Abstract and Introduction
Abstract
Ms. H is a 78-year-old woman with a history of congestive heart failure, chronic obstructive pulmonary disease, and recent stroke who was discharged 1 month ago from a subacute rehabilitation facility. She moved in with her son because she now requires a walker and cannot return to her third-floor apartment. One evening, Ms. H develops a low-grade fever and mild shortness of breath intermittently relieved by her albuterol inhaler. Her son is worried, but knows that his mom does not want to return to the hospital.
Introduction
Introduction: Home-based Medical Care
The coronavirus disease 2019 (COVID-19) pandemic has placed unprecedented strains on our healthcare system. Emergency rooms, hospitals, and nursing facilities around the nation have been particularly affected. Given capacity limitations during the initial crisis and continuing into another season of increasing infection rates, there is tremendous pressure to keep high-risk patients out of acute care settings and discharge those who are admitted to appropriate post-acute care. At the same time, disease outbreaks and visitor restrictions at skilled nursing facilities (SNFs) create barriers to placement, both at an individual and public health level. In this context, care at home became and continues to be an increasingly critical option, particularly for older, comorbid patients who represent a large proportion of those affected. Patients discharged from an acute care setting to their homes, as well as those in the community diagnosed with both COVID and non-COVID illness, require robust systems for monitoring and support with an interdisciplinary team of providers.
Home-based medical care (HBMC) is a powerful modality to address these challenges. Importantly, HBMC already functions across the continuum of care, providing primary, hospital-level, post-acute, and palliative care to multimorbid and functionally impaired older adults throughout the United States.[1–4] Additionally, HBMC providers work closely with other home care services and often utilize technology for remote monitoring and virtual care. Many of these programs have been shown to reduce healthcare costs through lower rates of hospitalization, emergency room visits, and institutionalization while improving quality of life and patient satisfaction.[1,5–8]
The HBMC model, quietly evolving over the last two decades, has rapidly transformed in response to COVID-19 with many health systems expanding established home-based care programs to further meet the needs of vulnerable populations. The potential contributions of HBMC during this challenging time include (1) to continue tending to the chronic but substantial health needs of medically complex patients, thus reducing the need for emergent care in overburdened hospital systems; (2) to provide hospital-level care for both COVID and non-COVID illness ("hospital at home"); (3) to provide post-acute level care as an alternative to SNFs; and (4) to provide palliative care to help clarify patient goals and manage symptoms of acute and chronic illness. With additional resources, HBMC has the potential to not only decompress the healthcare system, but also provide high-quality, patient-centered care during this time of crisis and beyond.
Expanding HBMC to Face the COVID-19 Crisis
As an exemplar of value-based care both before and during this pandemic, we suggest several steps to incorporate HBMC more fully into our country's coordinated response to COVID-19:
Leverage Existing HBMC Practices
It is estimated that there are over 1,000 practices providing HBMC visits in the United States.[9] Home care practices within a health system should work with clinical and strategic leadership to determine how existing programs can expand with the support of the health system. In systems without HBMC programs, the American Academy of Home Care Medicine directory or the Centers for Medicare & Medicaid Services (CMS) claims data can help identify established HBMC providers across the nation. HBMC teams are already adept at the triage of frail, high-risk patients and prompt appropriate referral to community agencies for collaboration with skilled and unskilled home care. However, there is wide heterogeneity in the structure of existing HBMC practices.[10] For example, a national survey of HBMC programs (excluding those affiliated with the Department of Veterans Affairs (VA)) found that 20% were sponsored by a hospital or health system whereas the majority were owned by an independent provider or provider group. Practices more often served urban and suburban patient populations, with only 30% reaching rural patients.[10] In contrast, more than half of home-based primary care sites affiliated with the VA serve rural veterans.[11] Given this variation in practices, it is essential to develop a standardized quality framework to identify programs that are providing effective care as HBMC expands. To start, CMS must add codes for home-based medical visits to Merit-based Incentive Payment System quality measures relevant to medically complex home care patients so that practices can begin to quantify value-based care.[12] Notably, many of the widely used disease-specific quality measures often do not apply to the health goals of multimorbid, frail HBMC patients. Experts in the field are actively working to develop a quality framework for HBMC that overlaps with accepted quality metrics and may better align business incentives with patient and caregiver outcomes.[9]
