Years ago, I worked in a long-term acute care hospital. We employed social workers whose job was discharge planning. They charted out where to move patients once they had been treated by our hospital. This process was started before patients were admitted. Patients with no clear path to move elsewhere were not admitted. Our average length of stay was in excess of 30 days. At that time our type of facility was PPS exempt and cost reimbursed based on a TEFRA limit (see p. 71 for more information).
Some of our patients left in a hearse, some were transferred to a rehabilitation center. Some patients were discharge to a nursing home with skilled nursing care, while others were sent home with home care. Our hospital was the type that few (if any) patients were able to walk out of under their own power.
Our patients mostly came from acute care hospitals, after the patients were stable and it became clear they needed weeks to convalesce before leaving a hospital. The scenario I described is what’s known as the continuum of care. Each patient is progressively moved to lower cost settings to avoid wasting resources. By that I mean Medicare stops paying after so many days and we needed the patients out of our beds.
What if Medicare was willing to care for patients in their own homes? The average cost of a stay in the hospital per day is $13,600. Of course, it tends to be higher on the first few days than the last few. We’ve already talked about being discharged home with home care, but what if patients could be discharged home with hospital care? That’s a program that is being done in Boston and across the country.
The eight-year-old Home Hospital program run by Brigham and Women’s Hospital, to which Faulkner Hospital belongs, is one of the country’s largest and provided care to 600 people last year; it will add more patients this year and is expanding to include several hospitals in and around Boston.
“Americans have been trained for 100 years to think that the hospital is the best place to be, the safest place,” said the program’s medical director, Dr. David M. Levine. “But we have strong evidence that the outcomes are actually better at home.”
A few such programs began 30 years ago, and the Veterans Health Administration adopted them more than a decade ago. But the hospital-at-home approach stalled, largely because Medicare would not reimburse hospitals for it. Then, in 2020, Covid-19 spurred significant changes.
While this was in response to Covid, some hospitals may be able to continue the program.
In November 2020, Medicare officials announced that, while the federally declared public health emergency continued, hospitals could apply for a waiver of certain reimbursement requirements — notably, for 24/7 on-site nursing care. Hospitals whose applications were approved would receive the same payment for hospital-at-home care as for in-hospital care.
I’d love to see competing virtual hospitals spring up that don’t need big buildings and can contract to perform hospital-at-home for less than a stay in an actual hospital bed.
Since then, Medicare has granted waivers to 256 hospitals in 37 states, including to Mount Sinai in New York City and to Baylor Scott and White Medical Center in Temple, Texas. Initially, hospital-at-home programs treated mostly common acute illnesses like pneumonia, urinary tract infections and heart failure; more recently they have also started dealing with liver disease treatments, post-surgical care and aspects of cancer care.
Hospitals are not safe for seniors. There are numerous reasons why. Hospitals can spread infections and being tethered to a hospital bed doesn’t allow for much activity. At my former employer we would get patients moving with so-called gait training. This involved the patient walking while pushing an empty wheelchair. A physical therapy technician would follow holding on to the patient’s belt. Yes, we got paid for this, CPT code 97116. This from The New York Times.
Older adults and advocates for their well-being have reason to hope that these programs stay. Studies have repeatedly documented the risks of hospital stays to seniors, even when the conditions that made the stay necessary are adequately treated.
Had Mr. Johnson remained in the hospital, “he would have been lying in bed for four or five days,” Dr. Levine said, adding: “He would have become very deconditioned. He could have caught C. diff or MRSA” — two common hospital-acquired infections. “He could have caught Covid,” Dr. Levine continued. “He could have fallen. Twenty percent of people over 65 become delirious during a hospital stay.”
My father went into a hospital for an aneurysm and died of kidney failure after he caught MRSA. Another thought. This could possibly help people who would otherwise have to travel from a rural area to a regional city. So how does a hospital-at-home program work?
At home, a doctor saw him three times, twice in person and once by video. A registered nurse or a specifically trained paramedic visited twice daily. They brought the drugs and the equipment Mr. Johnson needed: prednisone and a nebulizer for his asthma, and diuretics (including one administered intravenously) to reduce the excess fluid caused by heart failure. All the while, a small sensor attached to his chest transmitted his heart and respiratory rates, his temperature and his activity levels to the hospital.
Had Mr. Johnson needed additional monitoring (to ensure that he was taking medications as scheduled, for instance), food deliveries or home health aides, the program could have provided those. If he needed scans or experienced an emergency, an ambulance could have returned him to the hospital.
With the advent of the digital age, it became easier to remote monitor and care for patients in their own homes. Let’s hope programs like this expands and can ultimately save taxpayers money by cutting hospital costs rather than just function as another hospital revenue source.
Read more at The New York Times.