The COVID-19 crisis, while devastating, has accelerated digital capabilities like video visits, patient engagement platforms, AI-enabled triage solutions, and more. Another accelerated capability that has received less attention is “hospital at home.” Hospital at home programs deliver hospital-level services in the home and receive near or complete payment parity for inpatient DRG payments. In November 2020, The Centers for Medicare and Medicaid Services opened up the floodgates with new regulations that encourage providers to build and expand these programs. 

Some provider organizations have been working on home-based acute care services for years. Leaders from institutions like Johns Hopkins Medicine, Presbyterian Healthcare Services in New Mexico, and Brigham and Women’s Hospital have spent years figuring out the logistics, clinical service models and technology to drive outstanding clinical care in the home. 

The clinical, financial, and patient experience outcomes realized by these programs are, in most cases, jaw-dropping. A meta-analysis of hospital at home programs in Australia concluded that those programs delivered a 25% cost reduction, 20% mortality reduction, and 25% fewer hospital readmissions. Furthermore, these programs routinely meet or beat these outcomes while delivering significant improvements in patient experience scores.

Home Hospital Attending Dr. Gregory Goodman and his peers at the Brigham and Women’s Hospital in Boston are pioneers in this space. AVIA spoke with Dr. Goodman about what it takes to build a successful hospital at home program, why it matters, and how hospital at home is redefining the future of care. 

Gregory Goodman, M.D. is an Associate Physician at Brigham and Women’s Home Hospital program and Instructor in Medicine at Harvard Medical School. His clinical focus is on building new models of innovative home-based care. He is the Founder of Dr. Gregory, a medical designer product line for home care. Gregory is a graduate of Tufts University School of Medicine and Brandeis University

How do you define “hospital at home” and why is it important?

“Hospital at home” is a community provision of services that would normally be provided in an acute care space. Hospital at “home” can really take place anywhere. I’ve treated patients at Airbnbs and downtown hotels. As long as you have a safe place that we feel comfortable we can deliver care, we can treat you. It isn’t a new concept, but every idea has its time. The idea and the timing is now. The challenge is how to balance the clinical touch with the technology, operations, and logistics.

I am personally inspired by this work because my grandfather Dr. Fainman, originally from South Africa, was a house call doctor. I want to take care of my community in the same way, so I followed my heart. It’s beautiful to get people home, have them around family, and get them the care they need. I was also inspired by Dr. David Levine, who published a small randomized control trial in 2018. Dr. Levine’s first study showed close to 50% cost savings compared to the same treatment delivered in the hospital setting. 

For me, pushing into the home and community, connecting on all of those fronts, is so important. It makes so much sense in a large academic setting to find a subset of patients you can care for in the home and open up beds for patients who require really complex surgeries, complex care, and subspecialty teams. 

It comes down to doing right by the patient. Recently I had a 92-year-old woman sick with cancer on her third hospitalization. You could argue she needed acute care, because she was way below her functional baseline, she couldn’t walk anymore. So I asked her, “what do you want?” She had a wish of staying at home with her great grandchild, and that’s the direction we took.

How do you find the right patients to participate in this type of program?

The key is getting the right patient population. We have specific social and medical criteria:

1. Emergency department (ED) substitution: Patients get evaluated and worked up in the ED, and we have specific medical conditions that we can provide safe and high-quality care for transfer from the emergency department. For example, someone who had heart failure or COPD exacerbation.
2. Early inpatient transfer: Patients are transferred from inpatient medical services after receiving additional work-up including more advanced imaging or additional studies.

A lot of patients who need “bread and butter medicine” are good fits for hospital at home. For example, if they need IV antibiotics, less than a few liters of oxygen, have diabetes, hypertension, etc., these are basic cases that cause you to ask: Do you really need the four walls of the hospital? Can we take care of this patient at home? 

I also consider the right touch points and appropriate levels of service. How much care does the patient need? If it’s a lower level, maybe it’s a daily physician telemedicine visit with a twice daily nurse visit. Then how do I intervene and what’s the monitoring structure? The options for acute care needs could be traditional inpatient care, observation, telemedicine, hospital at home, or the ICU.  Everyone has a different definition of what is medically appropriate, so you need clinical buy-in for safe care transitions. 

What are your recommendations for other health systems looking to get started with a hospital at home program?

The key components of getting started are clinical, technology, and logistics. They all factor into measuring success and ensuring safety. At BWH, we started small. We had one doctor and one nurse. Over the last few years, our program has tripled in size. We’ve doubled the number of doctors on call and really thought through the operational piece of things. We have a passionate group of people who are aligned with BWH’s mission to take the best care of our community. 

Digitally, you can have the tech stack, but it can be really expensive. If you have a smaller budget, there are great programs that are less expensive. If you can start small and show a proof-of-concept with the right team, you can then consider investing in a more comprehensive suite of tech services. For speed to market, you have to find internal champions at all levels, in all departments. From there, you find the tech that works for you. 

What are the key challenges to a successful hospital at home program?

It comes down to getting the clinical criteria right, getting clinical buy-in, finding the right tech solution, executing logistics, and getting started.

The biggest challenge is logistics. How do you get the right provider with the right medical equipment and resources to the right patients? Pure AI isn’t going to work. It’s about finding the sweet spot of matching the type of virtual or in-person visit with the right patient, and then asking what your tech platform looks like for that. I would tell people starting out to partner with an external group or develop that capability in-house.

There’s room to innovate. Having a more focused list of patients that can be targeted and approached in a faster, more streamlined fashion would be helpful. You also need buy in from leadership. You need a group that believes in the program and understands the value. 

From a staffing perspective, there’s a gap in how we’re training clinicians for the wave of the new clinical touch in the home. In medical school and residency, they don’t train you to be a home physician. You need an educational approach to educate at top of license. With hospital at home, you have to feel more comfortable not ordering daily labs (unless appropriate), not doing things the way hospitals do things. It comes down to behavior change and building a clinical pipeline.

What does the future of hospital at home look like?

Ultimately, we want to identify someone in the community that otherwise would require an ED evaluation and triage them to see if they’re a fit for hospital at home before they get admitted. Eventually, looking upstream, the goal would be to directly admit patients to a hospital at home program and avoid the four walls of the hospital altogether. 

Hospital at home is still in its early days. I do think there are going to be hospitals that go out of business. It’s hard to argue you need brick and mortar for certain types of care. There will be sub-specialties at big hospitals to do what they are built to do, to take care of sick patients, the highest level of specialty and procedural care. Then you have a wave of hospitals and facilities that ask how they add value. You’re going to have patients and clinicians who love hospital at home. It’s hard to argue with a model that meets financial incentives, improves outcomes, and boosts patient and physician satisfaction. 

A large chunk of what we do in inpatient acute units can be done at home. The technology is there today. Still, we have a long way to go with the logistics. As people become more familiar with this model and people get trained in this approach, it will be exciting. This is where the future of care is. My north star is more people at home. It’s that simple.