Some big thinkers believe that the heart of the U.S. health care system is shifting away from hospitals and other institutional settings, into people’s homes. Those who need proof that this occurring may find some in New York City, where Mount Sinai Health Network is in the vanguard of providing hospital-level care for patients at home.
Hospital at Home has been a concept at least since the 1980s, when it was pioneered at Johns Hopkins University School of Medicine in Baltimore. It has been slow to gain momentum, in part because Medicare does not have a system to reimburse this type of care.
However, the Centers for Medicare & Medicaid Services (CMS) has been testing many alternative payment methods since passage of the Affordable Care Act in 2010, with the goal of reducing costs while improving outcomes. Through these experimental payment models, hospital at home programs have been able to gain a foothold in some areas. In 2014, the agency awarded nearly $10 million to the Icahn School of Medicine at Mount Sinai to launch its Mobile Acute Care Team services.
Under this three-year project, certain patients who arrive at Mount Sinai emergency departments are given the option to be technically admitted to the hospital but receive their care at home, through visits from specially trained doctors and other clinicians. Equipment such as IVs and X-ray machines can be brought into the home as well.
With the project now entering its last year under the CMS grant, Mount Sinai Health Network President Arthur Klein, M.D., spoke with Home Health Care News about the commitment to serve more patients at home, the “re-engineered hospital” of the future, and the opportunity for home health providers.
HHCN: What patients qualify for hospital-level care at home, and how many have participated?
Klein: At Sinai, we have a project to look at our capabilities to provide safe care at home for a group of patients who would otherwise be hospitalized, under the medical supervision of our Department of Geriatrics’ Visiting Doctor program, one of the oldest and largest in the country.
In the hospital at home program, we have a group of patients who show up at our ER, who have a relatively low-acuity diagnosis that otherwise would have mandated their admission to the hospital. Cellulitis, CHF [congestive heart failure] tune-up, rehydration, et cetera.
When these patients are evaluated in our ER and our doctors deem them worthy of admission, they’re offered the opportunity to be treated at home. That means they get prescribed a number of doctor visits, nurse visits, all the medical devices they may need—IV fluids, poles, pulse oximeter, and so on—and they go home.
We have treated over 150 patients in this program.
HHCN: What feedback have you gotten from these patients?
Klein: Assuming they get good and safe care at home, it’s not destabilizing, they don’t become disoriented [as they might] at the hospital. They’re home with family, with pets. We’re seeing that patient satisfaction is excellent.
What happens to an elderly patient in the hospital, you can’t predict. Even if it’s a relatively low-acuity condition, they can fall, they’re in an unfamiliar environment. They can become depressed. They can become agitated.
HHCN: Are you seeing good clinical outcomes as well?
Klein: [We’ve recorded] no increase in morbidity, mortality, and overall, it’s more cost-effective than getting admitted to the hospital.
HHCN: It seems to make sense to treat more patients at home, but do you think hospitals are possessive of their patients? Might it change their revenue model if more care moves into the home setting?
Klein: I think it’s just a truism that we can’t afford health care delivery as it is now. Progressive providers don’t want to put their head in the sand.
We’re saying that a re-engineered hospital should deal with the sickest. Otherwise, commit to good outcomes in the most cost-effective manner possible. Will hospital revenues change? Sure. But I think hospitals already have experienced a tremendous change from inpatient to outpatient [services]. This is a continuation along that trend.
There is certainly a role for inpatient subacute rehab. There’s no question there are some patients who really need it. On the other hand, there are clearly patients who are in relatively good condition who could go directly from a surgical procedure to being treated at home. As in all things in medicine, there’s a spectrum. Our desire is to pick the right points on the spectrum where people could be treated at home versus in an institutional setting. A lot depends on the home environment, [considerations such as] are there stairs? There’s no cut-and-dried answer.
Having said that, as you know, in orthopedic and increasingly in cardiac cases, the federal government is looking at bundled payments, payments for episodes of care, and that includes a rehab component.
And we will be anxiously waiting for the federal government and private insurers to take this [hospital at home model] to a commercially viable way to deliver health care, from being a pilot.
HHCN: What’s the role or opportunity for home health or personal care agencies if this hospital-at-home trend gains more steam?
Klein: Our challenge is to make this scalable. In my estimation, to make it scalable, [you’re] going to have to reach out and have new partnerships. When testing the validity [of the model], you want to keep the provider network very controlled to get good data and feedback, but once you’ve established that, think about scalability. Obviously you need partners to do this.
HHCN: Even if these are low-acuity patients from the hospital’s standpoint, they’re still sick enough to be considered hospital inpatients. So what do home health providers need in order to be good partners?
Klein: From our vantage point, one of the things we want to do is make sure they’re appropriately resourced. The first part is help them in their recruitment needs for skilled nursing [clinicians], medical directors. That’s a crucial part of it. We want to help them recruit and get the committed and quality people we need.
HHCN: What about hospitals running their own home health companies, or acquiring one, versus partnering up with providers in the space?
Klein: I think hospitals needs to be very careful about what their sweet spot is, in terms of effective management. The verticalization of the industry often can’t be achieved by the skillsets that currently exist within the hospital system. I and many of my colleagues are supportive of partnership rather than ownership and acquisition.
If you’re an academic health system, as we are, tremendously interested in keeping your labs viable, with genomic medicine investments, the question you ask yourself is, do I diversify and also start running a home health agency or insurance company? You’ll find different answers across the spectrum, but we can’t be everything to everyone.
Written by Tim Mullaney