It seems counterintuitive, but the hospital is sometimes the worst place for a sick person. It is an unfamiliar environment; there are numerous interruptions to one’s sleep; the bed is uncomfortable; and — especially with the Covid pandemic — family is frequently unable to be present the entire time. That is on top of dealing with the illness which landed the person in the hospital in the first place.
As a result of this, there are many possible complications of hospital stays: hospital-associated infections, pressure ulcers, delirium and disorientation, and long-term, there may be cognitive deficits well after the hospital stay has ended. Elderly patients are especially vulnerable to these complications.
And so, wouldn’t it be great if some patients can be “hospitalized” at home? This is providing hospital level services, but at the patient’s own home. This approach has already been tried, and there is good evidence that it leads to better outcomes for patients. A recent study out of the UK reiterated this point.
A trial conducted in the United Kingdom enrolled 1055 patients (mean age 83) and randomized them to hospital at home plus comprehensive geriatric assessment versus standard hospital admission. They had similar rates of living at home, but those randomized to being hospitalized at home had a lower rate of admission to long-term care at six months. In both groups, the most common presenting problem was acute functional deterioration due to infection.
This is significant. If we can reduce the number of patients admitted to long-term care, the better it will be for patients and better for the overall healthcare system. Of course, the patients treated at home would not be sick enough to need more advanced care that can only be provided in an actual hospital, such as critical care services or advanced cardiac care.
Still, this innovative approach has great potential to create capacity in the healthcare system, especially if we see another Covid wave in the winter or we suffer another global pandemic (which, truly, is bound to happen eventually). For example, if there are patients with Covid who are not that sick and only need oxygen, they can be treated at home with oxygen and perhaps some IV medications such as antibiotics or even remdesivir. And, they can be cared for with Telephysicians who can electronically round on them every day.
I already know of hospital systems that did just that with mildly-ill Covid patients: sent them home on oxygen to be monitored by Telephysicians. It was a life-saver for an already overwhelmed hospital with literally dozens of critically ill patients with Covid.
This “hospital at home” concept needs to be greatly expanded. The biggest barrier, however, is reimbursement. This needs to change. If we are to innovate, then payment schemes need to innovate as well.
Thankfully, the Centers for Medicare and Medicaid Services (CMS), the government program that administers Medicare, has an “Acute Hospital Care at Home” program, and more hospitals are participating in the program. If this system is to work, the payments to hospitals at home — with the proper oversight to prevent fraud and abuse — should be on par with payments to physical hospitals.
The Covid-19 pandemic has forced healthcare to rapidly innovate, such as the more widespread adoption of telehealth and telemedicine services. I myself have worked many tele-ICU shifts caring for Covid patients across the country. This will ultimately benefit the entire healthcare system, leading to better care and better outcomes. And part of this innovation should be a greatly expanded “Hospital at Home” program.
Shepperd S, Butler C, Cradduck-Bamford A, et al. Is Comprehensive Geriatric Assessment Admission Avoidance Hospital at Home an Alternative to Hospital Admission for Older Persons? : A Randomized Trial. Ann Intern Med 2021.