INTERVIEW TRANSCRIPT

Q: What is the most accepted definition for Hospital at Home (HaH) in your country/ region/ society?

Definition of Hospital at Home has certainly been a topic of discussion within our field, within the community. Here in the US, we define Hospital at Home as care that substitutes for care that would otherwise be provided in the hospital. And we see two main forms of that.

We see what in the literature is called substitution Hospital at Home or admission avoidance Hospital at Home. That is, a patient often starting their care in the emergency department and then being taken from the emergency department directly back home.

And then the model that we tend to call here continuing hospitalization at home, that is, someone started off their care in the traditional hospital setting, they still need ongoing hospital level care, and then they're transferred home. So, transfer Hospital at Home or continuing hospitalization at home. We tend to avoid the term early discharge Hospital at Home just because in the US that term tends to get confused with what we call here skilled home health care. That is, not hospital level care in the home, but someone goes home, and they get nursing. They can get occupational therapy or physical therapy, but usually not physician care very much with that model.

How did you get involved with Hospital at Home (HaH) care/model/ecosystem? What is your HaH story?

A: My hospital home story goes back to when I was doing my training in internal medicine as a second year internal medicine residents, we picked up second clinic. And my clinic was home based primary care. So, this was providing ongoing longitudinal care, primary care in people's homes for people who were too frail to come to our office-based practice. These patients had multiple chronic conditions, they had difficulty doing basic activities, and they were homebound. I really enjoyed doing that kind of care. It was not uncommon to have patients develop acute medical illness, which really required that they go to the hospital. What we learned was that many times patients would refuse to go to the hospital, partly because they had had bad experiences there before. And often we were a little anxious about sending these very frail patients to the hospital because we were worried that the hospital environment would potentially cause more harm than good. So, it's not uncommon for older adults to experience delirium or acute confusional states or to have a fall or to have an adverse drug reaction, develop weakness and inability to move around because they're confined to bed. And we thought, based on that experience, that if we could provide acute hospital level care in the home, patients might avoid that.

Fast forward to when I joined faculty at Hopkins just after getting out of the army in 1994. We started working on developing the underlying theory for Hospital at Home. So, who are the right patients to treat? Developing criteria to choose the right patients. You want patients who absolutely need to be in the hospital but are not so sick that they must be in the hospital and could actually get their care at home. We developed those criteria. We did some work to figure out whether patients would actually accept care in Hospital at Home. We did some early clinical pilots, and we were the first to do that in the US. Back in the mid-90s and found people's heads did not explode. They had good clinical outcomes. The cost seemed to be a lot lower. Satisfaction with care was much better at home. And with that we went to our Medicare program which is the single payer for older adults’ healthcare in the US and asked them to come up with a payment for Hospital at Home. They said no at that time, but they said do Hospital at Home incapitated care capitated Medicare, what we call Medicare Advantage. So, we did that and did a multi-site study around the country and found that in fact people wanted to get this care. Their clinical outcomes were excellent in many ways better than the hospital with reduced rates of important complications like delirium, like mortality. Patient and family experience was much better, and the costs were lower. So that was some of the early work and sort of the start of my story in the Hospital at Home.

What does a day in your life look like?

I'm a clinical geriatrician and health services researcher so I'm usually taking care of patients or working on research or teaching here at Hopkins. Also I do a lot of work with colleagues here in the US, based at Mount Sinai and at Brigham and Women's Hospital in New York Dr. David Levine, Dr. Al Siu, Dr. Linda DeCherrie, and we lead the Hospital at Home Users Group, which is a special interest group of the American Academy of Home Care Medicine, sort of a quasi-professional society for Hospital at Home here in the US. And the Users Group helps to lead technical assistance efforts to help Hospital at Home programs around the country get started and develop and develop their best programs. We've been very busy since November 2020 when our Medicare program in the context of the COVID-19 pandemic created a payment mechanism for the first time in our fee for Service Medicare program. Before that there were probably about 15 or 20 Hospital at Home programs in the US. And since that time now about 250 hospitals have obtained that payment waiver to enable them to get paid to provide Hospital at Home care to Medicare patients in the fee for service world. So, we've been very busy providing technical assistance and the like. That's a lot of what my time looks like.

What motivates you in your work?

I think what motivates me is trying to improve care delivery for older adults. Hospital at Home is not confined to the care of older adults. But I think as a geriatrician we've always had a point of view that older adults and frail people, no matter what age, are most susceptible to the challenges of being cared for in the hospital. And to see care improve and to see that happen is wonderful.

