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Could a Hospital at Home Work for Neurology?

Shaw, Gina

doi: 10.1097/01.NT.0000419194.33362.f8
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THE HOSPITAL-AT-HOME model of care is much more prevalent outside of the US, but American hospitals are beginning to investigate this treatment approach as well

THE HOSPITAL-AT-HOME model of care is much more prevalent outside of the US, but American hospitals are beginning to investigate this treatment approach as well

Experts discuss the challenges and opportunities for establishing hospital-at-home programs.

Imagine this: a 72-year-old woman is brought to the hospital emergency room showing symptoms of an acute stroke. It is her first stroke, and she is not a candidate for tissue plasminogen activator (tPA). After being evaluated by a neurologist and undergoing standard clinical evaluations and a CT scan, it's determined that she has had an uncomplicated ischemic stroke, and her cardiovascular and respiratory status is stable. The patient is then sent home.

Wait — what? A patient is sent home within 24 hours of having an acute ischemic stroke? That's exactly what would happen at San Giovanni Battista Hospital in Turin, Italy, which since 1996 has been managing many such patients in their own homes through its Geriatric Home Hospitalization Service.

Patients presenting to the emergency room with specific, carefully chosen clinical conditions are “admitted” to the hospital by a physician, but that hospital is actually their home. In most cases, the patient receives extended nursing care for an initial period and appropriately reduced supervision thereafter. Doctors usually visit daily, and in their own beds, patients can receive IVs, oxygen, electrocardiograms, and other services normally associated with hospital care.

“Hospital-at-home” programs like the one at San Giovanni Battista are much more common outside the US, with similar models in use in Australia, the UK, Israel, and Canada. But with the skyrocketing cost of health care in the US — and increasing pressure from government and private payers to lower costs and improve outcomes at the same time — American hospitals are beginning to investigate this model as well.

It's taken a long time to catch on here, according to Bruce Leff, MD, professor of medicine and director of the Center on Aging and Health at Johns Hopkins University, and the guru of the hospital-at-home movement in the US.

“We first began studying this model back in the mid-1990s. I saw that older, frail patients would go into the hospital with pneumonia, and they might get that fixed but they would come out of the hospital in much worse shape for having been there, due to falls, hospital-acquired infections, or ‘hospital delirium.’ They'd come into the hospital able to walk, get up out of bed and go to the bathroom, and they'd leave the hospital after a few days on bed rest so impaired that they could do none of those things independently.”

Dr. Leff wondered if there might not be some way to provide hospital-level care for more stable patients in their homes. “I've had plenty of older people tell me, ‘You give great medical care, but you run a crappy hotel,’” he said.

In 1996, Johns Hopkins launched its Home-Hospital program, led by Dr. Leff, and three years later reported its first results in a pilot study published in the Journal of the American Geriatric Society. The 17 home-hospital patients in the study fared just as well clinically as hospitalized patients, at a fraction of the cost for their care — approximately 60 percent of the cost of acute hospital care for a similar group of patients, Dr. Leff reported in a 2001 paper in the Journal of American Geriatrics Society.

Over the next 12 years, the data continued to pile up, documenting the benefits of hospital-at-home approaches. In 2005, Dr. Leff reported on the results of a three-site national demonstration project on Hospital at Home, conducted in three Medicare managed care plans at two sites in Massachusetts and New York, and the Veterans Affairs Medical Center in Portland, OR. They found significantly lower rates of many complications for hospital-at-home patients — everything from delirium to bowel and urinary complications to falls was significantly reduced in the intervention group, as was total length of stay — 3.2 vs. 4.9 days (p = 0.004). Hospital-at-home patients and their families also reported greater satisfaction, and their care cost about one-third less — $5081 vs. $7480 (p < 0.001), Dr. Leff and colleagues reported in a 2005 paper in the Annals of Internal Medicine.

In 2011, the Cochrane Collaboration published a review of 10 randomized controlled studies on the hospital-at-home model. Not only were costs reduced and patient satisfaction increased, when patients received hospital care at home, but six-month mortality rates were also lower in the hospital-at-home group (adjusted HR 0.62, 95% CI 0.45 to 0.87; p=0.005).

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With such solid evidence of improvements in outcomes, costs, and patient satisfaction, why have hospital-at-home programs in the US remained unusual? The answer is simple, experts say: reimbursement. The hospitals in the original demonstration project abandoned their programs due to financing problems, leaving only the Portland Veterans Affairs Medical Center in Oregon with an ongoing program.

“This is not a recognized model of care delivery for most payers,” said Mark McClelland, DNP, RN, an assistant research professor at the Center for Health Care Quality at George Washington University in Washington, DC, who has consulted on the hospital-at-home model.

“We live mostly in a fee-for-service world,” Dr. McClelland said. “Try going to the hospital president and saying, ‘Hey, instead of admitting some of these patients to a hospital bed that you'd get payment for from Medicare, send them home. Their care may actually be better, you'll reduce costs and get a 40 percent reduction in mortality at six months, but you won't get a Medicare payment.’ They'll look at you like you have two heads.”

Because Veterans Affairs systems don't have to rely on outside payers for reimbursement, the hospital-at-home program has had better fortunes in that environment; in addition to Portland's, there are now hospital-at-home programs in VA centers in Boise, Honolulu, and southeastern Louisiana, with more slated to open.

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Portland's program, called Program at Home, is celebrating its 10th birthday this year. During the initial pilot year, the program cared for about 44 patients, a number that has fluctuated over the years depending on the availability of funding. But beginning about five years ago, the program's census has been steadily increasing. This year, they are on track to see between 180 and 200 admissions. In February of 2012, they admitted their 1000th patient.

