Dr. Shulman, chief medical officer for Medically Home and one of the architects of Medically Home’s model for decentralized care discusses a moral imperative that healthcare has to “acknowledge that home hospital is not just the same care delivered in a different site for many groups of patients…it’s actually better care delivered in a better site of care…” At this year’s Quality Talks event, presented by the National Committee for Quality Assurance, Dr. Shulman further challenges the healthcare industry audience to, “Ask your payer and ask your doctor if home hospital is right for you or your family member, because it is time for all of us to demand what is good for our families should be available for all families.”
The full text of Dr. Shulman’s presentation is below and the video of the presentation is available here:
I’m here to tell you that I am part of a big problem. I’m part of a system that has hidden the benefits of home hospital from a vast majority of the public.
I classify it as a coverup.
Don’t believe me? There are a lot of doctors in the crowd today, nurses, nurse practitioners, ask them how many of you have kept a family member out of the hospital. Brought home a vial of something, hung some fluids in the living room…
I did it for my mother.
I realized in the green room, it’s 20 years ago this month, I drove up to an emergency department where my mother had been admitted after getting lost in the Target parking lot. Turned out she had a very large brain tumor that even a baby doctor like myself could see on the actual film they put on the light box.
She got admitted for a life saving surgery and then had a pretty prolonged hospital stay and finally was discharged home on a beautiful day in May. And this tree in her yard was blooming. It’s a Carolina Silver Bell and the one they had in their yard was huge and when the flowers come off of it, it snows. This pink-tinged snow. And she was so happy to be home.
She said over and over and over again, “I don’t want to spend more time in the hospital.”
And so she didn’t.
Now, don’t get me wrong. She had two years of therapies aimed at prolonging her life, and I made sure she went to all of her oncology appointments, all her treatments. But when the side effects of treatment threatened to land her in the hospital – when she got a fever – I made sure she didn’t end up there – and she never spent another night in the hospital – even while she was receiving active treatment.
So, why hasn’t home hospital scaled? Why isn’t this care available to everyone? Well, part of it is our fabulous system that we’ve put together. One of my mentors always said, every system is perfectly designed to get the results that it gets.
So think about it. You have a new illness, or you’re a patient with chronic illness. And you have a new symptom and so you go to your PCP or you call somebody. I’ve been a PCP, it’s a very difficult job. And they’re overburdened. And busy.
And so maybe they can’t fit you in or they can’t even get on the phone or maybe you don’t even call and you’re directed or you self-direct to the emergency department. And we’ve all seen what the emergency department looks like (and by the way, it looked like that before Covid – Covid just made everybody pay attention). And so now you’re in the hall, it’s crowded and if we are worried about you at all, if you are a risky patient (and if you’re over 65 that makes you risky) you’re getting admitted upstairs. And now the facility has swallowed you up. Right? And the hospital is great. We can do all kinds of things there, we can order every test under the sun. We can consult our 97 consultant friends.
Do we get clinically actionable data out of all that?
Jack Weinberg and a generation of researchers at Dartmouth have shown us that in healthcare unfortunately it is supply that drives demand and not the other way around.
And so this system perpetuates itself. And after about 3 and a half or 4 days, you’re discharged. 20% of the time or more, you’re discharged to a Skilled Nursing Facility. Otherwise, you go home.
And you have some confusing instructions.
And you have time to heal.
And the system repeats itself.
Over and over and over again.
And we know this doesn’t work and we know that readmissions are high. There has got to be a better way.
So who here wants to go to this hospital? I don’t see anyone raising their hands. Why is that?
Even when we go to the hospital for a happy occasion like the birth of a child, we bring bags o’ crap with us. We bring our pillows and pictures and flowers and outfits and all kinds of stuff that by the way you probably don’t need, but it’s all to create a different environment.
We did that for my mom. We had the blankets and the radios and the pillows and the flowers.
My dad set up a bar in the corner. I kid you not – to greet visitors, now you have some insight into my family, but we’ll move on from there.
But we know that we don’t like the food, the beds are uncomfortable, and the nights are really long, and lonely, and scary.
There is an incredible paper that colleagues from Mayo Clinic and Duke published in the Annals of Internal Medicine in 2020 and it as the kids say, “lives rent free in my brain…”
It was comparing the experience of hospitalization to enhanced interrogation — as described by the CIA manual on the same topic — The conclusion, was that a hospital stay resembles torture…TORTURE…You think I was provocative earlier, how about now!
Is it true?
All right, so you go into the hospital – you go into the ED that we talked about before. People start asking you questions – all kinds of different people — and they ask you the same questions in different ways over and over and over again. And they throw in just enough medical jargon that you may not understand what they’re asking you or why. And then we take off your clothes and we give you a uniform. And that uniform barely keeps you warm and does not offer you a whole lot of modesty if you know what I’m talking about. You’re put into a room where you don’t control the lights, the temperature, the schedule, the food and you’re taken at all hours of day and night for procedures and tests. And you never know when the person in charge is coming.
