Summary: An integrated delivery system in Albuquerque, New Mexico, has been able to better meet the needs of its patient population by offering those who need acute care and meet specific criteria the option of being treated in their homes instead of the hospital. The program has reduced the average length of stay and cost of care and improved patient satisfaction.
By Vida Foubister
U.S. hospitals face bed shortages that are expected to intensify as the population ages. To ensure access to care, health care system leaders have begun to look for creative ways to care for patients. "Hospital at Home," a program designed to provide acute care services in the homes of patients who might otherwise be hospitalized, has been demonstrated to increase the quality of care patients receive, improve their satisfaction, and reduce the cost of hospital care by at least 30 percent.  Despite its promise, broader adoption of the model by health systems across the country has been limited by payment policies that restrict reimbursement to care provided in the hospital setting. This case study profiles the work of one health system that launched a Hospital at Home program with the support of its health plan.
Organization and Leadership
Presbyterian Healthcare Services (http://www.phs.org/) (PHS) is an integrated delivery system based in Albuquerque that provides care to more than 750,000 patients throughout New Mexico. Presbyterian's network includes eight hospitals, a medical group with 34 locations statewide, home care services, and inpatient and outpatient hospice programs. Its managed care organization, Presbyterian Health Plan, provides commercial health insurance, Medicaid, and Medicare products to more than 500,000 members.
The Hospital at Home program was developed by leaders of Presbyterian Home Healthcare, the health system's home care and hospice agency, who include Lesley Cryer, R.N., the agency's executive director; Karen Thompson, clinical director of special programs and Hospital at Home; and Scott Shannon, M.B.A., director of finance. They worked with Bruce Leff, M.D., professor of medicine at Johns Hopkins University School of Medicine (Johns Hopkins), who developed the Hospital at Home model. The system's executive and senior vice presidents were also engaged in the development of the program.
Presbyterian Healthcare Services introduced its Hospital at Home program to achieve better clinical outcomes, increase patient satisfaction, and reduce costs. The program was also expected to address the hospital's need for increased capacity, a need that will persist after the opening of its new hospital in October. (The emergency department of this facility has already opened and is admitting patients to the Hospital at Home program). Demand in the area has increased both with local hospital closures and the growing number of patients with chronic disease—a population health system leaders project will double by 2030.
The health system's Hospital at Home program, implemented in October 2008, is based on a care model developed at Johns Hopkins. Through that program, clinicians evaluate patients arriving at the emergency department who require admission for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, cellulitis, and other conditions to determine whether their illnesses could be treated at home.
Those who meet specific criteria for home treatment are given the option of being admitted to the program. If they agree, the patients are then transported home with any necessary medications and equipment; a nurse arrives at the home within one hour to ensure continuity of care for patients who have arrived at the hospital with acute care-level medical needs; and the nurse and other clinical staff, including physicians, make subsequent visits as need. Upon discharge from Hospital at Home, the nurse gives patients follow-up instructions and sends detailed information to their primary care physician. At Johns Hopkins, where the Hospital at Home program was developed, it resulted in measurably improved outcomes, reduced iatrogenic complications, increased patient and family satisfaction, and lower costs of care. 1
Presbyterian currently offers the Hospital at Home program to three populations of patients who live in the Albuquerque area: those arriving at the emergency departments of Presbyterian Hospital, Kaseman Hospital, and Rio Rancho Hospital; those who are referred from physician offices, urgent care, and the health system's home health agency; and patients who are transferred to the program from the hospital. The latter category includes patients who have transitioned from the intensive care unit to a step-down unit.
To enroll in the program, patients must meet the following criteria:
- They are being treated for chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD), community-acquired pneumonia (CAP), cellulitis, complex urinary tract infection (UTI), dehydration, nausea and vomiting, deep vein thrombosis (DVT), and stable pulmonary embolism (PE).
- They are determined to be sick enough to be hospitalized but do not need the intensive care unit (ICU), a determination made using research-based criteria from Johns Hopkins for the first four disease categories and criteria that Presbyterian and Johns Hopkins developed together for the others. These determinations meet criteria for hospitalization established by Milliman and Interqual.