Beginning in FY 2010, the program was able to hire a full-time medical director; it's also staffed with one full-time nurse screener and one full-time registered nurse. The program primarily serves patients with one of four conditions defined by the pilot study: heart failure (about 70 percent of its census), chronic obstructive pulmonary disease (COPD), community-acquired pneumonia, and cellulitis.

“For example, we were referred a patient on Thursday who had had increased shortness of breath attributed to a flare in COPD as well as mild congestive heart failure and possible early pneumonia,” said Stephen Acosta, MD, medical director of Program at Home. “He preferred not to go into the hospital, so he was referred to us. We started him on oral antibiotics which we had delivered to him, followed him through the weekend, adjusted his diuretics and followed his oxygen levels. We gave him everything he would have gotten in the hospital, but at home.”

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The ideal hospital-at-home patient requires hospital-level treatment, but is at low risk of clinical deterioration with proper care, and is unlikely to require highly technical, hospital-based services such as frequent imaging or interventional procedures.

Could patients with neurologic conditions fit into that category? Absolutely, said Dr. Leff. His group has identified people with conditions such as community-acquired pneumonia, congestive heart failure, deep venous thrombosis and pulmonary embolism, and COPD as particularly suited for hospital-at-home care, but some other neurologic conditions could also benefit from home management. In addition to its home stroke care, San Giovanni Battista Hospital has also used a hospital-at-home approach to dementia care.

Kevin Biglan, MD, MPH, an associate professor of neurology at the University of Rochester Medical Center who directs their National Parkinson Foundation Center of Excellence and Huntington's Disease Society of America Center of Excellence, recently worked with a patient who was hospitalized with acute psychosis associated with his Parkinson disease.

“I think that could have been managed in the home without his having to be admitted,” he said. “Many people with chronic neurodegenerative diseases like Alzheimer's, Parkinson's, and Huntington's, can have exacerbations — often behavioral worsening — that frequently lead to hospitalizations but could very well be managed in the home with the right program. In fact, when you're talking about delirium or behavioral changes in someone with a chronic neurodegenerative disease, they're probably better served staying in the home.”



“If a condition is of a chronic nature, where we know what's going on with the patient and we have a treatment plan, but there are little variations in health status that require routine hospitalizations from time to time, that's perfect for hospital at home,” said Dr. McClelland. “As we get better at this, I think we're going to slowly but surely expand the list of diagnoses we can include.”

It's not an off-the-shelf approach, however. “This is a complex model. You don't just plug it in and let it go,” Dr. McClelland said. In Albuquerque, it took about eight months to get the program up and running. “Just like building a neuro-intensive care unit, you can't do it overnight.”

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In recent years, more hospitals have begun to catch on to the hospital-at-home innovation, most notably New Mexico-based Presbyterian Healthcare Services, which in a June 2012 article in Health Affairs reported a 19 percent decrease in costs for patients admitted through the program along with equal or better outcomes when compared with similar hospitalized patients. Presbyterian has the advantage of being New Mexico's largest managed care organization, providing commercial health insurance and Medicaid and Medicare products; as an integrated system with an internal payer, it has more freedom to pursue innovative models that wouldn't easily fly in a fee-for-service system.

This summer, Colorado's Centura hospital system began preparing to pilot a hospital-at-home program at its two Penrose-St. Francis Health Services hospitals, a project hospital officials aimed to formally begin in September.

Dr. Leff is exploring new ways to finance hospital-at-home initiatives. He recently discussed an approach with a large Blue Cross/Blue Shield plan in the Midwest, which is interested in writing incentives for hospital-at-home care into contracts with some of their leading hospitals. “If hospital at home costs 20 percent less, resulting in savings that can be shared between the provider and the payer, and good studies show we can improve care at the same time, then why not?”

The hospital-at-home movement was dealt a setback in mid-June when the Centers for Medicare and Medicaid Services announced its latest round of innovation grants — and a proposal from Dr. McClelland's center and Presbyterian, to expand hospital at home, bringing it to sites in Illinois, New York, Rhode Island, Florida, and Minnesota, was not funded.

But Dr. McClelland isn't giving up. “I will stay alert and focused for any other potential funding mechanisms that might help us disseminate this model,” he said. “As we move into an area where we're going to have many more people who are chronically ill, we have a silver tsunami bearing down on us. We're going to have to become more efficient and provide better care at the same time. Hospital-at-home has the potential to do that.”

The second in a continuing series on innovative models of care and disease management. The first, “‘Village of the Demented’ Draws Praise as New Care Model,” appeared May 17, 2012: Have suggestions for programs to feature? E-mail

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• Cryer L, Shannon SB, Leff B, et al. Costs For ‘Hospital At Home’ patients were 19 percent lower, with equal or better outcomes compared to similar inpatients. Health Aff 2012; 31(6): 1237–1243.
    • Leff B, Burton L, Steinwachs D, et al. Comparison of functional outcomes associated with hospital at home care and traditional acute hospital care. J Am Geriatr Soc 2009;57(22):273–278.
      • Leff B, Burton L, Burton JR, et al. Hospital at home: Feasibility and outcomes of a program to provide hospital-level care at home for acutely Ill older patients. Ann Intern Med 2005;143(11):798–808.
        • Shepperd S, Doll H, Wilson AD, et al. Hospital at home admission avoidance. Cochrane Database Syst Rev 2008; 4: CD007491.
          ©2012 American Academy of Neurology