The future hospital looks a lot like home — and it already is in many places. Through the hospital-at-home model of care, eligible patients can receive hospital-level treatment for an acute illness or an exacerbation of a chronic condition in their own bedrooms or living rooms. “From the point of creature comforts, being at home is much better,” says William Terry of Chestnut Hill, Massachusetts, 86, who in 2016 went to the emergency room with severe shaking and chills. After chest X-rays, blood tests, an electrocardiogram and an overnight hospital stay failed to reveal what was wrong with him, Brigham Health physician David Michael Levine gave Terry the option to head home with an IV needle in his arm so he could be hooked up to a pump that would deliver regular doses of antibiotics there.
Eventually it was determined that Terry had cellulitis. For five days, a doctor or nurse came to check on him twice a day, and his vital signs were monitored remotely via electrodes placed on his chest. “You can eat what you feel like eating rather than what happens to be served that day, and you can rest or go to sleep when you want to, without anyone waking you up,” Terry says. He was so pleased with the care that he chose it again in 2019 when he required treatment for a different infection.
As was the case for Terry, the process usually begins in the emergency department, where patients are evaluated and receive a diagnosis and the first round of treatment. If eligible patients choose the hospital-at-home option, a nurse or doctor will visit regularly and perform necessary examinations, blood work and other tests and treatments. Meanwhile, a patient’s vital signs and physical movement patterns are monitored around the clock with wireless technology and transmitted to the hospital staff. If patients have questions or concerns, they can talk to a nurse or doctor at the hospital at any time via video.
This is not simply a visiting nurse service, as many people assume, says Linda DeCherrie, clinical director of the Mount Sinai Hospitalization at Home program in New York City, which clicked into a higher gear this past spring as a way to free up precious inpatient beds for people battling COVID-19. “We provide the equivalent of hospital care,” she says, for patients “who in the absence of our program would be admitted to the hospital.” Granted, not everyone is eligible. Each patient has to be assessed to ensure there’s no need for ICU-level care or other services only performed in the hospital.
For many years, the model has been used in Australia, New Zealand, the United Kingdom, Italy, France, Spain and Brazil. But it has been slower to catch on in the U.S. — until quite recently.
“Interest in the hospital-at-home model has been taking off,” says Bruce Leff, a geriatrician and professor of medicine at the Johns Hopkins University School of Medicine, who began exploring the concept in the mid-1990s. “The word is getting out, and people are starting to see it as part of the bigger solution for overcrowded hospitals, capacity issues, the cost of care, and improving patient outcomes.” The growing availability of sophisticated technology has been a driving force, too.
The early weeks of the coronavirus pandemic certainly underscored the concept’s potential. In March, Mount Sinai expanded the scope of its program by launching “Completing Hospitalization at Home,” which allows patients who have been admitted to the hospital for at least a night to transfer home and continue care. Similarly, at Atrius Health in Boston, there was strong and urgent interest in keeping patients not infected with COVID-19 “out of the hospital to protect their health and safety” as well as to reserve hospital beds for seriously ill patients requiring infection control, says Pippa Shulman, chief medical officer of Atrius’ Medically Home Group.
In April, Mount Sinai extended access even to COVID-19 patients “on the recovering trajectory,” DeCherrie explains. While these patients needed another two to three days of oxygen therapy, testing and vital sign monitoring, they were able to safely have these treatments at home. Other hospital systems escalated their collaboration with companies offering remote monitoring technology to keep a close eye on people with mild COVID-19 symptoms and those most likely to suffer complications from it.
A Few Obstacles
Among the roadblocks the movement continues to face: Even as advances make remote monitoring and treatment more doable, diagnostic procedures are an issue. Right now there are no capabilities for portable CT scans or MRIs, for example. And getting health insurance plans to cover home-based hospital-level care has been a slow process. “Medicare doesn’t recognize home as a place for [hospital] care,” says Shulman, although some Medicare Advantage plans do cover this type of care, as does the Department of Veterans Affairs; some private insurers are starting to follow suit.
