‘Hospital at home’ programs grow

Pandemic strains health systems’ bed space, staff

With COVID-19 draining resources in Arizona hospitals, some health systems are accelerating and expanding ways to care for acutely ill patients in their homes.

The Mayo Clinic in Arizona and Dignity Health in Arizona are two major health systems that are maximizing their use of technology to free muchneeded bed space and staffing in their facilities with “hospital at home” or “home hospitaling” programs.

Home hospitaling also appears to save money, and, in many cases, patients prefer to be at home, program leaders say. The programs are voluntary and not mandatory for patients, health system leaders emphasize.

Patients such as Michael Carr of Scottsdale, a retired engineer and kidney transplant recipient, have been able to replace a hospital stay with treatment from providers who visit their homes, plus check in with them via technology. In Carr’s case, the home hospital program is provided through the Mayo Clinic in Arizona.

Carr’s care for an infection he developed in October includes daily checkins from a command center that’s 2,000 miles away at a Mayo Clinic site in Florida but is able to dispatch emergency help to Carr’s home.

“As you can imagine for someone like me, a frequent flyer in the hospital due to the infections, it can be very, very difficult for the patient to manage,” said Carr, who is 67 years old and received his kidney transplant in 2020.

“I’m immunosuppressed because of the transplant drugs, and it turns out transplant drugs have hit my immune system rather hard. Every infection seems to be opportunistic ... To be in a home environment, it’s just an outstanding opportunity.”

The hospital at home programs are not to be confused with home health care, which typically is post-acute care that focuses either on treating patients after they’ve been discharged from the hospital, or on treating patients whose medical needs are not serious enough to warrant hospitalization.

“COVID has opened up a lot of weaknesses in our system, and this is certainly one of the solutions that exists to try to increase that capacity,” said Dr. Chad Nelson, medical director of the Mayo Clinic in Arizona’s Advanced Care at Home program.

Not everyone qualifies for the program. Common diagnoses of patients who could be candidates are congestive heart failure, pneumonia, cellulitis, kidney infections and COVID-19, Mayo officials say.

Limiting factors for patients: Geography, insurance

The Mayo program, which launched Sept. 13, is restricted for now to Medicare fee-for-service patients, but the hope is that more health insurers will participate as the program gets more established.

“I definitely think this increases capacity. We’re not talking about large numbers now, but as the program ramps up, that’s the idea, that there are patients who need to be in the hospital but they aren’t so sick that we couldn’t safely care for them in their home,” Nelson said.

“I do think this is the future, and I do see us continuing it. We’ve seen that in a lot of other industries, that as technology comes in and changes things, the system has to change. We’re starting to see that in health care.”

The programs do have limitations, with insurance and geography being the biggest factors to determine whether patients are eligible. For the Mayo program, patients must live within 15 miles of the Mayo Clinic Hospital in Phoenix.

Patients enrolled in Dignity Health in Arizona’s Home Recovery Care program must live within 30 minutes of the hospital. The Dignity Health program is nearly 2 years old and is limited to certain patients with private insurance, but the health system wants to expand the program to Medicare patients, said Robin Shepherd, vice president and chief nurse executive for Dignity Health in Arizona and Nevada.

“The pandemic certainly has given us more inspiration to think about how we deliver health care differently in Arizona,” Shepherd said. “Patients definitely prefer receiving care in their home, especially at this time when visitors may be limited ... And many people are afraid of the threat of COVID and they are not sure how going to the hospital is going to be, separated from their pets, their family and their community.”

Patients are screened before hospitals will approve them for getting such high-level care at home. Hospitals look at home safety and vet social factors like who will be in the home with the patient and whether the patient is at risk for falling.

Ahwatukee Foothills resident Adam Skipper said Dignity Health in Arizona delivered medical equipment to his home, including an IV pole, a tablet device and wireless technology for taking his vital signs when he was accepted into its Home Recovery Care program in mid-October.

Skipper, 54, had a severe staph infection that providers in the emergency room initially told him would require hospitalization for five days.

“I was overcome with anxiety. I felt like sometimes you go to the hospital to die,” said Skipper, a military veteran who works in sales. “I was ready to walk out against medical advice.”

‘COVID was just kind of the push that got it happening’

The concept of providing hospital care in the home dates back several decades, but technology advances have significantly improved hospitals’ ability to put the concept into practice, Nelson, of the Mayo Clinic, said.

“COVID really accelerated everything. These were projects that were already in the works in a lot of places, and then COVID was just kind of the push that got it happening,” Nelson said. “Before COVID happened, they (Mayo Clinic) were looking into the idea of this, and things were just able to accelerate with COVID.”

A pilot program through the state of Arizona that allows a hospital to treat acutely ill patients in their own homes enables Mayo to meet federal requirements set out by the Centers for Medicare and Medicaid Services’ Acute Hospital Care at Home waiver program. The waiver program, which launched in November 2020, enables Medicare patients to get hospital-level care at home through approved hospitals.

Both the Mayo Clinic in Arizona and Dignity Health in Arizona lobbied for the pilot program to be included in a bill that expanded telehealth in Arizona and was signed into law by Gov. Doug Ducey on May 5.

The law tasked the Arizona Department of Health Services with developing a three-year pilot program that allows for the delivery of acute care services to patients in their homes by licensed hospitals in Arizona.

