Hospitals make house calls for intensive care
ALBUQUERQUE — The man’s face was pasty, his eyes closed as he lay back in bed waiting for a wave of nausea to pass. Physician Elizabeth Ward bent over him after checking his temperature, blood pressure and oxygen levels and finding that all were normal.
“Would you rather stay home or go to the hospital?” she asked Frank Blondin, 52, who suffers from severe rheumatoid arthritis and heart disease. He also had a nasty diarrhea-inducing bacterial infection. “Home,” Blondin responded without any hesitation.
Soon, the doctor was managing a “hospital at home” admission — an arrangement that provides intensive care and monitoring in the quiet of a patient’s own bedroom. Medical supplies and medications would be delivered as soon as possible, she told Blondin’s wife, Pamela. A nurse would come within the hour, take laboratory samples and return later that afternoon and in the days to come. Ward would check in by phone and visit daily, and help would be available 24/7, if required.
Hospital-at-home programs refashion care for chronically ill patients with acute medical issues, testing traditional notions of how to treat people who become seriously ill. Only a handful of the initiatives exist, including the Albuquerque program, run by Presbyterian Healthcare Services, and programs in Portland, Ore., Honolulu, Boise and New Orleans, offered through the Veterans Health Administration.
The concept is getting more attention with increased pressure from the national health overhaul to improve the quality of medical care and lower costs. Hospital-athome programs do both, according to research led by the concept’s pioneer, Bruce Leff, director of geriatric health services research at Johns Hopkins School of Medicine in Baltimore.
In a study of three experimental hospital-at-home programs published in 2005 in the Annals of Internal Medicine, Leff demonstrated that patient outcomes were similar or better, satisfaction was higher and costs were 32% less than for traditional hospitalizations.
Not for everyone
Excluded from the program are patients who are medically unstable or who cannot be cared for adequately at home. “The patient, the family, the nurse, the doctor and the referring physician all need to feel if it’s safe,” said Scott Mader, clinical director of rehabilitation and long-term care at the Portland VA Medical Center. If patients take a turn for the worse, an ambulance is summoned to take them to the hospital.
In most programs, doctors examine the patient daily, and nurses and aides visit up to three times a day, often for extended periods. Patients are admitted for three to five days after being seen in the emergency room, referred by a physician or discharged early from a hospital.
“It’s a very successful model, and in five years, I think, it’s going to be very common. But we’re still in the early adoption phase,” said Mark McClelland, an assistant professor at the Center for Health Care Quality at George Washington University.
Among current plans for hospital-at-home programs:
-Presbyterian Healthcare and McClelland’s center have applied for a Medicare “innovation” grant to bring hospital-athome programs to Florida, Illinois, Minnesota, New York and Rhode Island.
-This summer, Centura Health, Colorado’s largest hospital system, plans a hospital-athome experiment in Colorado Springs, partnering with United HealthCare’s Secure Horizons Medicare managed-care plan.
-The Veterans Health Administration has approved funding for a new hospital-at-home program in Philadelphia and an expanded program in Honolulu, said Kenneth Shay, director of geriatric programs for the VHA.
-Clinically Home, a commercial venture, has developed a hospital-at-home model that involves caring for patients over 35 days, combining acute and post-acute care.
Resistance from Medicare and private insurers is the biggest problem these programs face. Traditional fee-for-service Medicare does not pay for hospital-at-home services, although some private Medicare Advantage plans may.
For physicians, “doing hospital-level services at home sounds scary,” and “it’s a big jump” that they haven’t yet em- braced, McClelland said.
Starting a program requires a considerable upfront investment of time and money, and it’s not a priority for many institutions focused more on keeping hospital beds full.
Patients prefer home
For Frank Blondin, care began with a call for help from a home health nurse. Within an hour, Ward arrived, performed a thorough evaluation, obtained the patient’s consent for a hospital-at-home admission, and decided on a treatment for his dehydration and infection. Then, Ward explained to his wife that complications would not be dealt with as quickly as in the hospital.
“Is that OK by you?” the doctor asked.
“I’m a little apprehensive because I’ve had to call 911 so many times for Frank,” Pamela Blondin admitted. “But he really wants to be home, and I’d much rather have him here.”