The pandemic conditions that drove home hospital programs in the United States may now be waning, but the movement itself is maintaining its momentum. According to the consulting firm McKinsey, up to $265 billion worth of care is provided annually in health facilities to Medicare beneficiaries – a quarter of the total cost – could be carried into homes by 2025. A recent report from Chartis, another consulting group, found that nearly 40 percent of health executives surveyed intended to implement a hospital-at-home program in the next five years; Only 10 percent of respondents do not expect to develop any plan at all. when President Biden signed the $1.7 trillion sweeping spending bill At the end of December, the exemption from CMS was extended through 2024. Currently, there are no formal rules limiting conditions that can be treated at home, as long as care meets the same standards as inpatient care on hospital wards, but the federal government’s spending bill tasks with specifying Who should be hospitalized at home? In Liv’s vision, it could mean that almost everyone eventually ends up, which is not as likely as it seems now. He imagines that one day hospitals will consist only of emergency rooms, intensive care units and specialized operating rooms.
When you build hospitals “New building, they don’t do it themselves,” Pippa Schulman, Medical Home’s chief medical officer, told me. “We are the partner when you are building a home hospital.” Medically Home, a private company started in 2016, has contracts with about 20 organizations, many of which it signed during the pandemic. The company designs local employee and supplier movements, so that tests and visits can take place in people’s homes; If patients get very sick, they can easily be taken to the hospital. Medically Home has created a technology platform to coordinate each step, so that – if everything works correctly – the doctor will be able to enter the computer and thus prompt an action in the patient’s home as if it were being performed within a hospital.
An increasing number of companies such as Medically Home have moved into the home hospital business, among them Contessa, DispatchHealth, and Sena Health. Some companies only offer technology, such as video calls or remote monitoring. Others not only set up the hospital’s operations, but also manage the insurance contracts; Mount Sinai needed repayment after the federal grant ran out, so he partnered with Contessa to deal with insurance companies. (DeCherrie, one of the doctors who led the original Mount Sinai trial, has since gone on to work at Medically Home; Leff advises some of these firms.) Consulting firms sell their expertise to health executives. Even private insurers are becoming more involved, not only compensating hospitals for in-home care but also providing the services themselves, sometimes by working with start-ups to remove the hospital from the equation. Their clinicians meet patients in their homes before they set foot in the emergency room, as De Piero did with Manuelita Romero.
In April 2020, Medically Home Hospital’s first client, Kaiser Permanente Northwest—which, like Presbyterian, runs its own insurance plan—opened the home hospital program. Because Oregon allows community paramedics to provide care at home, Kaiser Permanente is able to treat patients in that condition using Medically Home nurses who operate from a virtual command center in Massachusetts. During a typical day, these patients can expect video calls with their doctor and nurse and in-person visits from a physician who checks vital signs and administers medications. Ultrasound, x-rays, and even echocardiograms can be done at home. For some problems, such as wound care, nurse practitioners may travel home. The nursing and physician remain mostly virtual, in contrast to the treatment offered through Presbyterianism; A Kaiser Permanente patient may be hospitalized in their home in Longview, Washington, while their doctor is in Portland and their nurse is in Boston.
In this way, Kaiser Permanente has served more than 2,000 patients in Washington and Oregon; Nearly 500 more people have been treated in the California program, which began in late 2020. To put those numbers in perspective, Presbyterian Home Hospital has cared for fewer than 1,600 patients since it began 15 years ago. Kaiser Permanente needs to operate on a scale like this, according to its executives, to make up for the significant investment that went into starting the home hospital program. “There is a cost to getting these programs,” says Marie Giswold, chief operating officer for Kaiser Permanente Northwest. In order to cover them, Gisold explains, hospitals need to reach certain economies of scale. This could be another reason why CMS didn’t support the hospital at home after the Mount Sinai study: To make financial sense, the hospital would probably need to treat at least 200 patients at home a year—a struggle to get access to for many places at the time.
However, making home hospitalization cost-effective for health systems comes with a different kind of cost. The patient may never feel the warmth of her nurse’s hand on her forehead, the reassurance of a stethoscope on her heart. During a video visit I sat in, including the Kaiser Permanente program, the only glimpse I got of the patient’s home was a bottle of Tums and a mug on her side table — a far cry from what De Pirro could see on her rounds. When the patient noticed some lower abdominal pain, the doctor could not reach through the screen to examine her; Instead, he had to rely on the doctor’s report. Archieh Macho, MD, medical director for Kaiser Permanente at Home for the Northwest, acknowledges the trade-offs. “Although I’m sacrificing that bedside interaction with the patient, I’m also increasing the number of patients I can see per day to provide better care at home for the patient, which kind of compensates for the losses,” Machao told Li.