Direct Primary Care should be called Concierge Lite. Patients pay $80/mo, totaling $1000 per year (yet still need health insurance).…
Curbside Consult with Dr. Jayne 8/8/22
In my work with large health systems, some of the projects I most enjoy are those that involve patient-facing technology. In sophisticated organizations, this includes actually bringing patients and caregivers into the product management and development work so that you can ensure that you are developing a solution that meets their needs. A lot of great ideas don’t necessarily resonate in the real world and it’s important to find those disconnects earlier in the process so that the solution can be refined. Otherwise, there is a risk that it will flop when it’s released into the wild. I’ve certainly seen plenty of initiatives go that route.
Healthcare delivery organizations have been in a state of transition for several years as they try to move more care out of the hospital and into the home or other care delivery facilities. Many of these efforts make sense. Getting patients out of the hospital quicker reduces the risk of hospital-acquired infections as well as costs. Patients may recover better in familiar surroundings than they might in an institutional setting. There are numerous other factors and these approaches have been successful for many same-day procedures such as orthopedic surgeries. However, when thinking about these types of programs there is a presumption that patients have family who are not only available to assist but who have adequate health literacy, appropriate physical capabilities (strength, dexterity, etc.) but also the emotional fortitude to assist in caring for a loved one at home.
A friend sent over this piece that was published on LinkedIn, with which I have a love/hate relationship as far as content creation and dissemination. It’s great to be able to share information, but there are a lot of people out there who interpret what they see on social media as being authoritative without fully understanding the background of a given issue. There’s a danger in drawing conclusions from narrow write-ups without fully understanding them or their downstream impacts. I saw this behavior often when working with large health systems that would pounce on an idea that they saw float by regardless of whether it applied to their situation or not. Significant resources were spent researching, evaluating, and assessing before the executive who thought it was a great idea could be convinced otherwise.
The LinkedIn piece is from The Health Management Academy and talks about five barriers to scaling the hospital-at-home concept. It draws in readers by leading with the phrase “digitally-enabled home-based care models” and quickly connects interest in the topic to both the COVID pandemic and to CMS reimbursement allowances. It notes that programs are often small, which makes them somewhat unsustainable, and questions whether programs will be able to continue beyond the pandemic. Below are the barriers the article cites, as well as my comments:
- Low patient enrollment. No surprises here, as patients have to be appropriately referred to the program, which requires time, effort, and coordination. Some organizations only allow patients who are in the emergency department to be referred, and others restrict patients to those who are already in an inpatient unit. This prevents other referrals which might be useful, for example, as an urgent care physician I would love to have referred patients with blood clots to such a program if they weren’t quite candidates to just manage it on their own yet didn’t really need a hospital admission to get started on blood thinners.
- Staffing challenges. This is the universal challenge of all industries right now, from fast food to construction to healthcare. In addition to having healthcare skills appropriate to inpatient care, frontline workers in hospital-at-home programs need other skills, such as managing remote technology and being able to self-support. In talking with several inpatient nurses, they’d be reluctant to give up their current level of predictability for increased volatility and personal risk.
- Provider support. Hospital-at-home workers have to be comfortable going into patients’ home environments, which sometimes have unfriendly living conditions, pets, and people. The article refers to this as “an uncontrolled setting,” and anyone who has ever done home care or rode along with EMS or the fire department knows what we’re talking about. This can be an extremely scary situation and there’s not a good way for those referring a patient for a program to know that Cousin Doug with severe uncontrolled mental illness also lives in the house, or that Aunt Julie has a handgun that she likes to leave on the end table.
- Coordination of services. The article sums this up as transporting providers and equipment along with care coordination. Given the fact that hospital-at-home is often related to a relatively acute situation such as an Emergency Department visit or an inpatient hospitalization, quick and efficient coordination is needed. Having shared the patient experience when a close friend couldn’t get the appropriate durable medical equipment delivered to her home when her surgery had a three-month lead time, I’m not convinced of some organizations’ ability to handle this rapidly. It’s not just equipment, but other medical supplies and services like imaging, phlebotomy, pharmacy, and the care itself that all have to be coordinated effectively.
