IDN OPPORTUNITIES
Hospital @ Home More and more providers are turning to acute care in the home. But how effective, and safe, is the new model? By Graham Garrison
When Bruce Leff, MD, is in his office space at Johns Hopkins seeing an older adult who is acutely ill, he thinks very
hard on whether hospital admission is the best choice. “I know I can take care of the heart failure, or the pneumonia, or anything else,” he said, “but will they end up worse for wear, just by virtue of having been in the hospital?”
It’s a question hospitals and health systems have been grappling with for decades, including Johns Hopkins. And it’s one that came front and center during the pandemic as providers, strained by volume and workforce shortages shifted to new models of care. Researchers started to think about the ability to provide acute hospital-level care in the home, instead of the bricks and mortar hospital in the mid-90s. Questions they asked themselves included: Who should be treated in Hospital At Home? What conditions? How do you choose the right patients?
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April 2022
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“You want patients who absolutely meet threshold requirements for an inpatient hospital stay, but they’re not so sick that they need an ICU or have a high risk of deteriorating during the hospital stay, so we developed those kinds of criteria,” said Dr. Leff, professor of medicine and the director of the Center for Transformative Geriatric Research at the Johns Hopkins University School of Medicine. Johns Hopkins conducted early studies on whether patients would actually sign up for this kind of care, and it seemed that they would. Anecdotally, researchers knew that many
older adults refuse to go to the hospital if they can avoid it. “There’s a very robust literature to suggest that the hospital is not always the most hospitable environment for older adults,” Dr. Leff said. Older adults can develop confusional states in the hospital, like deliria. It can cause long-term cognitive outcomes. “They develop more functional impairments, because it’s hard for them to get out of bed, and then they end up in a nursing home. They fall out of bed, they get nosocomial infections, all of that.” Researchers at Johns Hopkins did some early clinical trials of Hospital At Home, and reported that patients did well with clinical, economic and positive patient experience outcomes. Back then, there was no fee for service payment for Hospital At Home. Johns Hopkins tried unsuccessfully to get a payment waiver from CMS to pay for Hospital At Home in fee-for-service Medicare in the mid-late 90s, but was unsuccessful. So, they pursued larger studies with Medicare Advantage plans and the VA. Within 2014, a Center for Medicare and Medicaid Innovation demonstration of Hospital At Home was conducted at Mount Sinai in New York. “Again and again, it proved out all the basic hypotheses
