By Eric Rock
There has always been a fairly sharp distinction between what type of healthcare could be delivered at home and what had to be administered in the hospital. Much of this distinction came from the fact that hospitals were far better outfitted with equipment and staffed with healthcare professionals than the average American home.
Then came the COVID-19 pandemic, and suddenly there wasn’t enough space in virus hot spots to deliver care in the hospital to everyone who needed it.
It was this dire situation that created renewed, urgent interest in an alternative care concept known as Hospital at Home. The idea was that if hospitals could use remote patient monitoring (RPM) to safely direct patients home from an emergency department (ED) visit rather than admitting them, or release them earlier from an extended inpatient stay, they could free up beds for those who absolutely had to be admitted while still delivering the same level of acute care the released patients would normally receive in a hospital. It was a brilliant solution to a difficult problem.
During the pandemic, the types of patients recommended for Hospital at Home typically fell into two categories. The first group was patients who would normally be admitted for 23-hour observation. This group might include both those who were exhibiting some COVID-19 symptoms but who didn’t require hospitalization yet and non-COVID-19 patients suffering from injuries such as concussions. The second group was those who had experienced an acute event related to a chronic condition that was already being managed through an RPM program. Typically, this meant patients with congestive heart failure, chronic obstructive pulmonary disease, urinary tract infection, pediatric cancer, or wound care needs. No matter which category the patient fell into, however, participation in Hospital at Home first required clearance from a physician.
While Hospital at Home may sound like a direct reaction to the pandemic, the concept was originally developed in the mid-1990s by Dr. John Burton of the Johns Hopkins School of Medicine and Dr. Donna Regenstreif of the John A. Hartford Foundation. Their goal, which was established roughly a decade before the introduction of the Institute for Healthcare Improvement’s Triple Aim, was to safely bring down the cost of acute care while improving outcomes and increasing patient satisfaction.
Unfortunately, the healthcare industry wasn’t ready for this type of change—especially when it came to reimbursement. Under the fee-for-service structure, there was zero incentive to push patients out of the hospital early or to refrain from an ED admission. Hospital revenues were tied to “heads in beds,” not efficiency, so Hospital at Home drew little interest.
The transition toward value-based care, with reimbursement tied to outcomes rather than activities, made Hospital at Home somewhat more palatable, at least in certain instances. Still, with the push toward electronic health records (EHR) and everything else going on over the last decade or so, accommodating a new care delivery and business model simply wasn’t a priority.
From bulky to nimble
Once the pandemic struck, however, the Hospital at Home concept began to draw interest from hospitals and health systems. They had three goals: 1) free up bed space for their sickest patients (especially those with COVID-19); 2) keep patients who were coming to the hospital for other reasons from acquiring COVID-19; and 3) protect their frontline workers from the virus as well as the risk of burnout due to the high patient loads.
At least initially, though, these goals were challenging to implement. Delivering hospital-level care for acute incidents and recovery typically requires outfitting a room with a lot of large, complex, and/or expensive equipment. In a hospital setting, that is not a problem since much of the equipment can be permanently stationed in patient rooms for ease of use. The same, however, cannot be said for a home setting. Installing, setting up, and calibrating all the necessary equipment in the patient’s home requires an extraordinary amount of time, money, and work. Once the acute event has passed and the patient no longer requires hospital-level monitoring, the entire process must be reversed. That’s a lot of effort to go through, especially if the patient is only being observed for 23 hours.
The good news, particularly in terms of timing, is that the growth of RPM over the last few years has made Hospital at Home far more practical and nimble. Now, bulky and expensive machines can be replaced by prepackaged kits or by clinically approved, consumer-grade digital thermometers, EKG monitors, pulse oximeters, and blood pressure monitors—the same tools used to help manage a patient’s chronic conditions. The RPM devices then use Bluetooth™ connections to deliver near-real-time data to healthcare professionals through a tablet or smartphone, either on a scheduled or continuing basis.
Because the equipment is so much more portable, the entire “hospital room” is now quick and easy to ship via regular carriers such as UPS or FedEx and can be set up expediently in the patient’s home by a nurse. When the need for acute care has passed, everything can be disconnected and returned to the hospital just as easily. Additionally, unlike traditional hospital equipment, the RPM equipment used in these programs doesn’t require a lot of special training. Anyone who can use a tablet or a smartphone can learn how to take and report readings in minutes.
The new ICU
Although much of the focus is on hospital floor–level monitoring, in some cases Hospital at Home can even offer ICU-quality care. The only caveat is ensuring a nurse is available on-site 24/7 to attend to any immediate crises.
Moving the ICU to the home, where appropriate, offers benefits beyond freeing up hospital beds and reducing costs. Having the patient in the home environment rather than the hospital can contribute to faster recovery. It also enables family members to visit with the patient—something that is still not possible in many hospitals due to the pandemic. Finally, it is less disruptive to the lives of patients, caregivers, and their families—an important consideration in the healing process.
While it is impossible to state an empirical financial benefit of Hospital at Home that applies in all cases, there are some factors that can be taken into consideration.
For example, the cost of a typical admission for 23-hour observation after heart failure is $23,000. Hospital at Home powered by RPM costs a fraction of that amount. Now consider that according to the Centers for Disease Control and Prevention, six out of 10 Americans have at least one chronic condition, and four out of 10 have two or more. These conditions account for 90% of the nation’s $3.8 trillion annual spend on healthcare. If the industry could reduce that number by just 1% as a result of taking advantage of Hospital at Home, it could save $34.2 billion. That money could be redirected into patient care, research, and other programs that will deliver both short- and long-term value to the nation.
Also consider the impact Hospital at Home could have on readmission rates in an accountable care organization or other value-based care arrangement. RPM is already one of the best tools hospitals and health systems have for reducing unnecessary readmissions and ED visits because it alerts clinicians to developing issues, allowing them to be remediated before they require an admission or visit. By adopting RPM-driven Hospital at Home, healthcare organizations can apply these same principles to acute care. They can then avoid some readmissions entirely, helping hospitals and health systems avoid penalties from government and commercial payers while shortening some patients’ length of stay. Healthcare organizations can also intervene early to prevent the necessity of an ED visit, saving even more resources.
Ultimately, with a small investment in equipment and training for Hospital at Home, hospitals and health systems can reap huge savings and rewards—even after the pandemic is a distant memory.
Bringing it home
The idea of the home being a nexus of care has been growing for the last decade. Most of the time, however, its practical role has been limited. As this pandemic has now proven, RPM-driven Hospital at Home is not only viable and practical, but also a desirable, cost-effective, and safe solution for many conditions.
Let’s not lose the momentum. It’s time for hospitals and health systems to look deeper into how Hospital at Home can help them improve care quality, reduce costs, and increase patient satisfaction with their healthcare experience today and in the future.
Eric Rock is CEO of Vivify Health (part of Optum), an innovative leader in connected healthcare delivery solutions. The company’s mobile, cloud-based platform powers holistic remote care management through personalized care plans, biometric data monitoring, multichannel patient education, and functionality configured to each patient’s unique needs.