- Reimbursement uncertainty. To me, this is the largest area of concern. Healthcare delivery organizations aren’t going to invest the resources to build the infrastructure to do all the things listed above if they aren’t convinced that they will be paid for their efforts in the future. Given the state of healthcare spending in the US and the fact that many of these programs are operating under a CMS waiver that provides payment equivalent to inpatient care, it’s unclear how much programs are willing to invest to keep the lights on let alone expand.
The piece the article missed, of course, is the patient piece. Do patients really want this service, or do they feel it’s just another way to get pushed out of the hospital before they are ready? Do they find value in the offering, or do they find it stressful? How do they feel about having outsiders in the home when there are stories every day of scams, theft, and abuse of patients by unscrupulous caretakers? Is the family ready to start delivering nursing and other care? Any health system administrator who is considering this needs to have firsthand exposure to what it’s like to help care for family at home, including assisting with feeding, mobility, toileting, managing surgical drains, and more. Unless a program is going to provide 24×7 support, these tasks will fall to family and friends, and some of them are not for the faint of heart.
What is your organization doing as far as hospital-at-home? How do you feel about it as a patient, and as a family member? Leave a comment or email me.
Email Dr. Jayne.
“The piece the article missed, of course, is the patient piece…” This is so true. Particularly for those who work in innovation and are trying to drive change, there is a tendency to “know the right answer.” But it is only when one experiences the healthcare system in a specific situation that the patient, family, informal caregivers, and care team can collectively look for the best solution given their current circumstance. That answer will differ based on the preferences of the patient and the resources available to them, and it may change over time. Specifically, concerning caregiving, it is incredibly gratifying but also a great strain and not suitable for everyone.
Look at home hospice – they help get the supplies and meds taken care of pretty efficiently, but it can be a shock to the family to find out they will need to be their own nurses. As someone who learned this the hard way, I would not recommend it except in cases where the patient has few needs and just has to be monitored which can be done remotely. I feel that offloading more intensive care to families is how administrators think they can fix staffing shortages, but it isn’t good for the patients.
There are many validated and published studies on patient satisfaction with “hospital at home” models, along with individual statistics presented out by health systems, and the findings are very consistent – patients report higher satisfaction with care in the home setting compared to hospital or other acute care settings.
Here are a couple studies from a quick search:
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RESULTS: A higher proportion of patients were satisfied with treatment in Hospital at Home than with the acute care hospital in eight of nine domains, and this difference was statistically different in four domains. Hospital at Home patients were more likely than acute hospital patients to be satisfied with their physician (adjusted odds ratio (AOR)=3.84, 95% confidence interval (CI)=1.32–11.19), comfort and convenience of care (AOR=6.52, 95% CI=1.97–21.56), admission processes (AOR=5.90, 95% CI=2.21–5.76), and the overall care experience (AOR=2.98, 95% CI=1.08–8.21). Family members of patients treated in Hospital at Home were also more likely to be satisfied with multiple domains of care.
CONCLUSION: Hospital at Home care was associated with greater satisfaction than acute hospital inpatient care for patients and their family members. These findings support further dissemination of the Hospital at Home care model.
Leff, B., Burton, L., Mader, S., Naughton, B., Burl, J., Clark, R., Greenough, W.B., III, Guido, S., Steinwachs, D. and Burton, J.R. (2006), Satisfaction with Hospital at Home Care. Journal of the American Geriatrics Society, 54: 1355-1363. https://doi.org/10.1111/j.1532-5415.2006.00855.x
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RESULTS: One hundred and two patients were randomised to Hospital at Home and 97 to hospital. Forty-eight (47%) patients in the Hospital at Home arm and 35 (36%) in the hospital arm completed the satisfaction questionnaire, representing 96% and 85% of those eligible, respectively. Total scores were significantly higher in the Hospital at Home (median = 15) than in the hospital group (median = 12). (P<0.001, Mann-Whitney U-test.) Responses to all six questions favoured Hospital at Home, with all but one of these differences being statistically significant. In the Hospital at Homegroup, 24 patients and 18 of their carers were interviewed; in the hospital group 18 patients and seven of their carers were interviewed. Themes emerging from these interviews were that patients appreciated the more personal care and better communication offered by Hospital at Home and placed great value on staying at home, which was seen to be therapeutic. Patients largely felt safe in Hospital at Home, although some would have felt safer in hospital. Some patients and carers felt that better medical care would have been provided in hospital. Carers felt that the workload imposed by Hospital at Home was no greater than by hospital admission and that the relief from care duties at home would be counterbalanced by the added strain of hospital visiting.
