Did you know you can be in the hospital from the privacy of your own home? The idea of hospital care at home is not a new one. Nearly a century ago (1930s), nearly half of health care services were delivered at home. The local physician would make house calls to check on patients convalescing. The key word is convalescing, doctors at the time had few effective tools in their toolbox to care for patients. It was mostly up to patients whether they recovered or succumbed to their illness.
During the summer of 2020 hospital beds were full of patients sick with Covid. Even if there were free beds it was risky to admit people in need of hospital care who did not have Covid. The Acute Hospital Care at Home initiative was launched to provide hospital care outside of hospitals. About 320 hospitals were providing hospital care in patients’ homes last year.
Hospital care at home involves a homecare nurse (or homecare technician), who swings by to check on patients, administer medicines, change bandages, etc. This is primarily recovery. (i.e., There is no surgery being done on the dining room table.) One thing that is different today (besides better medicines) is the ability to monitor patients remotely. Vital signs can even be reviewed by a physician miles away.
Authorization for the Acute Hospital Care at Home program was due to end after Covid but has been extended several times. It is again due to expire before the year is out in 2025. The Houses of Representatives just voted to extend the program for five more years. Now the Senate must pass the extension. The following is from Scripps News:
Hospital-at-home, or acute at-home hospital care is for stable, acute-care patients. It could be used for someone who could be admitted to a hospital with a bad infection, COPD, or heart failure, for example. Medically Home operates a decentralized care model for patients with serious, complex or high-risk illnesses in partnership with health systems to safely care for their patients at home, across the care continuum. The patients are discharged more quickly or stay at home completely to heal in their own dwelling.
The concept is sound: there is no reason to recuperate in an expensive hospital bed longer than necessary. I worked for a facility 35 years ago that was similar, except instead of extremely sick but stable patients recuperating in expensive hospital beds in the acute care hospital, they were transferred to a cheaper setting called a long-term acute care hospital (LTAC). When patients were admitted to the LTAC hospital, they had to be stable with an expected length of stay of more than 25 days. From the LTAC hospital patients were discharged to nursing homes for additional recuperation, and later to home with home care. Hospital at home is an attempt to cut out some of these steps in the care continuum.
So, what is not to love? A large nurses union hates the idea, probably because it is easier for nurses to move from one hospital room to the next when caring for patients. Also, private equity and hedge funds are looking to get into the program. When this has occurred in other areas of medicine costs go up and quality trends downward. There is a vast difference between a heavily monitored patient recovering at home with home care, versus the same patient with little monitoring. Expensive hospital at home care could turn into faux hospital, just standard home care at a high price. More from Scripps News:
Johns Hopkins’ research in their hospital-at-home program showed the cost of hospital-at-home is a couple thousand dollars less, and length of stays were shorter. Cases of delirium — a complication — were dramatically lower.
A 2021 analysis in the Journal of American Medical Association of several studies of hospital-at-home patients found treatment lasted an average of five days longer and had a similar mortality risk. Hospital readmission risk went down 26%.
Patients are divided. Many who have tried it loved it. What could be better than recovering in your own bed with nurses coming by to check on you. On the other hand, not every home is equipped for hospital care at home. There may not be room. The house could be crowded. When given the opportunity, 60% of patients declined and requested inpatient stays. Another risk is that hospital at home care could be ordered when far cheaper home care is all that is needed.
Scripps News: What is hospital-at-home, and what’s the debate about it?
John Goodman is always the spear tip of new pushes into new policy issues. Here too he shows how more choices can produce better outcomes for both the patients and the “system” that is endevoring to address those issues. Another hat tip to John Goodman.