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Hospital-at-Home Programs Are Gaining in Popularity

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Your chest hurts, you are short of breath and you’re shaky from fever and chills. The ER doctors diagnose pneumonia. Since you also have a heart condition, they decide that you qualify for immediate hospital admission.

But you’re not admitted. Instead, you’re sent home to recuperate. A brush-off? Bad medicine? Not at all! You’ll be getting intensive hospital-quality care in your own home. Within two hours, you have the medications and equipment you need to get well, plus a team of health pros to check on you daily.

What sounds like a health-care fantasy may one day be routine. “Hospital-at-home” programs are increasingly the norm in England and Australia and gaining traction in the US, too. For good reason—people who recuperate at home have better outcomes than those who stay in hospitals.

Hospitals—despite the full medical staff, fully equipped labs and stocked pharmacies—are dangerous. Patients can suffer sleep interruption, exposure to superbug bacteria and risk “sundowner syndrome” (delirium that often happens during a hospital stay). Hospital care at home helps you avoid these risks—and get better faster.

YOUR BED IS BETTER THAN A HOSPITAL BED

Seniors are more likely to be admitted to the hospital than younger people. The hospital-at-home movement is seeking to change that. Technological advances that make that possible include…

• Home infusion—medication that must be delivered by needle or catheter, such as antibiotics, can now be safely administered at home by a health-care professional or, in some cases, you can do this yourself.

• Point-of-care testing—simple “lab” medical tests can now be done at the bedside.

• Telehealth technologies allow doctors to diagnose, treat and monitor patients from afar.

Even such conditions as severe urinary tract infections, pneumonia, emphysema and deep vein thrombosis, which normally keep older patients in the hospital, can be safely treated at home under the right conditions.

WHO CAN BE TREATED?

Only certain patients, with certain conditions, qualify for this kind of care. Doctors apply strict criteria, only accepting people who aren’t likely to require constant oversight, technical hospital-based procedures (such as endoscopy) or the kind of intravenous medication that can be done safely only in a hospital (such as intravenous cardiac medications or intravenous blood thinners). Research shows that about 30% of older patients are eligible for at-home hospitalization. Besides clinical qualifications specific to his/her medical condition, a patient is a good candidate if…

• He/she can get to the bathroom, prepare meals and answer the door or telephone.

• He/she has a caregiver (a family member or an aide) who can help out.

• It’s safe for the medical staff to go to the home (no unattended pets, not too much clutter, etc.).

• He/she lives within the area that the program serves.

HOW HOSPITAL-AT-HOME WORKS

If the patient is offered at-home hospitalization and accepts, as about 80% do, a hospital-at-home team—including a doctor who oversees care, an administrative assistant who checks insurance and arranges transportation and a nurse manager who schedules nurses—takes over.

Pharmacy and laboratory services are arranged, and medical equipment, if needed, is procured—all within two hours. If it takes longer and it’s after 8 pm, the patient is sent to a bed in the hospital for one night and hospital-at-home starts the next morning.

Here’s what we require in our program at Mount Sinai Hospital, where we are studying hospital-at-home under a federal grant…

• A nurse visits once or twice a day.

• A doctor or nurse practitioner visits once a day.

• A social worker or physical therapist visits at least once.

• Lab services are performed in the patient’s home.

• If a patient needs an extra visit with the doctor, the nurse will conduct a video visit with the doctor back at the hospital.

• Paramedics can also be dispatched, if needed, to evaluate the patient’s condition.

THE REWARDS

At Mount Sinai, patients in the hospital-at-home program remain under care for less time than those who are admitted to the “real” hospital for the same condition. Costs are substantially lower. Not surprisingly, patient satisfaction is higher, too. Complications and mortality are also reduced.

Despite these beneficial outcomes, there are only a handful of full-fledged programs in the country. Besides the Mount Sinai program, there’s one at the Presbyterian Hospital in Albuquerque, New Mexico (for Medicare Advantage patients), one at the Cedars-Sinai Medical Center in Los Angeles and one at Brigham and Women’s Hospital in Boston. The Veterans Affairs (VA) hospital system has programs at several locations, including Boise, Idaho…Honolulu…New Orleans…Philadelphia…Portland, Oregon…and Bend, Oregon.

A key reason why so few such programs are offered in the US is the way we pay for health care. Most hospitals get paid for every service they provide, but hospital-at-home often requires fewer services at less cost, so it’s less financially attractive for the hospital. On the other hand, “capitated” insurance plans (VA, some managed-care plans, Medicare) pay a fixed amount to the hospital to cover each patient based on the diagnosis. So if hospital-at-home care saves money, it benefits the plan. Capitated plans are gaining in popularity, but it will be several years before hospital-at-home programs are widely available.

In the meantime, if you are admitted to the hospital, ask whether you can arrange for the kinds of services that might allow for an early discharge—such as home visits by a skilled nurse or hospital treatments that can be provided at home.

No one should be discharged from the hospital too early, but if you can safely shave off a day or two (for instance, by finishing the last few days of an infusion for antibiotics at home), it will help you avoid some of the downsides of traditional hospitalization—and might give you some of the better outcomes of healing at home.

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Source: Linda DeCherrie, MD, associate professor at Icahn School of Medicine at Mount Sinai, New York City, and director of Mount Sinai Hospital’s Mobile Acute Care Team. Her clinical and research interests include the care of complex frail patients and innovative models of care. Date: December 1, 2017 Publication: Bottom Line Health
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