Home is where the hospital is

Rapid rise in home-based post-acute care options during the pandemic means patients recuperate in familiar surroundings – but continuation depends on policymakers.

5:00 AM

Author | Kara Gavin

Provider in mask and scrubs sitting on edge of bed talking to patient.
Credit: Justine Ross

No one wants to stay in an emergency room or a hospital bed any longer than absolutely necessary.

But heading home too soon can make patients feel like they're walking a tightrope without a net below them.

Now, a growing number of hospitals have started offering services that bridge this gap.

A few of them started before 2020, but the pressures of the pandemic, and new flexibility from Medicare and health insurance companies, have prompted a massive acceleration in the past year and a half.

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Whether they're called post-acute care at home, hospital at home, completion at home, observation at home, patient monitoring at home, or other names, these new offerings aim to help patients safely avoid or shorten a hospital stay.

But there's still far to go before they're available to everyone – and health policy decisions in the next few months could play a big role.

"Across the nation, people are trying to figure out how virtual care and home visits can help with keeping patients out of the hospital or sending them home as soon as it's safe to do so," said Grace Jenq, M.D., the geriatrician who directs post-acute care services at Michigan Medicine, the University of Michigan's academic medical center. "This is really about making sure that the right care is provided at the right place at the right time."

Jenq leads a growing team of 12 physicians, dozens of nurses and a range of other health care professionals who have helped Michigan Medicine extend its nationally known care into more patients' homes since spring 2020.

Signs of success

Jenq's team runs five programs, and are developing two others, that can serve a range of patients depending on their health status and insurance coverage.

Most include in-home visits by physicians, nurses, pharmacists, therapists and others, supplemented by virtual connections between visits.

Nearly all the programs allow patients to monitor their blood pressure, blood oxygen, temperature, pulse rate and weight, and complete daily symptoms surveys from home, using a kit of Bluetooth-enabled devices and a digital tablet that beams the data to a team of nurses and health providers.

One of the programs, called Patient Monitoring at Home, relies mainly on this type of monitoring. Most of its patients participate for several weeks, and some for months. A new analysis compared to the patients' hospital and emergency care use in the six months before and after they entered the program. Hospital readmissions dropped by 64% for the 462 patients studied.

"This Patient Monitoring at Home program helps cover what I call the 'voltage drop' between hospital and home," said Ghazwan Toma, M.D., a family medicine physician and geriatrician who heads the program. "In the hospital their vital signs are checked every four hours and nurses check on them often, then they go home and often there's nothing."

His team fills that gap for as many as 150 patients on any given day, keeping an eye on vital signs and symptoms such as chest pain and shortness of breath, and standing by to intervene if they see a troubling trend or if something unexpected happens.

The program has included many COVID-19 patients, freeing up hospital capacity for other patients at critical times without compromising patient health or safety. Toma notes, though, that some commercial monitoring-at-home organizations have very high ratios of patients to the nurses monitoring them, unlike Michigan Medicine's program.

Important policy decisions coming soon

But Jenq, Toma and others across the nation worry that the momentum they've built up over the past year and a half could slow, if health policy doesn't keep up with the innovations they've made.

They're keeping a close eye on the fate of a Medicare waiver program, and telemedicine rules, that could expire as soon as July along with the federal COVID-19 public health emergency, unless Congress takes action.

There are currently bills before the U.S. House and Senate.

This is really about making sure that the right care is provided at the right place at the right time.
Grace Jeng, MD

Michigan Medicine is one of 95 health systems in 34 states, which have a total of 215 hospitals currently taking part in the Medicare Acute Hospital Care at Home program, which started in late 2020 under a special waiver as part of the response to COVID-19.

Right now, hospitals that meet the program's standards for in-home and remote care can be paid as much for Medicare patients' care at home as they are for in-hospital care for the same patient.

Jenq notes many other hospitals may want to take part, but don't want to launch unless the federal program gets extended so they can get paid for home-based post-acute care for patients covered by Medicare and Medicaid.

In addition to Medicare and Medicaid, Michigan Medicine has worked with Blue Cross Blue Shield of Michigan to establish ways to bill for home-based post-acute services for some of its members, depending on where they live and what their medical condition is.

Because Michigan Medicine is part of an Accountable Care Organization called POM-ACO, the programs may also help it achieve goals for reduced readmission and better preventive care for Medicare participants.

