US model for hospital care at home reduces costs and increases patient satisfactionBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e3997 (Published 11 June 2012) Cite this as: BMJ 2012;344:e3997
An innovative “hospital at home” acute care programme has reduced costs by 19% with similar or better clinical outcomes and increased patient satisfaction, an analysis has found. The programme combines daily home visits by doctors and nurses with telemedicine technology.
The ongoing programme at Presbyterian Healthcare Services in Albuquerque, New Mexico, was offered to those who met entry criteria, and a total of 582 patients (93%) enrolled between October 2008 and April 2012. It was adapted from a model developed at Johns Hopkins University. The controls were patients with similar conditions and demographics—including those who declined to enroll and those who were not offered the option because of severity of disease, limited mobility, or distance.
“The savings were predominately derived from lower average length of stay [3.3 v 4.5 days’ mean stay in hospital] and use of fewer lab and diagnostic tests compared with similar patients in hospital acute care,” the authors concluded in an analysis of the programme for calendar years 2009 and 2010. It was published in the journal Health Affairs1and presented at a press briefing in Washington, DC on 5 June.
Presbyterian had similarly high rates of compliance on five key quality measures in both the home and hospital settings. For example, the rates for pneumococcal screening or vaccination for patients with pneumonia were 100% and 97% respectively. Patients with pneumonia at home were more likely to receive antibiotics within 6 hours (100% v 91%).
Overall patient satisfaction was high in both settings, with mean scores of 90.7 and 83.9 respectively, as measured by a post discharge survey.
The ratio of healthcare workers to patients is high in the hospital at home programme. Each home nurse is assigned only three to five patients at a time and visits once and sometimes twice a day for at least an hour each time.
Distance also is a factor in staffing patterns as patients are spread out across the sparsely populated region. Melanie Van Amsterdam, a doctor with the programme and coauthor of the paper, told the BMJ that she drives about 400 miles a week.
The telehealth unit allows instant communication with an off site nurse 24 hours a day, and provides basic tools of a blood pressure monitor, stethoscope, oximeter, and glucometer that can be used under the nurse’s direction.
Van Amsterdam said Presbyterian Healthcare Services could implement the programme because it is a fully integrated provider; savings from reduced hospitalisation help pay for in home services. One of the most significant limitations on greater use of the model is the rules insurers have for reimbursement.
Bruce Leff, who spearheaded development of the “hospital at home” model at Johns Hopkins, said that they have learned some basic lessons from a variety of innovation collaborations in geriatric health.2
Among them are that all healthcare is local, and local conditions are of paramount importance in choosing the appropriate model. Technical assistance often is key to implementing a model.
Being part of a learning collaborative helps to share experiences and adapt tools. He said models get adapted “in ways we never imagined,” and combining models often can have a synergistic effect.
“Payment clearly matters; some models are adopted because they fit into current payment schemes; some models do not,” Leff said. Current modifications to care delivery have grown out of acute care “because hospitals are where the money is.”
But that is changing under the reforms brought about by the Affordable Care Act, Leff said. The new focus is on linking patients to primary care and a medical home, and resources are following.
Also published in the journal is a case study on “deep listening” using video to help better understand patient needs and social/cultural contexts. It has allowed Kaiser Permanente to identify problem areas in care transition, often in communication, and better shape those transitions to improve quality.3
Sometimes the change is as simple as teaching patients, their carers, or both how to give an injection. One medical centre was able to reduce readmissions from 13.6% to 9% in just six months.
Cite this as: BMJ 2012;344:e3997