Hospital care at home, a concept introduced more than 20 years ago, provides acute-level hospital-quality care in the home as an alternative to hospital admission. It decreases many risks of hospitalization for older patients—delirium, falls, functional decline, and hospital-acquired infection—and reduces mortality and costs. Hospitalization at home is “a standard of care” in Europe and Australia, according to Marcy Bergeron-Noa, chief nurse officer of the Medically Home Group in Boston, a company that brings acute care into the home. In the United States, however, there are only a handful of programs. A chief problem has been the lack of a payment mechanism in fee-for-service Medicare.
In 2017, the Physician-Focused Payment Model Technical Advisory Committee, created to provide recommendations to the Department of Health and Human Services, recommended an alternative payment model in which acute hospital care at home is bundled with 30 days of postacute home-based transitional care. This model established Medicare billing codes for these services and formed the basis for a recent large study at Mount Sinai Hospital in New York City. In this study, the average acute care period, which is considered the length of stay, was 3.2 days for 295 patients receiving hospital care at home compared with 5.5 days for 212 hospital inpatients. During the 30 postacute days, those receiving care at home were significantly less likely than inpatients to be readmitted to the hospital, go to the ED, or be transferred to a skilled nursing facility.
Patients are candidates for home hospitalization if they are sick enough to require hospital admission but stable enough to receive treatment at home. After transport home by ambulance, they are visited as needed by a nurse who maintains continuity of care and by the assigned physician or NP at least once daily (or via video, since the model can be adapted for use in telemedicine). Vital signs are monitored electronically, and tests and therapies are done at home.
“There are lots of winners in this story,” Bergeron-Noa told AJN, including hospitals with overcrowded EDs and not enough beds to admit patients quickly. The biggest winners are patients—who consistently rate their care more highly—and caregivers, who don't have to travel to the hospital to see patients. She acknowledged that some caregivers experience increased stress from the added responsibilities.
Bergeron-Noa envisions hospital care in the home becoming a specialty within nursing and aims to partner with Boston nursing programs to offer student preceptorships. “There are so many other settings in which we care for patients, such as rehab and skilled nursing facilities,” she said, pointing to the in-home model as one more example of nursing care moving away from the hospital setting.—Joan Zolot, PA
Federman AD, et al JAMA Intern Med 2018 178 8 1033–40