High-Quality Hospital Care – Minus the Hospital
John Halamka, M.D., president, Mayo Clinic Platform, and Paul Cerrato, senior research analyst and communications specialist, Mayo Clinic Platform, wrote this article.
In a time of COVID, the current care models just can’t remain in place. We need innovative ways to address the high cost of acute care. One solution that is taking a front seat is telemedicine. Telecare has accelerated from 3-4% of visits in January 2020 to 90% in April to a new normal of 20% in 2021. Cultural change has modified patient expectations for the care they can get at a distance, which can be more convenient, less likely to result in COVID exposure, and more patient-centric.
Research has demonstrated that hospital-at-home programs for patients with specific acute medical conditions can reduce complications and reduce the cost of care by 30% or more. One of the most progressive programs to focus on this transition was spearheaded by Johns Hopkins Hospital in 1994. Bruce Leff, MD, and his colleagues have tested this program with 455 elderly patients from three Medicare-managed systems and a VA medical center. They found that the home model met the quality of care standards comparable to those expected of in-hospital programs. Also, "On an intention-to-treat basis, patients treated in hospital-at-home had a shorter length of stay (3.2 vs. 4.9 days) (P =0.004), and there was some evidence that they also had fewer complications. The mean cost was lower for hospital-at-home care than for acute hospital care ($5081 vs. $7480) (P < 0.001).”
A meta-analysis of 61 randomized clinical trials that looked at hospital-at-home projects found that among 42 trials, which included almost 7,000 patients, this approach reduced mortality (odds ratio, 0.81). Similarly, they decreased readmission rates by 25% (odds ratio, 0.75) and lowered costs. The same analysis revealed that treating every 50 patients in such a program saved one life. Realizing the potential advantages of hospital-at-home programs, several large U.S. provider organizations have entered this space in the last few years, including Mayo Clinic, Partners Healthcare/Brigham and Women’s Hospital, and Mount Sinai Health System in New York. Across the globe, there are also significant programs in Australia, South Wales, and Spain.
Advanced Care at Home, a partnership between Mayo Clinic and Medically Home., tracks heart rate, blood pressure, pulse oximetry, temperature, and respiratory rate in its patient population, using Bluetooth-enabled devices wirelessly connected to the Mayo/Medically Home system. It also uses tablets, a back-up battery system and a Wi-Fi phone. There are, however, critical differences between many home-care programs and the Mayo Clinic system. Many hospital-at-home programs are targeted and designed for low-acuity hospital patients. They use physician house calls as the clinical delivery model. They have a short patient engagement period (2-4 days).
The Medically Home affiliated setup is designed to handle an extended length of stay that includes acute, post-acute and preventative care. It uses a scalable “decentralized” model for high-acuity care and can manage a broad set of diverse use cases and support an extensive patient census. The program uses screening, training, contracting, quality management, and technology and converts "post-acute" community-based supply providers into “acute-level” providers, bringing goods and services to high-acuity patients at home while focusing heavily on the role of paramedics as the centerpiece of its ability to provide “rapid-response” capabilities. In practical terms, that means paramedics and other providers go into the home while being virtually connected with a centralized medical command center staffed by physicians who guide the care for decentralized patients and the decentralized providers that care for them.
Advanced Care at Home has made measurable progress within a relatively short period, going from a speculative pilot project about a year ago to a business plan that will likely prove profitable in 2022. During a recent Zoom call with Ajani (AJ) Dunn, Administrator for the program, he emphasized, “It’s a story about volume. As we looked at the model, we asked ourselves: Will it be effective? And we found that by scaling it up to the point where we can take out the fixed cost of a traditional hospital stay and replace that with the small variable costs of each service we deliver in the home, we can have a sustainable program.” Dunn explained that by working through a centralized command center staffed by physicians and getting buy-in from third-party payors, this approach is slowly turning the corner financially. Since most insurers do not have a hospital at home plan built into their policy, that has required the Mayo team to negotiate with payors one by one, explaining the cost-effectiveness of the new model.
The next step in the program’s growth will require finding ways to reinvent the existing system. “The off-the-shelf system we use to administer Advanced Care at Home is well-calibrated for traditional medical admissions, including COPD, CHF, pneumonia and the like. That approach involves drawing labs, titrating medications, etc. But we need other ways to use the system. Our plan now is to embed teams into other disease states, including oncology, cardiovascular disease, and transplantation, to understand the natural progression of each disease and the necessary interventions. Then we can create clinical protocols and administrative logistics that replicate in-hospital care in the home, but customized for each disease state.”
Undoubtedly, concerns about high costs and unexpected complications will continue to dissuade patients from seeking in-hospital care for many years. But as this new model expands, it's likely more patients will see the advantages of seeking high-quality hospital care — minus the hospital.
1. Klein S. “Hospital at home” programs improve outcomes, lower costs but face resistance from providers and payers. The Commonwealth Fund. Accessed January 15, 2020. https://www.commonwealthfund.org/publications/newsletter-article/hospital-home-programs-improve-outcomes-lower-costs-face-resistance
2. Leff B, Burton L, Mader SL, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005;143:798–808.
3. Caplan GA, Sulaiman NS, Mangin DA, et al. A meta-analysis of “hospital in the home.” Med J Aust. 2012;197:512–519.
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