Coronavirus Pandemic Drives Growth of Hospital at Home Programs
By Christopher Cheney
After modest uptake for nearly three decades, hospital at home programs are now growing faster across the country due to the coronavirus pandemic.
Johns Hopkins Medicine launched the country’s first hospital at home program in 1994. Largely because of inadequate financing mechanisms such as lack of reimbursement from Medicare, adoption of hospital at home programs was slow in the United States. The pandemic has changed that.
The biggest shift came in November 2020, with the Centers for Medicare & Medicaid Services (CMS) implementing the Acute Hospital Care at Home waiver program, which cleared the way for Medicare to pay for hospital at home services during the COVID-19 public health emergency. Six healthcare organizations were designated as the first participants in the waiver program, including two health systems that participated in this story: Mount Sinai Health System in New York City and UnityPoint Health in West Des Moines, Iowa.
The Mount Sinai Hospitalization at Home program is expected to grow significantly with the new Medicare reimbursement, says Linda DeCherrie, MD, clinical director of Mount Sinai at Home as well as professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai. Before the CMS waiver program, Mount Sinai Hospitalization at Home served 15–20 patients per month, she says. Now, she expects that census to double.
Many hospital at home programs are enrolling in the Acute Hospital Care at Home waiver program, DeCherrie says. “There is tremendous interest in the waiver. As of early February, there were 100 programs that had applied for the waiver and had received it.”
Medicare reimbursement for hospital at home services will likely continue after the pandemic passes, says Albert Siu, MD, MSPH, chair emeritus at the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine.
“My crystal ball tells me that when the public health emergency ends, there will probably be an interruption of the payment model. My hope is that we will have gained enough momentum during this pandemic that the genie will be out of the bottle. We will have to find a permanent Medicare payment model, even if it requires statutory change,” he says.
In addition to the Acute Hospital Care at Home waiver program, another driver of hospital at home growth during the pandemic has been the launch of virtual programs to monitor coronavirus patients outside the hospital setting. Denver Health has served more than 1,000 patients in its Virtual Hospital at Home program.
HealthLeaders spoke with three healthcare systems about how they are growing successful hospital at home programs amid the pandemic.
UnityPoint Health Hospital to Home
UnityPoint Health launched its Hospital to Home program in September 2018.
“By providing hospital-level care in the home, not only are we taking care of the patient’s healthcare needs, but we are also able to evaluate their living conditions and determine what support they need to stay at home. It allows us to work with their family members or friends and keep them in the home,” says Mag VanOosten, RN, president and chief clinical officer of UnityPoint at Home.
Patients are enrolled in the Hospital to Home program from UnityPoint Health hospital inpatient floors and emergency departments, says Dianne Schultz, DNP, MSN, RN, vice president of operations for UnityPoint at Home.
“Clinical coordination team members support Hospital to Home screening, and they signal further medical screenings to the providers. Hospitalists as well as emergency department providers actively refer patients to Hospital to Home. The Hospital to Home providers then engage in educational rounding with the care coordination team as well as ED and hospitalist providers to support their awareness and informed decision-making regarding Hospital to Home qualifications. If a patient is identified and anticipated to qualify for the Hospital to Home services, the referral is made and the Hospital to Home provider engages to assume that transition of care,” Schultz says.
Patients with several medical conditions are well suited for Hospital to Home care, she says. “Basically, we look at patients who have specific medical conditions such as cellulitis, chronic obstructive pulmonary disease, heart failure, pneumonia, dehydration, urinary tract infection, deep vein thrombosis, pulmonary embolism, and acute viral illnesses. That tends to be the core of patients who do very well at home under this model of care.”
Acuity is pivotal in determining whether a patient is appropriate for the Hospital to Home program, Schultz says. “These patients are the healthiest of our hospitalized patients. These are not patients who are medically at risk to escalate to the ICU while hospitalized. These are patients who require hospitalization; however, with having services and a model in place, we can safely provide their care in the home.”
Hospital to Home model of care
The primary elements of the Hospital to Home care model are daily in-person visits, remote monitoring, and a 30-day ambulatory care bundle.
“At our core, we have one daily provider in-person visit and twice daily nursing visits in-person as well. In-person ancillary services are provided as medically necessary. In addition to those in-person visits, we do perform video visits as needed. We also have telephonic visits. We use a complement of all of those methods to urgently and interventionally act on behalf of our patients’ medical needs,” Schultz says.
Remote monitoring is a “huge component” of the Hospital to Home program, she says.
