Where Hospital-At-Home Programs Go Next

The journey of the hospital-at-home model in the U.S. is a compelling one.

Much of it has transpired over the last few years, ever since the introduction of the Acute Hospital Care at Home waiver, which allowed health systems to provide acute care in the home during the public health emergency (PHE).

In May, the public health emergency will come to an end. But, thanks to the omnibus spending bill that was passed in December, the waiver has been extended for two years.

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Even if the waiver hadn’t been extended, hospital-at-home work would have continued. There are plenty of health systems operating programs outside of the waiver as well. Now that it has been extended, though, it allows providers that had not started on their programs to get going.

Kaiser Permanente is one of the health systems that operates within the waiver and outside of it. Dr. Stephen Parodi has overseen the development – and success – of those programs.

Parodi is the EVP of external affairs, communications and brand at The Permanente Federation and the associate executive director of The Permanente Medical Group. He sat down with Home Health Care News this month to chat about the future of hospital at home in the U.S., and all the opportunities it will bring to the greater home-based care ecosystem.

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That conversation is below, edited for length and clarity.

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HHCN: Dr. Parodi, thank you so much for joining us. Since we last spoke, there’s been a lot of developments with hospital at home. Given the extension, there’s a little bit more certainty moving forward. How welcomed is that?

Parodi: First of all, I think it’s critically important that the bill passed, because it provides stability for our existing program and for programs across the country in terms of being able to pursue this new model of care.

We have the assurance that, for the next two years, there’s going to be a regulatory framework and approval for being able to move forward. It allows for the collection of more data, more information on the quality, safety and efficiency of these existing programs. And I think just as importantly, it’s going to allow for additional programs to come online.

I think that there are a couple of things to learn from now. Obviously there will be a greater volume of patients. The ability to study those things that I was referencing will grow. But I think that we’re also going to learn with the newer programs coming online, how to build and scale the programs, more efficiently and more effectively.

It also opens up the opportunity, because of the way the bill was worded, to create measures and benchmarks for performance in these programs. And I think there’s two parallel tracks for that.

One is comparing these new programs to brick-and-mortar facilities. Then, actually identifying what new measures are available for these particular programs. They’re going to be unique because we’re providing the care in the home. The last part of this is that it opens up the door for looking to expand services beyond the hospital. So, looking at models that do look at lower-acuity care, particularly patients that need emergency care, and for complex-needs care, and being able to provide that in the home.

What are some of the benchmarks that you would like to see for these programs?

Number one, there are basic quality measures that we currently have in brick-and-mortar facilities. The Medicare stars program actually outlines a number of those, and we want to hold ourselves to the same level of accountability in the home. That’s when it comes to the safety measures, preventing health care-acquired conditions and infections, falls, making sure that patients are ambulating in the home, that we’re preventing delirium. Just like we would in a hospital, in the home. All of those basic things.

Then there’s sort of the second piece that’s important, which is making sure that we have good measures for patient satisfaction and the patient experience. There are measures that currently exist within the hospitals today, and we want to have those same ones for the home, and perhaps actually have some that are even better. We can actually measure response times to patient needs more accurately than we can in a brick-and-mortar facility, because I can actually track when the patient calls, when we respond, when we get on video. When did we dispatch somebody into the home, and either provide direct care or deliver a service or good into the home?

All of those things, we want to be able to measure.

What are a few things that you think could advance the hospital-at-home waiver? For instance, in the past, we talked about how being able to recognize eligible patients in the community – versus the hospital – may be advantageous.

In terms of the actual waiver protections that are now going to be extended for the next couple of years, that framework really is restrictive to the emergency department and the hospitals in terms of admissions of patients in the home.

That being said, the fact that you have that baseline, so you’re going to be able to at least get a program off the ground, will allow programs to expand into other use cases. For example, at Kaiser Permanente, we’ve already got examples of programs that are taking patients in not using the waiver program, and actually admitting patients from, say, an urgent care setting or even a home setting. In fact, our newest program that just opened up in Washington state is doing that as we speak.

Can you give us a general update first on how hospital at home is going at Kaiser – what the census looks like and any other details?

With our two largest programs that have been either operating under waiver, or parallel to the waiver, from 2020 to current, we’re running a census of approximately 17 to 20, on any given day. And the covered population that’s eligible is 1.1 million patients.

We’ve now, between Northern California and the Northwest, admitted over 2,500 patients.

And since we last talked, we launched our program in Washington state. What’s interesting about that is that we don’t own any hospitals in Washington state. So we’re primarily admitting patients from our own clinical decision units or urgent cares into the program, which is different from northern California and the Northwest. We also plan to, as of this month, open a program in Georgia as well. We also have a program in Southern California that actually has been around for a while, it’s a little different than the four other states that I referenced, in the sense that we have a homegrown program. So we’re also tracking that program as well.

There’s a lot of opportunity here to learn about the different approaches that we can take.

Why Georgia?

Kaiser Permanente is in eight different states, as well as the District of Columbia. Georgia is an interesting program, because it’s a mix of urban and suburban areas, we also don’t own a hospital there. We’re looking for alternatives to be able to place our patients and keep them within the total care of our integrated system. We were interested in launching in Georgia, because of those different reasons.

What is the next step for these programs?

I think our big focus is how to scale these programs effectively. Establishing clear delineation of what we need for the supply chain within a given locale, and making sure that we have built in redundancies to that supply chain so that the patients can get medications, they can get their equipment, and we can get the personnel to the homes in a timely fashion.

As you scale and have more volume, the easier it is to be able to have those built in redundancies. If you think about it, we’re trying to build a hospital from the ground up. Our goal is to have both the infrastructure that I was describing in place and also the personnel in place to be able to do it.

