While hospital at home is becoming more common in the U.S., there are some who still believe that cancer is too severe a condition to care for in the home.
Despite that, there are a number of cancer care at home programs and pilots in place right now, many of which are seeing success.
“Just as cancer is many diseases with many different facets, so too is cancer hospital at home,” America’s Physician Groups President and CEO Susan Dentzer said during a presentation at the Virtual Advanced Healthcare at Home Summit on Thursday. “Among the dozen or so cancer hospital-at-home programs in existence today in the United States, each is slightly different.”
Indeed, some of these programs are focused on hospital substitution, which means treating patients at home for exacerbations of their cancer symptoms or reactions to treatment.
Other programs are focused on delivering home-based infusions and the administration of cancer drugs. Some extend palliative care to cancer patients in the home.
These programs are all organized, staffed and financed differently. They are also at different stages of planning and implementation, Dentzer noted.
Huntsman at Home
One of the organizations operating in the hospital-at-home cancer space is the Huntsman Cancer Institute.
“Historically, cancer care delivery models have focused entirely on hospital and clinic-based services,” Kathi Mooney, a professor at the University of Utah’s college of nursing and a co-leader of cancer control and population sciences at Huntsman, said. “Hospital-at-home programs have generally not included care for people with cancer.”
In general, cancer and cancer treatment are notable for causing reoccurring acute episodes, such as dehydration infection, partial bowel obstruction and pain crises, according to Mooney.
The standard of care for these episodes is urgent care clinics and emergency department visits.
“While patients receive educational materials and classes about managing symptoms and side effects, they have not adequately prevented nor reduced acute episodes before requiring unplanned health care utilization,” Mooney said. “There is a need for a more effective approach to symptoms of disease progression and treatment side effects. Since cancer treatment is provided on an outpatient basis, these acute episodes occur when the patient is at home, and [thus] lend themselves to a home-based response.”
In 2018, the Huntsman Cancer Institute launched Huntsman at Home in Salt Lake City. The program provides both the traditional hospital-at-home model and subacute monitoring for individuals who were likely to have reoccurring episodes.
However, the program doesn’t provide chemotherapy in the home.
Huntsman at Home has seen strong results. When looking at outcomes in the 30 days after enrollment in the program, patients saw decreased hospital rates of 55%, a 45% decrease in emergency department use and 47% reduction in costs.
Mooney believes that one of the biggest barriers to making home-based cancer care a reality is that it’s an entirely new paradigm.
“Our whole cancer care system is based on bringing people to the cancer specialist rather than providing care at home and going to the specialists on limited occasions,” she said. “[Including] the home as a key cancer site requires restructuring mindsets, investing in new infrastructure, adopting and supporting technology and finding new reimbursement models.”
Supportive oncology care at home
The Supportive Oncology Care at Home model was developed at Massachusetts General Hospital’s cancer center.
As part of the pilot study of the model, patients report daily symptoms, daily vital signs, and their body weights. All of this information is monitored by the hospital-at-home team.
“We also developed some algorithms based on these symptoms and vital signs [to determine when] the hospital team should contact the patient via phone call to check in and say, ‘We noticed that you had pain today, or we noticed that your blood pressure was a little abnormal,’” Dr. Ryan Nipp, a gastrointestinal oncologist and cancer outcomes researcher at Health Stephenson Cancer Center at OU Health, said. “Based on that phone conversation and detailed algorithms … we can evaluate and manage those things at home.”
Nipp is a principal investigator on trials involving the Supportive Oncology Care at Home model. He previously served as a clinical assistant in medicine and medical oncology at Massachusetts General Hospital.
The Supportive Oncology Care at Home model sought to enroll 20 patients. It would go on to enroll 80% of the patients it approached to participate.
“That was one of our major outcomes with this first pilot study, just proving if we approach patients with this idea, they are willing to enroll,” Nipp said. “We asked them to do quite a bit, with the daily symptoms, the daily vital signs and the body weights.”
The model also received positive feedback when it came to patient satisfaction, according to Nipp.
“We also asked at the end of the study, ‘How helpful was this?”’ he said. “‘How convenient was it? What do you think about the timing related to the symptoms being monitored?’ [We saw] an extremely high intervention acceptability here, where patients and their loved ones were grateful for this opportunity to participate.”
Additionally, the model saw lower rates of urgent clinic visits, lower rates of ED visits, lower rates of hospitalizations and lower rates of treatment delays.
Looking ahead, Nipp is hoping to continue evaluating the efficacy of this model even further.