DINESH JOHN MD, MMM, FACP ׀ HEALTHCARE DELIVERY MODELS ׀ MAY 26, 2022
Picture this: you are sprawled out on your favorite couch watching the latest season of ‘Ozark’ on your large flat-screen, enjoying a home-cooked healthy meal when the doorbell rings. Presto-it’s the hospital! Or more specifically your Acute Hospital Care at Home (AHCaH) doctor and nurse who are here to check up on you, administer IV diuretics, and draw labs. They make good time, and even get out of your hair before the episode of ‘Ozark’ reaches its dark, dramatic conclusion.
Sounds too good to be true? Perhaps, but this is exactly what is happening across the country as the AHCaH movement gains steam. Except for the home-cooked meal part, maybe.
The COVID-19 pandemic and associated hospital bed shortages have seen the rise of Acute Hospital Care at Home (AHCaH) programs across the country, with over 114 programs receiving approval to launch AHCAH from the Center for Medicare and Medicaid Services (CMS). This is not including thirty-odd Veterans Affairs (VA) hospitals across the county, whose AHCaH programs have been evolving for the better part of a decade.
So What Exactly is Acute Hospital Care at Home (AHCaH)?
AHCaH is exactly what it sounds like- a viable home-based alternative to admission to a hospital bed. AHCaH is not a one-size-fits-all, but rather a spectrum of services that are based on the capabilities of the healthcare facility and the needs of its patients. These programs are generally best suited for medium-acuity patients who need inpatient-level services, but are stable enough to receive this care at home. Conditions with standard treatment protocols are best suited to AHCaH, such as pneumonia, heart failure, chronic obstructive pulmonary disease (COPD), and cellulitis.
There are two predominant models of AHCaH care:
The Hospital Substitution Model (a.k.a. Admission Avoidance): AHCaH takes the place of inpatient hospital stay for patients who come to the emergency room, or for those who need to be admitted directly from a physician’s office
The Early Transition Model: For patients who are already admitted to the hospital with an acute illness, AHCaH may be a suitable transition plan if they no longer require intensive nursing services and do not require multiple IV infusions per day.
AHCaH teams typically comprise a combination of doctors, advanced practice providers (APPs), registered nurses, respiratory therapy, physical/occupational therapists, pharmacists, and administrative support staff. They connect with patients regularly using a multi-modal approach, utilizing in-person visits, telemedicine, and remote monitoring devices.
Services that are offered by AHCaH programs include some or all of the following: point-of-care blood tests, electrocardiograms, point-of-care ultrasound, x-rays, oxygen therapy, intravenous (IV) fluids, IV antibiotics, IV diuretics, medicine reconciliation, home safety assessments, and skilled nursing services.
History of Acute Hospital Care at Home (AHCaH)
The Acute Hospital Care at Home concept is not exactly new, perhaps even as old as time. The modern avatar of what we know as AHCaH came into being in the mid-1990s, when John Burton, MD, and his team at Johns Hopkins conceived a program to provide safe and effective hospital-level care in the home, known as Hospital at Home© (H@H). The data from his pilot project showed that H@H had the following benefits:
Shorter average patient length of stay
Overall costs were a third lower than an inpatient stay
Lower chance of developing delirium, requiring sedatives, or needing chemical restraints
Patients and family members were more satisfied compared to those treated in the hospital, and family member stress was lower
Patients also regained their ability to do usual tasks more quickly
So why did it take until November 2020 for CMS to greenlight AHCaH, some 25 years after the first pilots showed promise? No matter how hard the AHCaH-vangelists at Hopkins or Mt. Sinai pushed, more pressing issues were always at hand.
Perhaps it was the lack of a burning platform. One which arrived in the form of the terrible COVID-19 pandemic, which has claimed the lives of over 1 million Americans and counting. As the pressure on hospital beds began to rise, former CMS Administrator Seema Verma announced a series of sweeping changes known as the ‘Hospitals Without Walls’ program. Dr. Verma was candid enough to admit that “our job is to make sure that CMS regulations are not standing in the way of patient care for COVID-19 and beyond.” These actions paved the way for a payment mechanism and framework that provided a hospital diagnosis-related group (DRG) payment for AHCaH care.
AHCaH- The Value Proposition
But is the AHCaH-juice worth the squeeze? While there is a paucity of data from the newly minted, CMS-approved sites, a significant body of evidence has come out from pilot sites that were independently funded.
Costs are typically a third or lower than traditional hospital care. For example, Presbyterian hospital in New Mexico has seen over 1400 patients in their AHCaH program, with no unexpected deaths, lower readmissions, satisfaction scores in the high 90s, and a 42% lower cost of care.
