Coalition fights to maintain home hospital health insurance support
The announcement of a new advanced home care coalition led by Kaiser Permanente and the Mayo Clinic signals the willingness of major healthcare systems across the country to provide acute hospital-level care to selected patients at home using new technologies that allow clinicians to monitor and stay in touch with patients remotely.
This burgeoning movement has broad implications for physicians, including those who now care for patients in brick-and-mortar hospitals, as well as community physicians who are involved in the post-acute care of patients, Jared Conley, MD, PhD, MPH, associate director of the Healthcare Transformation Lab at Massachusetts General Hospital, Boston, said Medscape Medical News.
“The role of physicians in acute care will certainly change,” said Conley. “I think there is a growing consensus that we have an opportunity, with all the tools at our disposal, to rethink the way we care for patients in acute care settings. There is the traditional model that we have used in hospitals for decades. , and now technology is leading us to rethink that model. “
However, the continued use of the home hospital (HaH) for a range of acute conditions depends to a large extent on a temporary program from the Centers for Medicare & Medicaid Services (CMS) which is to expire at the end of the period. this period. year, according to Michael Maniaci, MD, leading physician for advanced home care at the Mayo Clinic in Jacksonville, Florida.
CMS waiver program seen as crucial
Before the COVID-19 pandemic, the home hospital – backed by a large number of studies – had been growing slowly for about a decade, Conley says. The pandemic has accelerated the trend as more and more healthcare systems have started implementing HaH programs to relieve the pressure COVID patients have on their facilities.
In November 2020, CMS used the authority of Congress to establish its acute hospital home care program to help hospitals cope with the public health emergency. Funding provided to hospitals under this program has enabled them to allocate resources to HaH programs.
The main goal of the new advanced home care coalition led by Kaiser and Mayo is to get CMS to continue its coverage of home hospitals. This will require a law from Congress, and the coalition is pushing, Maniaci says. In addition, the consortium is advocating for the Center for Medicare & Medicaid Innovation to test a HaH model; such a demonstration project could eventually lead to CMS paying directly for acute hospital care at home. In the meantime, if CMS doesn’t extend the waiver program, it could launch the demonstration project and use it to reimburse participating hospitals for the next several years, he suggests.
Coalition members, in addition to Kaiser Permanente and the Mayo Clinic, include Adventist Health, ChristianaCare, Geisinger Health, Integris, Johns Hopkins Medicine, Michigan Medicine (University of Michigan), Novant Health, ProMedica, Sharp Rees-Stealy Medical Group, UNC Health, and UnityPoint Health. Another member of the coalition is Medically Home, a HaH service provider in which Kaiser and Mayo have invested $ 100 million.
Earlier this year, Intermountain Healthcare, Ascension, and Amazon Care formed the Moving Health Home Coalition with home care companies that include Dispatch Health and several providers of complex elderly care. Among other things, this coalition also wants CMS to continue to cover the hospital at home.
At the time of going to press, 179 hospitals in 33 states, belonging to 79 systems, had received waivers to participate in the acute hospital home care system, according to CMS. Hundreds of other hospitals, Conley says, are considering or are in the early stages of establishing HaH programs. Some private payers are also starting to cover this form of acute care, he says.
As the COVID crisis has accelerated the use of the home hospital, he says, many healthcare organizations are now considering how it could be used to improve outcomes and increase patient satisfaction in healthcare. short duration. In 5 years, he predicts, if Medicare continues to cover HaH and other payers commit, hospital home care could become mainstream.
How HaH Will Affect Doctors
The Mayo Clinic, which has treated about 500 patients in its home hospital program, is now rolling out it to facilities in its four regions, including Florida, Arizona, Wisconsin and Minnesota. Mayo’s Model HaH uses a central command center in Jacksonville, Florida for all telehealth and remote patient monitoring aspects of its program. Local doctors usually do not visit patients; instead, nurses, paramedics, and physiotherapists make home visits.