As the pandemic has made clear, the concept makes sense on many levels, experts say; a hospital, for many people, is a risky place to be. In particular, Leff notes, it “is not a hospitable place for older adults, who often develop complications or get weak while they’re there.” There’s the troubling risk of acquiring an infection, and sleeping can be difficult, given the noise and frequent check-ins. At home, patients “have better health and functional outcomes,” Leff says. “Stress is lower, and the caregiver experience is better.” What’s more, when patients are in their own environment, “they are oriented to where they are and active in ways they can’t be in the hospital,” says Shulman. The risk of falls and injuries is thus lowered.
Various hospital-at-home programs treat different age groups, but so far most are reserved for the over-18 crowd. The illnesses treated range from pneumonia and chronic obstructive pulmonary disease to congestive heart failure and asthma.
When Peggy Kelly got bronchitis that caused a severe flare-up of her COPD early this winter, she received care through the Atrius program. “I would have been in the hospital for quite a while, but instead they brought all the equipment and medicines to me,” says Kelly, 90, a retired nurse in Quincy, Massachusetts. When she’d take her blood pressure in the morning, the results would get transmitted, and a nurse practitioner would call to tell her what dose of her blood pressure medications to take. If she felt anxious about her symptoms, Peggy could contact a nurse or doctor on her iPad at any time. “Being at home is less stressful,” she says. “I could maintain my independence at home and I got more focused care this way.” Within two weeks, her breathing improved dramatically.
At Brigham Health, Levine, a physician in the division of general internal medicine and primary care, has been the director of the Home Hospital program since 2016. Along the way, he has tested its effectiveness. In a randomized controlled trial involving 91 adults, published in January 2020 in the Annals of Internal Medicine, participants were provided with either the usual in-patient hospital care or acute care at home, including home visits from nurses and physicians, intravenous medications, remote monitoring, and video communication.
The results? “We stopped the trial early because it was so successful. The home-based care led to great cost savings, lower 30-day hospital readmission rates, and high patient experiences,” says Levine, who is also an assistant professor of medicine at Harvard Medical School and co-chair of the North American Hospital at Home Users Group. “We were only seeing good outcomes.”
In fact, the direct cost of acute care for home patients was 38% lower than for those who received the usual care. What’s more, the home patients were more physically active and spent less time lying down.
The Brigham study findings weren’t a fluke: A case-control study involving 507 participants, published in the August 2018 issue of JAMA Internal Medicine, found that compared to those receiving inpatient care, patients who received hospital-at-home care through Mount Sinai had shorter lengths of treatment. They also had lower rates of 30-day readmission, emergency department visits, and admissions to skilled nursing facilities — and the patients were more enthusiastic in their ratings.
“I think everyone benefits from this kind of program,” Levine says. “We’re seeing fewer adverse events, such as the wrong medications being given, hospital-acquired infections, and falls.” Patients experience a sense of normalcy and control, and benefit from having their loved ones with them. This brings with it a shift in the doctor-patient dynamic, because physicians are essentially guests, often when other family members are around — a change many patients appreciate. Also, “in the home we’re seeing what goes on,” DeCherrie notes. “We can help troubleshoot how a patient is going to take their meds at home and improve their mobility.” A 2012 study from Australia found that “hospital in the home” services led to a 19% decreased risk of mortality.
The possibilities are expanding. Rehabilitation can be done at home after a patient leaves the hospital, for example. A COPD patient who leaves Cleveland Clinic might be visited by a paramedic who facilitates a telemedicine visit, including a physical examination and aerosol therapy for breathing problems. As at Mount Sinai, early discharge programs continue the care of stabilized patients back home. And there’s tremendous interest in the oncology community in creating access for patients who’ve had bone marrow transplants. The idea is to “take people who are immunocompromised out of the petri dish of the hospital and allow them to recover at home,” Leff explains. Moreover, there’s the potential to use this approach with pediatric patients, who often have an intense fear of hospitals.
“Over time, I think hospitals will become ERs, ORs and ICUs,” Leff predicts. Shulman certainly hopes so: “I look forward to the day when this becomes the default option and allows hospitals to do what they do best — complex surgeries and care for the most critically ill patients.”
“I have comfort and security and can move around here,” says Teresa Lazo, 79, who lives with her nephew and his family in Brooklyn and received care there for congestive heart failure through Mount Sinai. “It makes me feel good to be at home.”
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