Mass General Brigham’s Home Hospital program, one of the largest hospital-at-home initiatives in the country, serves more than 33 patients a day, with plans to grow to 45 patients daily in the near future.
But then things are going to speed up: The system’s five hospitals — academic medical centers Brigham and Women’s and Mass General Hospital and community facilities Newton-Wellesley Hospital, Salem Hospital, and Brigham and Women’s Faulkner — expect to move 10% of inpatient care to patients’ homes within the next five years.
Emergency physician Stephen Dorner MD, MPH, MSc, chief clinical and innovation officer for Mass General Brigham Healthcare at Home, believes that goal is not only attainable, but also inevitable. “I don’t think that 10% is a stretch goal for the country,” he says. “We see the number of patients flowing through this model skyrocketing.”
As programs proliferate, home hospital pioneer Linda DeCherrie, MD, says leadership from chief medical officers is essential to success. DeCherrie, vice president of clinical strategy and implementation at Medically Home, a company that partners with health systems to operate hospital-at-home programs, finds that hospitalists and geriatricians are often the champions for hospital-at-home programs, but they must have support from CMOs.
“Hospitalized patients (including those hospitalized at home) need consultants, so the CMO needs to work with the cardiologists, nephrologists, and infectious disease docs to get them excited about this as well,” she says. “We have seen that cross-department change management coming from the CMO offices has been really helpful in getting these programs launched.”
Hospital care at home is not appropriate for all patients, but it is a well-developed practice in Australia and several European countries; a few American leaders, including Presbyterian Health and the Veterans Affairs system, have been providing it for years. The concept began to explode in 2020, however, when the Centers for Medicare and Medicaid Services introduced a waiver to support hospital-at-home to alleviate inpatient overcrowding during the pandemic.
The waiver, originally part of the public health emergency measures, has been extended through December 31, 2024. As of late 2023, 128 health systems and 304 hospitals in 37 states had been approved to participate in the waiver. Some of those have not yet started operations, but some other systems operate hospital-at-home programs as a value-based care strategy supported by payers outside the CMS waiver initiative.
If the current rate of adoption continues, by 2030, one in every six U.S. hospitals will have hospital-at-home capability. “I think it will become something that patients demand such that if you don’t have a home hospital program, people may choose to go elsewhere when they recognize that ‘Oh, I’m less likely to die if I get my care at home’ and ‘I’m less likely to have to use a skilled nursing facility if I get my care at home,’ ” Dorner says.
RECOGNIZING THE BENEFITS OF HOME CARE
VCU Health in Richmond, Virginia, received its waiver in early 2022 and launched Home Hospital in January 2023. Geriatrician Julia Siegel Breton, MD, co-medical director of the program, has spent the last two years educating her colleagues about the care-delivery model and has identified a few important concepts about which healthcare professionals are often unaware.
The top concept: hospital-at-home is the acute care equivalent to inpatient care. Because clinicians have not been trained to care for patients in their homes, they may mistakenly assume that the level of care is lower than that for inpatients. “It’s not outpatient and it’s not home health,” Breton explains. “It’s like another unit of our hospital, except it happens to be in the patient’s home.”
Secondly, hospital care at home is safe. A study, published in JAMA Health Forum, of 11,159 patients admitted to hospital-at-home programs under the CMS waiver between late November 2021 and late March 2023 found 38 unexpected deaths (0.34%), most of which were related to COVID-19. Except for three cases, each of the 38 had been moved to an inpatient bed or an intensive care unit several days before they died.
Overall, 7.2% of hospital-at-home patients were transferred to a brick-and-mortar hospital during their care. “Here, we have experienced less than 5%,” Siegel Breton says. “That means 95% of our patients complete their inpatient care in the comfort of their homes.”
Another point that is often missed: Seeing patients in their own environment helps clinicians improve care. “When you’re in the patient’s home, you get a much, much better sense of what’s going on in their lives, what supports they do or don’t have, how they are managing their medications,” she says. “You get to dive deep into diet and activity and safety in a way that we can’t possibly do in brick-and-mortar hospitals.”
Having this type of knowledge helps build trusting relationships between patients and clinicians and helps physicians know the types of support and resources patients need after discharge to avoid readmission.
Lastly, Siegel Breton says it surprises clinicians to find out how much patients — and the clinical teams caring for them — like the at-home model. “You just never see Press Ganey patient-satisfaction ratings as high as you see in hospital-at-home programs,” Siegel Breton says.
David Levine, MD, clinical director of research and development at Mass General Brigham Healthcare at Home, has research and anecdotes that show burnout levels among hospital-at-home clinicians are lower than their inpatient peers.
“We see folks who basically say, ‘I’m never going back to just working in the hospital because it is such a different experience,’ ” he says. “They have more time with their patients; they get to know their patients better. It is a very authentic way of practicing that most of us don’t ever learn about in school.”
Before assuming his current role with Mass General Brigham, Levine launched Brigham and Women’s Hospital’s pilot program and made it operational in 2016. His research on its efficacy has propelled the hospital-at-home movement. In two randomized controlled trials, he and his colleagues found that:
Direct costs were 38% lower for patients hospitalized at home compared to those for inpatients.
On average, at-home patients received far fewer lab tests and imaging studies.
At-home patients required less post-acute care.
