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Hospital at Home Is a Piece of the VBC Puzzle
Hospital at Home solves the hospital bedrest problem
Dana Prommel Strauss
January 22, 2024
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Hello friends, old and new,
Today, I’d like to share some thoughts about hospital at home.
Like some of you, I’ve been watching the recent reports of data collected during the Acute Hospital Care at Home (AHCAH) waiver that began during COVID.
I’m delighted, and not surprised, by the results, all consistent with the hospital-at-home literature:
Low mortality rate
Low rate of transfer back to the brick and mortal hospital
It’s not that hospital-at-home was new with the pandemic. But it was largely limited in use to demonstration projects and pilot programs for commercial patients.
The AHCAH waiver waived some specific Conditions of Participation for CMS-approved individual hospitals to provide inpatient, hospital-level care in the home for Medicare fee-for-service and non-managed care Medicaid beneficiaries.
Here’s a link to the November 3, 2023 JAMA Health Forum Research Letter sharing these initial results. The article has other great links for additional details on hospital-at-home.
Who was treated during the 16 months this data was collected?
The article is brief, but it was important to communicate these early findings as we enter the 2nd of 2 years of the AHCAH waiver extension funded by Congress and signed by President Biden as part of the Consolidated Appropriations Act of 2023.
The letter doesn’t go into detail about other findings, but it does call out a few important nuggets of information leading up to policymakers having to at least decide whether or not to fund an additional extension of the waiver.
Patients presenting to the ER, found to be eligible for inpatient admission and sent home for their hospital stay, were not negatively impacted in terms of safety and quality of care. The findings were consistent with other literature on hospital-at-home efficacy.
Dr. Bruce Leff may be considered the modern-day father of hospital at home
Johns Hopkins’ website: “Home, sweet hospital”
I enthusiastically agree with Bruce Leff, but would perhaps humbly add that some percentage of childbirth and neonatal care will likely remain in brick-in-mortar hospitals, also.
In any event, my mantra goes something like this:
“When something in healthcare can be done, and it is and is perceived to be highly valuable, eventually it will be accepted and expected to be done.”
I’m willing to bet hospital at home will be accepted and expected within the next five years, with market-specific adoption dependent on state and local dynamics and incentives.
Health policy and regulatory changes generally happen out of necessity, not proactivity. It takes, well, quite a lot of will and timing to get big, permanent things done.
Feels like a lifetime ago, so to recap the last few years:
March, 2020.
Hospitals were overrun with patients in acute distress from COVID. Many couldn’t manage the volume, severity, risks, and impacts to staff. People were dying. Coming to the hospital was a risk in and of itself.
The Trump administration lifted a slew of barriers to make it easier for hospitals to act for everyone’s survival (in addition to rolling out a vast array of other waivers, like telehealth, which have largely been extended through 2024 via the CAA of 2023).
One of those waivers was to allow hospitals to admit patients to a setting outside the inpatient hospital setting. Keep those already ill away from anyone with COVID, and keep those with mild to moderate COVID home, reducing the risk to a larger population in the hospital.
There’s no reasonable explanation why the only time HAH should be available is out of necessity in response to a pandemic, when incentives were aligned. As data continues to show HAH is safe and valuable, will there be enough political willpower to get a long-term solution done?
Here’s a 3-minute case study of a woman with a recurrent UTI admitted to hospital at home through UMass in 2021:
Yes, this is produced by a company that sells a program to partner with hospitals and help administer HAH programs. But it’s a real-life example.
If I had to guess, I’d imagine “Joy” would be pretty disappointed if she needed HAH in the future but couldn’t access it because it was never made into permanent law or funded after 2024.
This isn’t a scenario legislators want to face. In states with:
hospitals who have built significant programs because of the waiver and expect the largest payer to continue to fund this care
beneficiaries who have opted into HAH as a choice and had good experiences
it would seem like a solution might be a priority and Congress might act.
Maybe it won’t be anything more than another extension, but something “else” might have to wait until after the 2024 Presidential election and perhaps even with the next (119th) Congress. Right now, the goal is no gap, no pause.
The Value of Being Able to Get up and Move Around
Hospital-at-Home has a host of potential benefits. One of my favorites:
Bedrest orders in the home? Rare.
Bedrest is bad. Simple, true, but still very common in hospitals.
Yes, I know. There ARE circumstances in which it’s contraindicated to get out of bed. There aren’t too many of them. Unstable fractures are a classic example of medically necessary bedrest.
Here are some of the downsides of bedrest:
deterioration of muscle strength, which happens quickly in seniors
deterioration of connective tissue
decline in physical endurance
quick to fatigue
fall risk increases
fear of falls increases
developing loss of control
learned helplessness
sleep disorders
cognitive decline, depression
increased dependence on others
Long-term impacts of bedrest can include these and more:
a lack of return to pre-bedrest physical functioning
the risk of readmission and cycling through inpatient stays
suffering a loss of self-confidence
suffering anxiety and depression
experiencing long-term physical and functional impairments
needing support from family or paid caregivers to remain safe at home
losing financial savings and security if and when 24-hour care is required in their own homes, an assisted living facility, or nursing home (these costs can range from 5-18k per month!)
Bedrest remains alarmingly common. Below is the concluding paragraph in an article in Applied Nursing Research published online in September, 2019, right before the pandemic started.
We KNOW how bad bedrest is, but a large portion of hospitals still use it routinely outside circumstances in which it’s medically necessary
Here’s number 2 on the list of 25 things nurses and patients should question in Choosing Wisely:
So given the grave dangers of bedrest, why would any physician or non-physician practitioner write (or not lift automatically-placed) bedrest orders unless absolutely necessary, ESPECIALLY for the geriatric population?
Why wouldn’t hospital mobility be a standard, expected part of every patient’s plan of care unless there’s a medically-necessary reason for bedrest based on evidence-based practice?
(Yes, these are rhetorical questions!)
Drumroll, please…
Ah, misaligned incentives—of course!
NO, it does not require rehabilitation staff with doctoral degrees to get patients out of bed that were walking on their own a week ago and did not experience an acute event with a direct correlation to impaired movement/mobility/balance, etc.
Yes, it does require nursing or ancillary staff to walk with patients enough to prevent the detrimental effects of bedrest.
But—
How are hospitals paid?
Prospective payment. One payment for the Diagnosis Related Group (DRG) covering essentially all but physician visits in the hospital, which are billed separately.
So here’s that that means. While you might get 5 consults you may not actually need from providers you may never see again, you will be left almost entirely in your bed for 5 days.
(Goes without saying there are plenty of exceptions-hospitals who have established robust mobility programs and both mandate and track compliance among physicians and staff.)
Yes, this is crazy..
With all the problems bedrest causes, and all the money it costs downstream in repeated admissions, falls, cognitive and behavioral problems, loss of independence, avoidable inpatient post-acute stays, and more, it’s not enough incentive to change it.
WHY?
Hospitals struggle to make the business case for hospital mobility programs. Do the negative impacts on patients downstream from the hospital impact the hospital’s payment in a meaningful way?
Nope.
So bedrest is still common.
“The public” largely doesn’t know how dangerous it is for them to be in bed for days. Who is going to tell them?
Back to Hospital at Home:
One thing you can count on—you are HOME—where you have autonomy!
Okay, Dana, stating the obvious here…
Yes, I know.
But hey, home means comfort, familiarity, family and/or friends, and no additional time or staff needed to “mobilize” or “walk” someone.
People have their favorite couch or chair, their own bathroom, and need no one’s permission to get up and move around.