Remember Doc Baker from Little House on the Prairie ? He treated the sickest residents of Walnut Grove in their own homes. There was no ER or hospital.
As modern medicine and technology grew, we left the Doc Baker style of medical practice behind. We’ve moved to the hospital model for severe illness and embraced the more-is-better philosophy. More treatment, more hands on care, and more cost must mean better results.
But more isn’t always better. Hospitalization comes with its own set of risks. Delirium is a common problem for inpatients. The combination of unfamiliar surroundings, disrupted sleep, and medication are instigators of the confusion.
Falls are a common problem for elderly hospitalized patients. More than 700,000 falls occur in hospitals each year due, in part, to unfamiliar surroundings.
Hospital-acquired infections such as pneumonia and urinary tract infections are a constant threat to admitted patients.
In the 1990’s, about a hundred years after Doc Baker was doing his thing, some physicians at Johns Hopkins wondered if there wasn’t some way to combine the best of both worlds. Could we blend the comfort and familiarity of friendly home surroundings with the best medical practices available? They believed the answer was yes, and Hospital at Home was born.
Their concept was simple. Elderly patients with certain diagnoses are evaluated for eligibility. The Emergency doctor offers eligible patients Hospital at Home. If they choose to enroll, they receive initial care in the ER, then transportation back home. A nurse meets them at home to continue care and ensure all needed services are in place for the in-home hospitalization.
After the patient is set up at home, the nurse returns for twice-daily visits. The Hospital at Home physician visits daily. More visits by the nurse or doctor can be arranged based on clinical need. Basic imaging and lab needs are performed at home, while more significant testing requires brief visits to the hospital.
The patient receives the same level of care as they would in the hospital, but in familiar surroundings, with familiar food, and with less sleep disruption.
The physicians were so confident in this plan that they set up a small pilot program which proved to be a success. The program was studied extensively over the next decade and half, with outstanding results . In fact, for every 50 patients enrolled in Hospital at Home rather than admitted to the hospital, one death was prevented. This Number Needed to Treat, or NNT, is a common method used to evaluate the benefit of a given treatment. Hospital at Home has a lower threshold for benefit than many drugs. Widely prescribed statins , for instance, often have a NNT of 100 or more to demonstrate a benefit.
Today, multiple VA programs have Hospital at Home in place, as does Presbyterian of Albuquerque for their Medicare Advantage plan.
Not only do patients have fewer falls and a lower mortality rate than their hospitalized counterparts, the program has offered a 19 percent cost savings .
This model has been widely adopted in Victoria, Australia with excellent results. After the health authority there decided to pay for Hospital at Home at the same rate as inpatient care, they were able to prevent 33,000 admissions. They estimate that the region would require another 500 bed hospital if it weren’t for this approach.
The question is, if this is such a great program, why isn’t it more widely adopted?
Follow the money. Getting paid for Hospital at Home in the U.S. is about as tricky as it was for Doc Baker back on the prairie.
VA systems and Medicare Advantage care for their cohort of patients with a set budget. Any cost savings is money left in the budget. It makes financial sense for them.
Most hospitals, however, make money from hospitalizations, not from preventing them. The more patients admitted to the hospital, the more they can bill insurance and traditional Medicare. Keeping patients out of the hospital hurts the bottom line. Why would those in charge want to change that? Sadly, financial incentive too often trumps outcomes in the high dollar world of medical care.
There is hope that this will change in the near future. The Center for Medicare and Medicaid Services has given one of their Health Care Innovation Awards to the Icahn School of Medicine. They will use it to pay for outpatient acute care services, based on the hospital at home model.
In this season of political warfare, there is at least
agreement that our healthcare is too expensive and the quality outcomes are
sub-standard for the amount we spend. Innovative approaches like this should be
embraced. Systems that won’t even consider it are suspect.
Amy Rogers MD is not a practicing physician and nothing written here should be taken as medical advice from either Amy or AssetBuilder. Medical decisions should be made with care in consultation with your health care provider.