Nurses Rethink Where Patients Heal

Hospitals are struggling with long emergency room (ER) wait times, capacity issues, and staffing shortages. A growing number of patients with cellulitis, chronic obstructive pulmonary disorder, pneumonia, and other chronic conditions are being asked to skip hospital stays and return home.

Hospital at Home models may be the answer. The explosion of Hospital at Home programs now makes it possible to provide acute level care at home. Today, 378 hospitals in 140 health systems and 39 states have been approved to provide healthcare at home. And a recent report found that 71% of health systems planned to launch Hospital at Home models.

“Digital care is the way of the future,” said Melissa Meier, MSN, RN, manager of Digital Care for OSF OnCall, the Digital Health Division for OSF HealthCare in Peoria, Illinois. “We’re always looking at ways to help reach more patients [and] always being on the cutting edge to reach our patients wherever they are is super important…[Hospital at Home] is certainly an answer for that.”

A New Model of Care

In 2020, the Centers for Medicare and Medicaid Services (CMS) issued the Acute Hospital Care at Home initiative that made it possible for Medicare-certified hospitals to provide inpatient-level care at home. The COVID-era waiver was designed to address capacity issues during the pandemic but has proven popular as a long-term solution.

Mass General Brigham is among the hospitals that launched programs to offer inpatient care in patient homes. Since the 2017 pilot, the Boston-based hospital has served more than 6000 patients and unlocked 30,000 bed days through its Healthcare at Home program.

“Patients absolutely love this service,” said Stephen Dorner, MD, MPH, emergency physician and chief clinical and innovation officer at Mass General Brigham Healthcare at Home. “The experience is unmatched.”

Hospital at Home is best suited to patients with infectious diseases or respiratory, circulatory, or renal conditions. Patients receive in-home visits from providers at least twice a day, continuous monitoring of vital signs, portable ultrasounds, blood work, and other diagnostics, and access to medications and other therapeutics. The programs also include 24-hour access to virtual care teams.

Mass General Brigham begins screening for eligibility for Healthcare at Home in the emergency room based on clinical criteria, distance from the hospital, and payer coverage. In Renton, Washington, Providence takes a similar approach to screening patients who are eligible for its Hospital at Home program before initiating a conversation with patients to assess their interest in receiving care at home.

“Unsurprisingly, it’s not right for everyone,” explains Christopher Dale, MD, MPH, medical director, Clinical Innovation at Providence. “It could be that they [patients] don’t want other people in their home…and there’s a segment of people who feel more comfortable getting care in the hospital, thinking that the nurses and doctors are right there all the time…and they feel safer that way.”

However, there can be significant benefits for patients who receive acute care at home. Studies have linked Hospital at Home programs to reduced hospital-acquired infections, less time spent in skilled nursing facilities, fewer hospital readmissions, and lower mortality rates; there are revenue benefits, too. Hospital at Home programs at Johns Hopkins, Baltimore, saved 19%-30% compared to in-hospital care.

“It’s a way to create capacity in the system,” said Dale. “We all know about [issues with] boarding in the emergency department and how long it takes to get a bed…and we don’t want that…and this creates capacity so that hospitals can stay available for the sickest of the sick.”

Providers have embraced the model. Physicians and registered nurses providing acute in-home care reported lower burnout, higher job satisfaction, healthier work environments, and a feeling that their professional values were well-aligned with the program in a home hospital pilot program.

“We know that healthcare is hard, and this has provided another model of care for nurses, physicians…to still have that in-person care component and be able to provide hands-on care in a different setting that really helps them to focus on one patient at a time,” Meier added. “It really has helped to remind them [nurses] why they got into healthcare in the first place.”

Charting the Challenges

The model might be successful, but Hospital at Home is not without its challenges. The logistics are complicated. Mass General Brigham manages a dedicated Healthcare at Home team, schedules home visits, provides access to 24-hour virtual patient care, and ensures that healthcare providers have the right supplies to provide patient care. To facilitate communication, OSF HealthCare does (virtual) interdisciplinary rounds every morning to bring the whole care team together.

“The coordination of ensuring you’ve got the right people with the right supplies at the right place in a remote location gets very complicated very quickly,” Dorner said.

Launching a successful Hospital at Home program requires a strong commitment from leadership. It touches multiple hospital departments, from providers to revenue, accreditation, and food services, and, as an initiative still in its adolescence, Dale cites the importance of working with leadership to adjust as needed.

Health systems are always concerned about navigating the logistics; they are considering the long-term viability of Hospital at Home. CMS has extended the Acute Hospital Care at Home waiver, initially set to expire at the end of 2024 and now extended through 2026 — but the future is uncertain.

Reimbursement remains challenging. Under the waiver, Medicare-certified hospitals can provide inpatient-level care at home, but most private payers have not followed suit. The lack of reimbursement coupled with uncertainty about waiver extensions has made some hospitals reluctant to launch Hospital at Home programs.

Dorner believes that making Hospital at Home a permanent option for patients is critical to the future of healthcare and plays a critical role in alleviating burnout, reducing wait times, and providing safe, effective, value-based care.

“We’re not going to be able to exclusively build our way out of the capacity crisis…and so we have to find new ways to support that growing demand,” he said.

“It’s hard to look at the landscape of what can be afforded through home hospital care delivery from a quality perspective, an experience perspective, a capacity perspective, a financial perspective and think, ‘No, we don’t want to do that.’”

Jodi Helmer is a freelance journalist who writes about health and wellness for Fortune, AARP, WebMD, Fitbit, and GE HealthCare.