Health care is moving back home

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When people are sick, the last thing they want to do is travel. But that’s not the main reason why health care delivery is moving away from hospitals and toward home.

The focus on value and right-sizing medical services to the patient’s needs is driving new thinking about how to use appropriate professionals in settings that are effective and convenient for patients. That means finding ways to deliver an array of services -- from post-surgical physical therapy to medication reconciliation that includes over-the-counter products, to fall prevention and even some traditional inpatient acute-care services -- in people’s homes.

And, to do it safely.

The advantages of delivering care at home include decreased overhead for organizations and convenience for patients. But there are challenges as well, such as training practitioners to work in spaces not designed specifically for medical care and sharing information among far-flung team members. 

So far, there is not enough data to know if convenience might come at the expense of safety. Organizations experimenting with ways to deliver care at home emphasize their use of new technologies, specialized training, and old-fashioned compassionate care to deliver care at home that they believe will lead to better, cost-effective outcomes for patients of all ages.

Brigham Health, a system that includes Brigham & Women’s and the Faulkner hospitals, has been providing hospital-level care to a select group of patients in their homes since late 2016. Each month, the Home Hospital program treats about 20 acutely ill patients who would normally be hospitalized, but who are at low risk of needing intensive care services.

David Levine, M.D., Assistant Medical Director for the Brigham & Women’s Physician Organization and Director of Brigham Health’s Home Hospital, says the average “length of stay” at home is five days, similar to a hospital stay.

David Levine Cropped
David Levine

Home visits by are augmented with sensors that register patients’ vital signs, including heart and respiratory rates. Clinicians are able to access the data remotely. The patient’s care team can also use videoconferencing to assess if the patient needs urgent care. “If we need to be at a patient’s house at 2 in the morning, we absolutely are,” says Levine.

Complex care where it’s needed

Commonwealth Care Alliance (CCA), a not-for-profit, community-based organization, provides both health insurance and care for Massachusetts residents who are dually eligible for Medicaid and Medicare, including many with complex medical, behavioral health and social needs.

Since 2013, between five and seven percent of CCA’s 27,000 members have received care at home, often because a health condition prevents them from traveling to medical appointments.

The visits may include enhanced primary care services or management of ongoing health issues, according to Laura Black, D.N.P., F.N.P.-C., Vice President of Care Partnership and Clinical Services at CCA.

Laura Black Headshot
Laura Black

“If someone is at the end of life, or has chronic disease that impairs their ability to get care, it can be an ordeal to get to a provider’s office,” she says. “There’s a real gap.” Home care can also prevent some trips to the emergency room.

CCA home visits usually take 30 to 45 minutes and fall under the auspices of an integrated team of nurse practitioners, physician assistants, registered dieticians, and/or behavioral health specialists. In some cases, technology helps maintain connection and contribute to living more safely at home with internet-enabled devices, digital decision-support tools and voice-based technology, such as Amazon’s Alexa. 

More importantly, she says, “It’s crucial to work with care providers and practitioners who appreciate they are guests in a member’s home and go the extra mile to treat members with compassion and sensitivity.”

Safety for all at home

“The emphasis is on providing the right care at the right time and the right place,” echoes Lahey Health at Home’s Chief Operating Officer Deborah Costello, M.S.M., R.N. The Beverly-based organization provides care for about 1,500 patients, using 180 nurses and 100 therapists to deliver physical and occupational therapy, skilled nursing care, social worker services and other home health assistance in communities throughout the North Shore of Massachusetts.

Deborah Costello Headshot
Deborah Costello

Costello notes that safety is important for both workers and patients. Staff members are trained to follow the Center for Disease Prevention and Control’s universal precaution guidelines, and to help patients and families contribute to the safety of care at home.

“We help educate for potential problems, such as increased risk for infection due to a weakened immune system. We teach patients and families how to minimize that risk,” Costello explains. “We also talk about how to prepare foods in the home to lower the potential for contamination.” 

Early evidence is promising

Levine of Brigham’s Home Hospital program is pleased with early results of the pilot program to treat acutely ill patients at home. He found that costs for patients receiving care at home were 52 percent lower compared to patients treated in the hospital.

Home care patients had fewer consultations and tests, slept more, were more active and less likely to be readmitted than hospitalized patients. The pilot randomized controlled trial, which included just 20 patients, found “no significant differences in quality, safety or patient experience.” Levine’s findings were published in this month’s Journal of General Internal Medicine.

Will other hospitals follow? If so, Levine recommends they reach out to others working in the hospital-at-home space and scale their first efforts carefully. “We started conservatively with a high-touch model,” he says. 

Shirley Scomember2 V2
Dirce (right), a health outreach worker with Commonwealth Care Alliance visits with Shirley, a member of CCA’s Senior Care Options plan, in her kitchen.

Getting to know patients better

Commonwealth Care Alliance’s Black believes that clinicians learn more about their patients’ needs by treating them at home, contributing to positive outcomes. For example, during one home visit, she asked an elderly patient if she was taking anything to help her sleep at night. The woman, diagnosed with kidney failure, pulled out a bottle of Motrin PM. 

“Motrin PM is a combination of ibuprofen, which is very bad for the kidneys, and Benadryl, which is contraindicated in elders because it can cause falls,” says Black. 

Working with the patient’s primary care provider, Black was able to prescribe melatonin as a sleep aid instead. 

“Had I not done that visit, we might never have found that out,” she says. “When people bring a bag of medications into a visit with the primary care provider, they might not think to include everything. In the home, you see it all.”

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