Encouraging providers to refer

The Michigan Medicine team is also working to educate more of their provider colleagues about the potential power of these programs to help patients continue their care in familiar surroundings, while freeing up hospital bed capacity and easing emergency department capacity crunches.

That buy-in is critical, because in order for a patient to get referred to a post-acute care home-based service, a hospital-based physician or emergency physician must agree that the patient is a good candidate.

Soumya Rangarajan, M.D., M.P.P., the geriatrician who serves as medical director for Michigan Medicine's hospital-level care at home, recently gave a Grand Rounds talk to Michigan Medicine's Department of Internal Medicine faculty and trainees, as part of encouraging more in-house referrals.

She shared data from studies conducted in the United States before the pandemic, and from the experience in Europe and Australia, where national health care systems actively facilitate hospital-at-home care.

On the whole, she said, "these show equivalent quality of care, with lower cost, and greater patient satisfaction, compared with in-hospital care for the enrolled patients."   

She also noted that in the 19th and early 20th centuries, receiving care from visiting providers at home was the norm – but that the rise of hospitals as hubs of advanced services and specialized providers all but ended the idea of a "house call" to check on an ailing patient.

"Right now, some emergency providers and hospital-based physicians may hesitate to make a referral because they may feel patients may not qualify medically," she said.

She and her colleagues often consult with providers about specific patients to determine what services they might need to support their transfer from the emergency department or observation unit to home, or their safe discharge from hospital care to home.

They describe the range of services that can be provided in patients' homes – including daily physician or advanced-practice provider visits, intravenous medications and fluids, point-of-care blood testing, ultrasound imaging, physical therapy and more.  

This adds to the skilled nursing visits that have long been a mainstay of post-hospital care, and specialized home pharmacy programs for patients with very complex needs. The program also includes immediate on-demand audio connection to a provider around the clock for emergencies.

Even if a patient might qualify, they must be covered by an insurance plan that participates in the program, and must live within the area served by the Michigan Medicine team or the local emergency medical organizations they partner with. These criteria can vary by program.

Getting the kit of monitoring equipment into patients' hands before they leave the emergency department or hospital, and educating them on what they should do with it and what other services they can receive at home, is also critical.

Jenq notes that hospital-based providers who write referrals for conventional home care that the patients themselves must follow up on once they get home may not realize how many of those patients don't actually get that care, or face delays, because of difficulties finding agencies that accept their insurance or have adequate staffing.

A career opportunity for providers

The rise in home-based post-acute services has spurred hiring of nurses who are interested in working from home as patient monitoring and case management specialists, and of physicians, physician assistants and nurse practitioners who can make the near-daily "house calls" needed to provide truly hospital-level care.

It's also meant adding more registered nurses, and physical and occupational therapists, to provide in-home care.

"Providers are really interested in this model, which is new and innovative and gives them a chance to connect with patients in a different space," says Jenq.

For providers looking for a career change or a new kind of connection with patients, the national trend toward more of this kind of care could mean new opportunities.

Looking to the future

Rangarajan notes that the Michigan Medicine team is working to expand access to home-based post-acute care further, including ways for some outpatient clinics to directly refer a patient to the service without needing to send them to the emergency department or for a hospitalization.

Less-intensive services, such as an app-based way for some diabetes and hypertension patients to keep their care teams up to date on their condition, are also being rolled out.

Toma notes that for patients who have their own wearable devices that can collect health-related data, a new program is being developed to let them transmit those readings to their Michigan Medicine providers.

But more research is needed on how well different programs actually work, and whether the short-term post-acute intervention has long-term effects on outcomes and costs, without diminishing patient satisfaction or safety. Telehealth researchers at the U-M Institute for Healthcare Policy and Innovation are helping do some of that research.  

At Michigan Medicine, readings from at-home monitoring and notes from home visits go directly into the patient's electronic health record. But around the country, some post-hospital programs run by large employers or commercial entities are cropping up – and may not communicate with the health system where the patient received their inpatient or emergency care.

Jenq also expects that as awareness grows of home-based options for more advanced care, patients and their loved ones will begin asking providers what's possible for them.

"We and other hospitals are amping up what we can provide at home, so it's absolutely a good idea for patients who are hospitalized or in an emergency room to talk to their doctors and nurses about this, and the team can tell you whether you're appropriate for the available programs," she said. "When patients initiate the conversation, then we create plans uniquely tailored to them, and work to keep them at home if that's the best option for them."

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