And I think the other piece of it is that over the last 20-30 years you've had a lot of home-based medical care models developed, each individually. And there's a robust evidence base to suggest that models like home base primary Care and Care Transitions and Rehabilitation at home and Hospital at Home are good models for people, but they've all been in their own silos. I think the thing that motivates me now is the ability to start to think about putting all those models together into a full homebased care ecosystem so that in the future, hospitals will be these big emergency departments and operating rooms and intensive care units and everything or most everything else should be able to move out to the community. Hospital at Home is a key component of that because you have to have that acute care capability, that hospital level care capability in the community to sort of be the backstop the wall to help make that happen. I'm really interested to see how that develops over the next few years. And I think in the US we're starting to see homebase medical care get more attention, started to see it a bit more mainstream, starting to see a lot of investment from health systems, from capital markets. It's become becoming, I think, increasingly important. And I think the key is to make sure it happens in the right way and that it's not just a flash in the pan.

What are the greatest obstacles for the HaH ecosystem and how can we overcome them?

I've always thought that the most important one is the culture of healthcare. It's very hard to change hardwired systems. And right now, I would say the healthcare system is very hard wired to be provided in bricks and mortar facilities. So, I think that culture change is really the biggest obstacle.

That said, right up there with it is our payment issues. And what we've seen here in the US is that when you can get a payment for an innovation like Hospital at Home, that can be an important impetus to change the culture. I think payment and culture are at the top.

I think right up there with that, another barrier is creating the supply chain and the logistics to support hospital at home. You need to have redundant hardened supply chain so that when a hospital at home clinician orders a medicine or a service, it's part of the system and it's done and it's safe. And the programs are not being held together with a posted note or scotch tape. They really need to be deeply embedded into the system in the same way that the hospital is a system.

I think another challenge, and this varies a lot by geography, is the regulatory environment. Do the regulators in a particular place think of Hospital at Home as hospital and regulated as a hospital. Do they regulate it as community based home care. That's another big challenge that needs to be overcome.

I would say that over the last few years it feels like things are all moving in the right direction and those challenges are becoming a little bit easier, but still a lot of work to do.

What are the most common misconceptions about HaH?

I think some of the most common misperceptions are based on the fact that a lot of people, a lot of leadership in medicine, at least here in the US does not have a clear understanding of what homebased care is all about. They tend to confuse Hospital at Home with more typical home care. So, a personal care assistant to help someone walk a few steps in front of the toilet, or what I referred to it before, skilled home health care, someone leaving the hospital, they don't need hospital care anymore, but they may need some nurse to look in on them from time to time or a physio or an occupational therapist to help them. I think there's a lot of confusion that Hospital at Home is those other forms of home based care.

 The other misconception that we run into a fair bit is that because that's very difficult, if not impossible, to provide hospital level care in the home for people, that you just can't even do it. And that it's this new thing, it's only because of COVID when in fact Hospital at Home has been studied in randomized controlled trials for coming up on 50 years. The misconception is that this is not an evidence-based model, when in fact it's probably one of the most evidence-based health service delivery innovations of the last half century.

One more misconception. Healthcare equity is getting a lot of attention here in the US. And I think there's a misconception that Hospital at Home inherently makes inequity worse, when in fact I think it's just the opposite. And we've done some early research on that. A lot more work needs to be done, but if you can get into people's homes and provide care, you can actually enhance trust and actually have better outcomes.

What is something about HaH you would like everyone to know?

Number one - a deeply evidence-based model, dozens and dozens of randomized controlled trials proving that this model is at least as safe and as good as hospital care and in most cases better than hospital care for the right patients.

Number two, that Hospital at Home can really be a terrific asset for health systems and for healthcare delivery at large. If Hospital at Home can scale, it should help health systems and governments build fewer hospitals. Hospital beds are very, very expensive to build. The idea of providing hospital care in the home to create capacity when you need it during a pandemic, whether it's COVID-19 or influenza, and to be able to meet the care needs of the community by having capacity that you can build out very quickly, that's a really important thing as well. And then overall, it's safe, high-quality care, and that we should be doing a lot more of it.

Can you share any tips for professionals interested in HaH?

I have the sense that Hospital at Home tends to attract a workforce with a deep sense of mission. I think wherever you are aligning yourself or finding a program that is ongoing in your geography and making yourself available, I think that's really the best way to get involved. Certainly, a lot of literature to read if you want to catch up, and a lot of resources now online to start to study up.

What do you think is the value of attending the World Hospital at home Congress?

I think you'll get to see folks who are doing Hospital at Home from around the world. You'll meet researchers, you'll meet clinicians, you'll meet investors, and you'll really get to see the field at its best.


Last modified: Thursday, 13 October 2022, 12:52 PM