“The remote clinical monitoring provides basic clinical monitoring such as heart rate, respiration, pulse oximetry, and patient weight. This data allows our clinicians to monitor the patient, then engage with the patient. For example, a clinician could notice that the patient’s oxygen saturation has gone down, and they can contact the patient right away and go through an assessment telephonically. If the clinician wants to see what the patient looks like, they can get on a video visit. If there is further concern, they could immediately deploy an in-person visit.”
The remote monitoring provides immediacy in care, VanOosten says. “Remote clinical monitoring has been a bonus to our program. It allows for immediate intervention. Our clinicians get notified on their phone if there is any unexpected variance.”
After a patient’s acute care period, which generally lasts three to five days, Hospital to Home patients are transitioned to a 30-day ambulatory bundle. “We continue to manage the patient in an ambulatory model with clinician engagement and the remote clinical monitoring. With the ambulatory bundle, we can still urgently and interventionally manage patients to avoid the need to go to the ED or hospital,” Schultz says.
The 30-day ambulatory bundle was launched in October 2019. The initiative had a dramatic impact on ED and hospital escalation rates, which are the number of Hospital to Home patients who had to seek care at an ED or be hospitalized. The following data compares escalation rates in September 2019 and November 2020:
• The seven-day ED escalation rate fell from 8.5% to zero
• The seven-day hospital escalation rate fell from 6.8% to 3.8%
• The 30-day ED escalation rate fell from 27.1% to 2.9%
• The 30-day hospital escalation rate fell from 22.0% to 5.9%
Operating via the Acute Hospital Care at Home model
UnityPoint Health served its first patient under the Acute Hospital Care at Home waiver on February 1. “The impact of the Acute Hospital Care at Home waiver has been profound in our program. It opens eligibility to even more patients, allowing us to care for more patients in their home aligned with traditional Medicare,” Schultz says.
Operationally, the Hospital to Home program is largely compatible with the Acute Hospital Care at Home waiver. Enrollment of Medicare patients for hospital at home services under the waiver follows the same procedures as the Hospital to Home program. And the Hospital to Home daily visits by clinicians and nurses comply with the requirements of the waiver.
The key changes to adapt to the waiver operationally have been related to Acute Hospital Care at Home being an inpatient rather than an outpatient program, Schultz says. “We worked to meld together the workflows that we had established in the ambulatory space with our inpatient services.”
For example, inpatient services typically do not schedule clinicians, who round on patients as a normal part of their activities. Scheduling clinicians in the electronic health record is essential in hospital at home programs, she says. “It is very important that the activities of clinicians are scheduled, so we understand where all of the clinicians are at and are able to help navigate them through various home environments. We worked closely with Epic and our UnityPoint Health Epic build team to get that functionality in place for the Epic inpatient platform.”
Financially, there is a stark difference between the Hospital to Home and Acute Hospital Care at Home programs, Schultz says. “The Acute Hospital Care at Home waiver provides inpatient hospital reimbursement for qualified program billing. Our Hospital to Home ambulatory model utilizes outpatient visit encounters for professional billing. The waiver program certainly offers us a revenue stream that helps to cover the costs of the new program.”
Achieving success in the Hospital to Home program
In addition to achieving low ED and hospital escalation rates, the Hospital to Home program has achieved high patient experience scores and cost savings, Schultz says. About 99% of patients give the quality of care they receive a score of 10 on a scale of 1 to 10. When comparing Hospital to Home and traditional hospitalization, the average cost reduction is about $6,000 per patient.
The ability of UnityPoint Health to provide all Hospital to Home services in-house has been crucial to the program’s success, VanOosten says.
“Having all the services under UnityPoint Health is our secret sauce. It allows us to keep our patients within our system so we can integrate between our service lines. We do not have to rely on third-party partnerships, which allows us to provide better care for our patients and better continuity of care across the continuum,” VanOosten says.
Mount Sinai Hospitalization at Home
The New York City–based Mount Sinai Health System expects its Hospitalization at Home program to improve financially and grow significantly with participation in the Acute Hospital Care at Home waiver program.
“We will probably double the number of patients coming through our hospital at home program because of the waiver. That will help us financially. In a program like ours, you need a minimum staff to operate. Having more patients coming through helps financially on the standard baseline operating costs,” DeCherrie says.
Prior to being accepted for the Acute Hospital Care at Home waiver, the Mount Sinai Hospitalization at Home program admitted 15–20 patients per month, she says.
The Hospitalization at Home program’s financial model has evolved over time.
