Hospital inpatient is obviously the most expensive setting for care. Bad things also often happen in the hospital, including acquiring infections or being the victim of other medical errors. A hospital stay is often an anxiety and depression-causing event. A lot of effort over the last three decades has gone into reducing hospital stays, triggering a need for better post-acute care. The cheapest setting for care tends to be the patient’s own home. Given advances in treatment and communication technology, the next step is to see how much care can be delivered in the home. A Commonwealth Fund report explores the emerging trend. (Comm. Fund Paper) One model for “hospital at home” was developed at Johns Hopkins. A care team, including a physician, nurses and home health aides, makes regular home visits to patients in the program and uses technology to monitor patients’ conditions. Providers learn a lot about a patient’s overall needs by being in their home and they typically are spending much more time with the patient than they would in the hospital. The critical determination is whether a patient who meets the criteria for hospitalization can instead be safely treated in their residence. Common conditions treated include heart failure, COPD, pneumonia, complicated urinary tract infection and cellulitis. To be most effective, the patient needs to be identified and the hospitalization intercepted before the patient ends up in an ER. Primary care and other physicians need to be aware of the program and proactively thinking of when it can be used. Patients tend to prefer being at home, so their acceptance of the concept is rarely an issue. Growth of hospital at home models is inhibited by Medicare’s failure to pay for the concept, although as usual, commercial payers, including Medicare Advantage plans, are ahead of curve in encouraging its use. Studies conducted to date suggest that caring for patients in this manner may as much as a third less expensive and some quality outcomes, such as mortality, may be better, while patient satisfaction is greater as well; but more systematic research is needed to confirm the value of the approach.
