Since early pilot tests of the hospital-at-home model in the United States more than 20 years ago, the promise of treating patients where they live instead of hospitalizing them has tantalized health care providers.
These programs, which care for patients with acute illnesses such as pneumonia, cellulitis, and exacerbations of congestive heart failure and chronic obstructive pulmonary disease (COPD), are among the most studied innovations in health care. That research has shown varying but clearly positive impacts on mortality, clinical outcomes, readmission rates, and cost. A 2012 meta-analysis of 61 randomized, controlled trials, for instance, found that the hospital-at-home patients had a 19% lower six-month mortality rate compared to hospitalized patients. Another review found the rate reduced by 38%. Caregivers and patients themselves also give hospital-at-home high marks. But despite the enthusiasm for these programs, they’ve been slow to take off in the U.S. At Mount Sinai Health System in New York, our experience illustrates the reasons why.
We’ve long aimed to take the lead in addressing larger trends in the health care industry by shifting our emphasis from hospital stays toward preventive care, ambulatory care, and home-based care. To support these goals, in 2014 we launched the Mobile Acute Care Team (MACT), a pilot program of health care delivery for acutely ill patients that replicates the services they would have received in the hospital, right in their own home. It has treated more than 750 patients, and now forms the core of a new service line called Mount Sinai at Home, which also offers in-home rehabilitation, observation, and primary care.
Mount Sinai at Home is distinct from home health care, the more familiar and common offering, which most often describes a visiting nurse service that provides non-acute treatments like wound care and chronic care management.In our program, we treat acutely ill patients who would otherwise require hospitalization, providing them with a suite of integrated services that may include daily visits from nurses, doctors, and social workers; IV support; oxygen; X-rays; and physical therapy. Our research finds that patients who receive hospital-at-home care have fewer complications and readmissions; they also rate their health care experience more highly.
Our protocols allow us to provide home hospital care safely for a set of specific conditions, including community-acquired pneumonia, congestive heart failure, COPD, cellulitis, and dehydration. Patients are either referred to the program by their primary care physicians or are enrolled in it after visiting the emergency department. Once home, they receive a combination of in-person visits, video visits, and monitoring. One of the first steps is to have a nurse visit the patient at home and set up a tablet with a connected blood pressure monitor, which allows the patient to send a blood pressure reading while talking to the nurse remotely. But ongoing at-home management of acute-care patients requires making services available 24 hours a day. We have physicians on call around the clock, and we collaborate closely with community paramedics who we can dispatch to a patient’s home at any hour. Say it’s 2 am and a patient isn’t feeling well. We immediately send a paramedic who can set up a video link with a doctor that is compliant with patient privacy laws; then, in consultation with the physician, the paramedic provides treatment, or, if necessary, transports the patient to the hospital.
Designing and running a hospital-at-home program is not without challenges, of course. How do you price care, and get reimbursed for it? How do you scale your initiative? How do you address regulatory barriers? For instance, in the state of New York where we’re located, home nursing visits are regulated separately from hospitals, and so we have partnered with a home health agency for our nursing services.
Other challenges include getting the right services to the right patient at the right time. For instance, we’ve struggled with oxygen delivery. Here in New York, you can get pizza and Chinese food delivered at midnight, but you can’t get oxygen delivered outside of business hours. So, we’ve needed our vendors to rethink their delivery model.
Each health system will face its own set of obstacles, depending largely on the structure of the system and the state regulatory context in which it operates. But each also brings its own strengths to the table. In our case, for example, the Mount Sinai Visiting Doctors Program, founded in 1995 to provide care to frail, elderly or ailing home-bound adults (and now part of Mount Sinai at Home) helped pave the way. Other institutions might have different strengths they could play on. For example, some hospitals already have their own home health care agencies; we did not.
The main challenge to setting up a hospital-at-home program that all of us in the United States face is financial. The U.S. health care system is simply not adept at devising a payment model for an entirely new mode of care. Abroad, hospital-at-home is much more common: Australia, Israel, and Italy, in particular, have robust programs. But those countries have single-payer systems, where one agency or government department pays for most if not all health care.
In the U.S., the hospital-at-home model has been used most effectively in the Veterans Affairs network, which essentially amounts to a single-payer system for its population. Health systems that combine hospitals with insurance plans would have the same opportunity. But those, like us, that do not must take another tack. So, to enable private insurance companies to pay for hospital-at-home, we formed a joint venture with Contessa Health to facilitate the development of contracts with health plans and other payers.
The biggest hurdle on the payments side is Medicare. While our program isn’t exclusively geriatric, many of the conditions we can take care of, like pneumonia, are most likely to result in hospitalization for older patients, and Medicare would account for the majority of patients eligible for hospital-at-home.
The launch of our Mobile Acute Care Team grew directly out of a $9.6 million grant we received as a Health Care Innovation Award from the overall Medicare governing agency, the Centers for Medicare and Medicaid Services (CMS). Subsequently, we proposed a payment system for hospital-at-home to Medicare, and in September 2017, our payment model was approved by Medicare’s Physician-Focused Payment Model Technical Advisory Committee, which recommends payment models to CMS. But CMS itself has yet to act on the proposal.
We’ve seen tremendous benefits to providing patient-centered care at home for acutely ill patients. Mount Sinai at Home acts as a cornerstone for our commitment to population health and being accountable to the needs of a population. This is the kind of medical care that we think will be necessary in the next century. We hope CMS will agree and establish a way for the U.S. health care system to expand these programs nationwide.