Any past debate over whether hospital-at-home (HaH) is a viable model is settled, as leading health systems across the country have established more than 100 programs over the past two years. The question now is how quickly it will replace a large chunk of bricks-and-mortar treatment in each health system.
A growing list of evidence-based studies has demonstrated, conclusively, that delivering acute care in a patient’s home rather than in a bricks-and-mortar hospital leads to better outcomes, and in doing so also reduces the overall cost of care.
The next phase is already underway: home-based high-acuity hospital care is moving toward becoming the default option for a wide variety of patients. Overall, many hospital-at-home leaders expect one-third or more of all “inpatient” hospital care to be delivered in the home, with far higher proportions for specific categories of inpatient care.
In embracing hospital-at-home, the United States is following a path blazed in countries such as Australia, France and the United Kingdom, where HaH has for years been an option, and where the public payer reimbursement model has made it easier to introduce and make widely available.
“Rather than explaining why you’re admitting a patient to the hospital-at-home, health systems will increasingly be asked by patients why they’re being admitted to the bricks-and-mortar hospital,” explains Medically Home CEO, Rami Karjian. In other words, both physicians and patients will be so accustomed to the idea of people receiving high-acuity care in the comfort and privacy of their homes for post-transplant care, congestive heart failure, treatment of infections such as pneumonia, and even chemotherapy, that this option will be front of mind and the preferred option for all.
The CMS Advanced Hospital Care at Home Program has established a common model that has been widely adopted by health systems – more than 114 systems and 256 hospitals in 37 states had applied with CMS for approval by late September of this year. Where the health systems differ is in how quickly the programs scale up to become a larger proportion of their inpatient census. This varies according to the success hospital systems experience in establishing the logistics of home-based hospitalization, as well as receiving effective direction from executive leadership, successfully applying change management techniques, and marketing to make patients aware that HaH is an option.
UNC Health in North Carolina, with the partnership of Medically Home, began accepting patients into its program on August 30, 2021 (its own Advanced Care at Home program). Dr. Ila Mapp, Director for Advanced Care at Home, says that incorporating the HaH program within the daily workflow of the patient admissions and care plan review process would increase the utilization and provider awareness for this type of program. Providers must feel comfortable with the HaH care model for their patients and getting them to that comfort level is one of the program’s main goals.
Logistics
The single biggest contributor to the ability to scale HaH, Karjian says, is logistics – the ability of a health system to transition from providing tests, treatments, medicine and supplies in the hospital to providing them quickly and reliably in a home, on demand at any time of day or night. Some health systems have been building their own HaH infrastructure, relying often on home health providers and existing remote patient monitoring tools that were designed for low acuity, post-acute patients, creating a misfit between what can be delivered and what an HaH program requires. Health systems taking a DIY approach have struggled, relying on manual process that without a supplier network and logistics platform can only support an average daily census of just a few patients.
Other health systems have partnered with a services provider like Medically Home, which brings all the service providers, software, and processes needed to implement and scale HaH rapidly and reliably – and to ensure that backup systems are in place for each vital service.
“Once physicians see that their orders are executed reliably and see the benefits of hospital-at-home for their patients, they begin referring more and more patients to into the program,” Karjian explains.
The Learning Curve
Because the processes and logistics of decentralized hospital care for patients in their homes are so different from how a centralized brick-and-mortar facility runs, a comprehensive model that includes a software solution to help coordinate care at scale, robust training and a change management program is crucial for a smooth rollout and rapid scaling up of the service.
Part of that is by offering top-notch training, including extensive simulations with actors playing the role of patients and peers offering feedback, to providers preparing to establish a HaH program. “What builds comfort is simulations, having clinical educators who train people – nurses and physicians who are used to this model and have successfully trained many others,” says Dr. Pippa Shulman, chief medical officer for Medically Home. Medically Home’s change management curriculum, for instance, trains providers not just on the use of Medically Home’s Cesia software but also on how to most effectively interact with and evaluate patients over a video link, working in tandem with in-home clinical providers who can be the “hands in the home.”
Building a solid base for a HaH program also means providing clinicians with the confidence to treat the most complex medical and social situations imaginable in this new-to-them system. In real-life scenarios, medical professionals never know what might happen next, and a home-based care model has to show them just how to address the unexpected outside the walls of the bricks-and-mortar hospitals that they’ve operated within all of their professional lives.
Medically Home’s approach from the beginning has been to focus first on the highest-acuity care, and then broaden access to lower-acuity care. The opposite approach, which has been tried by other providers and health systems, often struggles to move from lower-acuity into higher-complexity care, limiting the average daily census.
“We’ve learned that the best way to have clinicians gain confidence in admitting patients to home hospital is by having them experience not only providing care in the home but also seeing and incorporating the rich information that is gained from seeing patients in their home environment,” Shulman says.
Seeing the successful outcomes for those complex cases is leading physicians to embrace the HaH care model almost automatically for patients with more straightforward diagnoses or treatment plants. That’s the pathway that will ultimately lead to HaH becoming the default option for care.
Change Management
Numerous studies conducted over the last 25 years have shown that at most one out of every three organizational transformations that is begun succeeds. John Kotter, a Harvard Business School professor who has led research into this topic since the mid-1990s, suggests that these failures may be due to leaders who can’t communicate a sense of urgency to their teams, who aren’t able to build a broad and enthusiastic coalition of supporters internally or to develop and communicate a vision.
Successfully scaling HaH requires effectively tackling this question of change management. As a later study by McKinsey showed, preaching reason and common sense isn’t enough: Leaders have to challenge the ‘business as usual’ mindset of their colleagues and convince employees or other stakeholders of the compelling need for that change. Then comes the hard work: ensuring that admired colleagues are seen to support the change, that systems and incentives are redesigned to encourage new attitudes. That’s on top of providing the infrastructure and education programs required to ensure success. Within the healthcare industry – and particularly on the frontlines, among physicians and other providers – the overarching commitment to place patient health and wellbeing helps to increase the willingness to listen and learn.
For instance, more than one Medically Home health system partner built the program results into their organization’s goals, relying on their virtual hospitals to expand the health system’s capacity. Another system constructed its program so that every department in the organization had a stake in its success on behalf of patients. Others have implemented powerful internal communications strategies to educate their staff in parallel with external communications to show the public at large what HaH care means.
However, unlike companies attempting to transform their own unique business models, no health system has to establish a hospital-at-home service on its own or from scratch. Just as partnerships are key to successfully running brick-and-mortar hospitals today – from enabling technology to group purchasing to facilities management – enabling technology and services are critical to building and scaling new models in healthcare. HaH specialists like Medically Home have been working collaboratively with leading health systems to blaze just such a path in healthcare delivery over the last several years.
Now, with the number of physicians and nurses being trained in the model growing rapidly, the expertise and tools needed to establish and expand home hospitalization are strong and growing.