented in several VA medical centers, as well as in Presbyterian Healthcare System in Albuquerque, N.M. Hospital at home programs are well established in other countries such as Australia, Canada, England and Israel.
The Johns Hopkins model includes daily home visits by physicians and nurses. In place of most of these visits, a newer HaH model relies on telemedicine and remote monitoring to connect clinicians and patients. Mayo is pursuing the modern approach, along with Tufts Medical Center in Boston and Adventist Health Partners in southern California, among others.
Health care systems are exploring hospital at home, partly because of the coronavirus pandemic.
Most studies of hospital at home have evaluated the Johns Hopkins model. Nevertheless, Dr. Bruce Leff, professor of medicine at Johns Hopkins School of Medicine, who has led many of these studies and also consults for MedicallyHome, said he believes that their results are largely applicable to the telemedicine approach as well.
The studies show that hospital at home is generally accepted by patients, improves the experience of patients and their caregivers, offers quality of care comparable to that of usual care in the hospital, shortens the acute-care length of stay, improves functional outcomes, has better or equivalent disease outcomes and lowers costs. Patients at home are less likely to experience delirium than in the hospital and tend to get more exercise than inpatients do. There is some evidence of fewer health complications and readmissions among HaH patients.
One review paper on hospital at home studies showed a 38% reduction in mortality for HaH compared to usual hospital care. Leff said while this is a credible finding, other studies, including his own, have not found a lower mortality rate in hospital at home patients.
In 2011, researchers at Advocate Health Care in Chicago did a study of a hospital at home program that let physicians communicate virtually with patients and monitor their vital signs remotely. The patients had either chronic obstructive pulmonary disease (COPD), congestive heart failure, deep vein thrombosis, asthma or community-acquired pneumonia. (Mayo also admits patients with urinary tract infections and cellulitis to its HaH.)
The HaH patients had a significantly lower number of readmissions at 90 days after discharge than the control group. During the post-acute phase of their care, they were more likely than the control patients to be cared for at home rather than in a rehab facility. Overall, their outcomes were comparable to those in the usual care group, and their satisfaction with care was significantly higher.
While this trial did not look at costs, some studies of the Johns Hopkins model have found the average cost of caring for hospitalized patients was nearly $2,000 less when they were cared for at home. The savings to patients may depend on their insurance or lack thereof, as well as their medical situation and the hospital that admitted them. With technology greatly reducing the number of clinician home visits, the telemedicine approach should lower costs even further, making it possible to scale up the HaH approach to a larger population.
Little Insurance Coverage
In the United States, the biggest barrier to hospital at home has been a lack of health insurance coverage. Traditional Medicare and most private health plans don't cover it, although Leff says a growing number of health insurers are getting interested.
Several health plans are supporting the Mayo Clinic pilot in Eau Claire, said Dr. Margaret Paulson, chief clinical officer for advanced care at home at the Mayo Clinic Health System, Northwest Wisconsin Region.
Other health care systems are also exploring hospital at home, partly because of the coronavirus pandemic.
Tufts Medical Center, for example, has used its HaH program to increase the "surge capacity" of its hospital wards to handle new COVID-19 patients by reducing its inpatient census. Both Tufts and Mayo Clinic, however, view hospital at home as an integral part of their clinical strategy going forward.
The lack of high-speed internet in some areas can be a challenge for the technology-dependent hospital at home model, however.
MedicallyHome says it can use a cellular phone network to connect patients at home with its medical command centers. But Paulson notes that in rural areas without high-speed Internet service, cellular networks are often poor or nonexistent.
Despite this problem, Mayo's hospital at home project has been a revelation to her as a physician. "With this technology, we can essentially be at the patient's bedside twenty-four hours a day, seven days a week," she explained.
"When I'm in a brick and mortar hospital, rounding on a patient, I can't tell you the number of times they've said to me, 'Gosh, can you come back in an hour, my family's coming then," said Paulson. "With this type of model, we can be there twenty-four/seven. When the patient and the family have questions or concerns, they can just push a button, and we're there."