Hospital at Home: The coming of age and the value of telemedicine

• High acuity care in the home aligns with the growing preference for home-based and decentralized care
• Advanced technologies are able to support efficient workflows, real-time remote monitoring, predictive analytics and risk stratification
• Hospital teams could transform how acute care is delivered in the US
• Potential improvements in cost, health care use, and readmissions.

After making gradual inroads over the past few years, the hospital-at-home model seemed to have its breakthrough moment in November 2020, when the U.S. Centers for Medicare & Medicaid Services (CMS) introduced its “Acute Hospital Care At Home” waiver program.
^{1 Famakinwa}

Having high-acuity care in the home is indeed a transformation for the hospital systems and aligns with the growing preference for home-based and decentralized care, where possible.
^{1 Famakinwa}

Hospital-at-home programs aim to provide acute, hospital-level care in the home as an alternative to hospital admission. However, identifying eligible patients whose medical conditions can be cared for in the home setting, and coordinating nursing and clinician visits, plus necessary testing and treatment, remains challenging. Setting up and maintaining a successful hospital-at-home program is not easy and requires an organization to have a strong clinical staff and operational support in place. ^{2 Levine 2019}None the less, companies are investing heavily in this business model as evidenced by the recent Mayo Clinic and Kaiser Permanente joint venture investing approximately $100 million into the technology company Medically Home Group for a new healthcare delivery model that delivers “advanced care” into patients’ homes. ^{3 Japsen} Mayo Clinic president and chief executive Gianrico Farrugia said the partnership with Kaiser Permanente and Medically Home “will create the next generation of patient-centric, compassionate health care that seamlessly integrates advanced technology with clinical expertise.” ^{3 Japsen}

Why the hospital-at-home model has come to the forefront

Our aging population, the increase in chronic morbidity in all age groups, as well as the skyrocketing healthcare costs and work overload in hospitals has highlighted the global need for innovative solutions in the provision of quality medical services. The COVID-19 pandemic simply amplified this need ^{4 Levi, 5 Casteli} Organization and delivery of the current healthcare system is suboptimal, as evidenced by emergency room overflows in hospitals around the world. In addition, hospitalization holds significant risks for older adults, including iatrogenic complications, functional and cognitive decline, and loss of independence. For example, the prevalence of acute delirium in elderly patients (aged 65 or older) hospitalized on medical wards may be as high as 42 percent, according to some studies  ^{6 Kukreja}  – in major part due to the unfamiliar surroundings and routines the patient needs to adapt to at their most vulnerable time. Integrating home care services is a necessity for front-line health services organizations. ^{5 Casteli}

How technology has augmented the success of the hospital @ home implementation

Home telemonitoring is a promising potential solution to providing care for patients with chronic diseases. ^{7 Annis, 8 van der Burg} Various at-home medical devices are used for remote monitoring to collect information on targeted physiologic signs and symptoms. This clinical data is then digitized and sent to healthcare providers. During the COVID-19 pandemic, RM proved invaluable in limiting potential exposure to and/or spread of the SARS-CoV-2 virus by keeping patients at home. ^{9 Cummings} Patients and clinicians have reported high satisfaction rates for telehealth services, with comparable clinical and service outcomes. ^{10 Hutchings} Home hospital care reduces nursing staff, use of ancillary services and consultations, and limits readmissions, which reduce costs. Care is delivered in a patient-centric manner by a home hospital team as patients are able to be supported by their family and friends, eat their own food, move around in their own home, and sleep in their own bed. ^{2 Levine 2019}

Remote monitoring (RM) provides earlier recognition of actionable data, with the potential to reduce morbidity, mortality, emergency department (ED) utilization and hospitalization. ^{9 Cummings} Positive return-on-investment (ROI) for RM may be evidenced in a value-based care scenario. For example, RM could reduce the overall length of stay (LOS) and associated costs by admitting the patient only when it becomes necessary. A typical ED visit for a respiratory infection could cost $2,000 more than that for a patient managed in a less intensive setting. ^{9 Cummings}

The technology for RM has undergone rapid expansion in recent years

In addition to the rapid advances in digital technology, mobile communications, high-speed networks and wireless technologies, the information technology associated with RM is currently undergoing rapid growth. There is a rapidly growing trend for RM devices that utilize mobile smartphone technologies for data capture and transfer, with features that include mechanisms to provide educational information, the input of patient-reported outcomes from designed questions, manual or automatic digitization of physiologic data, asynchronous upload, interactive chat features, capability for video visits and emergency call functions. The use of evidence-based treatment algorithms to determine parameters with clear targets or thresholds are expected to result in the best outcomes, and ensure optimal use of RM. ^{9 Cummings} Smartphone enabled technologies, also known as mHealth technologies, include numerous apps and associated sensors such as a thermometer, a clip-on fingertip pulse oximeter or a blood pressure cuff. Continuous non-invasive sensors are available as “wearables”, like watches, rings, bracelets, necklaces and adhesive patches and are able to measure an array of vital signs. ^{9 Cummings} These may be useful in triggering early intervention and preventing hospital readmission. ^{11 Michard} The value of telemedicine virtual visits can be enhanced by RM as it provides objective data and trends over time. It allows for timely intervention if conditions change, allowing for effective management of patients with acute infectious disease. By allowing for earlier intervention, RM could improve clinical outcomes, lower resource utilization and improve quality of life. ^{9 Cummings}

Home hospital care for acutely ill adults requires careful patient selection in order to minimize risks ^{2 Levine 2019}