We know that hospitalizations and repeated hospitalizations have created this syndrome that’s now in the literature called post hospital syndrome that’s characterized by post traumatic stress disorder, anxiety, depression, sleeplessness.
Now layer on top of that, if you’re in a vulnerable community, if you’re a person of color, if you are part of the trans community or other queer patients. If you are a rural patient, or poor, or have mental illness who already the system has mistreated you in some way and now we have taken away all of your autonomy and personal control.
And this leads you – all these groups are at higher risk for complications from that hospitalization and it’s not just readmissions.
So, how could this be different?
20 years of data have shown us that there is a better way. Home hospital is not new, I didn’t invent it, it’s been around a long time here and across the world.
Great study, Journal of American Geriatrics Society, showing rates of delirium in the home hospital compared to bricks and mortar cut by almost half. Falls decreased. Hospital acquired infections – guess what — your own dirty house doesn’t give you the same infection a dirty hospital does, that’s for sure. What about pressure ulcers? Functional status?
Readmissions are something we talk about a lot.
Study after study after study, including large meta analyses show that readmission rates in the home hospital are cut by (it’s a long range) but on average about half compared with bricks and mortar hospital.
Mortality. Again, multiple studies including one just published by Mayo Clinic shows that mortality is lower in the home hospital than the bricks and mortar.
Oh, well you’re cherry-picking patients…uh uh uh…Guess what, we have ways that we can compare – severity of illness of patients in the home hospital and patients in the bricks and mortar — and they’re the same and sometimes even sicker.
We also look and make sure (for our programs) we want to make sure that we’re taking care of the widest range of patients. And so we look at payer status and we look at neighborhood deprivation index and make sure that matches the home hospital.
So again, I ask you why is this not bigger. Why are we doing for our own families what we will not do for everybody else? And I will argue, it’s the culture.
There is a hospitalist in Knoxville, TN and their hospital about a month ago opened a new home hospital program, and it’s going to be spreading across that region over the next two years.
This hospitalist was part of a group of physicians that were voluntold that they would be participating in this new model. This was not someone who was a champion of the model and came in with a healthy amount of skepticism to training (did come to the training which was step one) and after the first patient, we spent some time interviewing the physician to see how it went and they said, look, I was going to do my best (thank you) but all I could think about coming into my shift that day was what I couldn’t do in the home that I could do in house.
Their first patient was a late 70s early 80s year old woman who’d had multiple hospitalizations and she had a bunch of chronic medical issues and she had a relatively uncomplicated stay – she did twice daily intravenous medication, daily labs, meals, some nursing care, the usual things that we provide in the home hospital and on her day of discharge the physician took the time to ask her how her experience had been. Now when was the last time by the way that a doctor has ever asked you how your stay has been, I just love that they took the time to do this.
And she loved it and we see this all the time that the virtual hospital / the home hospital is the best performing hospital in a system’s network and she said, oh, I got to sleep, and you responded so quickly to everything that I needed.
And the physician said, and I realized that she’d never had a good night’s sleep in house and she never felt like she had control over the situation and it would have seemed insignificant to me for her to be separated from her pets but she got to be around her pets and that was so important. And he said, the next time I went into the hospital, to do a regular bricks and mortar shift, all I could think about is what I couldn’t do in the hospital.
Because when we see patients in the hospital they are two-dimensional figures in a bed, no matter how much we try to create that connection — but when we see people in their homes, see how they really live — when I can — even on video:
What’s on the table next to you?
Who’s with you or not with you?
Is it cluttered, is it clean?
What are you eating our not eating?
How do you actually take those medications?
I love the speaker before said, half of the people don’t pick them up and take them…Or they’re picking up multiple prescriptions.
That is the opportunity. And we see this over and over and over again.
We’re partnered with a group at Mass General Hospital that’s doing home hospital and actually decentralization of all of acute care for blood cancer patients nearing the end of life. So really their acute visits, urgent visits, hospital visits, in the home. All while receiving active treatment.
Patients in the control group 80% of their time is spent in the hospital and 65% of them die in the hospital despite a wish to die at home. And when we decentralize away, they report symptoms earlier because they know they aren’t going to be forced to go back in house and lose time with family and 80% of their time was spent at home. And more than that many got to stay home while receiving active treatment. And THAT is the power and the opportunity and THAT is the moral imperative on us to acknowledge that home hospital is not just the same care delivered in a different site for many groups of patients — 30%, 40% of what is in a bricks and mortar hospital, now, it’s actually better care delivered in a better site of care.
So now, I have a call to action for you.
This is a really exciting and distinguished audience.
I want you to go home and understand why or why not is home hospital allowed in your state.Cause guess what, we now have waivers under CMS that will allow payment, payers are starting to catch on but states are, in some cases saying this is not permitted here, in some cases they are. Ask why there is such a variation in licensure across elements of our workforce that is so needed to expand to be able to make home hospital stronger – home hospital is a team sport, it’s one of the best things about it. And ask (we have payers in the room, so ask yourselves) but ask your payer and ask your doctor if home hospital is right for you or your family member, because it is time for all of us to demand what is good for our families should be available for all families.