Is Hospital-at-Home Right for You?
Thinking critically about the pros and cons of this approach is vital for both caregivers and patients
A couple of months before my father died, he fell. While no bones were broken, the fall catalyzed a series of events that included hospitalization, a blood transfusion and permanent damage to his right leg.
One day he could walk, albeit slowly and not quite steadily. A week later, the doctor told us it was unlikely my father would ever walk again. Less than an hour after that world-shattering news, a hospital social worker told us they were ready to discharge Dad back home. They just needed to confirm the address to have a hospital bed delivered.
This incident was one of several sudden "we're ready to send them home now" experiences I had while caregiving for my parents.
Unless we thought he'd want the ability to get out of bed. In that case, we'd need a Hoyer lift and probably a Brody chair. We should find a caregiver, she said. Full-time, she recommended. Could we be ready the day after tomorrow?
Could we, in two days, convert my father's bedroom into a hospital room, complete with a full-time caregiver to manage the new equipment and care routines, while I also worked a full-time job? In a word, no.
This incident was one of several sudden "we're ready to send them home now" experiences I had while caregiving for my parents. These events' fear, anger and stress feel as real today as when they happened.
So, please forgive me if I'm a little nervous as I watch the popularity of hospital-at-home programs explode.
The Growth of Hospital-at-Home Programs
These programs provide hospital-level care in a patient's home as a substitute for acute hospital care. While the model has existed for decades, the number of CMS-approved hospitals (Centers for Medicare and Medicaid Services) offering this kind of care has increased by 118% since April 2021.
The rapid expansion is driven in part by the success of the programs. For example, some studies indicate that caring for certain patients outside the hospital improves health outcomes and patient satisfaction while reducing the cost of care by as much as 38%.
These programs also help hospitals manage capacity, which became especially important during the public health emergency. In 2020, the urgent need to manage acute care capacity in hospitals led CMS to suspend the requirement for nursing services to be provided on-premises.
This removed one of the primary barriers to the widespread adoption of the model: it allowed hospitals to be reimbursed for acute-level care beyond their walls.
The Upside of Hospital-at-Home
It's not hard to see why hospitals are interested in this type of program: they can serve more patients, unrestricted by the number of beds in their facility. They allow hospitals to serve lower-acuity patients at home and higher-acuity patients in the hospital. The economics are attractive.
It's also easy to understand why many patients want to be treated at home. For instance, the hospital isn't always the safest place to treat immunocompromised patients. In addition, many patients are more comfortable at home, and surveys indicate they feel less stress in this setting.
Caregivers Fill the Gaps
This is all great. But if we want to provide hospital-level care for patients at home, we need to create a system that measures and values patient satisfaction and the family care experience. Is anyone measuring the impact of this approach on family caregivers?
Is anyone measuring the impact of this approach on family caregivers?
My father, just trying to survive, wasn't thinking about how hard it would be to support him at home. I don't fault him for that. Instead, I criticize the legislation, regulation and payment policies underpinning the social worker's push to send him home before we even understood what that would entail.
My father would probably not have been qualified for a hospital-at-home program had his hospital offered one at the time. He was "medically stable" – though physically disabled – at discharge. But his case highlighted the extent to which the health care system relies on "someone" to fill in the gaps at home.
Asking the Right Questions
I wonder if health care teams are asking the right questions – or the right people – before qualifying patients for these programs. Who will answer the door when the equipment and supplies arrive? Perhaps more importantly, do they have the physical strength to move the furniture or reorganize the closets to make space for it all?
Even when providers do their best to ensure patients are appropriately qualified, it may be hard for patients and their caregivers to know what to ask to determine if hospital-at-home is a fit for them.
Here are some things to consider if you're asked to participate in a hospital-at-home program rather than receive care at a hospital:
● Equipment and Supplies: Understand the space and storage requirements of any equipment and supplies required to manage care at home. Will items be delivered in bulk? How often?
I wonder if health care teams are asking the right questions – or the right people – before qualifying patients for these programs.
● In-Home Visits: Who delivers care in the home? Do nurses or doctors visit in person, or does an affiliated third party provide home care?
● Care Coordination: Who is responsible for coordinating care? Who is responsible for monitoring patients day-to-day?
● Caregiver Support: What care tasks would not be provided by professionals as part of the program? Ask about training. And if no family is available to help with these tasks, consider whether you will be able to find a private caregiver to support you.
● Technology: Are you comfortable using any technology the program requires? If remote monitoring is used, who is responsible for overseeing patient data?
● Emergencies: What happens when your condition changes? Is there a rapid-response team available to manage emergent issues?
● Emotional Impact: How will you feel about merging the clinical and home environments? Do you need a clear separation between your home and where you receive care, or do the benefits outweigh this consideration?
The rhetoric around hospital-at-home programs is overwhelmingly positive, and that may well be justified. But that doesn't mean it's the right choice for all of us or our families.
Only when we think critically about the pros and cons of this approach can we partner with our providers to make informed decisions about the best place to receive our care.