Health systems experiment with providing hospital care at home

When primary care physicians affiliated with Presbyterian Healthcare Services, a large integrated system based in Albuquerque, N.M., tell some patients with community-acquired pneumonia or another illness from a short list of acute but common conditions to get hospital care, the patients don’t go to a room — they go home. The hospital comes to them, with hospitalists stopping by at least once a day and nurses and other staffers becoming frequent visitors, sometimes for hours at a time.

“[Hospital at home] is an alternative to a hospitalization, and primary care physicians always have access to what is going on with the patient during the episode of care,” said Karen Thompson, director of Presbyterian’s program. “If a patient thinks they need to go in, we send them to the hospital. If we feel that the patient is declining further and we are not able to meet their clinical needs, we send them to the hospital. It’s hospital-level care, but it’s not ICU care.”

The program launched in 2008 as an attempt to lower costs. Data released in the June issue of Health Affairs found it had the desired effect. Medical expenses for patients cared for at home were 19% lower than for patients who received similar care in one of Presbyterian’s hospitals. This was primarily achieved by reducing patients’ average length of stay from 4.5 to 3.3 days and fewer lab and diagnostic tests. None of the hospital-at-home patients fell, while 0.8% of those in hospital did. Ninety-one percent of hospital-at-home patients were satisfied with their care, while 84% of those hospitalized were.

Interest in testing innovative care models, such as this one, has grown since the enactment of the Affordable Care Act in 2010 and other legislation shifting some hospital pay away from fee-for service to greater incentives to improve outcomes and lower costs.

ACA mandates that the Center for Medicare & Medicaid Services establish accountable care organizations for Medicare beneficiaries that provide bonuses for achieving certain cost savings and meeting quality metrics for a group of patients. Presbyterian has been designated as one of CMS’ accountable care organization pioneers.

The health system reform legislation states that hospitals will be penalized for high readmission rates. Beginning in October, Medicare will cut by up to 1% payments to hospitals with a significant number of readmissions. This reduction may go up to 3% in October 2014. But ACA is not the only reason health systems need to contain costs. Medicare stopped paying for certain preventable events such as catheter-associated urinary tract infections in 2008. Health industry experts expect the shift away from fee-for-service to continue, even if the U.S. Supreme Court, which is reviewing ACA, rules that the law is unconstitutional.

Presbyterian is applying to the Center for Medicare & Medicaid Innovation for a grant for further development. Centura Health, the largest health care network in Colorado, is launching a hospital-at-home program in the fall. The Veterans Affairs medical system has several such programs across the country that have been running for several years, and the number of participating facilities is expected to grow.

“If you are actually doing population management, then it’s a great fit,” said Bruce Leff, MD, a geriatrician at Johns Hopkins University School of Medicine in Baltimore. He helped run the first U.S.-based pilot projects of this concept in the mid-1990s. “We’re starting to get lots more calls from payers and large health systems about this model. The push for a system change has really helped quite a bit.”

The Johns Hopkins projects were funded by the John A. Hartford Foundation, which is working to improve care for the elderly, and the Dept. of Veterans Affairs. A paper in the December 2005 Annals of Internal Medicine, co-written by Dr. Leff, found that average length of stay was lowered from 4.9 to 3.2 days. Cost per episode of care declined from $7,480 to $5,081.

Those involved in these programs say changes in the payment mechanism are the key for this model to work. Hospital-at-home initiatives first emerged in the 1980s as a means to save money in countries with single-payer health systems but remain rare in the United States because of the fee-for-service system. Johns Hopkins, where the program was pioneered in the U.S., doesn’t have one for that reason.

Part of managed care

Presbyterian is able to make its program financially viable because the patients who take part are in its managed care plans, meaning the system receives a bundled payment for all care provided. The VA is able to sustain its programs because the federal government gives it money to provide services, and this is not affected by the amount of care given. The program at Centura Health will be for those enrolled in its Medicare managed care plan.

“We have to be willing to let go of what traditionally has been done and be willing to be open-minded,” said Erin Denholm, RN, CEO of Centura Health at Home.

But limitations in how this type of program is funded means that growth has been constrained even at systems with established programs. Presbyterian has treated about 600 hospital-at-home patients, but the program expanded the list of eligible beneficiaries and conditions multiple times to do so.

Although these programs have demonstrated some good results, they don’t always achieve all of the preferred ends. The Health Affairs study reported that Presbyterian’s hospital-at-home patients had a 10.8% readmission rate within 30 days, which is slightly higher than the 10.5% who were readmitted in the hospitalized group. Researchers said this was due to program physicians being unavailable on weekends, when a significant number of readmissions occurred. The system has since hired physicians for weekend and evening coverage to address this issue.

A paper in the July 2005 Journal of Health Services Research & Policy looking at a program in Auckland, New Zealand, found that the per-patient cost was actually higher than usual hospitalization. This was due to the program not operating at full capacity.