A program called Hospital at Home is producing results for older patients that seem too good to be true. Instead of being in a hospital, imagine getting acute-care services from your local hospital in your home, accompanied by at least daily visits from doctors and nurses, plus all the equipment and related tools needed to treat your health condition.
You'd think the program would be prohibitively expensive, but it actually costs less than providing the same care in a hospital. The health outcomes in early tests are better for Hospital at Home patients than control groups receiving similar care in a hospital. And, not surprisingly, consumers show a strong preference for receiving care at home over being hospitalized.
The implications of a successful system of home-based care are enormous. Growing numbers of older Americans face the possibility of needing to be in nursing homes or other institutional-care facilities. There are simply not enough facilities to meet the projected demand. Even if there were, consumers can't afford such expensive care. Neither can Medicare and Medicaid, which are sustaining huge deficits just to support current levels of institutionalized care.
There is a growing "aging in place" movement to support older Americans who wish to remain in their homes. Providing intensive healthcare services in a home-based setting would meet a major need to help people successfully age in place. Hospital services are, of course, only part of an older person's healthcare needs. But shifting the focus of care to home-based solutions would be a huge societal change. And if it can be done with highly-skilled and often high-tech hospital care, providing other types of home-based services doesn't seem so daunting.
The reasons Hospital at Home can succeed, even for patients living alone, reflect major advances in healthcare technology. Electronic health records and patient management systems are needed to enable in-home care. Telemedical advancements use Internet-enabled devices to monitor home-based patients. Patient communication and billing systems can track everything and monitor a patient's care needs and progress.
The reasons Hospital at Home is not more widely used reflect the healthcare system's continuing focus on hospital care. Healthcare providers receive money for treating patients through often-costly procedures and tests, not for producing better outcomes and healthier patients. Hospitals, in particular, have enormous fixed costs for facilities and healthcare professionals. Encouraging home-based care is not part of their business model, especially if it means fewer people occupy the hospital beds that generate needed revenues when they are filled.
The Hospital at Home model was developed over more than 15 years by the Johns Hopkins University Schools of Medicine and Public Health. Bruce Leff, a Hopkins medical professor and expert in aging and geriatric care, recalls that he started working on home-based services in 1994. "Many of our older patients would refuse to go to the hospital," he says. "They just flat-out would not go because they didn't like the experience. Others reported poor [health] outcomes" from their hospital stays.
The model has been most widely adapted by Veterans Administration hospitals, Leff says, in large part because their financial incentives are aligned with finding less-expensive ways of providing care. In the Medicare fee-for-service market—the most common way of providing healthcare to seniors—there is little incentive for hospitals to seek at-home care solutions. They get paid for providing on-site care, including medical procedures and tests.
But a large-scale use of Hospital at Home by New Mexico's largest nonprofit healthcare provider, Presbyterian Healthcare Services, has produced positive financial and health outcomes. As reported in the journal Health Affairs, the Presbyterian program provides home hospital services to older patients across a range of acute care needs.
The program has produced savings of nearly 20 percent compared with comparative in-hospital care. Much of the savings stems from doing fewer medical tests in the at-home care settings and in needing fewer days of at-home care than the same care required in a hospital. Hospital readmission rates—a key measure of effective hospital care—are similar for both at-home and in-hospital patients. Mortality rates for at-home patients have been substantially less than for comparable patients admitted to a hospital, and patients treated at home suffered fewer falls than those in hospitals.
"Hospital at Home in the United States has been limited by attitudes, payment, and policy," the Health Affairs article said. "Attitudinal issues arise from the assumption that hospital care is safer and that providing acute care in the home setting is inherently inferior." Traditional Medicare does not have a payment mechanism for at-home hospital care, it added. "In fee-for-service Medicare, the economic imperative for many health systems is to fill hospital beds to generate revenue."
"One of the things we can do with Hospital at Home is to provide even higher quality of care at home than in a hospital," Leff says. "We also can achieve a 40 percent reduction in mortality at home as compared to being taken care of in a hospital." And while the Presbyterian program achieves a 20 percent cost savings with its Hospital at Home program, Leff said earlier research efforts produced double that level of savings.