A Different Kind of Perioperative Surgical Home

Hospital at Home After Surgery

Kyan Cyrus Safavi, MD; Rocco Ricciardi, MD; Marilyn Heng, MD; Eric Lawrence Eisenhauer, MD; Dana Sheer, ACNP; Ryan Wesley Thompson, MD; Marcela Guadalupe del Carmen, MD

Disclosures

Annals of Surgery. 2020;271(2):227-229. 

In This Article

A Promising Innovation With Implications for Surgical Care

Postoperative surgical care in the United States continues to be shaped by strong financial incentives in the healthcare system designed to control cost and enhance value.[1,2] There has been substantial investment to control drivers of surgical cost, such as length of stay (LOS) and readmission. None have examined whether postoperative hospital-based care can be substituted for hospital-level care at home—an emerging model now backed by evidence that it is a safe and less expensive alternative.

Hospital at Home (HaH) is a healthcare delivery model in which a patient receives services in their home similar to inpatient hospital care. Patients are enrolled through the Emergency Department (ED) as an alternative to inpatient admission or during inpatient hospitalization as an early transition to home. HaH mirrors an inpatient stay: (1) an admission intake performed by a provider team, typically a physician or nurse practitioner (NP); (2) scheduled visits daily by the physician or NP and multiple times per day by a nurse; (3) laboratory tests obtained from home phlebotomy; (4) imaging including x-ray and ultrasound using portable machinery; and (5) administration of intravenous medications and fluids. Patients are cared for until they are appropriate for discharge.

HaH has been studied in patients with acute medical problems, such as chronic obstructive pulmonary disease exacerbations, heart failure, and cellulitis. The earliest programs in the United States were initiated at Johns Hopkins in 1997.[3] Studies emerged in the 2000s from experiences with patients in Medicare Advantage Plans and since then data have continued to accumlate.[4–8] Two metanalyses of randomized controlled trials found that HaH programs have the same or lower mortality compared with standard inpatient admission.[9,10] Adverse events such as transfer to ICU, intubation, myocardial infarction, delirium, urinary tract infection, and fall were either the same or lower in HaH cohorts.[6,9,10] No difference was found in process of care metrics, such as the timeliness of antibiotics for infection.[6] Patient satisfaction with their care was consistently higher.[10]

Furthermore, HaH demonstrated a 19% to 30% reduction in cost compared with traditional inpatient care. Savings accrued from a reduction in LOS compared with equivalent inpatient admission, fewer laboratory and imaging tests, and elimination of room and board fees. Metanalyses have confirmed these findings.[9,10]

In the United Kingdom, Canada, and Australia, HaH has become part of routine care. In Australia, 6% of bed-days are provided by HaH.[11] One challenge in the United States has been a lack of HaH-specific payments in Medicare. In 2017, however, CMS funded a pilot program in which HaH was bundled with a 30-day postacute care episode payment. Federman et al demonstrated that such a payment model could be implemented successfully, paving the way for new CMS billing codes.[12] In the meantime, several commercial insurers have taken the lead by including HaH among their reimbursable services.[13]

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