Examining hospital-at-home from a myriad of perspectives

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The hospital-at-home (HaH) concept is evolving but not as quickly as many would like, particularly among patients who are enthusiastic about receiving care in their own space instead of at a conventional facility. HaH is a home-based alternative to traditional inpatient hospitalization that uses a combination of remote monitoring technology and in-home clinician visits. Several scientific studies have shown equal or improved clinical outcomes, improved patient and caregiver satisfaction, and reduced healthcare costs.

At the beginning of HaH model development, the focus was more on taking care of lower acuity hospitalized patients and finding ways to care for them in the comfort and convenience of their homes. With subsequent advancements in technology, we can begin to safely expand this high-quality care model to more and more patients so they too can benefit.

Jiang Li, PhD
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Jared Conley, MD, PhD, MPH
_{© Mass General Hospital}

Michael Augusti
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As of last year, Mass General Brigham had cared for more than 2,000 acutely ill patients and saved 10,000 hospital bed days since implementing a hospital-at-home program in 2016. They’ve had such success they are now planning a significant expansion to build a 200+ bed home hospital. More than half of the patients enrolled have been 65 or older, requiring the technology interaction to be accommodating and intuitive to make it easy to use.

A comprehensive HaH system assigns and delivers resources, allocating tasks across a provider team. Sensors worn by a patient at home provide continuous vitals. The clinician then monitors the information relayed to their end device through intelligent software. This process can enable communication to be as comprehensive as that of inpatient care without excessive burden on the patient or caregiver.

However, the HaH concept extends beyond remote patient monitoring (RPM). RPM is only one of the pieces of the puzzle when monitoring patients outside the hospital. Implementation requires multiple types of interactions to ensure a seamless, interoperable solution including methods of communication, interaction, and diagnostics.

To enable situational awareness and drive proactive care, the patient’s information must be collected, analyzed, and pushed out to the clinician in a format that both informs and alerts through web-based device integration in partnership with wearable devices. It’s a combination that requires the use of medical-grade wearables, software, and the means to connect all the entities with the same quality found in in-patient facilities.

HaH clinician care is often a hybrid of in-person and facilitated video visits by physicians, along with in-home visits by a nurse or paramedic (with nursing and physician oversight). The physician can use RPM and technology such as facilitated ultrasound to ascertain necessary vital data and create a high-quality patient experience right in the patient’s home. By also using the data to apply predictive analytics, clinicians can proactively address issues.

The necessity

The advantages to patients are obvious, but hospital systems benefit as well. As the U.S. population ages and the silver tsunami is inevitable, Medicare spending alone is expected to double. G-codes via the Centers for Medicare and Medicaid Services (CMS) make it possible for RPM and home health monitoring using synchronous telemedicine to be reimbursed as part of a defined patient care plan.

A JAMA study shows that patients receiving HaH care had a slightly longer than average treatment period, however, that care cycle is offset by a lower readmission percentage and lower depression and anxiety rates than conventional in-facility chronic disease patients who started in emergency care. If a provider can be reimbursed for delivering a service equal to that offered in-facility while more efficiently caring for patients, it eliminates a significant barrier to implementing HaH in acute care environments.

With issues ranging from staffing shortages to a lack of space during crisis situations as evidenced by the COVID-19 pandemic, it’s time to think outside conventional care models to ensure hospital beds are leveraged for more critical patients. At the end of the day, the capital, effort, and cost to build hospitals to care for aging populations is a significant time and financial burden when there could be a better answer.

Strategically, there are alternatives. Australia has successfully transitioned almost 10% of hospitalized patients to a HaH care model. Australia, New Zealand, and the United Kingdom have expressed interest in implementing RPM for specific therapeutics to facilitate HaH applications. Different countries have different requirements, but a successful example is the work with stroke patients at the Imperial College in London which enables them to recuperate at home.

The rationale

A successful HaH program accounts for both perceptual acuity and condition deterioration to support appropriate care action. While there are medical-grade monitoring devices that can detect a variety of vitals, cardiac care is one of the most common applications at this point. The type of monitoring must match the clinical need. For example, continuous RPM with single-lead ECG is well-suited for those with heart failure exacerbations.

With appropriate risk stratification, patients experiencing an acute heart failure episode can recover at home comfortably. Various monitoring technologies have been utilized in post-surgical cases, respiratory patients, and individuals at low to moderate risk of falls. Following open-heart surgery or certain types of invasive cardiac procedures, if there's a high level of confidence for discharge, health care providers may opt to monitor patients for 10-15 days to mitigate the risk of readmission.

Implementing an enterprise technology that can be utilized across multiple departments is the most efficient approach for a hospital system, ensuring long-term compatibility, even if the initial deployment targets only one specific disease area. Cardiac care represents the most common focus, with oncology being the second most prevalent therapeutic area of interest.

The possibilities

Adoption of these concepts is likely to increase, driven by the need for more efficient and effective healthcare delivery. Advancements in wearable technology, telemedicine, and artificial intelligence are likely to enhance the capability. However, successful implementation requires addressing challenges and limitations such as the need for standardization guidelines, adequate training, and reimbursement. It also requires trust. Patients can be wary of inviting unfamiliar clinicians into their homes, and care providers need to trust the technology to provide viable data without undue alarm fatigue.

At Mass General, we've been exploring ways to employ technology to significantly expand our ability to care for more hospitalized patients in the comfort and convenience of their homes. With proper diagnostics upfront – either in the emergency department or from a hospital floor – and appropriate risk stratification, there’s a significant group of patients who are safe to care for in a hospital-at-home care model with remote patient monitoring.

Roughly 15% to 30% of inpatient care could be delivered in U.S. homes within the next 10-15 years. There’s still much work to be done in the acute care at home space, but aside from the cost savings, the underlying goal to provide a high quality, better experience for the patient is attainable with cooperation between hospital systems, research institutions, technology manufacturers and facilitators, and government regulators.

Jiang Li, PhD, is CEO of Vivalink, a Silicon Valley company developing medical wearable sensor solutions for patient monitoring and telemedicine. Jared Conley, MD, PhD, MPH, is an assistant professor at Harvard Medical School and emergency physician at Mass General Hospital. He serves as associate director of the Healthcare Transformation Lab with clinicians and engineers improving health care quality and affordability. Michael Augusti is head of marketing innovation, North America, for Ascom, a health care software and telecommunications company.