Sustain Expanded Reimbursement for Remote Care Delivery
Congress should extend the regulatory modifications of the CARES Act to cover telehealth modalities that minimize exposure to COVID-19 for providers and patients. Both properly protected in-person home visits and telehealth tools for remote management are vital to providing acute and chronic care in the safety of patients' homes. The adaptation of telehealth during the pandemic depends on many factors, including access to technology and connectivity for both providers and patients, clinical circumstances amenable to remote evaluation, local rates of COVID-19 transmission, staffing, and availability of personal protective equipment (PPE). It is essential that home care practices can pivot between virtual and in-person care modalities in the face of an unpredictable pandemic. For example, Northwell Health, which provides home-based primary care to approximately 2000 patients in downstate New York, was able to complete telehealth visits with 48.6% of eligible enrollees from March to May 2020, while 11.5% of patients who consented to telehealth ultimately required a face-to-face visit during this time frame.[13] The authors' home-based primary care colleagues at the University of Pennsylvania adopted similar practice patterns, with telehealth utilized for the majority of visits early in the pandemic and then carefully integrated with face-to-face evaluation as local transmission rates fell and PPE became more widely available. In addition to primary care, telehealth is also a powerful tool to engage subspecialists in the team-based care of complex older adults. Pre-COVID research supports the benefits of telehealth for select patient populations.[14] However, the rapid transformation of telehealth services during the current crisis is uncharted territory, and efforts to engage older adults with new technologies can be particularly challenging.[15] We must prioritize telehealth research, and we must be deliberate about including medically complex older adults in these studies to evaluate feasibility and effectiveness. Moreover, we must select appropriate outcomes measures that reflect the goals of value-based care.
Develop COVID-specific Care Delivery Protocols Backed by Robust Supply Chains
Home-based care delivery during the COVID pandemic requires adequate PPE, as well as kits to administer COVID-19 testing in the home. HBMC providers at some institutions are already coordinating at-home COVID-19 testing, which is crucial to reducing community spread of disease among this high-risk population. HBMC practices require a protected supply chain of PPE to reduce the risk of virus transmission as providers move between patients. In addition, as hospital treatment protocols for COVID-19 are rapidly developed and modified, the application of these protocols to COVID patients receiving treatment in the home will need to be researched and standardized. Examples include appropriate use of dexamethasone and venous thromboembolism prophylaxis.
Expand Inpatient-level Care at Home
"Hospital at home" is a model that provides acute care services typically requiring inpatient hospitalization to patients in their homes. It has already been adapted by several health systems across the United States and shown to reduce cost, healthcare utilization, and readmissions when compared to usual hospital care.[2,3] We agree with Drs. Nundy and Patel that expansion of hospital at home should be a priority in our country's COVID-19 response.[16] Home management of acute non-COVID illness can reduce bed utilization, avoid isolating patients from their families, and reduce the risk of hospital-based transmission of disease. When backed by adequate resources, it may also be safe and effective to enroll lower-risk COVID-19 patients in a hospital at home program. The hospital at home model has rapidly gained traction during the pandemic. For example, the relatively new Boston-based company Medically Home, which partners with hospitals across the United States to provide acute care to patients at home, has seen a 10-fold increase in patient volume compared to 1 year ago.[17] Well-established hospital at home programs, such as Mount Sinai at Home in New York and those operated by the Veterans Health Administration, have also seen an increase in patient volume.[17] Northwell Health in New York has developed COVID-specific hospital at home protocols that utilize telehealth and support from pulmonologists to offset pressure on hospitals.[18] Continued expansion of this model requires coordinated efforts between health systems, HBMC providers, homecare agencies, telemonitoring infrastructure, durable medical equipment suppliers, and mobile diagnostic services. Care for COVID-19 patients also requires enhanced respiratory monitoring and access to respiratory therapists. Beyond clinical operationalization, CMS must consider reimbursement for inpatient-level care at home commensurate with usual hospitalization.
