Recent findings highlighting the success of hospital-at-home programs point to “tremendous opportunity” for in-home care providers, health care experts say.

But that opportunity largely depends on the Centers for Medicare & Medicaid Services (CMS) and its continued development of innovative payment models, they argue.

Broadly speaking, hospital-at-home programs try to identify acute patients with certain medical conditions that could be effectively cared for and monitored at home through daily nursing and clinician visits, along with any necessary testing or treatment, including antibiotic, IV fluid and oxygen delivery. It’s an ambitious—yet potentially risky—concept being pursed by multiple health care stakeholders, Atrius Health, Medically Home and New York City-based Mount Sinai Health System among them.

“There’s a great deal of hospital at home nationally,” Al Siu, director of Mount Sinai at Home, told Home Health Care News. “We’ve fielded many calls from hospitals, home care agencies and [health] networks around the country who have an interest in what we’re doing.”

Mount Sinai launched its hospital-at-home program in 2014 as part of a three-year CMS Innovation Center grant.

Funding expired last year, but the health system has been able to keep the program operational with the support of private payers, said Siu, who is also a professor of medicine at the Icahn School of Medicine at Mount Sinai.

The program is now beginning to share some of its results—and they’re pretty encouraging.

Patients who participated in Mount Sinai’s hospital-at-home model between 2014 and 2017 had shorter stays, lower readmission rates and fewer emergency department visits, a study published last month in JAMA Internal Medicine revealed. Mount Sinai’s hospital-at-home patients also reported better care ratings than individuals receiving treatment in a traditional hospital setting, according to the study.

“Outcomes were better and we were able to reduce complications,” Siu, one of the study’s authors, said. “We were able to show we could do this safely and that was was another option for patients and their families.”

More than 507 patients in total participated in the case-control study. Of those, 295 were hospital-at-home patients and 212 were control patients, or individuals with similar conditions who continued treatment in a traditional hospital.

Participants commonly had diagnoses of community-acquired pneumonia, heart failure, urinary tract infections and chronic obstructive pulmonary disease.

The 30-day readmission rates were about 16% for patients in the control group and about 9% for those in the hospital-at-home group, according to the study.

Similarly, the rate of emergency department visits was about 6% for the control group and about 12% for the hospital-at-home group.

“We actually had significant savings on the main drivers of costs in the immediate 30-day period,” Siu said. “We expect to see cost savings because the main driver of costs in the 30-day period are readmissions, which were decreased by about 50%.”

Cautious optimism

 CMS is currently considering two alternative payments models related to hospital at home.

In October 2017, the Physician-Focused Payment Model Technical Advisory Committee (PTAC) recommended implementation of a new hospital-at-home alternative payment model that bundles acute episodes with 30 days of post-acute transitional care. The model was known as “HaH-Plus” and was supported by the Icahn School of Medicine.

PTAC also recommended a separate but similar hospital-at-home model in May.

Despite the recent promising findings out of Mount Sinai, the United States health care system may not be quite ready for a nationwide hospital-at-home rollout, Matthew Press, an associate professor of medicine at the Perelman School of Medicine at the University of Pennsylvania, told HHCN.

Press wrote a corresponding commentary on the study, also published in JAMA.

“I think we’re not quite ready for that,” said Press. “I think it’s important to explore further before we just kind of turn the switch on for everyone to be able to do this.”

Specifically, more clinical research needs to be done focusing on what types of health care can be safely provided to patients in a home, which may have more uncontrollable environmental factors than a hospital, he said. Patients in the study may have experienced positive health outcomes, but they were largely self-selected and could have already had strong support systems in place at home, he added.

Considerations need to be made on the payment side as well.

“On the payment side, there’s potential consequences we really need to examine more closely to better understand, you know, the right away to pay for [hospital at home],” Press said. “A potential consequence would be you have inappropriate shifting [of a patient from a hospital into a home].”

CMS needs to ensure it’s not creating a “perverse incentive” of putting patients in the wrong setting, he said.

If a hospital-at-home alternative payment model is eventually implemented, it would need to be for a broad range of conditions in order to establish a critical mass of patients and medical professionals to provide service “in a robust manner,” Siu said.

CMS needs to approach hospital-at-home programs with caution, according to Press.

Ultimately, though, they will likely present exciting opportunities for home health providers, he said.

“To me, this is one more opportunity for home health to continue to evolve the way it delivers care,” Press said. “Obviously, though, home health, the care model, is very much dictated by the payment model … It’s a tremendous opportunity for the home health industry to apply its skill set in other contexts.”

Written by Robert Holly