Risk stratification is closely aligned to the intensity of monitoring required with targeted use in the most vulnerable patient populations being the most cost-effective. ^{9 Cummings} A randomized control trial by Levine et al. compared outcomes of home hospital versus usual hospital care for patients requiring admission. The study included 91 adults (43 home and 48 control) admitted via the emergency department with selected acute conditions such as primary or possible diagnosis of any infection, heart failure exacerbation, COPD exacerbation, or asthma exacerbation. Patients were excluded if they lived in a long-term care or rehabilitation facility, required routine administration of controlled substances, required the assistance of more than 1 person to reach a bedside commode, or were considered to be at high risk for clinical deterioration on the basis of validated general and disease-specific risk algorithms. The results from this trial demonstrated that, compared with traditional hospital care, home hospital care for acutely ill adults reduced cost, decreased health care use and 30-day readmissions, and improved physical activity. It was also found that home patients had fewer laboratory orders and consultations than usual care patients without noticeable differences in the quality of care, safety, or patient experience. ^{2 Levine 2019}

Critical for at-home adherence are processes and technologies that are the most reliable and user-friendly as these may result in better outcomes and long-term patient satisfaction. The technology used for remote monitoring must be able to acquire, transmit, store and facilitate the analysis of relevant clinical parameters. ^{9 Cummings}

Hospital @ home – hope for the future

“The home hospital model aims to get the right care to the right patient at the right time in the right place” ^{2 Levine 2019} Reimagining the best place to care for selected acutely ill adults holds enormous potential. More trials and work are needed to better define the conditions and illness severity of patients who could be successfully cared for at home. New technologies need to be deployed and tested and more efficient workflows put in place that can optimize home-based teams and allow for expansion on a bigger scale. If scaled correctly with a favorable benefit: risk ratio, home hospital teams could transform how acute care is delivered in the United States, with potential improvements in cost, health care use, and readmissions. ^{2 Levine 2019}

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References:

1. Famakinwa J. Hospital-at-Home Holdouts: Why In- Home Acute Care Isn’t for the Faint of Heart – Home Health Care News. 28 March 2021. Available from https://homehealthcarenews.com/2021/03/hospital-at-home-holdouts-why-in-home-acute-care-isnt-for-the-faint-of-heart/ [Accessed 14 June 2021]
2. Levine DM, Ouchi K, Blanchfield B, Diamond K, Licurse A, Pu CT, et al. Hospital-Level Care at Home for Acutely Ill Adults: A Pilot Randomized Controlled Trial. J Gen Intern Med. 2018;33(5):729-736 DOI: 1007/s11606-018-4307-z
3. Japsen B. Mayo Clinic and Kaiser Permanente Invest $100 Million In ‘Hospital Care At Home’ Venture. Forbes. 13 May 2021. Available from https://www.forbes.com/sites/brucejapsen/2021/05/13/mayo-and-kaiser-invest-100-million-in-hospital-care-at-home-venture/?sh=24e47d1b6063 [Accessed 6 June 2021]
4. Levi B, Borow M, Wapner L, Feldman Z. Home Hospitalization Worldwide and in Israel. Isr Med Assoc J. 2019;21(8):565-567 Available from: https://www.ima.org.il/MedicineIMAJ/viewarticle.aspx?year=2019&month=08&page=565 [Accessed 14 June 2021]
5. Casteli CPM, Mbemba GIC, Dumont S, Dallaire C, Juneau L, Martin E, et al. Indicators of home-based hospitalization model and strategies for its implementation: a systematic review of reviews. Syst Rev. 2020;9(1):172 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7415182/ [Accessed 14 June 2021]
6. Kukreja D, Gunther U, Popp J. Delirium in the elderly: current problems with increasing geriatric age. Indian J Med Res 2015;142(6):655-662. doi: 4103/0971-5916.174546
7. Annis T, Pleasants S, Hultman G, Lindemann E, Thompson JA, Billecke S, et al. Rapid implementation of a COVID-19 remote patient monitoring program. J Am Med Inform Assoc. 2020;27(8):1326-1330 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239139/ [Accessed 14 June 2021]
8. van der Burg JMM, Ahmad Aziz N, Kaptein MC, Breteler MJM, Janssen JH, van Vliet L, et al. Long-term effects of telemonitoring on healthcare usage in patients with heart failure or COPD. Clinical eHealth 2020; 3:40–48. Available from: https://www.researchgate.net/publication/341537129_Long-term_Effects_of_Telemonitoring_on_Healthcare_Usage_in_Patients_with_Heart_Failure_or_COPD [Accessed 14 June 2021]
9. Cummings J. TechFlash: At-home remote monitoring of COVID-19 patients. June 2020. Available from https://www.vizientinc.com//media/documents/sitecorepublishingdocuments/secured/collaboratives/techflash_remote_monitoring_jun_2020.pdf [Accessed 9 June 2021]
10. Hutchings OR, Dearing C, Jagers D, Shaw MJ, Raffan F, Jones A, et al. Virtual Health Care for Community Management of Patients With COVID-19 in Australia: Observational Cohort Study. J Med Internet Res. 2021;23(3): e21064. Available from: https://www.jmir.org/2021/3/e21064/ [Accessed 14 June 2021]
11. Michard F. Smartphones and e-tablets in perioperative medicine. Korean J Anesthesiol. 2017 Oct;70(5):493-499. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5645581/ [Accessed 14 June 2021]