A chronically ill patient limps into the emergency room, clearly sick enough to be admitted. Prepare a hospital bed, right?
Think again, says Erin Denholm, chief executive of Centura Health at Home in Englewood, Colo. A better way may be to provide hospital-level care in the patient's own home.
That counterintuitive strategy, at least in terms of traditional health care, is the goal of Hospital at Home, a concept developed by Johns Hopkins University School of Medicine. The notion is that providing the full benefits of acute care in a patient's home can produce a better chance for recovery, lower the risk of infection and cost considerably less than a hospital stay.
Denholm is leading preparations to launch the Hospital at Home program this fall at St. Francis Medical Center, a Centura Health hospital in Colorado Springs, Colo. Centura is part of Catholic Health Initiatives. The Johns Hopkins model already is in use at Presbyterian Healthcare Services in Albuquerque, N.M., and at six Veterans Health Administration hospitals.
"This is the future, and it is evidence-based," Denholm said. "The outcomes are fantastic."
Opt-in, live long
Denholm said Centura's program will offer Hospital at Home to geriatric patients with chronic conditions, such as congestive heart failure, chronic obstructive pulmonary disease or pneumonia. A patient will decide whether he or she wants to return home for care. Centura will provide the necessary medical equipment, including a hospital bed if needed. Nurses and a doctor will make daily house calls.
Denholm cited a study, summarized in the June issue of Health Affairs, confirming significant results at Presbyterian in Albuquerque. Since October 2008, it says, participating patients had shorter lengths of treatment, reported better satisfaction, used fewer pain medications and were less likely to contract infections. The study also said the treatment cost 19 percent less than a standard hospital stay.
The Albuquerque study compared the outcomes of 323 Hospital at Home patients and 1,046 who were admitted to the hospital.
Dr. Bruce Leff, a professor of medicine at Johns Hopkins and founder of Hospital at Home, said participants also were 40 percent more likely to be alive in six months. "If Hospital at Home were a pill or a medical device, as opposed to a service-delivery model, it would be ubiquitous," said Leff, one of the authors of the Health Affairs report.
Payer hurdles
The concept already is in widespread use in some countries, including Canada, Australia and Israel. Clearly, it's not for everyone — medically unstable patients need to be in a hospital. And it doesn't yet fit with the fee-for-service systems of most hospitals and insurance providers, including standard Medicare, which presume patients whose acuity requires hospital care will be treated in a hospital proper.
But Denholm said health care payers nationwide are likely to embrace alternatives to fee-for-service payments in the future, allowing providers to share in the risk and rewards of improving care outcomes while lowering costs, a payment system that could support Hospital at Home programs.
Denholm said Centura is testing the idea in Colorado Springs because about 9,000 senior citizens there are enrolled in a Medicare Advantage plan, a managed-care system that pays a standard per-capita fee to health systems. To be eligible for Hospital at Home, patients must live within 25 miles of St. Francis.
Tapping the source
Centura's Hospital at Home is a pilot project with the federal Centers for Medicare and Medicaid Services. Denholm is one of the agency's 73 "innovation advisors" nationwide, and had been studying early progress of Hospital at Home. Leff is advising her on the Centura pilot through Hospital at Home, a trademark program licensed through Johns Hopkins.
Denholm said she was particularly intrigued by results showing that Hospital at Home patients used fewer pain medications. The reasons, she believes, are embedded in the hospital environment.
"If you want to have all your power taken away, go into a hospital," said Denholm, a nurse for 31 years. "It is such a foreign setting. When you are in your home, with all of your familiar surroundings, your anxiety goes way down. It's 'home, sweet home.'"
She said Hospital at Home is in step with Centura Health 2020. "We are transforming ourselves from a hospital system into a health care system — health care instead of sick care, which is consistent with our legacy and ministry," she said.
Telehealth expertise
Denholm said Centura Hospital at Home will build upon the hospital's telehealth program, eight years in operation, in which patients with chronic disease get basic care in their home and provide nurses daily with vital signs, oxygen saturation and other information through telephone hookups. She said hospital readmission rates for telehealth patients with congestive heart failure have been less than 2 percent, compared to 25 percent for patients not in that program.
Denholm said the difference between Hospital at Home and traditional home care visits is that the new program "is acute care hospitalization administered at home. Patients will get doctor visits, just like (they would) if they were an inpatient."
Nurses already working for Centura's home care program affiliated with St. Francis' owner, Penrose-St. Francis Health Services, will make visits at least daily to patients in the Hospital at Home program. Centura is contracting with a doctors' group to provide daily visits as well.
Denholm said the pilot is designed to care for about 50 patients in the first year, and 60 to 75 in the second year.
Leff praised Denholm's work and said Penrose-St. Francis Health Services already provides quality care through its telehealth and home health programs. He said Centura understands "where health care is heading in an era of value-based care."
Safeguarding frail seniors
Southeast Louisiana Veterans Health Care System, the Veterans Health Administration hospital in New Orleans, adopted Hospital at Home in 2007. Dr. Lumie Kawasaki, who oversees the program there, said the original motivation was to preserve hospital beds after Hurricane Katrina, which flooded the VA hospital and other medical centers in 2005. Kawasaki said the VA system in New Orleans has expanded the program since then and offers it "as an early-discharge program to assist in getting patients out of the hospital sooner."
Kawasaki, a geriatrician, said 276 patients have taken part in Hospital at Home there since 2007. She considers it a safe and successful option to traditional inpatient stays.
Because Hospital at Home doesn't generate traditional fees for service, Kawasaki said hospitals operating on that financial system might consider it a way to open up hospital beds for other patients and reduce the risk for infection.
"Many of the patients eligible for Hospital at Home are older, frail, medically complex, and more vulnerable to some of the potential complications of being in a hospital," she said.
Centura, which operates 13 hospitals and other health centers in Colorado, is a joint operating agreement between CHI of Englewood and Adventist Health System in Altamonte Springs, Fla.