CONCLUSIONS: Patient satisfaction was greater with Hospital at Home than with hospital. Reasons included a more personal style of care and a feeling that staying at home was therapeutic. Carers did not feel that Hospital at Home imposed an extra workload.
Patient and carer satisfaction with 'hospital at home': quantitative and qualitative results from a randomised controlled trial.
Andrew Wilson, Alison Wynn, Hilda Parker
British Journal of General Practice 2002; 52 (474): 9-13.
Participants in a randomized trial have to be able and willing to be part of the trial regardless of what arm they are assigned to. Also people doing trials are typically enthusiastic and dedicated to their intervention which can add to success. Staffing and followup in funded trials is often more robust than routine care. This makes it hard to say if the results would generalize to other contexts. That the cited study is from 2002 seems notable as well — if this were easy and beneficial, why isn’t it more widespread? And there’s no escaping that the real focus is to cost shift care burdens on to someone else (family, other unpaid or poorly paid caregivers).
I agree, in my haste I did grab some older studies. Here is a meta-analysis (albeit from Australia) which is a bit more recent. In any case, the evidence is pretty clear that Hospital at Home improves patient outcomes while simultaneously increasing patient satisfaction. While less scientific, here is a recent article on Mass General’s expansion of Hospital at Home, which underscores many of the same benefits – https://www.bostonglobe.com/2022/07/11/metro/mass-general-brigham-plans-massive-expansion-hospital-home-program/. I am not sure there is much debate around the benefits of Hospital at Home for the right conditions. We’re not really at a point of “does it work?”, we’re at a point of “how do we effectively scale this?”
To your question of “if this were easy and beneficial, why isn’t it more widespread”? Dr. Jayne’s post effectively highlights many of the current barriers, so we don’t need to rehash them here. Its much like any other major change to healthcare delivery in the US – to scale, it requires major healthcare infrastructure changes accompanied by payor adoption. And we know how long that typically takes.
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Data synthesis: 61 RCTs met the inclusion criteria. HITH care led to reduced mortality (odds ratio [OR], 0.81; 95% CI, 0.69 to 0.95; P = 0.008; 42 RCTs with 6992 patients), readmission rates (OR, 0.75; 95% CI, 0.59 to 0.95; P = 0.02; 41 RCTs with 5372 patients) and cost (mean difference, − 1567.11; 95% CI, − 2069.53 to − 1064.69; P < 0.001; 11 RCTs with 1215 patients). The number needed to treat at home to prevent one death was 50. No heterogeneity was observed for mortality data, but heterogeneity was observed for data relating to readmission rates and cost. Patient satisfaction was higher in HITH in 21 of 22 studies, and carer satisfaction was higher in and six of eight studies; carer burden was lower in eight of 11 studies, although not significantly (mean difference, 0.00; 95% CI, − 0.19 to 0.19).
Conclusion: HITH is associated with reductions in mortality, readmission rates and cost, and increases in patient and carer satisfaction, but no change in carer burden.
Caplan, G.A., Sulaiman, N.S., Mangin, D.A., Aimonino Ricauda, N., Wilson, A.D. and Barclay, L. (2012), A meta-analysis of “hospital in the home”. Medical Journal of Australia, 197: 512-519. https://doi.org/10.5694/mja12.10480
Care from the “Home Care” industry, housecleaninig, companionship, etc, is trying to move into the Hospital at Home space, but their business practices are weak when it comes to caregiver stability. Caregiver stability affects communications and feelings of personalized care. Can the various different parts of healthcare, including Hime Care, clean up their employment practices to make Hospital at Home work?