Hospital-at-home (HaH) care may be a good replacement for traditional inpatient services among some patients who arrive at the emergency department (ED) with an acute condition, a health system reported.
In 2014, the Icahn School of Medicine at Mount Sinai in New York City was given a Health Care Innovation Award by the Centers for Medicare & Medicaid Services to demonstrate the clinical effectiveness of HaH care bundled with a 30-day postacute period of home-based transitional care. Since then, the institution’s Albert Siu, MD, MSPH, and colleagues observed that several measures did favor HaH care over inpatient hospitalization:
- Acute period length of stay: 3.2 versus 5.5 days (weighted P<0.001)
- All-cause 30-day hospital readmissions: 8.6% versus 15.6% (weighted P<0.001)
- ED revisits: 5.8% versus 11.7% (weighted P<0.001)
- Admissions to skilled nursing facilities: 1.7% versus 10.4% (weighted P<0.001)
- Rating their hospital care highly: 68.8% versus 45.3% (weighted P<0.001)
Yet rates of referral to a certified home healthcare agency yielded no difference between groups, Siu’s group reported online in JAMA Internal Medicine. Even so, they maintained that that their findings justify creation of a new payment model within Medicare’s current portfolio of shared savings programs.
In the fall of 2017, the Physician-Focused Payment Model Technical Advisory Committee — an independent group in charge of evaluating new payment models and reporting its findings to the secretary of the U.S. Department of Health and Human Services — recommended implementation of HaH-Plus, an alternative payment model (APM) for a new model of HaH that bundles the acute episode with 30 days of postacute transitional care, Siu’s team explained.
“Creation of an APM for such a model of HaH care would establish Medicare billing codes, allowing clinicians to bill directly for HaH services and paving the way for broad-scale adoption of the HaH program in the United States,” they said. “The aim of this study was to evaluate the complete data on clinical outcomes, patient experiences, and safety of this new HaH model.”
The HaH model was tested in 2014-2017 among fee-for-service Medicare patients with an acute condition such as an asthma attack or a urinary tract infection. Patients were excluded if they were clinically unstable, required cardiac monitoring or intensive care, lived in an unsafe home environment, or resided outside of Manhattan.
HaH care consisted of a physician or nurse practitioner (NP) providing home-based acute care services including physical examination, illness and vital signs monitoring, IV infusions, and wound care. Nurses visited patients at least once a day to provide most of the care, and a physician or NP saw patients at least daily in person or via video call facilitated by the nurse. Each patient also received a social worker visit at home at least once.
In the case-control study, a HaH cohort (n=295) was matched and compared to a concurrent control group of hospital inpatients who either refused participation or were seen in the ED during off-hours when no HaH clinician was available (n=212).
The overall study population had a mean age of 74.6 years and was 68.6% women. The HaH cohort was older and more likely to have a preacute functional impairment.
Siu and colleagues acknowledged the relatively small sample size and potential for selection bias in their observational analysis.
“Results from the Mount Sinai program did not consistently corroborate those from prior studies, perhaps due to heterogeneity in several dimensions of HaH programs (e.g., design, target clinical populations),” according to an invited commentary by Matthew Press, MD, MSc, of Philadelphia’s University of Pennsylvania Health System, and colleagues. “Some positive outcomes, such as the average length of stay and changes in patient satisfaction, mirrored those observed in other programs. In contrast, other work has not demonstrated lower readmission rates.”
Additionally, the proposed HaH-Plus payment model “could have far-reaching implications for care delivery,” the editorialists said, citing issues such as the safety of shifting patients from hospital to home and the logistics of deploying HaH-Plus in alignment with existing value-based payment programs.
It may be “more appropriate,” then, to perform more rigorous testing of the model before any wide-scale implementation, Press’ group suggested. “Such a test could involve experimental or quasi-experimental methods, stringent eligibility criteria based on more than clinician assessment and patient preferences, direct measurement of cost impacts, quality and safety standards, and different ways to fine-tune the technical payment details.”
Siu disclosed no relevant conflicts of interest.
Press was previously employed by the Centers for Medicare & Medicaid Services but did not work directly on the program discussed in the study.
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Primary Source
JAMA Internal Medicine
Secondary Source
JAMA Internal Medicine
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