- They live close enough to the three Albuquerque hospitals participating in the program to be able to return to the emergency department within 30 minutes, if needed.
- The patient is covered by Presbyterian Health Plan or chooses to pay for the Hospital at Home service, as the program is not covered by other payers.
Process of Change
Presbyterian began in 2007 by convening 12 multidisciplinary teams and giving each a charter with specific deliverables and a timeline for achieving them. The teams spent the first nine months of 2008 creating the processes necessary to roll out the model, with each team focused on one of the following areas: marketing/communication, pharmacy, emergency department, physician care, quality, billing/financial, vendor contracting, clinical nursing, intake and scheduling, human resources, legal, and documentation/coding.
One obstacle the human resources team encountered was hiring a lead physician for the program. "We went through three rounds of interviewing before we found a Hospital at Home doctor," says Cryer. "It seemed way too risky to physicians who were used to working in a hospital setting." (The health system has since hired two more physicians for Hospital at Home and is in the process of training them to work within the new model.)
While the clinical teams worked to build staff acceptance of the model, the marketing and communications team was tasked with building patient awareness and acceptance of treatment at home. They developed a commercial featuring a patient receiving care through Hospital at Home, which ran on television for three months, and promoted the program through billboard advertising. However, they are finding that many patients are learning about the program through word of mouth. Patient acceptance of the program is high; about 90 percent of eligible patients agree to be admitted.
Using this multidisciplinary process helped to create "incredible buy-in for the program," says Cryer, as it created institution-wide awareness of the new care model. "It's really the only way we were able to create this virtual hospital in a nine-month period."
The Care Model
Once admitted to the program, patients are transported home and seen by a nurse within one hour, and are visited once every day by a physician. A registered nurse comes one to two times per day, as does an aide. These visits are supplemented by telemedicine-based video monitoring. Through shared staffing arrangements with departments whose clinicians are cross-trained in hospice and home care, the program is able to provide patients with round-the-clock physician and nursing coverage. Their care follows specific pathways, which were developed initially by Leff and have since been modified and expanded for the needs of Presbyterian's population.
If needed, Hospital at Home patients have access to social workers; rehabilitation services, including occupational therapy, physical therapy, and speech therapy; and nutritionists. In addition, contracted vendors, with whom the system had existing relationships through its health plan, provide patients with any necessary equipment, oxygen, medication, infusions, diagnostic services, and transportation. Similar to the hospitalist model, the Hospital at Home program discharges patients when they are stabilized and the lead physician provides a detailed summary of the patient's treatment to their primary care physician. In some cases, patients that continue to need care, albeit at a lower level, are discharged to regular home care.
Concurrent with the development of the patient care services, quality measures were created to enable Presbyterian to evaluate the outcomes of Hospital at Home patients and compare them with those of patients admitted to its hospital facilities. These outcomes include patient and family satisfaction, illness-specific clinical quality measures, hospital readmission rates, and total cost.
The rollout of the program depended heavily on the system's ability to create a mechanism to pay for the service, as Medicare does not cover it.
The health system relied on its relationship with the Presbyterian health plan to do so; the plan reimburses providers using a bundled rate that covers the full continuum of costs, including physician fees and ancillary costs for services provided by contracted vendors, such as oxygen or diagnostic tests. Presbyterian is able to do this because a high percentage of its patients are covered by its health plan and only about 40 percent of its home care patients are covered by Medicare, as opposed to 80 percent to 90 percent of patients in most home care agencies nationally, says Cryer.
In addition, the system agreed to be reimbursed at a discount of the Medicare Prospective Payment System, which determines payments based upon Medicare Severity-Diagnosis Related Groups (MS-DRG), sweetening the pitch to its health plan, says Shannon. Presbyterian had been tracking its costs per Hospital at Home episode of care and those managing the contracting were confident that the discounted rate would enable the program to break even. The health system chose to contract as this rate as it believes the Hospital at Home care model benefits patients.