The program launched in 2014 under a CMS Innovation grant, which allowed Hospitalization at Home to serve Medicare fee-for-service patients. When the grant ended in 2017, the program had to adopt a new financial model, DeCherrie says. “We formed a joint venture with Contessa Health. We then started to get contracts with Medicare and Medicaid managed care plans. And we had to stop taking care of Medicare fee-for-service patients.”
The joint venture contracts are 30-day bundles that include acute care in the home and active monitoring of patients after the acute phase of their condition.
How the Hospitalization at Home program works
The patients in the Hospitalization at Home program primarily come from the four emergency departments that the Mount Sinai Health System operates in Manhattan, DeCherrie says.
“We look almost every hour, Monday through Friday from 8 a.m. to 8 p.m., at all patients who arrive in the emergency rooms to see if they meet our insurance and geography requirements. Then, we start to follow patients with a nurse who screens out patients who are clearly not eligible for the program clinically. Then, the nurse will discuss with a hospitalist whether it is indeed the case that we can take care of a patient at home. Finally, we approach the patient to see whether they are interested in the program.”
If a clinically eligible patient is interested in the program, the patient is admitted to the Hospitalization at Home program and transported home via ambulance, she says. A nurse meets the patient at home within two hours of emergency room discharge.
The primary clinical criterion for Hospitalization at Home patient eligibility is whether patients can be treated safely and effectively at home, DeCherrie says. Prior to this determination, “the emergency room physician has designated that there needs to be inpatient-level care. Then the criteria turn to whether we can treat the patient in the home.”
Patient eligibility is not based on a diagnosis because patients are often not immediately diagnosed in the emergency room, she says. “We look to see whether we can operationalize the treatment plan in the home. What we do very well is taking care of patients who need IV antibiotics, IV fluids, labs monitored, and fluid diuresis for congestive heart failure. In the end, a diagnosis is coded such as congestive heart failure, cellulitis, chronic obstructive pulmonary disease, pneumonia, or dehydration. These are our bread-and-butter diagnoses.”
During the acute phase of their condition, Hospitalization at Home patients receive two daily visits from a nurse and one daily visit from a clinician. About half of the clinician visits are conducted using telemedicine, DeCherrie says. “Our patients go home with a telehealth kit, which is how we do our video visits. A nurse can be in the home facilitating a video visit with a physician or nurse practitioner.”
Physicians, nurse practitioners, social workers, and a phlebotomist are employed by Mount Sinai, she says. The nurses are employed by an agency, under a contract initiated by Contessa Health. If there is a need for physical, occupational, or speech therapy, the agency provides those services as well, she says.
There are care coordinators who are employed through the joint venture. “They are the nurses in the emergency room who identify potential patients and coordinate the process of getting a patient home such as acquiring oxygen, arranging the ambulance ride home, and providing the telehealth kit,” DeCherrie says.
The Hospitalization at Home program has generated positive results, according to a JAMA Internal Medicine study published in 2018. The research article compared 295 patients who participated in the Hospitalization at Home program and 30-day postacute care bundle with a control group of 212 hospital inpatients who were eligible for the Hospitalization at Home program but declined to participate or were seen in an emergency department when a Hospitalization at Home admission could not be initiated.
Compared to the control patients, Hospitalization at Home patients experienced:
• Shorter lengths of stay (3.2 days versus 5.5 days)
• Lower hospital readmission rates (8.6% versus 15.6%)
• Fewer transfers to skilled nursing facilities (1.7% versus 10.4%)
• Higher likelihood to positively rate their medical care (67.8% versus 45.6%)
Adapting to Acute Hospital Care at Home waiver
Mount Sinai started seeing its first patients under the Acute Hospital Care at Home waiver in December. Participation in the waiver program required significant changes, Siu says.
“The Medicare waiver program operates in a very different way from the program that we had been running previously. By design, Medicare wanted to run the waiver program through hospitals. They want to use the hospital payment mechanism as the financing mechanism for this program. That is why there is not a 30-day transitional care bundle, for example. We have modified and developed parallel workflows for our patients because everything must be consistent with our hospitals’ operating procedures. Whereas, before we had been operating Hospitalization at Home in many ways as a physician practice,” he says.
The logistics under the waiver program are significantly different, DeCherrie says. “Previously, we would discharge a patient from an emergency room and admit them to our Hospitalization at Home program. But because an inpatient stay includes your emergency room visit under the hospital process, it is not a discharge from the emergency room anymore—it is treated as a transfer from one inpatient department to another.”
Pharmacy has been another major change, she says.
