Brigham and Women’s Hospital in Boston was among the very first to secure an “Acute Hospital Care at Home” waiver from the U.S. Centers for Medicare & Medicaid Services (CMS) in November.
That shouldn’t be too surprising, considering Dr. David Levine, an assistant professor of medicine at Harvard Medical School, is one of the biggest backers of the hospital-at-home model around. Levine had already established “Brigham Health Home Hospital” more than five years ago after seeing the value of in-home care early in his career.
“This was something that I started as a research project,” Levine, medical director of strategy and innovation for Brigham Health Home Hospital, told Home Health Care News. “I’ve always been extremely, extremely ensconced in home-based care. It is very important to know what’s going on in the patient’s home.”
Brigham and Women’s Hospital is Harvard’s world-renowned teaching hospital. It’s also part of Mass General Brigham, a single, integrated health care system that consists of 16 different member institutions.
Originally, Levine launched the Home Hospital program out of Brigham to deliver high-value care to a wide range of patients who would have otherwise been admitted for an institutional stay. The intense, hands-on program has a typical patient census around nine, though Levine hopes to grow that total to 16 or more in coming months.
“We really treat the bread and butter of internal medicine,” he said. “So infections, heart failure exacerbations, COPD exacerbations, asthma and a whole slew of other diagnoses.”
Brigham Health Home Hospital’s core team is made up of a physician, a nurse and a paramedic. Normally, a patient admitted to the hospital-at-home model will be seen in person twice a day, with additional virtual visits taking place as needed.
In a study published last year in the Annals of Internal Medicine, Brigham Health Home Hospital was found to cost 38% less than a traditional hospital stay. Additionally, the study found that its patients saw fewer readmissions and experienced more physical activity at home, a key component to the recovery process.
“We know from our research, as well as from others’ research, that things like readmission rates are decreased,” Levine said. “People have really great experiences at home. People move more at home. These are all patient-centered things that people want when they’re sick.”
‘Not for every nurse’
Along with his teaching role at Harvard and medical director role at Brigham Health Home Hospital, Levine co-chairs the Hospital at Home Users Group, an organization dedicated to sharing resources and best practices.
The Hospital at Home Users Group has members from several hospital-at-home programs, including Brigham, Johns Hopkins, Mount Sinai and others. It used that experience to help CMS design its Acute Hospital Care at Home initiative, which now includes more than 35 health systems and more than 90 hospitals in 20 states, a spokesperson for the agency told HHCN.
“CMS looks forward to ongoing discussions with other health care systems interested in providing acute hospital care at home,” the spokesperson said in an email.
Interest in the hospital-at-home concept has exploded in recent years, even before the COVID-19 pandemic and current acute care capacity challenges. But reimbursement has always been a challenge for the model, making the new waiver from CMS all the more important, Levine noted.
“I was really privileged to help work with CMS on the waiver,” he said. “This allows us to further scale our work. Prior to this, there was not a mainstream fee-for-service payment mechanism.”
While hospital-level care at home has become a popular talking point, it’s not something that everyone can do. Brigham Health Home Hospital required buy-in from the entire hospital, from the C-suite to “the parking lot guys,” Levine explained.
“You need leadership buy-in from the very, very top of the C-suite,” he said. “If your CSO, CFO and CMO are not bought-in, you have little chance of succeeding. Home hospital is an all-hospital undertaking.”
The success of Home Hospital is also built upon its strong partnerships, especially with Partners Healthcare at Home, the home health agency of Mass General Brigham that works closely with Brigham Health. Sturdy relationships between home-based care players — internal or external — and hospitals is something most hospital-at-home programs have in common.
“We’ve seen some high-performing home health agencies that can get into this work and be really successful, with great collaboration with a hospital,” Levine said. “We’ve also seen some home health agencies get into this work and find out they didn’t realize what it takes to provide acute care.”
Similarly, Levine has seen hospital staff get involved with in-home care and realize it’s not for them.
“You need to be sure that you have either partnerships in the home or the staffing capability to hire people who work in the home,” he said. “It’s a different ballgame compared to the hospital. While I do think that acute care hospital nurses can make phenomenal home hospital nurses, it’s certainly not for every nurse. It’s really not for every doctor.”
Geography is likewise important to success. Most urban hospitals with a high density of patients located nearby can probably roll out a hospital-at-home program, but some rural ones may struggle if the people they serve live too far away.
“Depending on how you build your program and how sick your patients are — you’ve got to be able to touch them,” Levine said. “If they are too far away and your team is too spread out, it’s not going to work.”
Making a big impact
Levine established Brigham Health Home Hospital long before anybody knew about the COVID-19 virus. Yet it and similar programs have proven to be critical capacity lifelines in 2020 and in the new year.
As of Monday, nearly 74% of all in-patient beds in the U.S. were occupied by a patient, according to publicly available federal data. More than 77% of all ICU beds were occupied.
On its end, Brigham Health Home Hospital cared for about 70 patients during the first coronavirus surge in Boston. Early on, the program made the strategic decision to not care for COVID-positive patients in the home. Instead, Home Hospital is used to free up in-patient bed space for those COVID-afflicted individuals.
“Our program at Brigham actually made the decision to not care for patients with COVID, but to actually increase the work we were doing for patients without COVID because the hospital needed help,” Levine said.
Not all hospital-at-home programs have taken that approach.
UNC Health in North Carolina, for example, uses its program, supported by Medically Home, to care for a mix of COVID and non-COVID patients. Allegheny Health Network’s hospital-at-home model, facilitated by a joint venture with Contessa Health, also cares for a mix of patients.
Other pre-existing hospital-at-home programs have “shut down” during the pandemic, with hospital decisionmakers opting to deploy those resources elsewhere, according to Levine.
Overall, the Hospital at Home Users Group has at least “tripled in size” in recent weeks, Levine added. Moving forward, the group hopes to demonstrate just how valuable the hospital-at-home concept has been during the pandemic, advancing its case for a dedicated reimbursement mechanism once the public health emergency is called off.
“We are hoping we are going to be able to show CMS the big impact of home hospital care during the pandemic,” Levine said. “We’re hoping that the impact is very clear. And as a result, we’re hoping [CMS] sees a reason to continue to pay for home-hospital care, irrespective of the pandemic.”
It’s possible that Brigham Health Home Hospital will specifically have more financial support in the near future.
On Tuesday, the Boston Business Journal reported that Mass General Brigham is moving forward with as much as $2 billion in capital projects in Massachusetts and New Hampshire.
“These projects will enable us to meet the needs of our patients by bringing lower-cost care options to their home and community, making community-hospital investments to accommodate more routine care, and improving access for the most complex cases at one of our flagship hospitals,” Dr. Anne Klibanski, president and CEO of Mass General Brigham, told the publication. “While the pandemic temporarily postponed our long-standing plans, it also reinforced the need to provide more health care options for our patients.”
*Editor’s note (Jan. 31, 2021): This story was updated to clarify that Brigham Health Home Hospital works with Partners Healthcare at Home, the home health agency of Mass General Brigham.