Expand Post-acute Care at Home
Patients with intensive rehabilitation or medical needs after acute hospitalization often receive post-acute care in a SNF. Recent work by Augustine et al suggests that it is both feasible and effective to deliver SNF-level post-acute care in patients' homes.[19] Malone and Fain highlight the key infrastructure necessary to make this a sustainable model, namely: involvement of a mature interdisciplinary clinical practice with organizational support, participation of home-based primary and palliative care, and collaboration with community resources.[20] Many of these building blocks have already been mobilized in response to COVID-19. Encouragingly, outpatient physical, occupational, and speech therapy visits have successfully pivoted to telehealth ("telerehabilitation") during the pandemic with high patient satisfaction.[21] In addition to rethinking skilled care delivery, the home-based SNF model requires formal training and reimbursement of caregivers to support patients' daily needs and to oversee rehabilitation.[22] The staggering impact of COVID-19 on nursing facilities gives us a strong incentive to invest in further expanding the home-based model of post-acute care.[23] Notably, existing studies of home-based acute and post-acute care have largely been conducted in urban settings, such as Boston[3] and Manhattan.[19] There are unique logistical barriers to providing intensive skilled home services in rural America, where access to healthcare remains a major challenge. Ariadne Labs, the center for health systems innovation at Brigham and Women's Hospital and Harvard School of Public Health, is currently working with University of Utah Health to test a novel rural home hospital program.[24] Their proposed model of care utilizes local paramedics who travel to patients' homes and work under the guidance of hospital-based physicians via video conference. If successful, incorporation of telerehabilitation services for ongoing post-acute care at home certainly warrants further investigation.
Expand Palliative Care at Home
The current pandemic has driven increased demand for palliative care services, as well as innovative ways of delivering this care to patients.[25–27] Home-based palliative care is not new, and has been shown to improve patient satisfaction while reducing emergency room visits and hospitalizations in the last year of life.[4] More recently, advances in technology have allowed us to bring virtual palliative care support to patients in their homes.[28] Home-based palliative care, ideally in partnership with other HBMC providers, can help manage the symptom burden of acute and chronic illness and thus avoid unnecessary hospitalizations. In addition, frail, older adults who decompensate despite the support of home-based primary care or hospital at home may prefer to pursue palliative goals rather than present to an emergency room or hospital. Organizations such as VitalTalk and the Center to Advance Palliative Care have developed publicly-available, COVID-specific communication tools to help providers engage in these difficult conversations.[29,30] Close collaboration with palliative care would allow teams to elicit patient preferences and rapidly implement supportive measures to provide true patient-centered care.
Conclusion
As it has for decades, HBMC stands ready to meet the challenges of a strained healthcare system. With the services described above, a patient like Ms. H could receive timely COVID-19 testing in the safety of her home, utilize hospital at home for management of her chronic obstructive pulmonary disease exacerbation, and participate in intensive physical and occupational therapy at home to promote functional recovery. She would avoid COVID-19 exposure in the emergency room, hospital, and SNF, the risks associated with multiple transitions of care, and the isolation imposed by visitor restrictions. Unfortunately, Ms. H's course followed the more common trajectory in our current health system. She ultimately had delayed access to primary care evaluation and was readmitted to the inpatient ward via the emergency room, with stay complicated by hypoactive delirium. Her son opted for discharge home with twice-weekly physical therapy given concerns about virus transmission and visitor restrictions at SNF, and she struggled to regain her baseline function.
Like other medical services which improve patient safety and outcomes during an unprecedented public health emergency, HBMC is a critical resource in urgent need of expanded investment, reimbursement, and research. Thousands of HBMC providers across the nation are ready for the challenge and equipped to work together with their colleagues on the front lines to provide high-quality, comprehensive, and patient-centered care. HBMC's valuable services at this important time will undoubtedly change how we approach healthcare delivery and pandemic response in the decades to come.
