With Nathan R. Handley, MD, of Sidney Kimmel Cancer Center at Thomas Jefferson University
By Sarah DiGiulio
In the year following diagnosis with an advanced cancer, nearly three-quarters of patients are hospitalized. Some of those hospitalizations are necessary and some could be avoided with better management of symptoms throughout the treatment process.
In a recent "Comments and Controversies" article in the Journal of Clinical Oncology co-author Nathan R. Handley, MD, Assistant Professor of Medical Oncology at Sidney Kimmel Cancer Center at Thomas Jefferson University, explains why the "Hospital at Home" model could lower the number of those avoidable hospitalizations, lower costs to health care systems, and improve the quality of care for patients with cancer overall (2019;37(6):448-452).
Importantly, he also acknowledges the several challenges that must be addressed to implement such models of care (in the U.S. and elsewhere): selecting appropriate patients for such models of care, staffing and resource allocation (so that high-level care is available to patients in a timely manner), and reimbursement. But he argues that these challenges are surmountable.
"Logistics of care delivery are a barrier. Getting care to the patient, rather than having the patient come to care, changes the way we think about health care in general," Handley told Oncology Times. But he believes the benefits will be worth it.
1. Can you start by defining what "hospital at home" means—and when it comes to cancer care, what types of patients would benefit most from utilizing it?
"'Hospital at home' is a mode of care delivery in which hospital-level care is delivered in the home setting, rather than in the traditional inpatient unit. For something to be considered hospital at home, the quality and level of care received at home should be at least equivalent to what the patient would receive in the hospital.
"Hospital at home exists in the U.S. for general medicine conditions, with major active programs at Johns Hopkins [Medicine], Mount Sinai [Health System], and Cedars Sinai [Medical Center]. In these programs, commonly treated [conditions] include pneumonia, chronic obstructive pulmonary disease exacerbations, congestive heart failure exacerbations, and cellulitis (or similar infections requiring IV antibiotics).
"Most [hospital at home] programs have generally seen significant decreases in total costs of care. Quality of life is as good or better. Patients tend to be significantly more mobile in the [hospital at home] environment than the hospital environment. Hospital-acquired infections are less of a problem. Patient satisfaction tends to be as good or better as well.
"Many of the potentially preventable causes of admission described in OP-35 (a quality metric for outpatient care recently added to the CMS Hospital Outpatient Quality Reporting Program that will impact payments in the 2020 [financial year] and beyond) could likely be managed in a hospital at home program. These include things like anemia, nausea, dehydration, neutropenia, diarrhea, pain, emesis, pneumonia, fever, and sepsis. I would anticipate a significant amount of overlap in the selection criteria used by existing hospital at home programs.
"[But] the logistics are more challenging for a hospital at home model—it moves more of the work to the provider and the health system. And it's not right for every patient. A patient requiring advanced imaging, multispecialty consultation, or procedures would not likely be a good candidate for a program like this."
2. This model is being utilized outside of the U.S. already. Is it feasible in the U.S., too?
"A great example of a robust hospital at home program comes from Australia. In the state of Victoria, about 5 percent of all acute care bed-days actually occurs in the home setting. Examples exist through much of Europe as well. Some programs with a cancer focus also exist. For example, intensive chemotherapy can be given at home in Switzerland.
"The advantage all these programs have is that they either exist in fully capitated single-payer systems or they have arranged reimbursement equivalent to that received for traditional inpatient admissions. The challenge in the U.S. is that reimbursement mechanisms are lagging.
"It could be feasible in the U.S. Reimbursement makes it a bit challenging at present. That being said, some health systems that operate under a global risk model are already positioned to succeed in a hospital at home program (e.g., places like Kaiser Permanente or Geisinger). And policy is moving toward increasing reimbursement for home-based services. For example, CMS has proposed reimbursing providers for remote patient monitoring, which could be an important component of an effective hospital at home model. And Mount Sinai submitted a payment model (HaH-Plus) for their program to CMS; the Physician-Focused Payment Model Technical Advisory Committee recommended it be implemented, so that may happen.
"[But] it will require a significant mental shift. Reimbursement is still a barrier—hospitals are generally not going to be excited about moving patients out of the hospital if the total revenue decreases.
"I would say that the logistics of a program such as this may be simpler in an urban setting due to the geographic localization of patients. The biggest barrier in rural settings might be the time required for a provider to get to a patient—it would not be ideal if the patient were declining and the nearest provider was 3 hours away, for example."
3. What would you say is most important to know about the hospital at home model and its potential role in cancer care?
"The hospital at home model could have several compelling advantages over traditional inpatient care. Many patients with cancer spend a significant amount of time seeking and receiving care. By delivering care in the home setting, we can allow them to spend more time where many of them would prefer to be: at home. Hospital at home has the potential to deliver care in a safe, cost-effective manner while driving patient satisfaction."