Late last month Raymond Johnson, 83, began to feel short of breath. “It was hard to get around,” he recently recalled over the phone from his apartment in Boston’s Jamaica Plain neighborhood. “I could barely walk up and down the stairs without getting tired.”
Like many older people, Mr. Johnson suffers from a variety of chronic health conditions: arthritis, diabetes, high blood pressure, asthma, heart failure and a heart arrhythmia known as atrial fibrillation.
His doctor ordered a chest X-ray and, when it showed fluid was building up in Mr Johnson’s lungs, told him to head to the emergency room at Faulkner Hospital, which is part of the health system Mass General Brigham.
Mr Johnson spent four days as an inpatient with heart failure and exacerbation of asthma: one day in a hospital room and three in his own apartment, receiving hospital care through an increasingly alternative more popular — but possibly endangered — than Medicare calls Acute Hospital Care at Home.
The eight-year-old Home Hospital program, run by Brigham and Women’s Hospital, to which Faulkner Hospital belongs, is one of the largest in the country and provided care to 600 people last year; it will add more patients this year and is expanding to include several hospitals in and around Boston.
“Americans have been trained for 100 years to believe that the hospital is the best place to be, the safest place,” said the program’s medical director, Dr. David M. Levine. “But we have strong evidence that the results are actually better at home.”
A few of these programs started 30 years ago and the Veterans Health Administration adopted them more than a decade ago. But the hospital-at-home approach stalled, largely because Medicare would not reimburse hospitals. Then, in 2020, the Covid-19 caused significant changes.
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With hospitals suddenly overwhelmed, “they needed beds,” said Ab Brody, professor of geriatric nursing at New York University and author of a recent editorial on hospital home care in the Journal of the American. Geriatrics Society. “And they needed a safe place for the elderly, who were particularly at risk.”
In November 2020, Medicare officials announced that as the federally declared public health emergency continues, hospitals may seek waivers of certain reimbursement requirements, including for 24-hour onsite nursing care. 24, 7 days a week. Hospitals whose applications are approved would receive the same payment for hospital care at home as for hospital care.
Since then, Medicare has granted waivers to 256 hospitals in 37 states, including Mount Sinai in New York and Baylor Scott and White Medical Center in Temple, Texas. Initially, hospital-at-home programs primarily treated common acute illnesses such as pneumonia, urinary tract infections, and heart failure; more recently, they have also begun to deal with liver disease treatments, post-surgical care and aspects of cancer care.
Uncertainty about future Medicare involvement is preventing wider adoption of the approach. “If this were to become permanent, you would see at least a thousand hospitals in the next few years” adopt hospital home care, said Dr. Bruce Leff, a geriatrician at Johns Hopkins University School of Medicine who started one of these treatments. programs.
But Medicare waivers are not permanent. The public health emergency remains in effect until January; though the Biden administration is likely to extend it, state health officials expect it to end sometime next year, possibly in the spring.
So what will happen to hospital care at home? Twenty-seven percent of programs that participated in a Hospital at Home Users Group survey said they were unlikely to continue offering the option without a waiver, and 40 percent were unsure; 33% said their programs were likely to continue.
Seniors and advocates for their well-being have reason to hope that these programs will continue. Studies have repeatedly documented the risks of hospital stays for older adults, even when the conditions that necessitated the stay are adequately treated.
The elderly are vulnerable to cognitive problems and infections; they lose their physical strength through inadequate nutrition and days of inactivity, and they may not regain it. Many patients require a new hospitalization within a month. A prominent cardiologist called this debilitating pattern “post-hospital syndrome.”
If Mr Johnson had stayed in hospital, ‘he would have been lying in bed for four or five days,’ Dr Levine said, adding: ‘He would have become very deconditioned. He could have caught C. diff or MRSA “, two common nosocomial infections. “He could have caught Covid,” Dr. Levine continued. “He could have fallen. Twenty percent of people over 65 are delirious during a hospital stay.
Patients must consent to hospital care at home. Nearly a third of Brigham and Women patients decline to participate because the hospital setting seems safer or more convenient.
But Mr Johnson was delighted to leave, when a treating doctor told him his conditions could be treated with hospital care at home. “I was not comfortable around the hospital,” he said.
At home, a doctor saw him three times, twice in person and once via video. A registered nurse or specially trained paramedic visits twice a day. They brought the drugs and supplies Mr Johnson needed: prednisone and a nebulizer for his asthma, and diuretics (including one given intravenously) to reduce excess fluid caused by heart failure. Meanwhile, a small sensor strapped to his chest transmitted his heart and breathing rates, temperature and activity level to the hospital.
If Mr Johnson had needed extra monitoring (to make sure he was taking his medication as scheduled, for example), food deliveries or home help, the program could have provided them. If he needed tests or had an emergency, an ambulance could have taken him back to the hospital.
But he recovered well without any of these interventions. About a week after his discharge, Mr Johnson said he was ‘much, much better’ and would recommend hospital home care to everyone.
Studies have shown that patients in hospital-at-home programs spend less time as inpatients and, subsequently, in nursing homes. They are less sedentary, less likely to report sleep disturbances, and more likely to rate their hospital care highly.
A New York City study found that hospital home care also worked well for economically disadvantaged patients who qualified for Medicaid or lived in neighborhoods with high poverty rates, including those who lived in social housing.
A 2012 international meta-analysis of 61 clinical trials (inpatient home programs are more widely used in other industrialized countries) reported lower mortality and fewer hospital readmissions.
Most studies have also found significantly lower costs. At Brigham and Women’s, the average cost per hospitalization was 38% lower for home patients than for those in an inpatient control group, in part due to fewer lab tests, less imaging, and fewer consultations with specialists.
“It doesn’t come cheap to have amazing paramedics and nurses on the ground, to have doctors available 24 hours a day, to have a biometric monitoring system,” Dr. Levine said. “But compared to hospital care, there are substantial cost savings.”
But the future of hospital home care depends on federal action. A bill introduced in the House of Representatives this spring would have extended Medicare’s waiver program for two years after the public health emergency ended. The legislation has not moved forward, despite bipartisan support from 29 co-sponsors, but supporters believe a similar bill could still pass.
Medicare could also authorize a multi-site demonstration project, which would keep some hospital-at-home programs running.
“Are there people who need to be hospitalized? says Dr. Leff. “Absolutely.” Surgeries, complex tests and intensive care always require a building and its staff. Still, he added, hospital-at-home initiatives demonstrate that more care could be provided outside of brick-and-mortar facilities.
“The hospitals of the future will be large emergency rooms, operating rooms and intensive care units,” Dr. Leff said. “Almost everything else will be moved to the community – or should.”