Maniaci sees the program affecting hospital physicians in two ways: First, as the more stable and recovering patients are moved to the HaH facility, those who remain in the hospital building will be the unstable and most acutely ill patients. , which will present the hospitalized doctors. with additional challenges, he predicts. Second, physicians who virtually treat patients with HaH will need to get used to a new way of practicing.
“It’s still the same medical care, but interacting with people at home, having them as your hands and eyes during physical exams, using technology to listen to the heart wirelessly – these are new skills you you will have to learn It is doable, but you have to adapt to change, ”he emphasizes.
“I can collect data on heart sounds, lung sounds, heart rate and blood pressure through continuous monitoring,” adds Maniaci. “Camera technology can now read your heart rate and pulse by looking at you. I think it’s going to be a combination of one person’s camera and iWatch technology that feeds data continuously, and we’ll use computers to cut out the noise and use the right product. “
MGH’s Conley says the jury is still out on how many physical exams can be done remotely, although studies on this are ongoing. With the help of new tools such as digital stethoscopes and digital otoscopes, he says, doctors might be able to do some physical exams remotely, or they might find better safety and patient outcomes. they do some exams in person.
The extent to which a patient can be treated remotely also depends on the type of acute illness that person has. Studies support the use of HaH for patients with exacerbations of congestive heart failure, chronic obstructive pulmonary disease and pneumonia, as well as complicated urinary tract infections and cellulitis, both of which require IV antibiotics. , notes Conley. Rarer conditions like rhabdomyolysis also lend themselves to HaH care.
Expand to post-acute care
Some HaH participants extended to post-acute care. A 2011 pilot project at Advocate Health Care in Chicago, for example, showed that HaH patients had a significantly lower number of readmissions 90 days after discharge than the control group. During the post-acute phase of their care, they were more likely than control patients to be cared for at home rather than in a rehabilitation center.
“A lot of post-acute care could be done at home for the right patients, supported by the right technology and the right processes of care,” said Conley. While this transition of care needs to be done with care, he says, there has been an improvement in sensing devices “which allow us to care for patients at home that in the past would have required close human interaction.” These tools include fall detectors and devices that can “pick up heart and respiratory rates from the ambient”. As a result, there may be less need to send some patients to qualified nursing or rehabilitation facilities.
The impact of this on community physicians, he said, would be “significant.” They should start paying attention to data flows about their patients’ condition during the transition from acute to post-acute care, possibly with the help of data filters and clinical staff to inform them of important changes requiring their attention. Warning.
“It will take a lot of work on the technology side to make sure the data is not overwhelming, but allows the community doctor to make quick decisions that are in the best interests of the patient,” he said. .
There is also an opportunity, he adds, to send patients home after surgery to recover in a HaH setting. This would reduce the length of stay for inpatients – a benefit for hospitals – and patients would rather recover at home than in a rehabilitation center, he notes.
Care transitions are part of the whole
The Mayo HaH model focuses on care transitions. An eligible patient is enrolled in the HaH program, usually out of the emergency department, for a period of 30 days. During the first 6 or 7 days, they are cared for in a hospital room that has been set up at their home, equipped with a hospital bed, an IV stand, remote monitoring equipment and a audiovisual conference facility. After that, they are still watched, but less closely. Mayo’s healthcare team educates the patient about their condition, makes sure they receive their medication, and makes an appointment with their attending physician.
The care team also contacts the community doctor, informs him of the hospitalization and asks him what that doctor needs, says Maniaci. Mayo will provide surveillance data and computer analysis to the doctor if he wishes.
This all adds up to extra work for doctors who previously might not have known their patient was hospitalized until they came to the office. But Maniaci sees it as a big improvement over current hospital transfers that end when the patient leaves the building. Plus, he notes, Mayo does all the bridging work, so the primary care doctor doesn’t have to.
“We’re making the transition and making the primary care provider an active partner to the extent they want,” he says.
Ken Terry is a health journalist and author. His latest book is “Physician-Led Health Care Reform: A New Approach to Medicare for All”.
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