As of Nov. 3, the Mayo Clinic in Arizona program had enrolled eight patients, with plans to ramp up.

“It’s not like we’re going to turn the switch on and have 20 patients in the program,” Nelson said. “We’re very deliberate in how we go about it, making sure that as we do the program, the program is safe and that we’re meeting all the expectations of the Mayo Clinic.”

The Mayo Clinic in Arizona program is the third Mayo Clinic site to have an Advanced Care at Home program. The first was in Jacksonville, Florida, where the health system’s command center for the home hospital program is located. The second was in Eau Claire, Wisconsin.

“It’s a designed process to slowly ramp up. Florida did the same thing. For their first few months, they had one patient a week, and now you can see the graph has ramped up where now it’s 50 patients,” Nelson said.

“Our goals were really only to have one patient per week to make sure that everything is working appropriately and that things are going well, so we’re actually ahead of that ... We have forecasting and goals for the program, so we’re actually ahead of our goals.”

Nelson said if people in the at-home program want meals, the Mayo Clinic will deliver them. But few people love hospital food, so most people are happy to eat at home, he said. The program also will provide a hospital bed, if needed.

“Most people don’t need a hospital bed, and to be honest with you, that’s one of the biggest complaints that we get — that hospital beds are not comfortable,” Nelson said. “Most people are just really happy to be at home in their own bed.”

The program has offered some unexpected advantages. In one instance, a patient whose medical condition necessitated low salt intake was observed during a remote visit with a large bag of potato chips on the kitchen counter behind him, Nelson said.

“I’d never get that information in the

hospital. We’re able to gain information we wouldn’t otherwise have,” Nelson said.

Adam Skipper, the Ahwatukee resident, hates hospitals and does his best to avoid them. He ended up spendingt one night in the hospital for his staph infection, which was required by his insurance carrier, and then discharged home.

Within two hours of his discharge, a Dignity Health nurse showed up at Skipper’s house and taught him how to use the equipment to record his vital signs. The nurse visited daily to do infusions of antibiotics, and in mid-November, he still was having regular visits with providers monitoring his condition via telehealth.

“I don’t know how I could have survived without this program,” Skipper said. “Hospitals are just not a comfortable place for me.”

Carr, the Scottsdale resident in the Mayo program, was similarly relieved his infection was not going to send him to the hospital yet again.

Though he still goes to the hospital for weekly blood draws, it’s been much lower stress to stay at home with his wife, Mary, and their miniature dachshund, Heidi, Carr said. He was interviewed on Nov. 11, shortly before his 8 a.m. daily check with the Jacksonville command center.

Using equipment provided by the Mayo Clinic, Carr takes his temperature, weight, blood pressure and blood oxygenation level and the results automatically go to the Mayo Clinic command center in Florida. Carr does not need to enter any of the data himself.

‘What has been most impressive has been the patient satisfaction’

Arizona hospitals are in a precarious situation with burned-out staff, unfilled nursing jobs and higher-than-usual patient demand. On Tuesday, there were just 111 intensive care unit beds available statewide — 6% of the state’s supply.

On Tuesday, clinical leaders of major Arizona hospitals and health systems pleaded with the public to get vaccinated as a way of ensuring that patients who need hospital care can get it.

Hospitalizations of COVID-19 patients in Arizona on Tuesday climbed for a 12th consecutive day to reach 2,574, which is a level that Arizona has not seen since early February.

While case and hospitalization levels overall have been lower than Arizona’s first two major surges of COVID-19, this wave is combined with higher-thanusual patient need, some of it caused by pent-up demand from health care delayed earlier in the pandemic.

The numbers underscore the need for ways of maximizing the use of hospital beds so that there are enough available for the sickest of the sick.

Monoclonal antibodies, a preventive treatment for COVID-19, is being widely used to keep COVID-19 infections from getting severe enough to require hospitalization.

Hospital at home programs are another way of ensuring an adequate supply of inpatient beds, some leaders say.

“Now we’re also entering a potential flu season,” Dignity Health’s Shepherd said. “We believe that this allows us to care for more patients than ever before. We believe we are increasing access to care, our effectiveness and really caring for patients in their preferred location.”

Hospital leaders are expecting home hospital programs to grow as the pandemic persists.

As of Nov. 12, Banner Health had seen 81 patients in its COVID at Home program since launching in August 2020, and patient numbers in that program have been increasing since October, Banner spokeswoman Becky Armendariz wrote in an email.

Banner’s COVID at Home program allows shorter hospital stays for some patients who are hospitalized with COVID-19 but have not been in the intensive care unit.

Phoenix-based Banner is Arizona’s largest health care system. In addition to evaluating other hospital-at-home development opportunities, Banner plans to build off of its COVID at Home experience by expanding into other conditions in 2022, Armendariz wrote.

Nelson said the Advanced Care at Home program at the Mayo Clinic in Florida is working on getting bone marrow transplant patients into the program. And the Florida program has expanded its geographical range where patients may live, which eventually could happen in Arizona, too, he said.

“From my standpoint, what has been most impressive has been the patient satisfaction. People sometimes don’t love being in the hospital, understandably, beyond just the fact that they are sick ... You lose privacy and independence and things when you are in the hospital, and you get a lot of that back at home.”