A Cochrane Review found that there was no difference in mortality or readmissions, along with higher satisfaction, and lower costs for AHCaH programs
A meta-analysis of 61 studies showed a 20% lower mortality rate among AHCaH patients
It bears mention that CMS' reimbursement for AHCAH is similar to hospital care, adding to the value proposition.
Physician Views
Here's my disclaimer- I have been directly involved with grant-writing, set-up, implementation, and staffing of a successful AHCaH program, and have been involved with others in a consulting role. From my viewpoint, I consider AHCaH to be one of the few silver linings of the pandemic, along with the rise of telehealth and the spotlight on health equity. Thus far, patients appear to be very satisfied with the care they receive from the comfort of their homes, as are family members and caregivers.
Some of my hospitalist colleagues have expressed their concerns about the program’s quality of care or worries about patients decompensating. Not to mention fears about job security, as AHCaH programs funnel patients away from the hospital. They are often surprised to learn of the data in favor of AHCaH programs, and that well-defined treatment protocols specify the next steps for the caregiver to take when a patient decompensates. And job loss? If the sheer volume of recruiter emails that hospitalists generally receive is anything to go by, it is currently a non-issue.
I gathered additional viewpoints from physician colleagues in Upstate New York who are affiliated with AHCaH programs. Here’s what they have to say:
Tim Creamer, MD, AHCaH physician and hospitalist at SUNY-Upstate University Hospital in Syracuse, NY, states that while AHCaH has been on providers’ radars for some time, the pandemic forced the hand of health systems to use every available resource. The hospital works with external partners such as Nascentia home health care to provide home infusions and nursing care.
Dr. Creamer is quite comfortable seeing patients at home, given his previous experience with primary care which included house calls. Currently, he sees a broad mix of patients, although COPD exacerbations and infections needing IV antibiotics are the more common reasons for admission. In addition, AHCaH is utilized effectively to bridge the gap for patients who are on comfort measures and are yet to be established without outpatient hospice services.
While Dr. Creamer’s program screens 15 patients a day on average, volumes are still relatively low- about one or two patients admitted per week. Even so, the program serves as a ’magnifying lens upon ants,’ in Dr. Creamer’s words, effectively bringing discharge planning into focus- with a desirable side-effect of redoubling inpatient teams’ effort to safely transition patients out of the hospital. In his opinion, even the six or seven patients admitted to a program such as AHCaH can sometimes be the difference between keeping the ER open or closed for business. And that in itself, is worth the price of admission, no pun intended!
Mahesh Padmanabhan MD, Hospital In Home (HIH)Lead Physician and primary care physician at the Donald J. Mitchell VA Outpatient Clinic in Rome, NY has been involved with VA’s version of AHCaH, known as Hospital in Home (HIH), for several years before the pandemic. He has seen the program evolve from being merely desirable to one that clinical leadership banks on to help unclog the ER and inpatient floors.
Yet there is still reluctance from providers to send patients home from the ER. Perhaps this is due to a lack of familiarity with the program, despite the HIH team’s ongoing efforts to get the word out. Lack of buy-in is not limited to the ER, but extends to primary care and inpatient settings, says Dr. Padmanabhan. It calls for a culture change in practice styles-one that needs champions within these groups to promote the program's utility.
Dr. Padmanabhan is also looking at using HIH to bring eligible veterans who are admitted to outside hospitals back into the VA system, the goal being to shorten hospital stays and facilitate the recovery of these vets at home.
How to Get Started?
Setting up an AHCaH program undoubtedly require significant activation energy, but CMS has made a good faith approach to streamline the process. Waivers can be requested for the duration of the COVID public health emergency, i.e. through July 2022 and likely beyond.
In my opinion, CMS reporting measures are not particularly onerous, and include:
Patient volumes
Unanticipated mortality
Escalation rate, i.e. how many patients were transferred to a traditional hospital
Active involvement of a safety committee
A patient list
Conclusions- Is AHCaH more a gimmick or game-changer?
AHCaH is a novel means of providing inpatient-level care to patients of medium acuity, which is now CMS-approved and is being reimbursed at the inpatient DRG rate. Is it more gimmick than game-changer? I’ll let you be the judge of that. But it is hard to deny the fact that it can be a useful tool in the arsenal against ER overcrowding and inpatient bed shortages, along with telemedicine and intensive case management. After all, there’s no place like home.
If you think AHCaH is right for your healthcare facility and are not sure where to start, I have listed some helpful resources for you below.
Useful Resources
Dinesh John MD, MMM, FACP- I’d love to work with your healthcare organization on AHCaH. Click here to get started!
Dinesh John is a physician and healthcare consultant.
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