Within the first year, the Hospital at Home program admitted 125 patients with CHF, COPD, CAP, or cellulitis. Because CAP and COPD were found to be less prevalent in the summer months, five more diagnoses—complex urinary tract infection, dehydration, nausea and vomiting, DVT, and stable PE—were added in January 2010. Presbyterian worked with Hopkins to develop enrollment criteria for these new diagnoses and by July 2010, 261 patients had been admitted to the program; this number reached 439 by the end of June 2011.
Though the implementation of Hospital at Home was not without its challenges, the program appears to be a success. Its performance indicators are all equal to or better than those measured at the hospital facilities. In 2010, patient satisfaction, as measured by a Hospital at Home Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey developed with Press Ganey, was 94.5 percent. In the first six months of 2011, among the 100 patients admitted to the Hospital at Home program, only one was readmitted to the hospital within 30 days for the same diagnosis.
The program also has a lower average length of stay and lower cost per episode than the hospital facilities. The average length of stay for Hospital at Home patients is 3.5 days; the length of stay for comparable inpatient admissions is 5.4 days. And the Hospital at Home variable costs per stay are $1,000 to $2,000 less than comparable inpatient costs per stay by diagnosis. These savings ensue from lower costs for diagnostic testing—including labs and radiology—and pharmacy; less clinical service consumption; cost avoidance due to prevention of complications and rehospitalization; and flexibility in the staffing model.
All clinical outcomes are equal to or better than those found among Presbyterian facility patients with 100 percent of patients meeting the indicators for: receipt of pneumonia and influenza vaccination; antibiotics within six hours of diagnosis for CAP; and receipt of angiotensin-converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARB) for CHF.
Beginning in April, Presbyterian began work on a modified Medical House Calls program, which uses physician home visits to increase the intensity of patient care in the home setting. "What we're attempting to do is prevent patients from deteriorating so much that they have to go into the hospital," Thompson says. This, in turn, is expected to prevent the iatrogenic complications—such as falls, delirium, infections, and exposure to medication errors—that so often go hand in hand with hospital admissions for many of these patients.
In addition to increasing the number of house calls, the system also plans to increase physicians' presence with at-home patients through use of telemedicine, especially for patients discharged from Hospital at Home and home care.
Presbyterian is committed to creating a community of early adopters and, to that end, has worked with Johns Hopkins to provide guidance to about 30 organizations interested in establishing similar programs. "Just having New Mexico able to do this isn't going to convince CMS to pay for it," says Cryer. The interested groups tend to be other integrated health systems or systems that own hospitals, employ doctors, and/or have home care agencies. Many of the organizations have close ties with a payer that enable them to negotiate innovative payment approaches.
Payment, however, remains a critical barrier. Presbyterian has worked to create a replicable bundle of care that covers all services, with Hospital at Home as a standalone benefit with one co-payment per admission. This, however, is only offered through its own health plan. Commercial payers have expressed interest in purchasing the Hospital at Home service as a product, but before these health plans can offer it to their members, Presbyterian must first test the bundled payment model that it has developed with its own health plan.
The model also depends heavily on strong connections with physicians throughout a care system. Those leading Hospital at Home programs need to constantly remind emergency department physicians, hospitalists, and primary and specialty care practitioners in the community to consider their services for patients requiring acute-level care and must maintain close relationships with caregivers to ensure their commitment to the program. "This is such a new concept and no one has a reference point to it," says Thompson. "We had to learn as we did it: 'What does a Hospital at Home patient look like? How do you get them to look to Hospital at Home as an alternative?' "
For further information, contact Lesley Cryer, R.N., executive director of Presbyterian Home Healthcare at [email protected]; Karen Thompson, clinical director of special programs and Hospital at Home, [email protected]; and Scott Shannon, M.B.A., director of finance at [email protected].
1 B. Leff, L. Burton, S. L. Mader et al., "Hospital at Home: Feasibility and Outcomes of a Program to Provide Hospital-Level Care at Home for Acutely Ill Older Patients," Annals of Internal Medicine, Dec. 6, 2005 143(11):798–808.