The 30-day readmission rate for home hospital patients was 7% compared to 23% for inpatients.
Patients treated at home took an average of 1,800 steps a day and spent 18% of the day lying down, compared to 160 steps per day and 55% of their time lying down for the control group.
In 2022, the Brigham and Women’s program and the program at Massachusetts General Hospital came together to form Mass General Brigham’s Home Hospital, and in 2023, the at-home option was extended to the health system’s three community hospitals.
The system uses a hybrid approach to provide patient care. Central leadership and operations reside at Mass General Brigham Healthcare at Home, but resources come from each of the five hospitals whose patients are admitted into the home hospital.
“Providers are cross-credentialed so that they can serve patients under different encounters across different hospitals,” Dorner explains. “We leverage courier services so that our clinicians are focusing on the clinical care and not the supply transportation between hospitals and storage sites and patients in their communities.”
Nurses and paramedics, as well as some advanced practice providers and physicians, take home hospital shifts as a component of their full-time job, spending, for example, 30% of their time in that work and the rest in a traditional hospital or home health position. “We also have moonlighting opportunities and per-diem staff that have a full-time job but find enough meaning in this work that they take on the additional work,” Dorner says.
By contrast, eight VCU Health hospitalists work a one-week rotation on its at-home program, just as they would rotate through any service in the hospital. Two clinician teams — the nurses and paramedics who make home visits and the command center team of nurses who provide 24/7 monitoring and coordinate patient care — are fully dedicated to the home hospital program.
Like all hospitals operating under the CMS waiver, Mass General Brigham and VCU Health provide at least two daily in-person visits to the patient’s home, by either a nurse or a paramedic working on a designated care team. Physician rounds are typically conducted by video, although sometimes they are made in person.
The patient has around-the-clock access to the care team via video or phone, and all the services available at a brick-and-mortar hospital, including pharmacy, infusion, respiratory, diagnostics, food, durable medical equipment and everything else, are provided as needed.
SAME MODELS YET DIFFERENT
DeCherrie, a long-time leader in Mount Sinai Health System’s home hospital program before she joined Medically Home, says home hospital units operating outside the waiver — for example, a health system using hospital-at-home to support value-based care arrangements — typically follow the same pattern as required by the waiver.
In other ways, however, home hospital programs vary considerably. For example, some nurses come from a home health background and therefore are accustomed to visiting patients in their homes; however, they need additional training for the higher level of acuity of hospital-at-home patients, but other nurses have inpatient backgrounds and receive training on in-home care.
“The exact skill set that is needed is not yet being taught in nursing school, so there is training needed regardless of the background of the individual. In a hospital at home model, nurses are working with patients from the medical command center or are working with patients at bedside in patients’ homes,” DeCherrie says. “Mobile integrated health/community paramedics are also a noteworthy resource in some areas — they are used to acute care and are used to being in the home.”
The logistics required for hospital-at-home care are beyond the normal scope of hospital administrators. “What happens if your command center electricity goes down, and what happens if the patient’s electricity goes down?” she asks. “We have put nurses in hotels nearby patients when we know there’s going to be a lot of snow.”
Similarly, how do all the services get delivered to a patient’s home in the best way? When a physician orders a lab test, for example, getting the blood drawn and analyzed requires making several arrangements.
“Does the time that the nurse is coming to do an infusion match up with the time that makes sense for the phlebotomy, or should we get a phlebotomist to go to the patient’s home?” DeCherrie asks. “Is it most efficient for the phlebotomist to drive the sample to the lab or should a courier come so the phlebotomist can go to the next person?”
Working out all those processes and protocols to be delivered within a specific geography — at VCU Health, it’s within a 25-mile radius of the hospital — is unfamiliar territory, but hospital-at-home programs are supporting one another. “It’s a really collaborative space,” Breton says. “We have just been wowed with the time that other programs are willing to invest in our success.”
DeCherrie and Levine, along with two other hospital-at-home pioneers, co-chair the Hospital-at-Home Users Group. The group organized before the pandemic as an information-sharing group for the 20 or so hospital-at-home programs then in existence. With the rapid growth of the field, the scope has since expanded, DeCherrie says. “We’re there for those who are already up and running, and also we are providing information for those who are in the newer stages of starting a program.”
In the early stage of operation, units typically are challenged to get patients referred to acute care at home. One obstacle is payment; although commercial payers generally like the concept, contracts typically have to be amended before they reimburse for at-home care. Another barrier is the time it takes for physicians to become knowledgeable about the at-home option and start referring patients from the emergency department.
RIGHT CARE, RIGHT PATIENT
Aside from the increased patient and clinician satisfaction, the lower cost of care, and the better patient outcomes, the added capacity to treat patients may be the home hospital attribute that grabs their attention.
“When some patients can be safely transitioned into the home, that frees up a bed for a patient who maybe needs surgery or some very intensive diagnostics or imaging procedures,” Siegel Breton says.
Dorner points out that home hospitals reduce the need to build new inpatient capacity — at a savings of at least $2 million per bed.
“That’s just to build the bed, not to provide care in the bed,” he says. “It’s comparatively much cheaper to provide care in your home, without capital investment or the associated construction time. So, we need to provide a lot of care in patient homes. It is really a balance of giving the right care to the right patient at the right place.”