The other thing that we’re going to be exploring is how to use virtual technology to actually connect the different programs together. Is it going to be possible, for example, to cross-license a physician across different states to be able to provide the care to these patients in different locales? Particularly since we’re building specific skill sets for who can provide this care, and it is a different type of care than it is traditional hospital care.

So, how can we use technology to also allow us to scale in ways that we wouldn’t be able to do with a brick-and-mortar facility?

You all are very far ahead on this. But what do you think is the next step for hospital-at-home programs in general?

I think the immediate opportunity here is to get additional stakeholders interested in moving forward with programs. Firstly, with health systems like Kaiser Permanente. But I think there are other opportunities here to look at health care payers, particularly health plans, who have an interest in preventing readmissions, preventing health care-related harm.

So, to actually build this into a benefit structure for a patient so that they can actually avail themselves of the benefits of this kind of a program. That’s a big opportunity.

I’d say, in terms of the advocacy front, it’s ensuring that we have a working partnership with CMS and CMMI to determine what good looks like. And actually have concrete measures that we’re gonna be held accountable to so that we can actually study it and understand what a sustainable clinical and business model needs to look like for hospital at home.

Do you have any interesting data to share when it comes to hospital-at-home programs at large, or even just within your program?

We’re seeing continued, good results when it comes to the number of patients that are requiring either return to the emergency department or return to actual readmission to the hospital. That compares favorably to the brick-and-mortar hospitals.

For example, with our readmission rates, we’re seeing rates between 7% and 10% with the hospital-at-home program, that’s a lot lower than the national benchmarks when we look at 30-day readmissions. With the seven-day return to care for ED, it’s down below 2% for our program, which again compares favorably.

In terms of the number of patients that are needing escalations into an emergency department from our actual hospital-at-home program, that’s extremely low – we’re talking about 0.1% to 0.5%. This is all translated into both patient outcomes that are better, and also reductions in health care costs.

The average length of stay for our programs is between four and four and a half days, which again compares favorably to a brick-and-mortar census. We’re seeing a lot of good signals from the standpoint of the operational efficiencies of the program. And from the standpoint of health care-acquired conditions, they’re almost unheard of in the program. That’s also really favorable.

The last thing is that a lot of the statistics that I had previously shared with you – in terms of patient satisfaction – continue.

The ability to be in your own environment, with your own pets, with your own support system, is so important to people. And for the other end here, the physicians that work in this program consistently say that this is an extremely satisfying part of their practice. We have people that are signing up for these shifts, they want to be in the program, because it is such a different way of practice compared to the traditional approach. And it’s not that people don’t want to do the traditional approach, but they find a great satisfaction in getting to know the patient at a different level than they ever had before.

Kaiser has a dedicated home health and hospice arm now, but home health is completely separate from hospital-at-home care. Are they involved at all?

It’s a good question. One of those four programs that I previously referenced actually is working under a home health licensure model. Some of the staff that are being employed go through that home health licensure approach.

But the answer to your question is that there is coordination with that approach. In one of the programs, we actually do what’s called restorative phase care, which approximates, but is not exactly the same as home health care. The hospital-at-home team also does the restorative care.

In our Northwest program, there is a handoff. So if a patient does need home health care, then they actually transition into the home health program. We do try to either be completely seamless, where just a single team does it all, or, in some cases, we do have the approach to being able to hand it off and transition if we need to into a direct home health setting.

I think the bottom line is that there’s a lot of opportunity for learning and evolving what this needs to look like. And I think we should be, quite frankly, creative with this. That goes back to the policy approach here, which is that if we have enough flexibility, we can actually learn about what kind of payment models need to exist to allow for more seamless care than what the traditional approaches have been.

If you could change one thing about hospital-at-home care in the U.S. right now, what would it be?

Let me speak to maybe two. One is that I think our approach in the country to paramedicine is something that’s going to be critical to the success of these programs, meaning that we need to be able to allow for different disciplines to be able to provide direct care in the home, and not necessarily have to transport patients out of their home. We have a number of states that require, if a paramedic visits a home, to actually transport the patient, and we’re finding with our programs that there’s so much more that the paramedic – when tethered to a well-designed hospital team – can do in the home.

If I could wave a wand tomorrow, and be able to have that additional capability across the country, I’d love to see that.

I think the other big picture thing that I’d love to see is to think about what an incentive, value-based payment model might look like for a hospital-at-home program. Can we do this in a way when a person that’s being seen – in the emergency department or in an urgent care setting – the first question that’s asked is, ‘How do I get that person home?’ That’s as opposed to, ‘How do I get that person in a brick-and mortar-hospital?’ To actually reverse the paradigm for the way we think.

I do think the movement towards providing evermore care in the home will be incredibly important.

I think, specifically when it comes to emergency department care in the home, that that is going to be a critical need. Why do I think that?

Number one, if there’s anything that we’re seeing coming out of this pandemic, it’s that our emergency departments are extremely busy, they’re at unprecedented levels of patients that are coming in. And what we’re seeing within Kaiser Permanente is that these patients are sicker.

We actually have a five-point scale for determining how sick patients are. And the top two levels of acuity are the ones that have gone up the most in the last five years. With the aging of our population, I only expect that to continue. And we haven’t had a large growth in emergency department infrastructure.

I think there’s actually a need for being able to provide this type of service somewhere other than a traditional emergency department, if we can do it safely. So I do think this is a new area of opportunity and a frontier for being able to provide effective services.

Secondly, from the hospital-at-home perspective, you can imagine a scenario where you’d have a more seamless transition. So rather than having a patient have to go to the emergency department, only to be told, ‘Hey, you’re okay, and you can be safely cared for in your home,’ why not just do that all in the home? I would love to realize that vision, and I’m excited by the potential opportunity here.

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