Hospital-at-Home Models, Home Health Partners Primed to Disrupt US Health Care System

With a shared goal of shifting more care into the home and improving patient health outcomes at a lower overall cost, hospital-at-home programs and at-home care providers are natural allies. But there are a number of hurdles that stand in the way of partnership opportunities truly taking off.

Broadly, hospital-at-home programs attempt to provide acute, hospital-level care in the home in lieu of an expensive, potentially dangerous hospital admission. To do so, programs try to identify eligible patients whose medical conditions can be cared for in the home setting through coordinated nursing and clinician visits, plus necessary testing and treatment.

Although hospital-at-home models aren’t as common in the U.S. as they are abroad, multiple noteworthy programs have emerged over the past 10 years. They include programs at Mount Sinai, Johns Hopkins and Marshfield Clinic Health System, which teamed up with PE-backed Contessa back in 2016.

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Existing programs have been so successful and well-tested, experts say, that they would otherwise be considered a “blockbuster drug” in pharmaceutical terms.

“[Studies have shown that] at six months after treatment, 50 people treated in hospital at home, one more [patient] is alive than they would have been if they had all been treated in the hospital,” Dr. Bruce Leff, a professor of medicine at the Johns Hopkins University School of Medicine, said while speaking at the 2019 Home Health Care News Summit in Chicago last month. “You think about the drugs that now command six-figure prices, [some] don’t come anywhere close to that.”

Furthermore, hospital-at-home care has been shown to achieve shorter average lengths of stay compared to traditional in-patient care, at 3.2 days compared to 5.5 days, respectively. Additionally, hospital-at-home models have also been found to have substantially lower rates of hospital readmissions and lower rates of emergency department visits, according to researchers at the Icahn School of Medicine at Mount Sinai.

“Once you have the ability to do acute care at home, you can start to do a whole lot of things at home and basically put the rest of the health system out of business,” Dr. Leff said. “The ability to disrupt the system with this model is vast.”

Specifically, skilled nursing, oncology care and follow-up care after certain surgical procedures can take place in the home, according to Dr. Leff.

But for all that to happen, at-home care providers will need to serve as the “boots on the ground.”

Hospital-at-home roadblocks

Although it has been around for a long time and is more popular in other parts of the world, the hospital-at-home model has not fully caught on in the United States. That’s partly due to reimbursement barriers.

Currently, there is no mechanism in fee-for-service Medicare to pay for the hospital-at-home model. However, the Center for Medicare and Medicaid Innovation (CMMI) has begun having conversations with the Physician-Focused Payment Model Technical Advisory Committee (PTAC) about future payment streams.

PTAC was established by the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015.

“Those conversations are going on,” Dr. Leff said. “I think there is interest from CMMI to at least understand the [hospital-at-home] model. I don’t know if and when CMS will come through with a payment model on that, but there is more interest now than before.”

Aside from reimbursement challenges, hospital-at-home programs often face supply chain roadblocks. There’s likewise widespread pushback from a health care industry that is historically resistant to change.

“We have to have the buy-in of all of the leadership,” Travis Messina, co-founder and CEO of Contessa, said at the HHCN Summit. “The one thing I don’t like about health care is that it takes everyone to approve [an idea] — and one to kill it. We have seen instances where 15 people have said, ‘This is an amazing idea. We need to move forward,’ and then one person says ‘nope,’ and that kills it.”

Despite the numerous challenges in the space, hospital-at-home startup Contessa has been able to make its mark within the industry, proving that the model can be profitable.

Founded in 2015, Nashville, Tennessee-based Contessa partners with health systems and health plans through its home recovery care model, which is designed to provide hospital-degree care in the home at a more efficient cost. With about 100 employees as of May, Contessa is one of the largest hospital-at-home programs around.

Covered by some Medicare Advantage (MA) plans, Contessa’s home recovery model revolves around a doctor-driven care plan. That plan is then carried out through in-home visits by an acute-care nurse along with virtual in-home physician visits, both of which are paired with access to a 24/7 recovery care coordinator.

Other keys parts of the company’s model include medication education and the delivery of other medical care at home such as IVs and wound care.

Because of reimbursement barriers in fee-for-service Medicare, MA has grown into an area of focus for Contessa, according to Messina.

“We focused pretty extensively on the Medicare Advantage health plans because we knew that they had the decision as to whether or not we are reimbursed for a program,” he said. “If you pick markets where there is high density in relation to MA enrollment, you could treat a credible number of patients, which could support a scalable model.”

As part of its appeal, Contessa’s home recovery care model has been shown to drive better health outcomes for patients. In its partnership with Marshfield, for example, Contessa achieved an almost 40% reduction in hospital readmission rates and a 92% enrollment rate, the New England Journal of Medicine previously reported.

In addition to Marshfield, Contessa works with CommonSpirit, Mount Sinai and Ascension Saint Thomas. The company also has two joint ventures in the works, according to Messina.

How home health fits in

Payment momentum and impressive health outcomes give companies like Contessa an edge moving forward, but home health companies also stand to gain as hospital-at-home programs continue to emerge.

Specifically, traditional at-home care providers are often the boots on the ground, so to speak, that makes the concept of hospital-at-home feasible.

“We feel like there is a huge synergy there,” Rebekah Couper-Noles, chief nursing officer of community-based care at Intermountain Healthcare, said at the HHCN Summit. “I don’t feel like you can have effective hospital-at-home if you don’t have the network of home health services to complement it.”

Salt Lake City-based not-for-profit Intermountain is the largest health care provider in the Intermountain West region.

When looking for partnerships, hospital-at-home programs could seek out home health providers for staff support for services they do not already have in place, which has been the case for Contessa.

“We partner with home health because they have licensure to send nurses into the home to do a skilled visit,” Messina said. “We have three external parties that are home health partners, and we work closely with them, train them on the model and hold them accountable for health outcomes.”

Above all, hospital-at-home models value home health partners that can deliver on logistics and can adapt quickly, according to Dr. Leff.

“This is not your uncle’s skilled home health care,” he said. “When someone’s coming from the emergency room, you have to get oxygen into the home within an hour, you need to get nurses into the home quickly.”

Presumably, non-medical home care providers also can play important roles in hospital-at-home models, especially as health care providers better begin to understand the connection between social determinants of health and staying out of the hospital.

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