“Prior to the Medicare waiver, because we operated as an outpatient practice, we could prescribe controlled medications just like you could prescribe anyone a controlled medication in an outpatient setting. But under the Medicare waiver, we cannot have the patients’ medication billed to their Medicare Part D plan because we are not using an outpatient community pharmacy. Instead, we have chosen to use the Mount Sinai inpatient pharmacy for all oral medications.”
Denver Health Virtual Hospital at Home
The coronavirus pandemic prompted Denver Health to launch its Virtual Hospital at Home program in April 2020.
The goals of the program were twofold, says Patrick Ryan, MD, medical director of the Hospital Transitions Clinic at the Denver-based health system.
“The first reason we developed Virtual Hospital at Home was to expedite discharges from the hospitals. That way, when patients were stable enough but still needed monitoring, they could be discharged in a safe way. The second reason was to potentially decrease the number of admissions to the hospitals through identification of COVID-positive patients in the emergency department who were doing well enough that they did not need to be in a hospital but needed monitoring,” he says.
Daily phone calls from clinicians and nurses are at the heart of the Virtual Hospital at Home program, Ryan says. “The basic structure of our Virtual Hospital at Home program is two phone calls per day for each patient. They receive one registered nurse call and one clinician call. One call is made in the morning, and the other call is made in the afternoon to allow for interval assessment of the patient. During those phone calls, patients have their vital signs assessed through patient self-monitoring with blood pressure cuffs, thermometers, and pulse oximeters at home.”
Using telephonic rather than video-based communication with patients has been simple and reliable, says Jeremy Long, MD, MPH, medical director of the Intensive Outpatient Clinic at Denver Health.
“We had the capacity to do video visits, but the technology piece was a challenge and would have required some patient components. So, we relied exclusively on the telephone; and on both the provider side and the patient side, it was beneficial. The video is great in theory, but there can be barriers for patients such as having to have an app on their phone and knowing how to use it. There was no doubt that the patients could do telephone visits,” he says.
Using video visits also would have posed a scheduling challenge, Ryan says.
“Especially during our busiest times, we could not guarantee to our patients that they would be called at a specific time. The goal for our clinicians and nurses was just to get through their assigned patients during their shift. So, we could not tell patients to log in to the MyChart app at a particular time and be ready for a video visit.”
Patient eligibility and enrollment
The kinds of patients who have been enrolled in the Virtual Hospital at Home program from emergency rooms and urgent care clinics have evolved over time, Long says.
“Initially, we took an all-comers approach for patients who needed some type of regular monitoring. As the pandemic went along, we tried to risk-stratify the patients. The Virtual Hospital at Home ended up being a higher-acuity monitoring program. Some of the lower-acuity patients who did not need the frequent calls that we offered in the Virtual Hospital at Home program could be monitored by their medical home clinic, with just a few calls per week,” he says.
A research article published by Infection Control & Hospital Epidemiology includes data from more than 200 patients who were enrolled in the Virtual Hospital at Home program in April and May 2020. The article features three data points:
•81.5% of the patients in the program were successfully discharged
•13.3% of the patients in the program required a higher level of care, with 38.7% of those patients admitted for hospitalization
•The majority of the program’s patients were either uninsured (28.3%) or covered by Colorado Medicaid (38.2%)
Through February, more than 1,000 patients had been enrolled in the Virtual Hospital at Home program.
Keys to success
Several factors have been critical to the Virtual Hospital at Home program’s success, Long and Ryan say.
A team of medical assistants played a crucial role in the program, Ryan says. “The medical assistants were particularly helpful in training patients on how to use their blood pressure cuffs and pulse oximeters. They told patients how to install batteries into those devices and how to operate them independently. The medical assistants were also important in arranging timely follow-up for our patients when they were discharged from the program.”
Collaboration has also been pivotal, says Ryan.
“When we started the Virtual Hospital at Home program, we had representatives from outpatient primary care, internal medicine, family medicine, inpatient hospitalist medicine, and the emergency department. There was also collaboration at the micro level among our team. For example, there have been open lines of communication between our nursing team and our clinician team. Many times, we think of inpatient medicine and hierarchal struggles between nursing and physicians about what to do with patients. But our nursing and clinician teams trusted each other.”
The Virtual Hospital at Home program stayed within the bounds of financial and other resources, Long says. “We used internal resources and did what we do best. We stayed within what we are good at rather than trying to stretch beyond what we are good at. The video visits are a good example. That would have stretched us—it was not something we were already doing. Whereas, with the telephone, it played to our strengths.”
Christopher Cheney is the senior clinical care editor at HealthLeaders.