Coalition Fights to Keep Medicare Support for Hospital at Home

Ken Terry

October 20, 2021

The announcement of a new Advanced Care at Home Coalition led by Kaiser Permanente and the Mayo Clinic signals a willingness by major healthcare systems across the country to provide hospital-level acute care for some patients at home with the help of 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 patients' post-acute care, Jared Conley, MD, PhD, MPH, associate director of the Healthcare Transformation Lab at Massachusetts General Hospital, Boston, told Medscape Medical News.

"Physicians' role in acute care will certainly change," Conley said. "I think there's a growing consensus that we have an opportunity, with all the tools we have, to rethink how we take care of patients in the acute-care setting. There's the traditional model that we've used in the inpatient setting for decades, and now technology is getting us to rethink that model."

However, whether the use of hospital at home (HaH) for a range of acute conditions will continue depends to a large extent on a temporary program of the Centers for Medicare & Medicaid Services (CMS) that is scheduled to expire at the end of this year, according to Michael Maniaci, MD, physician leader for advanced care at home at the Mayo Clinic in Jacksonville, Florida.

A CMS spokesman told Medscape Medical News that the program has been extended by 1 month through January 2022, which is the official end of the public health emergency.

CMS Waiver Program Seen as Crucial

Before the COVID-19 pandemic, hospital at home — supported by a large number of studies — had been growing slowly for about a decade, Conley says. The pandemic accelerated the trend as more health systems began to build HaH programs to relieve the pressure of COVID patients on their facilities.

In November 2020, CMS used congressional authority to establish its Acute Hospital Care at Home program to help hospitals cope with the public health emergency. The funding provided to hospitals under this program made it feasible for them to put some resources into HaH programs.

Dr Michael Maniaci

The main objective of the new Kaiser and Mayo-led Advanced Care at Home Coalition is to get CMS to continue its coverage of hospital at home. That will require an act of Congress, and the coalition is lobbying hard, Maniaci says. In addition, the consortium is advocating for the Center for Medicare & Medicaid Innovation to test an 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 that to reimburse participating hospitals for the next few years, he suggests.

Among the coalition's members, besides Kaiser Permanente and the Mayo Clinic, are 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 coalition member is Medically Home, a provider of HaH services 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-based care companies that include Dispatch Health and several providers of complex care to seniors. Among other things, this coalition also wants CMS to keep covering hospital at home.

As of press time, 179 hospitals in 33 states, belonging to 79 systems, had received waivers to participate in the Acute Hospital Care at Home system, according to CMS. Hundreds of other hospitals, Conley says, are considering or are in the early stages of forming HaH programs. Some private payers are also beginning to cover this form of acute care, he says.

While the COVID crisis accelerated the use of hospital at home, he says, many healthcare organizations are now mulling how it could be used to improve outcomes and increase the satisfaction of acute-care patients. In 5 years, he predicts, if Medicare keeps covering HaH and other payers come onboard, home hospital care could become mainstream.

How HaH Will Affect Physicians

The Mayo Clinic, which has cared for about 500 patients in its hospital at home program, is now rolling it out to facilities in all four of its regions, including Florida, Arizona, Wisconsin, and Minnesota. Mayo's HaH model uses a central command center in Jacksonville, Florida, for all of the telehealth and remote patient monitoring aspects of its program. Local physicians don't usually visit the patients; instead, nurses, paramedics, and physical therapists make home visits.

Maniaci sees the program affecting hospital-based physicians in two ways: First, as the more stable and recovering patients are moved to the HaH setting, those remaining in the hospital building will be the unstable and higher acuity patients, which will present the inpatient doctors with additional challenges, he forecasts. Second, the physicians who care for HaH patients virtually will have to get used to a new way of practicing.

"It's still the same medical care, but interacting with people at home, having them be your hands and eyes in physical exams, using technology to listen to the heart over a wireless connection — those are new skills you're going to have to learn. It can be done, but you have to adapt to change," he points out.

"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 Ox by looking at you. I think it will be a combination of camera technology and a person's iWatch that feed continuous data, and we'll use computers to weed out the noise and use the good stuff."

MGH's Conley says the jury is still out on how much of physical exams can be done remotely, although studies on that are underway. With the help of new tools such as digital stethoscopes and digital otoscopes, he says, physicians might be able to do some physical exams remotely, or they might find it better for patients' safety and outcomes if they do certain exams in person.

The extent to which a patient can be treated remotely also depends on what kind of acute condition that person has. Studies support the use of HaH for patients who have exacerbations of congestive heart failure, chronic obstructive pulmonary disease, and pneumonia, plus complicated urinary tract infections and cellulitis, both of which require IV antibiotics, Conley notes. Rarer conditions like rhabdomyolysis also lend themselves to HaH care.

Expanding to Post-Acute Care

Some HaH participants have expanded into post-acute care. A 2011 pilot at Advocate Health Care in Chicago, for example, showed that HaH patients had a significantly lower number of readmissions at 90 days after discharge than the control group did. 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 rehab facility.

"Much of post-acute care could be delivered at home for the right patients, bolstered by the right technology and the right care processes," Conley says. While this transition of care needs to be done carefully, he says, there has been an improvement in sensing devices "that allow us to care for patients at home that in the past would have required close human interaction." Among these tools are fall detectors and devices that can "ambiently pick up heart rates and respiratory rates." As a result, there may be less need to send some patients to skilled nursing or rehab facilities.

The impact of this on community physicians, he says, would be "significant." They would have to start paying attention to data streams about their patients' status during the transition from acute to post-acute care, probably with the help of data filters and clinical staff to inform them of important changes that required their attention.

"There will have to be a lot of work on the technology side to ensure the data isn't overwhelming, but enables the community physician to make quick decisions that are in the best interest of the patient," he points out.

There is also an opportunity, he adds, to discharge patients to home after surgery to recover in an HaH setting. That would reduce the length of the inpatient stay — a plus for hospitals — and patients would rather recover at home than in a rehab facility, he notes.

Care Transitions Are Part of the Package

The Mayo HaH model focuses on transitions of care. An eligible patient is enrolled in the HaH program, usually out of the emergency department, for a 30-day period. For the first 6 or 7 days, they are cared for in a hospital room that's been set up in their home, complete with a hospital bed, an IV stand, telemonitoring equipment, and an audiovisual conferencing setup. After that, they're still monitored, but less closely. Mayo's care team educates the patient about their condition and makes sure they get their medications and set up an appointment with their primary care doctor.

The care team also reaches out to the community physician, informs him or her about the hospitalization and asks what that physician needs, Maniaci says. Mayo will provide monitoring data and a computer analysis to the doctor if he or she wants it.

All of this represents some additional work for physicians who formerly may not have known their patient was hospitalized until they showed up in the office. But Maniaci sees it as a big improvement over current hospital handoffs that end when the patient leaves the building. In addition, he notes, Mayo is doing all of the transition work, so the primary care physician doesn't have to.

"We're doing the transition, and we're making the primary care provider an active partner to the extent they want to be," he says.

Ken Terry is a healthcare journalist and author. His latest book is "Physician-Led Healthcare Reform: A New Approach to Medicare for All."

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